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PROBLEM STATEMENT: The patient, a 57-year-old Hispanic male presented to the office with the chief complaint of “high blood pressure.” Reports having headaches in the morning, which make him tired throughout the day, and sleep apnea. These symptoms are complemented by heavy snoring and the lack of pain except for the headaches (behind the eyes), which are becoming more frequent (2-3 times per week) and last for a couple of hours. The fatigue started about six months ago, and the symptoms are treated by Ibuprofen 800 mg TID, 2-3x/week. The patient reports little exercise (walking the dog), smoking, and unhealthy eating patterns, and he is positive for a family history of diabetes mellitus and heart attacks.
Assessment: Headaches alongside high blood pressure can be symptoms of various conditions related to the impaired functioning of organs. First, they increase the risk of heart disease, attacks, and strokes, thereby adding to the patient’s family history of these issues (Watson, 2020). Second, these problems contribute to the probability of emerging issues with his eyes or, more specifically, hypertensive retinopathy, even though they have not been reported yet (Seltman, 2020). Moreover, this condition is frequently neglected by patients due to the lack of evident signs at the initial stages (Seltman, 2020). Therefore, the risks correspond to the situation under consideration and should be timely eliminated by further examination.
Primary Diagnosis and ICD-10 code: Other secondary hypertension, unspecified, I15. 8.
Differential Diagnoses
Pseudo-Resistant Hypertension – is a common cause of hypertension alongside headaches. It is important to distinguish between the factors triggering the emergence of this condition, which is seemingly unaffected by medication, supplements, or diet (“Pseudo-resistant hypertension,” n.d.). It should be controlled by managing the smoking and unhealthy eating habits of the patient.
Hypertensive Retinopathy – This diagnosis was not confirmed during a routine eye exam, but it is vital to consider the risks of the development of this condition in the future (Seltman, 2020). The lasting fatigue might result in this complication and cause vision problems, considering the fact that the experienced pain is similar to the one of this issue.
Obstructive Sleep Apnea – This problem was confirmed during the examination, and it includes most symptoms experienced by the patient. They are daytime sleepiness and fatigue, loud snoring, and morning headaches adversely affecting the overall well-being of the person.
Additional laboratory and diagnostic tests
Fasting blood glucose, total cholesterol, and HDL cholesterol.
Fluorescein angiography.
Polysomnography, AHI.
Consults: Referral to an ophthalmologist for further evaluation and regular examinations to trace the development of the condition (hypertensive retinopathy). Referral to a cardiologist for evaluating the risks of cardiovascular diseases resulting from the current issues and family history (Huang et al., 2017).
Therapeutic modalities
Pharmacological: Modafinil (200-400 mg/d.), Benazepril (Lotensin) (10 mg/day) (Huang et al., 2017).
Nonpharmacological: Healthy diet (avoid consuming too much salt), recommendations to stop smoking, regular visits to the hospital in order to monitor the condition and its development, and exercise (“Pseudo-resistant hypertension,” n.d.).
Health Promotion: The patient will start to engage in light exercise several times a week. He will also cut back on his salt intake and smoking, and eat healthier food instead of fast food and snacks. These measures will help reduce cardiovascular risks, lose weight, and maintain a good condition through healthy habits and limited consumption of some substances. They should be complemented by regular health screening, especially visits ophthalmologists to exclude the probability of vision impairment.
Patient education: The patient will be taught about the possible consequences of the neglect of hypertension as well as the revealed conditions (obstructive sleep apnea, pseudo-resistant hypertension) and their management. The education will also include the side effects of medication and recommended changes in his lifestyle.
Disposition/follow-up instructions: Meet up with a cardiologist in 48 hours. Meet up with an ophthalmologist in 72 hours.
References
Huang, Y., Huang, W., Mai, W., Cai, X., An, D., Liu, Z., Huang, H., Zeng, J., Hu, Y., & Xu, D. (2017). White-coat hypertension is a risk factor for cardiovascular diseases and total mortality. Journal of Hypertension, 35(4), 677-688. Web.
Pseudo-resistant hypertension. (n.d.). Johns Hopkins Medicine. Web.
Seltman, W. (2020). High blood pressure and eye disease. WebMD. Web.
Watson, K. (2020). Does high blood pressure cause headaches? Healthline. Web.
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