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.
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.
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
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.
The patient retired from job recently and therefore lives on social security.
She is alert with complaints of fatigue due to nausea.
The cardio denies chest pain or any other heart symptoms.
The skin of BR denies any skin issues such as rash or lesions.
She had a difficulty in breathing or cough.
Her eyes are dry. She seems to have blurred vision. Gastrointestinal
The client experienced nausea
Her hearing is okay. Genitourinary/Gynecological
An examination of external genitalia denies difficulty or felt pain in urinating.
There are no secretions from the nose, no flaring, and no colds.
There are some joint pains in the mornings.
There is no any lumps Neurological
The neurological section denies any loss in memory and seizures.
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
Weight 68kg BMI 44 Temp 98.4 F BP 140/101mmHg
Height 54 Pulse 101 RA Resp 22
The patient is alert.
The skin felt dry and warmth. No appearance of lesions or rashes and decreased turgor
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.
The patient has a normal rate and rhythm. The S2 and S1 are normal.
There was no suprapubic tenderness, Also there was no costovertebral angle tenderness.
There was no joint swelling and also there was no skeletal deformity.
The patient had normal coordination, memory was okay, NII and NIII were found to be within the normal limits.
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.
No special test was seen to be necessary
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.
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.
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.
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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