Hypertension Case Study

Date:  2021-05-17 04:21:12
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The current patient BR, 68 years old. She is a black woman who presented herself to this hospital complaining of headaches with blurred vision and nausea for two weeks. The patient stated that she have been experiencing low grade fever that morning. The patient also said that she was placed on Lisinopril 20 mg PO daily. She states that she have been placed on Lisinopril 20 mg PO daily.

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Medications:

The medications that were used include Zantac 75mg PO that were to be administered daily, Lisinopril 20mg PO also to be administered daily, ASA 81 mg PO daily, Advair 50mg PRN

PMH: Asthma, HTN, Arthritis.

PSH: Appendectomy ten years ago.

Immunization History: Immunization up to date age.

Allergies: NKDA

Chronic Illnesses/Major traumas

She does not have a chronic illness or major trauma

Hospitalizations/Surgeries. She reported to have undergone appendectomy 10 years ago.

Have you ever been told that you have: Diabetes, HTN, arthritis or asthma? She does have some instances in the past

Family History

The parents of the patient BR are no longer living and both succumb to death due to hypertension. The younger sibling also is said have HTN.

Social History

The patient retired from job recently and therefore lives on social security.

ROS

General

She is alert with complaints of fatigue due to nausea.

Cardiovascular

The cardio denies chest pain or any other heart symptoms.

Skin

The skin of BR denies any skin issues such as rash or lesions.

Respiratory

She had a difficulty in breathing or cough.

Eyes

Her eyes are dry. She seems to have blurred vision. Gastrointestinal

The client experienced nausea

Ears

Her hearing is okay. Genitourinary/Gynecological

An examination of external genitalia denies difficulty or felt pain in urinating.

Nose/Mouth/Throat

There are no secretions from the nose, no flaring, and no colds.

Musculoskeletal

There are some joint pains in the mornings.

Breast

There is no any lumps Neurological

The neurological section denies any loss in memory and seizures.

Heme/Lymph/Endo

The hematologic section denies her bruising. Psychiatric

She feels anxious related to the disease process.

Assess to check signs of depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE

Weight 68kg BMI 44 Temp 98.4 F BP 140/101mmHg

Height 54 Pulse 101 RA Resp 22

General Appearance

The patient is alert.

Skin

The skin felt dry and warmth. No appearance of lesions or rashes and decreased turgor

HEENT

Her eyes was normal, no nose bleeding, she had moist mucus membrane, no sore throat or tonsillitis, no oral ulcers and also there was no ear discharge.

Cardiovascular

The patient has a normal rate and rhythm. The S2 and S1 are normal.

Genitourinary

There was no suprapubic tenderness, Also there was no costovertebral angle tenderness.

Musculoskeletal

There was no joint swelling and also there was no skeletal deformity.

Neurological

The patient had normal coordination, memory was okay, NII and NIII were found to be within the normal limits.

Psychiatric

The patient had normal alertness and well oriented. The dressing was smart, where she was in slacks, and coat. She was able to maintain normal eye contact though it seems she cant see well. The rate of answering questions was normal though she could murmur some words.

Special Tests

No special test was seen to be necessary

DIFFERENTIAL DIAGNOSIS

Primary diagnosis- HTN. The patient is experiencing nausea, had fatigue especially in the morning. Due to the family history laid the patient might have inherited the Hypertension condition.

Secondary diagnosis- Diabetes it was of great importance to diagnose Diabetes since the body mass index of the patient was above the normal range.

Asthma is the second secondary diagnosis. This resulted due to breathing difficulty.

PLAN.

The patient above might be having Hypertension which is hereditary. It was observed that both her parents died because of hypertension. Also her brother is said to be suffering from the same condition. There was also the need to have the use of antidepressants, antidiabetic drugs and hypertensive drugs so that the severity of the condition could be reduced. Some of the antidepressant drugs that I recommended for her include fluoxetine (Prozac), and paroxetine (Paxil). The plan is for the patient to have medical prescriptions. A non-pharmacological intervention method is for the patient to exercise daily basis. The patient should also visit a dietician in order to get the best diet as much as possible. BR should visit the clinic after two weeks.

Reflective notes

From the case study above, I learnt that there are some conditions that are inherited. It is passed from one generation to the next through blood. People should exercise daily in order to assist prevent some lifestyle conditions. I would differently treat and manage the hypertension condition through diet therapy unlike the use of drugs.

References

Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A collaborative practice (4th ed.). St. Louis, MO: Mosby.

Dibona, G. F. (2013). Sympathetic nervous system and hypertension.Hypertension,61(3), 556-560.

Gagan, M. J. (2009). The SOAP format enhances communication. Nursing New Zealand, 15(5), 15. Retrieved from the Walden Library databases.Gagan, M. J. (2009). The SOAP format enhances communication. Nursing New Zealand, 15(5), 15. Retrieved from the Walden Library databases

National Heart Lung and Blood Institute. (2002). Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. Retrieved from http://www.nhlbi.nih.gov/files/docs/resources/heart/pphbp.pdf

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby's guide to physical examination (7th ed.). St. Louis, MO: Mosby.

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