I Human Case Week #7 56 Year Old Female Reason For Encounter: Blood Pressure Recheck Cla, Lab Reports of Nursing

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I Human Case Week #7 56 Year Old Fe Reason For Encounter: Blood Pressure Recheckmale

Class 6512

  Hypertension (diagnosed 2 weeks ago)Hyperlipidemia (diagnosed 2 years ago)   Obesity (BMI ~32)No history of diabetes  No known cardiovascular disease Past Surgical History (PSH):  Appendectomy in her 20s

. Plan (SOAP “P”)^ ^ Tubal ligation in her 30s Medications:  Continue Lisinopril 10 mg daily  Consider ti weeks tration to 20 mg daily if BP remains above goal in 2– 4  Monitor after any med change electrolytes and renal function (BMP/CMP) 1–2 weeks Lifestyle Modifications:  Continue DASH diet: low sodium, rich in fruits/vegetables   Encourage weight loss (target 5Physical activity: At least 150 minutes of moderate–10% reduction) -intensity  aerobic exercise/weekLimit alcohol (≤1 drink/day for women) Monitoring:  Home BP log: check 2x/day, log readings   Recheck inWatch for cough, dizziness (possible Lisinopril side effects) 2 – 4 weeks

Labs/Diagnostics:  Repeat BMP (renal fxn & potassium) in 2–3 weeks   Lipid panel Consider urine microalbumin annually or sooner if uncontrolled if diabetes suspected or CKD

Patient Education:^ concern   Importance of adherence to medicationUnderstanding BP targets (<130/80 mmHg per ACC/AHA)   Educate on potential side effects of ACE inhibitorsEncourage regular follow-up visits

✅ (^)  Follow Return to clinic in 2 - Up Plan – 4 weeks for BP recheck and med adjustment   Sooner if any side effects or symptomsReinforce long-term cardiovascular risk reduction

History of Present Illness (HPI): The patient is a 56-year-old African American female who presents for a follow ago when her BP was elevated at 162/98 mmHg. At that time, she was-up visit to recheck her blood pressure. She was seen two weeks advised to monitor her blood pressure at home, reduce sodium intake, increase physical activity, and follow up for reassessment. She reports feeling well overall and has been checking her blood pressure at home, which has ranged from 138/86 to 148/90 mmHg. She denies any headache, dizziness, chest pain, shortness of breath, or visual changes.

  Atorvastatin 20 mg nightlyMultivitamin Aller  gies: No known drug allergies Family History:  Mother: Stroke at age 67, hypertension   Father: Type 2 diabetesBrother: Hypertension Social History:  Lives with husband   Works as a school secretaryOccasional alcohol, no smoking or drug use   Poor diet, recentlyWalking 3x per week making changes ROS:  Negative for all major complaints (neuro, cardiac, respiratory, GI, etc.) 🧠 Vital Signs: ⚕️ 2. Objective Data (Physical Exam)   BP: ~145/88 in officeHR: 78 bpm   RR: 16Temp: 98.6°F  BMI: 32 (Obese)

General:  Well-appearing, no acute distress HEENT:  Normal CV:  Regular rate and rhythm, no murmurs or extra heart sounds Resp:  Clear to auscultation bilaterally Abdomen:  Soft, non-tender, no masses Neuro:  Alert and oriented x3, no deficits

🧠 Labs (if ordered or reviewed): 3. Diagnostic Considerations   Lipid Panel:CMP: Normal renal function (important for Lisinopril monitoring) Elevated LDL, low HDL   A1C:Urinalysis: Normal range or borderline (depending on case specifics) May be normal or trace proteinuria EKG:  Likely normal or shows mild LVH (if longstanding HTN)

Review of Systems (ROS):  General: Denies fatigue, fever, or weight change   Cardiovascular:Respiratory: Denies shortness of breath, cough Denies chest pain, palpitations, or edema   NeurologiGI: Denies nausea, vomiting, abdominal pain cal: Denies dizziness, headache, or visual changes   GU:Musculoskeletal: No urinary complaints No joint or muscle pain Physical Examination General:  Well acute distress.-developed, well-nourished, African American female in no   Alert and oriented ×3.Appears stated age, cooperative throughout the exam. Vital Signs:  BP (right arm, seated): 145/88 mmHg   Pulse:Respirations: 78 bpm, regular 16 breaths per minute, unlabored   Temperature:Height: 5’5” 98.6°F (oral)   Weight:BMI: 31.6 (obese category) 190 lbs

HEENT:  Head: Normocephalic, atraumatic  Eyes: retinopathy PERRLA, EOMI, no funduscopic evidence of hypertensive

 Ears/Nose/Throat: abnormalities Mucous membranes moist, no lesions or  Neck: No thyromegaly or lymphadenopathy, no JVD Cardiovascular:  RRR (regular rate and rhythm)   S1 and S2 audible, no murmurs, rubs, or gallopsNo peripheral edema   No carotid bruitsPeripheral pulses 2+ bilaterally

Respiratory:  Lungs clear to auscultation bilaterally   No wheezes, rales, or rChest expansion symmetricalhonchi

Abdomen:  Soft, non-tender, non-distended   Bowel sounds present in all quadrantsNo hepatosplenomegaly  No masses or bruits Extremities:  No cyanosis, clubbing, or edema   No tenderness to palpationFull range of motion

⭐️ 🧠 Subjective: Key Findings  Follow 162/98 mmHg)-up for hypertension diagnosed 2 weeks ago (initial BP:  Home BP readings improved but still elevated (ranging 138/86 to 148/90 mmHg)  Denies any symptoms (no headache, dizziness, chest pain, SOB, or visual changes)   Reports adherence to Lisinopril 10 mg dailyHas begun making dietary changes and increased walking to  3x/weekPositive family history of HTN and stroke (mother), diabetes (father) 👩⚕️ (^)  Objective:BP (office): 145/88 mmHg   Pulse:Heart/Lung Exam: 78 bpm, BMI: Normal (RRR, clear lungs) 31.6 (obese category)   No edema, bruits, or organomegalyNeurological exam: Intact   No signs of hypertensive urgency/emergency No evidence of secondary HTN on exam

🧠 Likely Diagnostics (if ordered or known):  CMP: Normal electrolytes, normal renal function   Lipid Panel:UA: Normal or may show trace protein Likely elevated LDL, low HDL

 No evidence of end-organ damage 📌 (^)  Clinical Summary: BP is improved with medication and lifestyle changes but not yet ^ at goal No sympt. oms suggesting complications or secondary  hypertension.Needs continued titration of antihypertensive therapy and close ^ monitoring Education and. lifestyle counseling essential to long-term  management. Follow-up and lab monitoring required for med effects and Diagnostic Tests^ progression. These tests help confirm the screen for end-organ damage diagnosis , per JNC, evaluate for-8 and ACC/AHA hypertension comorbidities , and guidelines. ✅ (^)  1. Basic Metabolic Panel (BMP/CMP) Purpose: o o EvaluateCheck renal function electrolytes (esp. potassium with ACE inhibitors) (BUN, creatinine) — critical for  Expected Findings:^ monitoring^ ACE inhibitors like Lisinopril Normal or mildly elevated creatinine; potassium should be within normal range ✅ 2. Lipid Panel

o Detect hypertensive patients microalbuminuria , a marker of kidney damage in  Recommended especially if diabetic, African American, or with high CVD risk Physical Examination General:  Well acute distress.-developed, well-nourished, African American female in no   Alert and oriented ×3.Appears stated age, cooperative throughout the exam. Vital Signs:  BP (right arm, seated): 145/88 mmHg   Pulse:Respirations: 78 bpm, regular 16 breaths per minute, unlabored   Temperature:Height: 5’5” 98.6°F (oral)   Weight:BMI: 31.6 (obese category) 190 lbs

HEENT:  Head: Normocephalic, atraumatic  Eyes: retinopathy PERRLA, EOMI, no funduscopic evidence of hypertensive  Ears/Nose/Throat: abnormalities Mucous membranes moist, no lesions or  Neck: No thyromegaly or lymphadenopathy, no JVD

Cardiovascular:  RRR (regular rate and rhythm)   S1 and S2 audible, no murmurs, rubs, or gallopsNo peripheral edema   No carotid bruitsPeripheral pulses 2+ bilaterally

Respiratory:  Lungs clear to auscultation bilaterally   No wheezes, rales, or rChest expansion symmetricalhonchi

Abdomen:  Soft, non-tender, non-distended   Bowel sounds present in all quadrantsNo hepatosplenomegaly  No masses or bruits Extremities:  No cyanosis, clubbing, or edema   No tenderness to palpationFull range of motion

Neurologic:  Alert and oriented ×

 Purpose: o Screen for left ventricular hypertrophy (LVH) or ischemic  Expected Findings:^ changes o o Likely normal in early stagesLong-standing HTN may show LVH, strain patterns

🚫 (^)  Optional/Only if Indicated: TSH: If concerned about hypothyroidism contributing to  hypertension Renin/aldosterone levels: If suspecting secondary hypertension  (less likely in this case) Echocardiogram: If EKG is abnormal or there's concern for heart structure/function 🗓 (^)  Follow BMP/CMP:-up Timing for Tests: Within 1–2 weeks after starting or adjusting

 Lisinopril Lipid panel and A1c: Annually or sooner if not done in past 6– 12  months Urine studies: Annually or based on risk profile Differential Diagnosis^ ^ EKG:^ Baseline, then as clinically indicated ✅ (^)  1. Essential (Primary) Hypertension Most likely diagnosis  Chronic elevation of blood pressure without secondary cause an identifiable

 Supported by: o Gradual onset o o Family history (mother and brother with HTN)African American ethnicity (higher prevalence) o o Obesity, sedentary lifestyle, and high sodium intakeNo signs of secondary causes on exam or history  Diagnosis of exclusion but commonly assumed if no red flags ⚠️ Hypertension due to an underlying cause. Less likely in this case, but 2. Secondary Hypertension important to rule out if BP remains uncontrolled despite treatment, or if there are red flags. Subtypes to consider:  Renal Artery Stenosis o Usually presents sudden onset with resistant HTN, abdominal bruit, or  Primary Hyperaldosteronism (Conn's Syndrome)^ o^ No bruit, normal renal function →^ unlikely o o Suspect if HTN + hypokalemiaNo hypokalemia reported → less likely  Obstructive Sleep Apnea (OSA) o Strongly associated with resistant HTN o o Ask about snoring, fatigue, witnessed apneaMay be a consideration based on obesity → possible  Thyroid Dysfunction (Hyper/Hypothyroidism) o Can cause BP changes o No thyroid enlargement, symptoms, or metabolic changes → less likely  Pheochr o Rare, usually causes paroxysmal HTN, palpitations, sweating omocytoma o No episodic symptoms → very unlikely