Continuing a series on how to make the oral boards more reflective of actual practice. 

Examiner: Hello, Dr. 10/10, your next case is a 47 year old white female with elevated blood pressure.

Me: I walk into the room and what do I see?

Examiner: You see a well developed, somewhat obese female looking slightly anxious but in no apparent distress.  She is staring intently at the monitor.

Me: May I have a set of vital signs please?

Examiner: Blood pressure 170/105.  Heart rate 85.  Respirations 16.  Temperature 98.9.

Me: And the 5th vital sign?

Examiner: You mean her pain scale?

Me: No, wait isn’t it pulse ox?

Examiner: No I think that’s 6th.  Unless D-stick is 6th…

(Unconfortable silence)

Me: Ok I think I’ll move on.

Examiner: Great.

Me: Hello, ma’am, what brings you to the emergency department?

Examiner: Young man, my blood pressure is too high.

Me: What makes you say that?

Examiner: Well.  I was feeling somewhat lightheaded earlier this evening.  I took my blood pressure at home and found it to be 158/98.  I rechecked it six minutes later and it was up to 165/100.  Two minutes later it had come down to 159/97, but eight minutes after that it was back up to 168/102.

Me: Uh huh.

Examiner: Now, I normally wouldn’t do this, but (glancing sideways and leaning forward) I took an extra half of one of my blood pressure pills.  

Me: Oh my.

Examiner: Do tell.  So then I placed a cool washcloth on my forehead and rested for an hour.  My blood pressure was better then, but as soon as I got up it went back up to 167/94.  Well, seven minutes after that it was 174/101, and three minutes later it was 177/106.  So I packed my suitcase and came right over.

Me: You packed a suitcase?

Examiner: Yes, yes I spoke with my doctor who said I’ll need to be admitted to the hospital.

Me: Your doctor told you this?

Examiner: Well, I spoke at length with the on-call nurse, who spoke with my doctor, and it was made clear to me that I should go to the ER immediately.

Me: What does your blood pressure normally run?

Examiner: About 140/90.  Is my heart rate really 16?

Me: No, that’s the number of times you’re breathing per minute.  Please don’t concern yourself with the monitor.

Examiner: Yes of course (continuing to stare). 

Me: Do you have a headache?

Examiner: In fact I do.

Me: Double vision?

Examiner: No, but it seems a bit blurry around the edges.

Me: Chest pain?

Examiner: Yes a little tightness here in the middle.

Me: Shortness of breath?

Examiner: Now that you mention it, yes indeed.

Me: Dizziness?  Nausea?  Weak all over?

Examiner: Yes Yes Yes.

Me: Having you been taking your medicines?

Examiner: Of course.

Me: Every day?  You never miss a dose?

Examiner: Well maybe every so often but not recently I don’t believe.

Me: Increased stress?

Examiner: No more than usual, although I must say I have quite a bit on my plate.  For instance the renovations–

Me: What medicines do you take?

Examiner: Diovan 40mg, Tenormin 50mg, Requip, and Xanax as needed.

Me: I’d like to proceed with the physical exam please.

Examiner: The head is atraumatic and normocephalic.  Pupils are equally round and reactive to light.  Extraocular movements are intact.  Fundoscopic exam unremarkable with sharp disc margins.  TM’s clear.  Oropharynx clear without erythema or exudate.  Neck supple without lymphadenopathy.  No thyromegaly.  No bruits.  Chest clear to asculatation bilaterally.  Heart regular rate and rhythm without murmurs gallops or rubs.  Abdomen soft, nondistended, and nontender with positive bowel sounds.  Extremities without clubbing, cyanosis, or edema.  2+ radial and dorsalis pedis pulses. Skin warm and dry.  Neuro alert and oriented x 3.  Cranial nerves II-XII intact.  Strength 5/5 x 4 extremities.  Gross distal sensation intact.  2+ patellar, achilles, and biceps reflexes.  Normal finger-to-nose.  Normal gait.  Negative Romberg.

Me: I’d like to order an EKG at this time.

Examiner: The EKG shows sinus rhythm.  No ST segment changes.  No T-wave inversions.  No evidence of left ventricular hypertrophy.  No ectopy.

Me: Repeat blood pressure please.

Examiner: Repeat blood pressure is 160/90.

Me: Ma’am, fortunately we are going to be able to let you go home.  You physical exam is completely normal, as is your EKG. 

Examiner: But what about my blood pressure?

Me: Well it was indeed elevated this evening, and while this absolutely can lead to serious problems if left untreated for months or years, you can rest assured that short term you will be fine.  In fact, we don’t want to dramatically lower your blood pressure tonight, rather we’d like to see it come down gradually over the next several days.

Examiner: I’m not having a stroke?

Me: No ma’am, there is nothing on your exam to suggest that.  You should go home, begin taking two pills of diovan instead of just one, and follow up with your doctor in the next day or so.

Examiner: How often should I check my blood pressure?

Me: You should not check it until you see your doctor.

Examiner: Then how will I know what it is?

Me: Exactly.

Examiner: This concludes your case.