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Description

This Assignment will assess your ability to evaluate subjective and objective information in order to arrive at an appropriate diagnosis and treatment plan for the patient.

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.

Your writing Assignment should:

  • follow the conventions of Standard English (correct grammar, punctuation, etc.);
  • be well ordered, logical, and unified, as well as original and insightful;
  • display superior content, organization, style, and mechanics; and
  • use APA 6th Edition format as outlined in the APA Progression Ladder.

User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

Explanation & Answer

Attached.

Running head: EVIDENCE-BASED MANAGEMENT PLAN IN HYPERTENSION

Your name

Instructor

Course

Date

1

Running head: EVIDENCE-BASED MANAGEMENT PLAN IN HYPERTENSION

2

The evidence-based management plan will give the prescriptions which will be followed
by the patient. The allergic rhinitis will be controlled by applying the Zyrtec which is a nasal
spray. The chemical that causes allergy symptoms is blocked by the spray. This medicine will be
applied four times a day. Mr. C.D will be washing his hands often using soap and water. Also,
the beddings need to be washed with hot water to reduce the allergens. Hypertension may be
caused by stress. The patient needs to simplify his schedule and minimize drinking of much
alcohol. The patient should also try yoga and meditation and have plenty of sleep. In the
prevention of hypothyroidism, the patient is advised to eat a balanced diet. Vegetables and fruits
such as berries and grapes are highly recommended since they are high in healthy antioxidants.
The patient needs to limit foods which have saturated fats such as the red meat and have the
seafood twice a week. The seafood contains omega-3 fatty acids which are nutritious (Frohlich,
2015).

The disease is hereditary since his parents had the HTN. His brother also died at a young
age of 20 due to the complications of CF. Mr. C.D needs to do a lot of exercises da...


Anonymous
Really helpful material, saved me a great deal of time.

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