56 yr old male with uncontrolled HTN

 NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. 

PATIENT HISTORY: Pt is a 56 yr old male, working as a researcher.

In 2006, one day while walking pt c/o of pain in rt. knee and difficulty in walking. His pain was so severe that he had to return home on a rickshaw. Dr. after examining prescribed painkillers and physiotherapy, following which his pain resolved within wks.

In 2011-12, while on a routine health checkup, a high (400 mg/dL) triglyceride level was detected. He did not take any medication. Next year again during a routine checkup, his triglyceride lvl was 1000+ mg/dL. Dr. prescribed Rosuvus 10 o.d, taking which his Triglyceride came within normal range.

In 2014 Dec, he met with an RTA and sustained minor injuries. Discharged after first aid. Dr. found him to be Vit D deficient and prescribed Rosuvus D 10 o.d {Rosuvastatin (statin) and Cholecalciferol (vitamin D3)}. Pt takes the drug 2-3 times per wk as per will. 2-4 months later he noticed his rt. foot thumb slightly rotated laterally (hallux vulgus). He reports no problem or difficulty in walking nor any pain or swelling.

7 - 8 yrs ago, while in a blood donation camp, his BP was reported to be 160/100 mmHg and Dr. prescribed doing exercise(morning walk) and controlling salt intake, following which his BP became normal. 6 months later, while on a follow up his BP was again high, so Dr. prescribed Cilnidipine 5 mg b.d. later dosage was increased to 10 mg b.d. With medication his BP was well under control.

In 2020 July, with symptoms of cough and cold pt went to Dr., who changed Cilnidipine to Propanolol 20mg b.d, but though he is taking it his BP is most of the time 140-145/90-95 mmHg, sometimes even more. 

For the past 4-5 months, even after a good sleep, he suddenly feels drowsy (10-15 mins) if sitting idly in the office. No other symptoms.

Pt reported no history of Diabetes

Addiction: Pt started consuming alcohol at age of 23-24 (peer pressure) and consumes 1-2 times per year 15-20 ml. Pt is a non-smoker.

CHIEF COMPLAINT AND PT. REQ: 1) uncontrolled HTN for past 3 yrs

2) Feeling drowsy for the past 4-5 months

FAMILY HISTORY: Mother - HTN

Sister - HTN

REPORTS: 

Diet: 

Morning BF: 2 pcs bread + 1 boiled egg.

                                                                            Lunch

Daily routine:

Wake up ~6:30 AM, morning walk 40-45 minutes, Office reaches by car , time 10-12 min, Office work mainly team monitoring, working as scientists in pharma R&D. Return home 7:30- 8 PM, Dinner by 8:30. Small Office work or watching TV. Bed time 10:45-11:00 PM. 

Conversational decision support:

Dr.: We need to see 10 readings of your BP taken randomly hourly over 24 hours on any free day of the week. What medications are you taking currently for your BP? 

Please continue to share your hourly activities (energy expenditure) everyday along with  your energy intake along with the sleep timings everyday. 

Please share when your symptoms of drowsiness happens amidst your hourly activities routine.

Dr.:Perhaps we could have avoided these additional X-rays and uric acid? 

Clinically the foot image and the sequence of events you shared was good enough to rule out gout. 

Also more importantly as per your assessment his 

1) uncontrolled HTN for past 3 yrs

2) Feeling drowsy for the past 4-5 months

And the above two just needed a better BP monitoring and hourly regular follow up?

Student: Yes Sir, a better record of his BP will help us. 

And as per his own records, he feels a bit drowsy only when he is sitting idle in his office. So, I think this is just maybe from boredom, and can be dealt with proper food and exercise.