what blood pressure meds are you on? and why? you're in great shape last I saw........I would think someone with your athletic background could manage high BP without the use of those fucking meds. Are you on a beta or ACE inhibitor? If so do yourself a favor and ween off of em...........look up dietary and lifestyle changes to manage high BP. I don't know what your BP is, but know that the medical industry here ROUTINELY characterizes what would be considered normal BP in Europe as high here.........they do this so they can prescribe their high profit margin meds.
How come you didnt ask her how quickly these symptoms appeared, how bad they are (use a 1-10 scale), if anything seems to aggravate/alleviate them, how long she's been on the bp meds (as well as all other meds), if she has ever noticed any symptoms directly related to missing a dose, what doses she's taking, obtain a complete family history, a social history to find out if she's using any other chemicals/drugs that can induce hypertension etc????????
If you want to play doctor, let's try and do it right.
Now do a "review of systems" go through system by system to get more info. Here lemme help. Use this as a template til you can do it from memory.
General/Constitutional
- Average weight, weight loss or gain, general state of health, sense of well-being, strength, ability to conduct usual activities, exercise tolerance
- Skin/Breast
- Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth or loss, nail changes
- Breast lumps, tenderness, swelling, nipple discharge
- Eyes/Ears/Nose/Mouth/Throat
- Headaches (location, time of onset, duration, precipitating factors), vertigo, lightheadedness, injury
- Vision, double vision, tearing, blind spots, pain
- Nose bleeding, colds, obstruction, discharge
- Dental difficulties, gingival bleeding, dentures
- Neck stiffness, pain, tenderness, masses in thyroid or other areas
Cardiovascular
- Precordial pain, substernal distress, palpitations, syncope, dyspnea on exertion, orthopnea, nocturnal paroxysmal dyspnea, edema, cyanosis, hypertension, heart murmurs, varicosities, phlebitis, claudication
Respiratory
- Pain (location, quality, relation to respiration), shortness of breath, wheezing, stridor, cough (time of day, of productive, amount in tablespoons or cups per day and color of sputum), hemoptysis, respiratory infections, tuberculosis (or exposure to tuberculosis), fever or night sweats
Gastrointestinal
- Appetite, dysphagia, indigestion, food idiosyncrasy, abdominal pain, heartburn, eructation, nausea, vomiting, hematemesis, jaundice, constipation, or diarrhea, abnormal stools (clay-colored, tarry, bloody, greasy, foul smelling), flatulence, hemorrhoids, recent changes in bowel habits
Genitourinary
- Urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color of urine, stones, infections, nephritis, hesitancy, change in size of stream, dribbling, acute retention or incontinence, libido, potency, genital stores, discharge, venereal disease
- (Female) Age of onset of menses, regularity, last period, dysmenorrhea, menorrhagia, or metrorrhagia, vaginal discharge, post-menopausal bleeding, dyspareunia, number and results of pregnancies (gravida, para)
Musculoskeletal
- Pain, swelling, redness or heat of muscles or joints,
l;imitation, of motion, muscular weakness, atrophy, cramps
Neurologic/Psychiatric
- Convulsions, paralyses, tremor, incoordination, parathesias, difficulties with memory of speech, sensory or motor disturbances, or muscular coordination (ataxia, tremor)
- Predominant mood "nervousness" (define), emotional problems, anxiety, depression, previous psychiatric care, unusual perceptions, hallucinations
Allergic/Immunologic/Lymphatic/Endocrine
- Reactions to drugs, food, insects, skin rashs, trouble breathing
- Anemia, bleeding tendency, previous transfusions and reactions, Rh incompatibility
- Local or general lymph node enlargement or tenderness. -Polydipsia, polyuria, asthenia, hormone therapy, growth, secondary sexual development, intolerance to heat or cold
Next I want you to do a thorough physical exam. Again I will provide a template until you can do it from memory. (Note: since this is the first time assessing this patient, I am requiring you to compete each task without regards to what you THINK is relevant.)
• Observe general appearance
• Examine hands & nails; examine skin throughout exam
• Vital signs
• measure blood pressure in right arm (in left arm and/or sitting/standing/lying if indicated)
• compare radial pulses (15 sec.)
• count respiratory rate (30 sec.)
• Head / Face
• observe and palpate head, face, hair, scalp, skull
• have pt. bite down while palpating masseter muscles (CN V)
• have pt. raise eyebrow, sqeeze eyes shut and show teeth (CN VII)
• Eyes
• test visual acuity (vision card)
• examine sclera and conjunctiva
• check extraocular movements (CN III, IV, VI)
• check corneal light reflection
• check pupillary light reflex (direct and consensual)
• instill mydriatic fluid (if indicated)
• perform fundoscopic exam – describe:
• red reflex
• cup
• disc
• vessels
• background (macula)
• Ears / Nose / Mouth
• pull helix, push tragus
• use otoscope to examine external canal and tympanic membrane, describing appearance and landmarks
• test hearing (CN VIII)
• inspect nose, septum and turbinates
• inspect mouth, buccal mucosa, teeth, gums, tongue, tonsillar fossa and pharynx
• have pt. phonate and inspect palate and uvula (CN X)
• have pt. protrude tongue (CN XII)
• Neck / Thyroid
• check range of motion of neck
• have pt. shrug shoulders, and turn against resistance (CN XI)
• palpate lymph nodes in anterior and posterior cervical triangles, submandibular and supraclavicular areas (can be done in front of or behind pt.)
• Neck / Thyroid (cont’d)
• examine lymph nodes (if not done previoiusly)
• examine thyroid gland
• check height (over heart) of jugular vein distension when tilted
• Chest
• inspect chest, observing breathing pattern and symmetry
• percuss spine and costovertebral angles with fist
• percuss posterior & lateral lung filds using bimanual percussion
• auscultate posterior & lateral lung fields, comparing both sides
• Chest (cont’d)
• auscultate anterior lung fields
• Breasts / Axillae
• observe breasts for symmetry, skin abnormalities, retraction
• observe breasts with hands on hips, and over head
• Breasts / Axillae
• using double drape technique, inspect and palpate 4 quadrants (including axillary tail)
• examine and palpate nipple
• palpate axillae
• Heart / Vessels
• inspect anterior chest wall
• palpate for PMI and for RV lifts and palpable thrills
• auscultate the precordium, listening for normal and abnormal heart sounds and murmurs
• palpate carotid artery
• auscultate the carotids for bruits
• Abdomen / Inguinal areas
• using double drape technique, inspect the abdomen
• auscultate the abdomen in 4 quadrants for bowel sounds and abdominal bruits
• palpate all 4 quadrants, superficially and deeply
• percuss liver
• palpate for liver and spleen
• palpate inguinal areas for lymph nodes
• palpate femoral pulses and auscultate for bruits
• Extremities (Neuromuscular)
• inspect upper extremities
• test upper extremity motor strength & joint mobility: grip, finger abduction, wrist flexion/extension, elbow flexion/extension, shoulder abduction/adduction, arms over head
• test for upper extremity drift/pronation
• inspect lower extremities
• test lower extremity motor strength and joint mobility: ankle flexion/extension, knee flexion/extension, hip flexion/ extension
• palpate for edema
• palpate dorsalis pedis and posterior tibialis pulses
• Neurological exam
• if mydriatic solution was used, perform fundoscopic exam
• test reflexes: biceps, triceps, brachioradialis, knee, ankle
• test plantar response
• test gait, observing balance and arm swing
Brief Pelvic Exam
- Inspect outer vagina for hair pattern, discharge, odor, lesions, etc
- Bimanual Exam
Rectal exam
• examine anal orifice
• perform digital exam, noting muscle tone and examining rectal vault for masses
• perform stool examination
Okay, that was the easy part. Now I want you to use the vast wealth of knowledge you seem to have and create an Assessment and Plan.
I'll need a differential diagnosis atleast 5 items deep. Please list them from most likely/most severe at the top. Also include all pertinent data supporting these diagnoses. Also include what medications/therapies/etc you would like to utilize in her treatment. Write orders for said meds/therapies/etc, sign, and activate.
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Too many ---? and I stop being a valuable resource and honestly, after 6+ years of working from home I don't think I know how to work with other humans again.
