Inability To Sleep And High BP

Question 1

Clerking: A 62 year old male presents with inability to sleep and high blood pressure reading this morning. Take a focused history.

Answer 1

Grip
Bio data Biodata - NASOMART
Please may I know your name and age? What is your occupation? What is your marital status?
Where do you live? What religion do you practice? +/- Denomination (If Christian). What is your tribe.

Question 2

C1-Chief complain.

Answer 2

It says here that you have been experiencing difficulty sleeping and your blood pressure was high this morning.

Question 3

C2 - Course
Insomnia - DOCTOR

Answer 3

Duration: When did it start?
Onset: Did it start suddenly or gradually?
Course: Has it been improving or getting worse?
Character: Is it inability to fall asleep, or you wake up very often/easily
Triggers: Any known triggers e.g. taking coffee in the evening, exercise or stress during the day?
Do you sleep/nap during the day time?
Other symptoms: Any headache, fatigue or weakness.
Related phenomena: Any weight loss, loss of appetite or fever.

Question 5

High blood pressure DOCTOR

Answer 5

Duration: When did you measure the blood pressure and how many times?
Onset:
Course/Character: What were the values you got?
Timing/Triggers: Did you smoke before taking the blood pressure, exercise or take coffee?
Other: Any chest pain?
Related: Any nose bleeding or blurry vision?

Question 6

C3
- Causes

Answer 6

Any personal or family history of high blood pressure?
Do you smoke or consume alcohol?
How often do you exercise? What activities do you engage in?
Do you consume a lot of salt?/How much salt do you consume a day?
Do you eat snacks/fast food on a regular basis?
Do you know your weight or body mass index?
Are you under stress from work or home?
Are your rings and shoes getting tighter progressively? - Acromegaly
Any sudden attack of sweating, excessive heartbeat and chest pain? - Pheochromocytoma
Any history of contraceptive use (If female)
Any neck swelling with heat intolerance? - Hyperthyroidism
Are you a known diabetic?

Question 7

C4 - Complications

Answer 7

Any history of stroke or weakness on one side of the body?
Any seizure, loss of consciousness or slurred speech? - Hypertensive encephalopathy.
Any blurry vision or loss of vision?
Any shortness of breath, leg swelling and exercise intolerance? - Heart failure
Any facial swelling with foam in the urine? - Hypertensive nephropathy
Any history of erectile dysfunction?
Any chest pain radiating to the shoulder?

Question 8

C5 - Care so far

Answer 8

For these symptoms, have you visited any hospital, pharmacy or prayer house?
Have you done any investigations, taken any medication or herbal concoction?

Question 9

PAST MEDICAL HISTORY

Answer 9

Have you had similar symptoms before? Are you a known epileptic, asthmatic or sickle cell disease patient? Have you been admitted before? Have you had any surgeries or blood transfusion?

Question 10

FAMILY AND SOCIAL HISTORY

Answer 10

Any family history of diabetes, epilepsy asthma or chronic diseases?
Does anyone around you smoke?
Do you smoke/drink? If yes, how many packs/bottles daily?

Question 11

DRUG HISTORY

Answer 11

Are you on any current or long-term medication?
Do you have any known drug allergies?

Question 12

SYSTEMS REVIEW

Answer 12

CNS: Any headache or blurry vision?
Chest: Any cough or shortness of breath?
CVS: Any chest pain or leg swelling
Endocrine: Any cold intolerance or weight gain?
Digestive: Any diarrhea or vomiting?
GUS: Any pain or difficulty urinating?
MSK: Any bone or joint pain?
Thank you sir, thank you ma.