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Hpi Case Study Aanlysis

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Subject
Nursing
School
Middle Georgia State University
Type
Homework
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Case Presentation History of the Current Illness • Ms. Metzdorf is 58 y/o Caucasian female • Recently Diagnosed with HTN (2020), hypothyroidism, GERD, Obesity, and dry eyes • The patient is on Restasis, which is helping her dry eyes • ACEi was applied to manage her blood pressure • The patient takes OTC fish oil, Calcium, and Meloxicam Past Medical History • • • • Essential hypertension Obesity Hypothyroidism No pertinent surgical history Subjective data • • • • Denies any hemoptysis Deny nausea and vomiting, constipation, and diarrhea Denies sob, chest pain, and lower extremity edema Denies frothy urine, seizures Social History • • • • Former smoker History of alcohol usage Never used smokeless tobacco Drinks one type of alcohol per week Family History Father • Gout • Cancer • Heart disease • Hypertension • Kidney disease Mother • Stroke Vital Systems Reviewed • • • • Constitutional HEENT Cardiovascular Pulmonary/ Chest More Systems Reviewed • • • • • Abdominal Musculoskeletal Neurological Skin Psychiatric Laboratory Examination • • • • • • • • Sodium Potassium Chloride Carbon dioxide Bun Creatinine Glucose Calcium Assessment and Plan • • • • Acute injury of the kidney (HCC) Hypertension Gastroesophageal reflux disease Long term current use o ...
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