1. investigations
1.1. BP measurment
1.2. fundoscopy
1.3. ECG
1.4. ECHO
2. Step1: identify cues and difficult words
2.1. A/ identify cues
2.1.1. over weight 58 yomale
2.1.2. hypertensive for 10 yrs , on treatment
2.1.3. snoring
2.1.4. general lack of energy
2.1.5. worried about BP medication
2.1.6. over last 5 yrs
2.1.6.1. change the distance of driving on work
2.1.6.2. gainning weight
2.1.6.3. loss of interest
2.2. B/ difficult words
2.2.1. long haul: long distance
3. Step2: problem formulation
3.1. 58 yo hypertensive, overweight male patient, presented with worrying of snoring and general lack of energy.
4. Step3: hypothesis generation
4.1. suspected underlying cause for hypertension. stroke , kidney problems(Adeeb)
4.2. the HTN medications are the cause of loss of interest and depression (Sulami)
4.3. all the symptoms are consequences of exposure to poisons facing in his work as a truck driver(Ghannam)
4.4. tending to sleep as consequence of his condition forced him to do some changes in his work (hassan)
4.5. use of substances to be awake for long time may cause HTN
4.6. the weight gained is bcz the edema that caused by kidney problem affected HTN(homoud)
4.7. caffien is the cause of HTN. gaining weight bcz the medecations.(essam)
4.8. gaining weight>>snoring. working time changes>>lack of energy. phsychological problem may be (faris)
4.9. work requirements > low muscular tone> affecting breath while sleeping > snoring . both aggrevates each other(kashi)
4.10. hear failure and LVH are complications(adeeb)
5. Step4: hypothesis organization
5.1. primary
5.1.1. HTN
5.1.1.1. causes
5.1.1.2. risk factors or aggrevating factors
5.1.1.3. consequences(short and long term)
5.1.2. snoring and general lack of energy
5.2. secondary
5.2.1. dysfunctional impact
5.2.2. less interest
6. Step5: learning objectives
6.1. 1-to know about HTN(definition, causes, risk factors, types, manifestation, mechanisms and complications)
6.1.1. emphasis on relation between HTN and OSA
6.2. 2-complications of antihypertensive drugs
6.3. 3- criteria of diagnosing depression.
7. Step6 : review
7.1. 1-to know about HTN(definition, causes, risk factors, types, manifestation, mechanisms and complications)
7.1.1. definition
7.1.1.1. Isolated HTN
7.1.1.1.1. Grade 1
7.1.1.1.2. Grade 2
7.1.1.2. HTN
7.1.1.2.1. Grade 1
7.1.1.2.2. Grade 2
7.1.1.2.3. Grade3
7.1.1.3. MORE THAN ONE READING ARE NEEDED TO CONFIRM THE diagnosis of HTN
7.1.1.3.1. 2 or more reading
7.1.1.3.2. comparing the both arms
7.1.1.3.3. also, compare with a normal person
7.1.2. causes
7.1.2.1. essential HTN
7.1.2.1.1. unknown cause
7.1.2.1.2. multifactorial
7.1.2.2. Secondary HTN
7.1.2.2.1. renal
7.1.2.2.2. endocrine
7.1.2.2.3. drugs
7.1.2.2.4. cohn's syndrom
7.1.2.2.5. pregnancy
7.1.2.2.6. vascular disease
7.1.2.2.7. coarctation of the aorta
7.1.2.2.8. low sodium intake
7.1.2.2.9. metabolic syndrome
7.1.3. types
7.1.4. manifestation
7.1.4.1. mostly asomptomatic
7.1.4.2. headache
7.1.4.3. blurred vision
7.1.4.4. angina(in some patients)
7.1.4.5. dizziness
7.1.4.6. sweating
7.1.4.7. palpitation
7.1.5. complications
7.1.5.1. angina
7.1.5.2. hypoperfusion to the kidney
7.1.5.2.1. renal infraction
7.1.5.2.2. sodium retention
7.1.5.3. heart failure
7.1.5.4. retinopathy
7.1.5.5. stroke
7.1.5.6. malignant hypertension
7.1.6. mechanism
7.1.6.1. BP=COP IN P.resistance
7.1.6.2. increase in after load
7.1.6.2.1. sympathetic activation
7.1.6.2.2. increased volume
7.1.6.2.3. stenosis of the artery
7.1.6.3. more contraction
7.1.6.3.1. chamber enlargment
7.1.6.4. return to eccentric LVH (on long term)
7.1.6.5. arterioles are most affected
7.1.6.6. new set point
7.1.6.6.1. increase COP
7.2. 2-complications of antihypertensive drugs
7.2.1. diuretics
7.2.1.1. HYPOkalemia
7.2.2. ACEI
7.2.2.1. coughing
7.2.2.2. nasuea
7.2.3. AT1 antagonist
7.2.4. Ca channel blockers
7.2.4.1. ankle edema and constipation
7.2.5. beta blocker
7.2.5.1. bradychardia, fatique
7.2.6. alpha1 adrenoceptor antagonist
7.2.6.1. p.hypotension
7.3. 3- criteria of diagnosing depression.
7.3.1. ICD-10 CRITERIA
7.3.2. DSM-IV CRITERIA
8. Step 7: inquiry plan
8.1. present history
8.1.1. diagnosed hypertensive 13 years ago
8.1.2. snoring become noiser over the last 6months
8.1.3. 185cm, 91kg
8.1.4. play tennis most of the time
8.1.5. 25cigarittes since age 15
8.1.6. amlodipine and carvesidwas described two yrs ago
8.1.7. BP=165/105 after addition of treatment
8.1.8. 150/100 is BP 6 months ago
8.1.9. carviside
8.1.10. less intresen in
8.1.11. lethargy
8.1.12. fall asleep in a day time
8.2. past history
8.2.1. no surgical history
8.3. family history
8.3.1. both of his parents are dead
8.3.2. his sister died from stroke
8.4. personal and social history
8.4.1. atenelol 1mg
8.4.2. 3 shooners per night and more on weekend
8.4.3. now is122 kg
8.5. vital signs
8.5.1. 165/105
8.5.2. 80/m PR
8.5.3. RR 20/M
8.5.4. TM= 37
8.6. PHYSICAL EXAMINATION
8.6.1. cardiac apex beat not palpable
8.6.2. no murmurs,
8.6.3. jvp=2cm
8.6.4. 2 cm liver palpable below the costal margin
8.6.5. unattentive
8.6.6. grade retinopathy
9. Step 8: diagnosis
9.1. LVH and ischemia
9.2. OSA
9.3. HTN
9.3.1. INCREASED PREPHERAL RESISTANCE
10. objectives
10.1. managment of complicated HTN(LVH and ishcemia)
10.2. epidemiology of HTN
10.2.1. 25.5%
10.2.2. in 1999 was 22-24 %
10.3. managment of OSA
11. step9:review
12. step10:managment
12.1. HTN
12.1.1. NON PHARMACOLOGICAL
12.1.1.1. goal less than 140/90
12.1.1.2. modifying risk factors
12.1.1.2.1. obecity
12.1.1.2.2. diabetes
12.1.1.2.3. sedentary life style
12.1.1.2.4. alcohol consumption
12.1.1.2.5. regular aerobic exercise
12.1.1.2.6. low sodium intake
12.1.1.2.7. physical therapy
12.1.2. pharmacological
12.1.2.1. younger than 55
12.1.2.2. more than 55
12.1.2.2.1. step1
12.1.2.2.2. step2
12.1.2.2.3. step3
12.1.2.2.4. step4
12.1.2.3. acei +diuretics(thiazide)+b blocker+CCB are recommended for the this patient
12.1.2.3.1. start with low dose
12.1.2.4. diuretics
12.1.2.4.1. hypokalemia and hyponatremia
12.1.2.4.2. thiazide and thiazide like diuretics are good choice in HTN
12.1.2.5. acei
12.1.2.5.1. cough
12.1.2.5.2. hypotension
12.1.2.6. CCB
12.1.2.6.1. generalized edema
12.1.2.6.2. constipation
12.1.2.7. alpha blocker
12.1.2.7.1. decrease the peripheral resistance
12.1.2.8. ganglionic blocker in HTN crisis
12.1.2.9. in the presence of adverse effects, it is better to change the treatment instead of adding other drugs
12.1.2.10. ARB is effective in decreasing LVH than b blocker
12.2. OSA
12.3. renal artery stenosis
12.3.1. hypoperfusion
12.3.2. causes
12.3.2.1. atheromatous plaque
12.3.2.2. fibromuscular dysplasia
12.3.3. managment
12.3.3.1. stent
12.4. depression
12.4.1. serotonin reuptake inhibitors