Hypertension case study

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Health Medical

Description

Hypertension Case Study

C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.

PMH

Allergic Rhinitis

Depression

Hypothyroidism

Family History

Father died at age 49 from AMI: had HTN

Mother has DM and HTN

Brother died at age 20 from complications of CF

Two younger sisters are A&W

Social History

The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.

Medications

Zyrtec 10 mg daily

Allergies

Penicillin

ROS

States that his overall health has been fair to good during the past year.

Weight has increased by approximately 30 pounds in the last 12 months.

States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.

Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.

Denies any nausea, vomiting, diarrhea, or blood in stool.

Self treats for occasional right knee pain with OTC Ibuprofen.

Denies any genitourinary symptoms.

Vital Signs

B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.

HEENT

TMs intact and clear throughout

No nasal drainage

No exudates or erythema in oropharynx

PERRLA

Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema

Neck

Supple without masses or bruits

Thyroid normal

No lymphadenopathy

Lungs

Mild basilar crackles bilaterally

No wheezes

Heart

RRR

No murmurs or rubs

Abdomen

Soft and non-distended

No masses, bruits, or organomegaly

Normal bowel sounds

Ext

Moves all extremities well

Neuro

No sensory or motor abnormalities

CN’s II-XII intact

DTR’s = 2+

Muscle tone=5/5 throughout

What you should do:

  • Develop an evidence-based management plan.
  • Include any pertinent diagnostics.
  • Describe the patient education plan.
  • Include cultural and lifespan considerations.
  • Provide information on health promotion or health care maintenance needs.
  • Describe the follow-up and referral for this patient.
  • Prepare a 3–5-page paper (not including the title page or reference page).

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Explanation & Answer

Attached.

Running head: HYPERTENSION CASE STUDY

Hypertension Case Study
Institution Affiliation
Date

1

HYPERTENSION CASE STUDY

2
Introduction

Hypertension also known as High blood pressure is a medical condition that affects
most people worldwide even though at times it goes undetected. When left untreated or
unmanaged, it can lead to severe conditions while increasing the risk of the patient suffering
from heart disease, stroke or even death. Blood pressure is a term that is used to refer to the
force that is applied by blood on the walls of the blood vessels. According to the guidelines
provided by the American Heart Association (AHA) defines hypertension as a blood pressure
that is higher than 130 over 80 mmHg since normal blood pressure is 120 over 80mmHg.
Hypertension affects millions of people globally and it is estimated that approximately 85
million people in the United States suffer from the condition (American Heart Association,
2017).
Evidence-Based Plan for C.D
It is important for patients who suffer from hypertension like C.D to learn more about
the condition so that they can be in a better position to manage it. The hospitals should have
enough doctors to handle patients with hypertension. The healthcare provider should
communicate to the patient all the information relating to hypertension as this will go a long
way in making the patient understand the condition (James et al, 2014). An evidence-based
plan will make the process of managing...


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