Anonymous
timer Asked: Apr 9th, 2020

Question 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).

Assignment Requirements:

Before finalizing your work, you should:

  • be sure to read the Assignment description carefully (as displayed above);

Unformatted Attachment Preview

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). Assignment Requirements: Before finalizing your work, you should: • be sure to read the Assignment description carefully (as displayed above); • consult the Grading Rubric to make sure you have included everything necessary; and • utilize spelling and grammar check to minimize errors. Class, below is some additional information that is needed for the week 3 assignment. Repeated blood pressure 180/101, 170/105. The patient denies any shortness of breath at rest, nocturia nose bleeds or hemoptysis. All of the diagnostics You ordered were within normal limits or normal. Review the lab work below. Treat the patient as needed and make the necessary referrals. Review the assignment requirements and grading rubric. Please make sure you list all of the diagnostics that you would order for the patient as if you were in clinical practice. Assume that all of the other diagnostics were normal with the exception of the ones that were abnormal below. • Albumin: 3.4 • Alkaline phosphatase: 30 • ALT (alanine aminotransferase): 6 • AST (aspartate aminotransferase): • BUN (blood urea nitrogen): 10 • Calcium: 9 • Chloride: 100 • CO2 (carbon dioxide): 25 • Creatinine: 1 • Glucose: 95 • Potassium: 3.7 • Sodium: 140 • Total bilirubin: 0.1 • Total protein: 6.0 • HDL 55 • LDL 100 • Cholesterol 230 • TSH 5.5 • T4 0.77 ng/dL 10 ...
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