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Adult Health Case study

Hypertension

Professor Gallegos

HPI:

E.W. is a 40-year old African American male, who has had difficulty controlling his HTN lately. He is visiting his primary care provider for a thorough physical examination and to renew a prescription to continue his blood pressure medication.

PMH:

· Chronic sinus infections

· Hypertension for approximately 11 years

· Pneumonia 6 years ago that resolved with antibiotic therapy

· One major episode of major depressive illness caused by the suicide of his wife of 15 years, 5 years ago.

· No surgeries

· Allergies to Penicillin (Rash)

FH:

· Father died at age 49 from AMI; had HTN

· Mother has DM and HTN

· Brother died at age 20 from complication of CF

· Two younger sisters are A & W

SH:

The patient is a widower and lives alone. He has a 15-year-old son who lives with a maternal aunt. He has not spoken with his son for four years. The patient is an air traffic controller at the local airport. He smoked cigarettes for approximately 10 years but stopped smoking when he was diagnosed with HTN. He drinks “several beers every evening to relax” and does not pay particular attention to the sodium, fat or carbohydrate content of the foods that he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted. He takes an occasional walk but has no regular daily exercise program.

Meds:

· Hydrochlorothiazide 50 mg PO QD

· Pseudoephedrine hydrochloride 60 mg PO Q6hr prn

· Beclomethasone dipropionate 1 spray into each nostril Q6 hr prn

Review of Systems:

· States that his overall health has been fair to good during the past 12 months

· Weight has increased by approximately 20 pounds during the last year

· Denies chest pain, 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 the stool

· Self-treats occasional right knee pain with OTC extra-strength acetaminophen

· Denies any genitourinary symptoms

Physical Exam and Lab tests

General:

The patient is an obese black man in no apparent distress. He appears to be his stated age.

Vital Signs:

BP: 155/96 sitting

HR: 73, regular

RR: 15, unlabored

Temp: 98.8 degrees F

Height: 5’11”

Weight: 221 lb

BMI: 31.

HEENT:

· Tympanic membrane intact and clear throughout

· No nasal drainage

· No exudates or erythema in oropharynx

· PERRLA, pupil diameter 3. mm bilaterally

· Sclera without icterus

· EOMI

· Fundoscopy reveals mild arteriolar narrowing with no nicking, hemorrhages, exudates, or papilledema.

Supple without masses or bruits

Thyroid normal

Negative lymphadenopathy

Lungs:

Mild basilar crackles bilaterally

No wheezes

Heart:

RRR

Prominent S3 sound

No murmurs or rubs

ABD:

Soft and nondistended

Non tender with no guarding or rebound

No masses, bruits, or organomegaly

Normal bowel sounds

Rectal/GU

Normal size prostate without nodules or asymmetry

Heme negative stool

Normal penis and testes

Ext:

No CCE

Limited ROM right knee

Neuro

No sensory or motor abnormalities

CNs II-XII intact

Negative Babinski

DTRs=2+

Muscle tone = 5/5 throughout

Laboratory tests

Na 139meq/L

RBC 5.9mil/mm33

Mg 2.4mg/dL

K 3.9meq/L

WBC 7,100/mm3

P04 3.9mg/dL

Cl 102meq/L

AST 29 IU/L

Uric acid 7.3mg/dL

HCO3 27 meq/L

ALT 43 IU/L

Glu, fasting 110mg/dL

BUN 17mg/dL

ALK phos 123 IU/L

T. Chol 275mg/dL

Cr 1.0mg/dL

GGT 119 IU/L

HDL 31mg/dL

HgB 16.9g/dL

T. Bilirubin 0.9mg/dL

LDL 179mg/dL

Hct 48%

T. protein 6.0g/dL

Trig 290mg/dL

Plt 235,000/mm3

Ca 9.3mg/dL

PSA 1.3ng/mL

Urinalysis results:

Appearance- clear, amber in color

Specific gravity- 1.017

Ph- 5.3

Protein- negative

RBC- 0

WBC- 0

Bacteria- negative

ECG:

Increased QRS voltage suggestive of LVH

ECHO:

Moderate LVH with EF = 46%

Adult Health

Hypertension Case study Paper

Category

Points

Percentage

Description

Pathology:

15 pts

· Define the patient’s disease process

· Explain the etiology of the disease process.

· Thoroughly explain signs and symptoms of disease process.

· State and explain any diagnostic measures utilized with this disease process.

· Cite sources

Assessment Data

10pt

· Clearly explain the difference between subjective and objection data.

· Identify Subjection and objection data that would be important to understand.

· Explain the information that would be information to understand from the chart.

· Identify the information from the chart that would be most helpful

· Identify what labs would be important to your assessment and why.


Medications

10pt

· Understand & explain first line treatment for the disease.

· Understand & explain second line treatment and why you would use second line treatment.

· Explain the patient’s medication: minimum of 3-5 medications.

· Explain the class of medication.

· Explain alternative therapies.

· Explain any Black Box warnings, contraindications, and nursing considerations for the medications.

· Identify 3-5 common side effects.

· Identify any medication interactions

· State the common indication for the prescribed medication.

· Explain 2 challenges that might prevent them from taking medication as prescribed.

· Cite sources

Diagnosis

10pt

· Provide 3 nursing diagnosis for the patients (primary physical, psychosocial and education) pertinent to this client’s medical diagnosis.

· List health assessment priorities for the nursing diagnosis.

· State 5 or more appropriate interventions with evidence-based practiced rationale for each action stated for each of the 3 primary nursing diagnosis (cite sources).

· Explain relevant lab work that is required with this medical diagnosis.

· Cite sources

Plan of care

15pt

· Explain what the patient is at risk for.

· Articulate safety concerns or issues at home.

· Explain 2 challenges that might prevent the patient from seeking medical care.

· Articulate all patient education for the patient and treatment plan.

· Explain an understanding of the diagnosis and treatment.

· Identify 2 short-term goals & 2 long-term goals.

· Identify 2 outcomes for the patients.

· Cite sources.

Discharge Instructions

10pt

· Articulate appropriate discharge instructions for these patients.

· Articulate appropriate follow-up care.

· Cite sources.

SOAPIE Note

10pt

The required elements include the following:

· Clear statement of subjective findings.

· Clear statement of objective findings.

· Clear statement of assessment findings.

· Clear statement of plan.

· Clear statement of interventions

· Clear statement of Evaluation

APA

20pts

All information taken from another source must be included on a reference listing using the 7th edition APA as per the Stratford University policy as of October 5th, 2020.

You are NOT allowed to use your book as a source Reference: You must use Peer Reviewed Sources/Articles.

Total

100

100

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