2-Month HPI: Severe H/A, Chest Pain,+Vision, -Heart Failure

HPI: The illness began two months age, over the time, the symptoms have always been severe headache, chest pain, and blood in urine, vision problems and difficulty breathing (Kaplan, 2010). The symptoms began at home in the leafy suburbs of California. Some of the aggravating or alleviating factors include high sugar intake and lack of physical exercise. Some of the pertinent positives include lack of weight gain while the pertinent negatives include heart failure (Hodgkinson et al., 2011). Other related diseases include coronary heart disease. Past illnesses include cerebrovascular disease. The client has no history of surgeries or the past diagnosis that is related to hypertension.

Medications:

Accupril: To reduce the level of sugar in the blood

Altace: To lower blood glucose

PMH Allergies: The client has been diagnosed with kidney problems; however, there is no history of surgery. At some points the patient was diagnosed with liver disease and stomach ulcers.

Only the patient's mother has been diagnosed with lung disease; however, she continues to survive.

The patient has strong social skills, the highest level of education is university, and he is a teacher by profession. Currently, the patient is married with one child. However, patients do not engage in any substance abuse.

ROS

General

Weight change, fatigue, fever, headaches, night sweats, and blood in the urine Cardiovascular

Irregular heartbeat, Chest pain,

Skin

Bleeding skin, bruising skin, and rashes.

Respiratory

Cough, wheezing and difficulty in breathing

Eyes

Vision problems, blurring, and visual changes in vision Gastrointestinal

Ulcers, eating disorders, and hemorrhoids

Ears

Discharge in ears, and hearing loss

Genitourinary/Gynecological

Frequency burning, change in color of urine. Contraception, sexual activity, STDs Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat

Frequent nose bleeding, throat pain and dysphagia.

Musculoskeletal

Muscular pain, pain in the joints, and back pain.

Breast

No changes observed Neurological

Weakness and syncope

Heme/Lymph/Endo

Swollen glands and night sweats Psychiatric

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx

Objective

Weight : 65kg BMI: 26.4 Temp: 37 BP: 160/90mmhg

Height: 160cm Pulse: 65bpm Resp: 12bpm

General Appearance

Healthy, strong, but pale yellow skin color.

Skin

Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.

HEENT

Head is atraumatic and lacks lesions; there is an equal distribution of hair. Eyes are normal and are intact. Ears have canals patent. Nose have normal turbinates; there is lack of septal deviation (Familoni, Ogun, & Aina, 2004). The neck has no cervical lymphadenopathy, in addition, there are no occipital nodes. Teeth or normal and are in good conditions.

Cardiovascular

There normal breathing with a regular rate of rhythm. Also, there is rubbing of the ribs and normal pulse rate.

Respiratory

There is a difficulty in the respiratory processes; the respiratory system is not regular and easy.

Gastrointestinal

Abdomen obese; BS active in all the four quadrants. Abdomen soft, non-tender. No hepatosplenomegaly

Breast

Breasts are in normal conditions

Genitourinary

In the genital parts, there is normal distribution of hair, and the bladder is non-distended. There is equal distribution of skin color with consistent pigmentation. In the testes, there is no lesions as well as the urethral discharge. The Prostrates are rough, tender and composed of nodules. However, the testes are of normal size, and the sphincter tone is firm.

Musculoskeletal

Full ROM seen in all four extremities as the patient moved about the exam room

Neurological

There is good tone, in other words, the speech is clear, and the gait is normal.

Psychiatric

The patient maintains eye contact; he answers the questions well and with no doubt. Besides, the patient has soft speech.

Lab Tests

Urinalysis-completed

Urine culture-completed

Wet prep-pending

Special Tests

Diagnosis

There was measuring of both the systolic and diastolic blood pressure

Measurement of pulse rate as well as the respiration rate

In the process of diagnosis, the was the measurement of the breathing rate

Final diagnosis

In the final diagnosis, there was the measurement of body temperature, respiration rate, and pulse rate.

PLAN Including Education

Plan:

Further testing

Medication

Education

Nonmedication treatments

Follow-up

References

Familoni, B. O., Ogun, S. A., & Aina, A. O. (2004). Knowledge and awareness of hypertension among patients with systemic hypertension. Journal of the National Medical Association, 96(5), 620. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640651/

Hodgkinson, J., Mant, J., Martin, U., Guo, B., Hobbs, F. D. R., Deeks, J. J., ... & McManus, R. J. (2011). Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. Bmj, 342, d3621. Retrieved from: https://doi.org/10.1136/bmj.d3621Kaplan, N. M. (2010). Kaplan's clinical hypertension. Lippincott Williams & Wilkins.