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Class 6512: I Human Case Week #7 56 Year
Old Female Reason For Encounter: Blood
Pressure Recheck
Physical Exam
- Vitals:
o Temp: 98.6 F
o Pulse: 64 regular
o BP: 118/
o Respiration: 12
o PE
:Questions
?or night sweats
- ?How can I help you today.
- ?Do you have any other symptoms or concerns we should discuss.
- ?When did your pain/discomfort with urination start.
- ?Do you have fever?/Have you been having fevers.
- ?What is the appearance, smell, texture, and quantity of the vaginal discharge.
- ?Does anything make your pain/discomfort with urination better or worse.
- ?How severe is your pain/discomfort with urination.
- ?Do you have vaginal discomfort or itching.
- ?Have you had vaginal discharge/discomfort like this before.
- ?Are you sexually active.
- ?Do you have more than one sexual partner.
- ?Have you had any sexually transmitted infections.
- ?Do you have allergies.
- ?Are your immunizations up to date.
- ?When did your last period begin.
- ?Are you having or have you had unprotected sex.
- ?Is your pain/discomfort worse with start or end of urination.
- ?Do you have pain with sex.
- ?Has there been a change in your urination frequency.
- ?Do you use precautions to prevent the transmission of sexual infections.
- ?Do you have bleeding between your menstrual cycles.
- ?Are you taking any OTC or herbal medications.
- ?Any new or recent changes to your medications.
- ?Do you have new or multiple sexual partners with similar symptoms.
- frequent. Do you have problems with heat or cold intolerance, increased thirst, increased sweating,
- ?(Is your urine pink or red in color (blood in urine. ?urination, or change in appetite
- gain, fevers. ,Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or
- nails. ?Do you have any problems with an itchy scalp, skin changes, moles, thinning hair, or brittle
?Do you have any problems with an itchy scalp, skin changes, moles, thinning hair, or brittle
nails.
Do you experience chest pain discomfort or pressure; pain/pressure/dizziness with exertion or
?getting angry; palpitations; decreased exercise tolerance; blue/cold fingers and toes
Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic
cough, or.
?sputum production
,Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds in your
vomit.
?dark tarry stools, bright red blood in your bowel movements, early satiety or bloating
,Do you have problems with muscle or joint pain, redness, swelling, muscle cramps, joint
stiffness.
?joint swelling, or redness, back pain, neck or shoulder pain, or hip pain
?Do you have genital sores or discharge.
?Do you feel when you need to urinate that you need to urgently.
Have you had problems with pain/discomfort with urination like this before.
dness, back pain, neck or shoulder pain, or hip pain
?Do you have genital sores or discharge.
?Do you feel when you need to urinate that you need to urgently.
Have you had problems with pain/discomfort with urination like this before.
EHR Documentation - Reason for encounter – High Blood Pressure HPI: PMH: Gastritis Hospitalizations/Surgeries: Right knee ACL repair Medications: Omeprazole, Ibuprofen 200 - 400 mg Allergies: NKA Preventative Health: Childhood immunizations “none since”, no annual 昀氀 u shot Family History: Father (Death at 62) stroke Mother 78: DM Grandmother: DM, Death at 82 Grandfather heart attack death at 52 Brother HTN Uncle HTN Son living in good health (19 yo). Social History: Works construction doing 昀氀 ooring installation and cabinet work. Drinks alcohol on weekends. Smoke 1 pack per day since age 20s. Denies recreational drug use. Diet consists of cup of co 昀昀 ee in the morning, fast food, texmex style food, chips.
Physical Examination Documentation General: Integumentary/Breast: Nails without clubbing, ridging, peeling, or pitting. HEENT/Neck: Head: normocephalic, atraumatic, no deformities, facial features symmetric with equal eye closure and smile, temporal arteries are non-tender to palpation. Maxillary and frontal sinuses non-tender on bilaterally. Hair thickness and pattern distribution typical for age and gender. Eyes: PERRLA, conjunctiva pink and no discharge. No sclera icterus. No edema, redness, tenderness, or lesions noted. Visual acuity 20/20 right eye, and 20/20 left eye. Prominent arteriovenous nicking bilateral fundi, some narrowing of vessels. Sharp disc margins without 昀氀 ame or dot hemorrhages, or soft or hard exudates. Ears: External ears without deformities, edema, lesions, or erythema. No discharge noted. Canals without erythema or cerumen. Bilateral tympanic membranes non-bulging, translucent, pinkish-gray. No scarring, discharge, or purulence noted. No hearing de 昀椀 cits.
Lymphatic: Cervical nodes mobile, non-tender, pea-sized, and soft bilaterally. Thyroid without mobile masses, tenderness, nodules, or enlargement.
Problem Statement: H.H. is a 57-year-old Hispanic male working in construction installing 昀氀 oors who presents after a visit to a community health fair for a referral for high blood pressure. Denies headache, chest pain, or
- The client should be instructed to self-monitor their blood pressure before taking any medication at home to prevent excessive hypotension
- The client should be educated on smoking cessation as it can be a major risk factor for hypertension
- The client should be encouraged to increase exercise as regular exercise can prevent the onset of hypertension
- The client should avoid foods containing excess salt and follow a lowsodium, hearthealthy diet
- Ca 昀昀 eine and alcohol intake should be limited or avoided altogether as they can contribute to hypertension
- Encourage the client to follow up with their primary care provider when recommended and annually for age-appropriate screenings, immunizations, and general care as well as follow-up on hypertensive status All lifestyle modi 昀椀 cations above are recommendations included in the clinical practice guidelines for the prevention and concurrent treatment of hypertension as they can prevent or (Unger et al., 2020 ). The client should also be educated on how to self-monitor their own blood pressure to prevent hypotension and also for comparison of o 昀케ce blood pressure readings (Unger et al., 2020). Follow-up: Follow up in one month with the clinician’s o 昀케ce for evaluation of hypertension and consider the titration of current medications or additional prescription(s) (Unger et. al., 2020). The patient should seek immediate health care either in the o 昀케ce or emergency department if experiencing chest pain, dizziness, heart palpitations, or intense headaches that may be signs of hypertensive-related complications
