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

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I Human Case Week #7 56 Year Old Female Reason For Encounter: Blood Pressure Recheck Class 6512 I Human Case Week #7 56 Year Old Female Reason For Encounter

• Reason for Visit: Blood pressure check
• Course: Class 6512 – Advanced Practice Care of Adults Across the Lifespan
• Date: 2025 Subjective:
• Chief Complaint (CC): "I came in to check my blood pressure. My doctor told me it was high last time."
• History of Present Illness (HPI): The patient reports that during a recent visit to an urgent care clinic 2 weeks ago, her blood pressure was noted to be 158/96 mmHg. She denies chest pain, palpitations, shortness of breath, or dizziness. No known history of hypertension. She feels well but wants to follow up as advised.
• Past Medical History (PMH):

o Hyperlipidemia (diagnosed 2 years ago) o Perimenopausal symptoms o No known history of diabetes, CAD, or kidney disease

• Surgical History: o C-section (age 29) o Hysterectomy (partial, age 48)
• Medications: o Atorvastatin 10 mg daily o Multivitamin o Occasional use of ibuprofen for back pain
• Allergies: o NKDA
• Family History: o Mother: HTN, Type 2 DM, deceased (MI at 68) o Father: HTN, alive at 78 o Sister: Alive, HTN and obesity

Objective:

• Vital Signs: o BP: 154/92 mmHg (seated, right arm, averaged over 2 readings) o HR: 78 bpm o RR: 16 bpm o Temp: 98.2°F o BMI: 29.5 (Overweight)
• Physical Exam: o General: Well-appearing, in no acute distress o Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops o Pulmonary: Clear to auscultation bilaterally o Abdomen: Soft, non-tender, no hepatosplenomegaly o Extremities: No edema, good pulses o Neurological: Alert and oriented x

o Skin: No rashes or lesions Assessment:

• Primary Diagnosis: o Essential (Primary) Hypertension – I ▪ Rationale: BP readings >140/ on two occasions; family history and BMI are contributing factors.
• Differential Diagnoses:
  1. White coat hypertension – consider home or ambulatory monitoring
  2. Secondary hypertension (less likely but consider if unresponsive to treatment)
  3. Metabolic syndrome

4. Follow-Up: o Return in 2 – 4 weeks for BP recheck and medication tolerance o Encourage home BP monitoring (log readings 2x/day)
5. Patient Education: o Discuss risks of uncontrolled HTN: stroke, heart attack, kidney damage o Emphasize medication adherence and diet o Provide printed materials on hypertension management Reflection: This visit reinforced the importance of identifying asymptomatic hypertension and initiating treatment early to prevent cardiovascular complications. Lifestyle changes, particularly weight loss and dietary

modification, are foundational. Shared decision-making was used in choosing Lisinopril due to its benefits and once-daily dosing for adherence. Would you like this adapted into a Word document or formatted differently (like a SOAP-only or care plan version)? Great! Here's the same case study in SOAP note format , simplified for clinical clarity: SOAP Note – Week #7 Case Study Patient: 56 - year-old female Visit Reason: Blood Pressure Check Course: 6512 – Advanced Practice Care of Adults Across the Lifespan Date: 2025

• SHx: Non-smoker, rare alcohol, sedentary job, irregular exercise, moderate processed food intake
• ROS: Negative for chest pain, SOB, dizziness, headache, or vision changes O: Objective
• Vital Signs: o BP: 154/92 mmHg (2 readings, seated) o HR: 78 bpm o RR: 16 bpm o Temp: 98.2°F o BMI: 29.
• Physical Exam: o General: NAD o Cardiac: RRR, no murmurs o Lungs: Clear o Abdomen: Soft, NT

o Extremities: No edema o Neuro: AO x o Skin: Normal A: Assessment

• Primary Diagnosis: o I10 – Essential Hypertension (new diagnosis)
• Differential Diagnoses: o White coat hypertension o Secondary HTN o Metabolic syndrome P: Plan

1. Labs/Tests: o BMP o Lipid panel