The Medical Certificate – Beyond Consultation

A 31 year old woman, YM, came in a month ago with a complaint of nausea and headache which she ascribed to a long holiday in Kuala Lumpur. She returned the night before and slept in the following morning. Actually she had to work but could not make it so the main reason her coming to see me was to get a medical certificate.As usual I engaged my patient so that they would relate their medical history. I do this often in the hope of looking for areas where I can advise on preventive medicine.

I asked her whether she was married; yes she was for two and a half years. Then I proceeded asking her about her menses like the last date of her normal period, the cycle any pain etc. Her last menses was in Nov 2010 and it had yet to come though all her pregnancy tests had proven negative. I didn’t take any chances I still ordered for UPT (urine for pregnancy test) and Urine microscopy. Both were negative.

Then I asked her whether she wanted to have children, yes, she replied. I asked her why she did not get herself investigated for irregular and prolonged amenorrhea (absent menses). No, she said because she did not know how to go around it.I persisted by asking her what her normal complaints were whenever she went to see a doctor, she replied normally headache and tiredness. No, no blurring of vision.

Without asking all those probing questions, I would’ve just given her a medical certificate and perhaps an anti emetic and a pain-killer and then send her off. But I felt uneasy. She was only 31, an active young professional with  a menstrual problem, failure to conceive and recurrent headaches. Something was not right.

I proceeded to take her blood pressure and could not believe my hearing and my eyes that the first recording was 190/120 (normal for her age is 120/80). I asked her to lie down for about 30 minutes.  After resting, the next reading both lying and sitting and standing was 190/118, essentially the same. I prescribed immediately a short-acting anti-hypertensive and measured her blood pressure an hour later and it went down to 150/100. 

Before I could ask her about her family history, she volunteered by saying that her mother suffered from high blood pressure and that her brother died of a stroke at the age of 30! That’s it the red flag was up! There could be  a genetic predisposition in this woman and that she needed to be investigated fast and fully and given blood pressure-lowering medication before the high pressure gradually destroys target organs such as the brain, the heart and the kidneys.

For young hypertension the work-up is slightly different because you need to look for preventable causes such as Conn’s syndrome or renal artery stenosis (narrowing). Both are operable and the hypertension can be cured.Without wanting to waste anymore time on diagnosing her condition, I ordered all the tests and promptly referred her to a Cardiologist for more evaluation and extensive investigations. High blood pressure in a young person, if not detected and treated early will lead to a premature death, just like YM’s brother, dead at 30. And as illustrated, probing history taking is extremely important in preventing such a death.

That was the longest “Medical Certificate” consultation I ever had. But I feel satisfied.