I Human Case A 56 Year Old Female Reason For Encounter: Blood Pressure Recheck, Assignments of Nursing

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COMPREHENSIVE I Human Case A 56 Year Old Female

Reason For Encounter: Blood Pressure Recheck class

6512 Case Study

History and Physical Exam

How can I help you today?

Do you have any other symptoms or concerns that we can discuss?

When did your high blood pressure start?

How severe is your high blood pressure?

Have you gained weight?

When did your headache start?

Case: Key Findings

 Key Finding

 Elevated BP

 Headaches

 Daytime somnolence and fatigue

 Smoker

 Overweight status

 Hypertensive retinopathy – AV Nicking

 Laterally displaced PMI

 Snoring, awoken by wife for breathing problem

 NSAID use

 Poor eating habits

The medical problem list you have compiled should be a list that includes

everything that is out of the ordinary about this patient, even when it is not a

“problem” in the true sense of the word.

Next, this list should be examined in an attempt to group those findings that are

related to the chief complaint or MSAP or that tend to be found together in specific

disease states. This is the first step in developing and ranking your differential

diagnosis.

In this case, HT stands out as the most significant active problem (MSAP). It is

central to your identifying the other findings belonging in 1 or more of the following

categories

•Risk factors

• Comorbidities

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. Nose: No discharge or polyps. Sinuses non-tender to palpation. Sense of smell intact. Throat/Neck: No crowding at posterior oropharynx. No tenderness of the tongue. Soft palate moves up symmetrically, speech phonation and articulation appropriate. Symmetrical, no scarring, visible masses or deformities. No supraclavicular or dorsal fat pad. Nodes mobile, nontender, pea-sized, and soft bilaterally. Thyroid without mobile masses, tenderness, nodules, or enlargement. Cardiovascular: S1, S2 present, regular rate and rhythm. No murmurs, gallops, or rubs noted. Carotid arteries regular rate and rhythm to auscultation. PMI palpated at 5th^ ICS. No accentuated sounds to Valsalva or with added squat. JVP measures 2 cm from the sternal angle with HOB at 30 degrees elevated. Chest/Respiratory: Lung sounds clear to auscultation in all 昀椀 elds bilaterally. No lifts or accessory muscle use. No scars, moles, rashes, erythema, or ecchymosis. Upon palpation no tenderness, masses, heaves, thrills, or crepitus. Upon percussion all anterior lung 昀椀 elds are resonant. The left anterior chest and right lower chest are dull to percussion. The remaining lung 昀椀 elds are resonant with no hyper-resonance noted. Sensation intact to pain and light touch at thorax and back bilaterally. Abdomen: Abdomen is protuberant with no scars, moles, masses, rashes, erythema, or ecchymosis. Waist circumference is 45 inches. Bowel sounds are normoactive and present in all four quadrants. Liver is 8 cm at midclavicular line, edge palpable just below costal margin. Spleen is not palpable. GU/Rectal: Not assessed. Musculoskeletal/Osteopathic Structural Exam: Full and painless ROM in 昀氀 exion, extension, lateral bending and rotation bilaterally. Arms without rashes, lesions, erythema, swelling or echymosis and no fasciculations or loss of muscle bulk. Lower extremities no hair loss, varicosities, or cyanosis. Active ROM full and painless, 5/5 bilaterally, painless upon 昀氀 exion, extension, internal rotation, external rotation, adduction, and abduction bilaterally. Neurologic: Light touch and pain grossly intact.

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 palpitations. Reported agerelated weight gain with a BMI of 28.9 and knee pain associated with work. Physical exam is notable for Left Arm BP elevated at 174/96 and fundoscopic finding of AV nicking. FH consists of HTN and related complications. PMH includes being told he has HTN but does not follow up with a regular doctor. Management Plan – Diagnostic Tests: ECG – Normal ECG, 75 bpm, regular rhythm CBC – Normal with di 昀昀 erential CMP – Normal CMP TSH, blood – Normal TSH UA – Normal UA All tests above with normal results indicated the patient has primary (essential) hypertension (Unger et al., 2020). Medications:

• Hydrochlorothiazide 12.5 mg PO once daily (Puckey, 2024a). - Lisinopril 10 mg PO once daily (Puckey, 2024b). According to the clinical practice guidelines, H.H.’s blood pressure of 170s/90s is Grade 2 and should immediately be treated with pharmacological therapy (Unger et al., 2020). Those with Grade 2 Hypertension and who are non-black should be started on a low-dose ACEI/ARB and a CCB and subsequently titrated to a full dose as applicable (Unger et al., 2020). The additional thiazide diuretic and/or spironolactone may be considered to be added to the client’s medication regimen (Unger et al., 2020). The client’s medication regimen should be simpli 昀椀 ed with once-daily dosing and single pill combinations as much as possible to promote medication adherence (Unger et al., 20200. Suggested consults/referrals:
• Dietician for education and plan for dietary modi 昀椀 cations

Ramirez, A., Schlaich, M., Stergious, G. S., Tomaszewski, M., Wainford, R. D., Williams, B., & Schutte, A. E. (2020). 2020 International society of hypertension global hypertension practice guidelines. AHA Journals. 75 (