Warveen Othman

Spring 2022                                                                           

Identifying Data:

Age: 50 y/o

Sex: F

Date & Time of encounter: January 27, 2022            10:00AM

Location: Jamaica, Queens NY

Race: African American

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Chief Complaint: Elevated blood pressure, 12 days ago

History of Present Illness:

Pt is a 50 y/o female with PMH of varicose veins, presenting to the office after her BP was elevated to 184/108 at her gynecology visit on 01/15/22. She was advised that day to be go to the emergency department for further treatment and evaluation. However, pt did not go as she was asymptomatic and wanted to avoid COVID exposure. She does not check her blood pressure at home as she states she has never been told her BP was high or needed to be monitored before. Pt notes increased stress in her life since September 2021 due to inconsistencies in her teaching job and juggling this with taking care of her 6 kids. She also mentions that her diet has not been the healthiest and that she is currently at the heaviest weight of her life. The pt denies headaches, chest pain, back pain, SOB, leg edema, palpitations, visual disturbances. Denies steroid or other medication use.

Past Medical History:

Varicose veins

Osteoarthritis – left knee

Immunizations – up to date

Colonoscopy still not done.

Mammogram and pap smear up to date, followed by pt’s gynecologist.

Denies recent hospitalizations.

Past Surgical History:
Varicose vein surgical stripping and sclerotherapy – 08/2021

Arthroscopy – left knee, 03/09/2019

Denies past blood transfusions. Denies history of stroke or DVT.

Medications: 

None.

Allergies:

Erythromycin. Reaction: diffuse rash. (date noted : 09/14/2020)

Family History:

Father: deceased, lung CA

Mother: alive and well, medical history unknown

Siblings: alive. Sister diagnosed with hypertension within the last few months.

Social History:

AB lives with her husband and kids. She works as an elementary school teacher and works online and in-person.

Habits – Drinks 1 cup of caffeine daily. Denies smoking history. Alcohol use ~1x a month, for special occasions. Denies illicit substance use.

Sleep – no complaints

Travel – No recent travel.

Review of Systems:

General – (+)weight gain. Denies recent fever, chills, fatigue, night sweats, or change in appetite.

Skin/nails – Denies rash, new moles, erythema, change in pigmentation, changes in hair distribution, or wounds.

Head – Denies headache, dizziness, lightheadedness, recent head trauma.

Eyes –Denies visual disturbances, photophobia, itchiness, redness, tearing, or discharge.

Ears –Denies change in hearing, tinnitus, otalgia, discharge. No hearing aid use.

Nose – Denies congestion, discharge, epistaxis.

Mouth/throat – Denies sore throat, difficulty swallowing, bleeding gums, dryness, ulcers, tongue pain, swelling.

Neck – Denies pain, stiffness, limited ROM, lumps, injury/trauma.

Pulmonary – Denies SOB, DOE, cough, wheezing, orthopnea, PND, hemoptysis. Sleeps with 1 pillow for comfort.

Cardiovascular – Denies chest pain, palpitations, lower extremity swelling, syncope.

GI – Denies abdominal pain, nausea, vomiting, diarrhea, constipation, rectal bleeding. No recent changes in BM.

Genitourinary – Denies dark urine, incontinence, urgency, dysuria, hematuria, frequency.

Nervous –Denies tingling, seizures, confusion, weakness, numbness, gait change.

Musculoskeletal – Denies body aches, back pain, joint pain.

Hematologic – Denies history of DVT/PE, blood transfusions, bruising.

Endocrine – Denies polydipsia, polyphagia. Denies heat or cold intolerance.

Psychiatric – Denies depression, suicidal thoughts, or hallucinations.

Physical Exam:

Vital signs:      BP: Seated                  L-arm: 190/110           R-arm: 193/113.. repeat 180/98

RR:      16 breaths/min, unlabored                 

Pulse: 89 bpm, regular                      

T:        97.2 degrees F (oral)

O2 Sat: 99% on room air

Height: 63 inches        Weight: 192 lbs.       BMI: 33.69

General: Pt alert, oriented. No acute distress. Obese. Looks stated age.

Skin: Skin is warm & moist. No ecchymosis. Nonicteric, no other lesions noted. No rashes appreciated.

Hair:  No evidence of female pattern baldness.

Nails:  no clubbing, capillary refill <2 seconds in upper extremities.

Head:   normocephalic, atraumatic, nontender to palpation throughout

Ear: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears. No mastoid tenderness b/l. (+)Mild amount of cerumen in auditory canals bilaterally. No discharge or other foreign bodies in external auditory canals.  Right and left TM pearly white and fully intact with cone of light in good position.

Nose: Symmetrical. No masses, lesions, deformities, trauma, discharge. Nares are patent bilaterally.

Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy.

Septum midline without lesions, deformities, injection, perforation.  No foreign bodies.

Sinuses: Nontender to palpation and percussion over the frontal, ethmoid and maxillary sinuses.

Mouth/Oropharynx: Lips appear pink and moist, with no masses, cyanosis, or ulcers. Mucosa pink and moist. No lesions or masses. No leukoplakia. Palate pink, moist, intact with no lesions, masses, or scars.

No gingival hyperplasia or recession.

Tongue is midline. No discharge, masses, or lesions.

Uvula is midline and rises symmetrically with phonation. No edema or lesions.

Oropharynx is pink and moist. Tonsils are symmetric and without hypertrophy. No swelling, erythema, exudates, masses/lesions, foreign bodies. Tonsils are grade I. Mallampati Class II.

Neck – Full ROM. Supple. Non-tender to palpation. No JVD. Trachea is midline. No masses or lesions. No scars. Lymph nodes non-palpable bilaterally. No stridor. 2+ carotid pulses bilaterally. No cervical adenopathy noted. Thyroid is non-tender with no palpable masses. No thyromegaly.

Eyes – Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white, conjunctiva pink bilaterally. PERRL.
Visual fields full OU. EOMs intact with no significant nystagmus.
Fundoscopy – Red reflex intact OU. Could not assess cup to disk ratio.

Chest/Pulmonary: Chest is symmetrical, without deformities or trauma. Lat to PA diameter is 2:1. Respirations unlabored. No use of accessory muscles noted. Lungs CTA bilaterally. No wheezes, rhonchi, rales, or other adventitious sounds. Chest expansion symmetric.

Heart: Regular rate and rhythm. Distinct S1 and S2. No murmurs, S3, S4, friction rubs, or splitting of S2 appreciated. PMI in 5^th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits.

Abdomen: Abdomen nontender to palpation, no guarding or rebound. Tympanic throughout. No hepatosplenomegaly. Abdomen flat, soft, symmetric. No scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants. No CVA tenderness noted.

Mental Status Exam: Appearance and behavior – patient alert, no abnormal movements, grooming/hygiene appropriate, appropriate facial expression and manner.

Speech and language – follows 2 stage commands. Speech is of appropriate quantity, rate, volume, flow, and articulation.

No SI/HI.

Conversation progresses logically towards a goal.

Oriented to name, date, time, location.

Neurologic:

Cranial Nerves –See “Eyes” for CN II assessment. Conjugate gaze without nystagmus. No ptosis. Facial sensation present and equal bilaterally to light touch. Symmetric and fluid facial movements. No difficulty with BMP speech sounds. Strong eye muscles that hold eye closed against resistance. See “Ear” for CN VIII.

Soft palate rises on phonation (“ahh”) and uvula remains midline. No hoarseness or nasal quality in voice. No facial droop.

Strong neck and shoulder muscles against resistance bilaterally. Strong and symmetric tongue. No difficulty with LTND speech sounds.

Peripheral Neuro –

Motor/Cerebellar

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout, including grip strength. Gait steady with no ataxia.

Sensory

Intact to light touch throughout. Sensation symmetric.

Reflexes: Patellar 2+ bilaterally

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. FROM of all upper and lower extremities bilaterally.

Differential Diagnoses:

• Hypertensive urgency
• Essential hypertension
• White coat hypertension
• HTN secondary to hyperaldosteronism
• Increased life stressors/anxiety causing elevated BP
• Obstructive sleep apnea
• Renovascular disease
• Hypothyroidism

Assessment:  50 y/o female presenting with elevated BP 180s/100s noted on 2 medical visits. Pt c/o increased stressors in life. No other complaints. Of note, she is due for her annual labs today.

BP at last office visit in 01/2021 was 143/87. Pt was educated at that visit on low-salt diet and behavior modification, which was not followed. 5 lbs weight gain since that time. Last CMP in 01/2021 was WNL. HgA1c 6.0 at that time.

Plan:

Hypertension:

• Patient given clonidine 0.1mg in office. Repeat BP 45 minutes later 170/91. Pt instructed to be seen in the ED if she experiences headaches, chest pain, back pain, visual disturbances, or any other concerning symptoms.
• Start amlodipine 5mg PO daily.
• Patient advised to buy a BP machine and measure her BP in the morning, every other day, at the same time, and to keep a log of values. Instructed to bring log and BP machine to the next visit.
• Return in 2 weeks to review BP log and labs.
• EKG done in office today, 85 BPM, NSR, no acute ST segment or T wave changes. No LVH. No significant change from last visit.
• Blood work: CMP, TSH

Prediabetes:

• Diet and lifestyle modification discussed. HgA1c included in labs today.

Annual check:

• Blood work: Lipid panel, HIV, CBC, UA, RPR, Hep C.
• Pt given GI referral to schedule colonoscopy for colon CA screening.  

——————————————————————————————————–

JOURNAL ARTICLE RELATED TO CASE: “The effect of pursed-lip breathing combined with number counting on blood pressure and heart rate in hypertensive urgency patients: A randomized controlled trial”

This study compared the effects of pursed-lip breathing (PLB) combined with number counting (NC) to antihypertensive medications (conventional medications) on blood pressure in hypertensive urgency patients. Fifty-five patients were assigned to PLB+NC, while the other 55 were assigned to conventional medical therapy (antihypertensive). In the PLB+NC group, the average decrease in systolic BP was ~28 mmHg and in diastolic BP it was ~17 mmHg. While the control group (treated with medicine only) also had a significant decrease in SBP and DBP, the PLB+NC group’s decrease was significantly better. This suggests that mindfulness strategies like pursed lip breathing with number counting may be an effective adjunct to conventional therapy in lowering BP in hypertensive urgency patients.

Mitsungnern T, Srimookda N, Imoun S, Wansupong S, Kotruchin P. The effect of pursed-lip breathing combined with number counting on blood pressure and heart rate in hypertensive urgency patients: A randomized controlled trial. J Clin Hypertens (Greenwich). 2021 Mar;23(3):672-679. doi: 10.1111/jch.14168. Epub 2021 Jan 7. PMID: 33410589; PMCID: PMC8029503.

PDF: