Assignment 7

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Clinical Case Study: Hypertension

Figure 1: Guideline for high blood pressure

Source: Harvard Medical School

Introduction

Hypertension happens when the blood moves at a higher pressure in the arteries.

The condition may be caused by stress, smoking, lack exercise, and obesity.

The main symptoms are shortness of breath, nose bleeding, and headaches (Kumar et al., 2015).

Hypertension also leads to heart diseases, kidney failure, and increased risk for stroke.

High blood pressure (hypertension) is a medical condition that happens when blood moves at a high pressure in the arteries. The disease is caused by several factors, including taking too much alcohol, stress, smoking, being overweight, and lack of exercise. The disease is called ‘the silent killer’ because most patients do not show any symptoms. However, some people may experience shortness of breath, headaches, and nosebleeds (Kumar et al., 2015). If left uncontrolled, hypertension can lead to kidney failure, heart attack, and stroke.

Chief Complaint and Demographics

Chief Complaint

“I have been experiencing headaches for three weeks now and swelling of the legs.”

Demographics

Patient initials: TJ

Age: 65 years

Race: White

Ethnicity: Native American

Gender: Male

Chief complaint for TJ, A 65-year old man is headaches. Mr. TJ came into the clinic stating, “I have been experiencing headaches for three weeks now. The condition often starts early in the morning, and at it occurs on both sides of the head.” The pain tends to pulsate whenever TJ engages in demanding physical activities. At times, the conditions lead to swelling in the legs.

Figure 2: Hypertension in middle age

Source: Mientka (2014)

Subjective Data: History of the Presenting Illness

Onset: 14 days ago

Location: Both sides of the head

Duration: 20 minutes

Characteristics: Numbness, pain in the head, and changes in vision

Aggravating factors: Stress and physical activities like running and jumping

Relieving factors: At rest

Timing: Continuous headaches in the morning with a repetitive pattern with exertion

Severity: TJ rates headaches as 8/10

TJ is a 65-year old man who has been experiencing constant headaches. He states the pain, swelling of legs and morning headaches have intensified over the past 14 days. The pain affects both sides of the head to an extent that he cannot handle his daily activities. The legs do not allow him to walk at times due to the swelling. When asked about the severity of the pain on a scale of 1-10, the patient rated pain as 8/10. The pain often lasts for around 20 minutes. It is characterized by loss in vision and numbness. The aggravating factors for hypertension include stress at work and physical activities like jogging, running, or jumping. Relieving factors: at rest

Allergies

Patient has NKA. T.J denies any allergies to drugs, food, environmental, herbal or latex.

Review of Systems

General: Denies unintentional weight loss. Denies night sweats. Admits weakness. Denies fever. Denies memory loss. Admits malaise. Admits weight gain. Admits fatigue. Admits diaphoresis. Admits polydipsia.

HEENT: Denies memory loss. Admits vision complications, last eye examination in 2018, normal. Admits dizziness. Admits headaches. Denies head injuries. Denies glasses. Admits change in vision. Denies flashing lights. Denies glaucoma. Denies cataracts. Denies changes in hearing. Denies any ear pain. Denies ear discharge. Denies ear ringing. Denies dizziness. Denies nasal stiffness. Denies tongue and lip swelling. Denies hearing impairment. Denies sore throat. Denies bleeding gums. Denies dentures. Denies extractions. Denies strep throat. Denies changes in voice. Denies dental disease, ulceration, or lesions in the tongue or gingivitis, last dental visit 01/2020.

Neck: Denies swollen glands. Denies goiter. Denies neck stiffness. Denies pain.

Lymphatics: Denies swollen lymph nodes on neck. Denies swollen lymph nosed on axillae. Denies swollen lymph nodes on epitrochlear areas. Denies swollen lymph nodes in inguinal area.

Breast: Denies lumps. Denies pain. Denies nipple discharge. Denies enlargement.

Lungs: Admits SOB. Denies cough. Denies wheezing. Denies congestion. Denies emphysema. Admits chest tightness. Denies bronchitis. Denies wheezing. Denies trouble breathing. Denies hemoptysis. Denies pleuritic chest pain. Denies blue discoloration of lips or nailbeds. Denies history of TB. Denies recurrent pneumonia. Denies history of environmental exposure.

Cardiovascular: Admits chest pain. Denies blue toe/finger. Admits Hx of heart medication. Denies murmur. Denies skipping heat beats. Denies palpitations. Admits hypertension. Denies Hx of murmurs. Denies dyspnea. Denies orthopnea. Admits edema on lower extremity. Denies Hx of rheumatic fever. Denies syncope. Admits varicosities. Denies thrombophlebitis. Denies abnormal electrocardiogram.

GI: Denies vomiting. Denies abdominal pain. Denies nausea. Denies rectal hemorrhoids. Denies palpitations. Admits constipation sometimes. Denies changes in bowel habits. Denies excessive flatus. Denies vomiting blood. Denies hepatitis. Denies liver problems. Denies change in appetite. Admits bladder problems. Admits dysuria. Reports last BM this morning, soft and brown.

The Review of Systems evaluated major body systems. Through medical consultation, Mr. TJ complains of weakness, malaise, weight gain fatigue, diaphoresis and polydipsia. He also admits vision complications, dizziness, headaches, and vision changes. T. J admits being SOB especially when he's moving around. He admits chest pain, history of heart medication admits edema in the lower extremities and admits varicosities. He admits constipation at times and dysuria.

Review of Systems con…

Male/female genital: Denies lesions. Denies Hx of STD. Denies testicular pain. Denies testicular swelling. Denies scrotal mass. Denies infertility. Denies impotence. Denies changes in libido. Denies hernia.

GU: Denies any discharge. Denies pain or burning sensation. Admits urgent need to urinate. Admits difficulty urinating. Denies kidney stones. Denies prostate infection. Denies dribbling. Denies incontinence. Denies blood in urine. Denies UTI. Denies suprapubic pain. Admits polyuria. Denies inguinal pain.

Neuro: Admits headache at times. Denies loss of muscle size. Denies seizures. Denies tremors. Denies fainting. Denies paralysis. Denies weakness. Denies feeling pins or needles. Denies loss of consciousness. Denies involuntary movement. Denies muscle spasm. Admits numbness. Denies local weakness. Denies tingling. Denies vertigo or dizziness.

Musculoskeletal: Denies joint stiffness. Admits varicose veins. Admits leg cramps. Denies clot in vein. Denies back pain. Admits joint pain. Denies neck pain. Admits muscle aches. Admits limitation of motions. Denies history of fractures.

Activity & Exercise: Denies routine exercise

Psychosocial: Denies depression. Denies obsessive- compulsive tendencies. Admits high stress. Denies mood swings. Denies suicidal thoughts. Admits anxiety due to pain. Denies nightmares. Denies nervousness. Denies irritability. Denies insomnia. Denies hypersomnia, phobias or tension.

Derm: Denies lesions. Denies rash. Denies itching. Denies moles. Admits dry and sensitive skin. Denies hives. Denies hair loss. Denies jaundice. Denies lumps. Denies changes in hair or nails. Denies open wound. Denies skin color discoloration.

Endocrine: Denies thyroid trouble. Denies heat or cold intolerance. Admits excessive sweating or flushing. Denies diabetes. Denies excessive thirst or hunger or urination.

Hematologic: Denies anemia. Denies easy bruising or bleeding. Denies past transfusion and reactions.

Nutrition: Denies occasional loss of appetite.

Sleep/Rest: Admits sleeping difficulties due to the pain.

STI Hx: Denies STI’s.

T.J admits the urgent need to urinate he also admits having difficulty urinating. He admits having headaches and admits numbness in the lower extremities. He admits having varicose veins, admits leg cramps, admits joint pain and admits anxiety due to pain. He also admits excessive sweating and flushing and admits sleeping difficulties due to the pain.

Vital Signs

BP 176/90 mmHg (patient was sitting, BP taken on left arm)

HR: 60 bpm

RR 16 breaths per minute

Temperature 96.7 F (Oral)

Weight 201 lbs.

Height: 180 cm (5 feet and 0.90inches)

BMI 29.68kg (Overweight)

The vital signs and lab test showed underlying issues with the blood pressure. The blood pressure was high at 176/90 mmHg.

Lab Tests

Fasting plasma glucose	100 mg/dl
HbA1c	8.5 %
BUN	23 mg/dL
Creatinine	0.60 mg/dL
Sodium	138 mmol/L
Potassium	4.5 mmol/L
Chloride	103 mmol/L
CO2	25 mmol/L
Protien, Total	6.9 mg/dL
Albumin	4.5 g/dL
Globulin, Total	2.8 g/dL
Bilirubin	36 mg/dL
Alkaline Phosohatase	35 U/L

ALT	20 U/L
Total Cholesterol	223 mg/dL
Triglycerides	175 mg/dL
LDL Cholesterol	120 mg/dL
HDL Cholesterol	25 mg/dL
Non-HDL	140 mg/dL
WBC	9.5 thousands/uL
RBC	4.80 miliion/UL
Hemoglobin	14.1 g/dL
Hematocrit	40.1 %
MCV	89.5 fL
MCHC	33.5 g/dL
RDW	13.1 %
Platelet Count	353 thousand/uL
MPV	11.4 fL

The glucose level was at 100 mg/dL, which is within the acceptable levels. His total cholesterol was high.

Medications

Nifedipine 30mg TID for angina

Omeprazole 20mg PRN for GERD.

Atorvastatin (lipitor) 20 mg orally once a day for high cholesterol.

Currently, Mr. TJ is is taking Nifedipine 30mg TID for angina, Omeprozole PRN for GERD, Atorvastatin (lipitor) 20 mg orally once a day.

Last MRI for migraine, 06/2018, Normal.

Last chest X-Ray, 04/2020, Normal

Last EKG 05/2020, Normal.

Last colonoscopy, 05/2018, Normal. Patient will be scheduled for next colonoscopy 05/2023.

Last digital rectal exam 01/2020, Normal. Patient will be scheduled for next DRE 01/2021.

Screenings

Immunization HX

T.J immunization record is up to date. He received all the necessary immunizations at childhood as well as an adult. Influenza 2020, Patient will receive 2020 vaccination in clinic in today. Patient wants COVID vaccine as soon as it’s provided to the community. Pneumococcal vaccination 2018. Td 2018, Varicella Zoster 2017.

Past Medical History

Major Chronic Illnesses: T.J past medical records reveals that he was diagnosed with angina in 2015. He still has angina and takes Nifedipine 30mg TID.

Trauma/Injury: T.J has not had any major trauma or injuries.

Hospitalizations: T.J was admitted 10 years ago for an appendectomy.

Past Surgical history

Tonsillectomy at age 13, in 1968 due to recurrent strep throat.

Appendectomy at age 26, in 1981.

Inguinal hernia repair at age 55, in 2020.

Family History

Father passed away from a stroke at age 80, His father also had hypertension and asthma.

Mother was diagnosed with hypertension and diabetes, she passed away in a car accident.

Brother diagnosed with hypertension at 35, currently alive.

Sister was diagnosed with breast cancer at 30, currently alive.

Parental grandfather passed away at 66, from a heart attack.

Parental grandmother passed away at 76 from breast cancer.

Denies family history of tuberculosis, kidney disease, anemia, mental illness and epilepsy.

Mr. TJ’s family shows possibility of genetic hypertension as evident in his father, mother, and younger brother.

His father passed away from a stroke at 80. His mother was also diagnosed with hypertension and diabetes but passed away in a car accident. His younger brother was also diagnosed with hypertension at 35. His sister was diagnosed with breast cancer at 30 and is currently alive. Hos parental grandfather passes away at 66 from a heart attack. His parental grandmother passes away at 76 from breast cancer.

T.J denies family history of tuberculosis, kidney disease, anemia, mental illness and epilepsy.

Social History

Living situation: T.J lives with his wife in a 3-bedroom house they bought 30 years ago.

Family composition: T.J has two children who are currently alive.

Marital status: T.J has been married for 40 years.

Occupation: T.J went to college and received a bachelor degree in construction management. T.J current employment is as a project director for a construction company. His previous employment was working as a bus driver.

Tobacco: T.J denies tobacco smoking.

ETOH/Drugs: T.J denies any use of drugs but admits drinking alcohol at least 3 times a week.

Sexual orientation: T.J is heterosexual and is currently sexually active with his wife about two to three times a week and uses condoms every time.

ADLs: Patient states due to swelling on his legs its hard to complete his ADLs.

General: Mr. T.J is a 65-year-old white Hispanic male who is overweight and tall. His speech is clear and coherent. T.J is cooperative, proper and responds well to questions. He is well nourished, well-groomed and dresses appropriate.

Dermatology: Skin is warm, dry and intact. Skin color is appropriate for his ethnicity. Skin is normal with standard hair distribution and temperature. No lesions, rash or scars noted. Redness and swelling observed on the lower extremities. Edema noted on lower extremities.

HEENT: Head: Head is normocephalic and atraumatic. No signs of abnormalities. Hair is dark brown and is evenly distributed Eyes: Vision 20/20 on both eyes. Visual fields full by confrontation. Pupils 3mm. Conjunctiva pink, sclera white. PERRLA. Extraocular movements intact. Disc margins sharp, no hemorrhages or exudates notable. No redness or discharge noted. No arteriolar narrowing or A-V nicking. Ears: Tympanic membranes are pearly gray. No cerumen blockage noted. Hearing intact. No signs of ear infection or discharge. No signs of lesions or sores. No signs of redness of discharge. AC > BC. Weber midline. Nose: Midline septum. Nasal patency intact. Mucosa pink. No signs of sinus tenderness. Mouth: Oral mucosa moist and pink. Patient’s uvula is midline and has gag reflex. Tongue midline. Dentition good. Tonsils are present. Pharynx is without exudates.

Neck: Patient has no masses, Full ROM. No tenderness or swelling of lymph nodes. Trachea in a midline position. No bruit. No signs of JVD distention. Thyroid isthmus not palpable. No lymphadenopathy.

Pulmonary: Symmetrical chest wall. Breath sounds clear to auscultation bilaterally. No adventitious breath sounds heard. No scars or lesions. Bilateral tactile fremitus.

Physical Examination

Mr. T.J is a 65-year-old white Hispanic male who is overweight and tall. His speech is clear and coherent. T.J is cooperative, proper and responds well to questions. He is well nourished, well-groomed and dresses appropriate.

Cardiovascular: Regular heart rate and rhythm. Normal S1 and S2 sounds. No signs of S3 or S4 heart sounds. No murmurs heard on auscultation. No JVD distention. Capillary refill less than 3, pulses are equally 2+ bilateral. No signs of bruits. Edema notable on lower extremities. Last EKG 05/2020, Normal.

Breast (Male Patient): No lumps. No tenderness or discharge. No redness or swelling. Breast normal. Symmetrical. No signs of masses.

GI: Abdomen soft nondistended. No bruits. Normal bowel sounds. Scar noted on the right lower abdomen from appendectomy at age 26. Normal bowel sounds in all 4 quadrants. Spleen and kidney not felt. No CVAT tenderness. Liver span 8cm on the right midclavicular line, the edge is smooth and palpable 1 cm below the right costal margin.

Male/female genital: No lesions. No masses. No penal lesions or discharge. Normal distribution of hair. Normal scrotum. Patient is circumcised. No masses or tenderness on testes. No signs of epididymitis.

Rectal: Stool brown, negative for occult blood. No masses noted.

Musculoskeletal (upper and lower): Muscle strength intact. Edema noted on lower extremities. Lower and upper extremities with full ROM intact. Varicose veins on both legs. Pulses week on lower extremities 1 +. Muscle strength 5.

Neuro: Mental status: Alert, oriented x4. Speech clear and thoughts are coherent. Cranial nerves: II-XII intact. Motor: Good muscle bulk and tone. Strength 5/5 in all extremities. Cerebellar: Posture erect. Unsteady Gait, limping noted. Scoliosis not present. RAM and point-to-point movement intact. Sensory: Stereognosis, vibration, pinprick, light tough and position sense intact. Reflexes: Brachioradialis and biceps reflexes 2+ bilaterally. Patellar 2+ bilaterally.

Psychosocial: Appropriate mood and affect.

Physical Examination con…

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Diagnosis A/ Differential Diagnosis

Principal Diagnosis

Hypertension

Peripheral Arterial Disease

Hypertensive retinopathy

Differential Diagnosis

Kidney disease

Whitecoat hypertension

Masked hypertension

Diabetes

Obstructive sleep apnea

The principal diagnosis for Mr. TJ is hypertension. To measure HBP, the doctor places an inflatable arm on the patient’s arm and uses the measuring gauge to measure high blood pressure (Gabb et al., 2015). A clinician uses a pressure cuff to measure the BP. The cuff is placed on the upper arm. When inflated the cuff compresses the artery. The clinician monitors the electronic readout. The patient’s description of chronic hypertensive damage, headaches, difficulty sleeping, and swelling of lower extremities, provide rationale for differential diagnosis because they are unique for hypertension. The potential organ dysfunction include eyes, brain, bone loss, and the kidney (Dunphy et al., 2015).

Diagnosis: Hypertension

Pharmacologic treatment: Lisinopril 40mg orally once a day and hydrochlorothiazide 12.5mg orally once a day.

Diagnostic Tests: ECG, echocardiogram and chest X-ray

Education: Begin a dash diet, exercise at least 3 to 4 times a week, stress management approaches and avoid alcohol consumption.

Referrals: Referral to cardiologist

Follow-up: Follow-up visit every 3 to 6 months to determine effectiveness and adherence to the regimen.

Anticipatory Guidance: Ensuring that the recommended diet is followed as well as exercise instructions. Take medications as instructed. Monitor your blood pressure daily. Patient is to inform physician if any adverse effects occur right away. Begin

disease and self-management program.

Hypertension

Lifestyle changes are crucial when managing hypertension . Health experts recommend taking healthy foods. The patient should take a diet with fruits, whole grains, vegetables, and fish (Dunphy et al., 2015). Get enough potassium to help regulate blood pressure. Also, decrease the consumption of salt. Patients should limit the sodium level below 2, 300mg every day. Keeping a healthy weight is vital when regulating blood pressure. Another important activity is increased physical activity. Simple exercises like sit ups help to lower the blood pressure.

Peripheral Arterial Disease

Diagnosis: Peripheral Arterial Disease Pharmacologic treatment: Clopidogrel 75 mg once a day

Diagnostic Tests: Ankle-brachial index, Ultrasound and Angiography

Education: Abstain from nicotine, Control hypertension, Dietary control must include limitation of fat and salt intake.

Referrals: Referral vascular surgeon

Follow-up: Follow up every 3 months to assess the effectiveness of lifestyle changes, skin care, and management of ulcers.

Anticipatory Guidance: Ensuring that the recommended diet is followed as well as exercise instructions. Take medications as instructed. Monitor your blood pressure daily. Daily foot care that includes inspecting feet daily for sores, ulcers, and abrasions, including the use of a mirror to check the soles of the feet.

Patients who have been diagnosed with PAD should be counseled about the modification of risk factors. They should totally abstain from nicotine. It is essential to

control hypertension and diabetes if present. Dietary control must include limitation of fat and salt intake. Patients must be taught to do meticulous daily foot care that includes inspecting feet daily for sores, ulcers, and abrasions, including the use of a mirror to check the soles

of the feet. Patients should not walk barefoot and should wear well-fitting supportive shoes. They should not soak their feet and should be careful trimming their nails. All patients should be taught to watch for the signs and symptoms that might indicate progressive ischemia, such as increased pain, increased pallor or cyanosis, and rest pain (Dunphy & Winland-Brown, 2015).

Hypertensive retinopathy

Diagnosis: Hypertensive retinopathy Pharmacologic treatment: Lisinopril 40mg orally once a day and hydrochlorothiazide 12.5mg orally once a day.

Diagnostic Tests: Fluorescein Angiography Education: Regular physical activity, reducing salt intake, and limiting the amount of caffeine and alcoholic beverages you drink. Control BP.

Referrals: Ophthalmologist

Follow-up: Follow-up visit every 3 to 6 months to determine effectiveness and adherence to the regimen.

Anticipatory Guidance: Ensuring that the recommended diet is followed as well as exercise instructions. Take medications as instructed. Monitor your blood pressure daily.

Health Maintenance/Anticipatory Guidance: Last colonoscopy, 05/2018, Normal. Patient will be scheduled for next colonoscopy 05/2023. Last digital rectal exam 01/2020, Normal. Patient will be scheduled for next one DRE 01/2021. Last MRI for migraine, 06/2018, Normal. Last chest X-Ray, 04/2020, Normal. Last EKG 05/2020, Normal.

Patient educated on importance to check BP daily.

Begin disease and self-management program.

Begin AA program.

Scheduled Influenza vaccine October 2021.

Scheduled Pneumococcal vaccination 2028.

COVID19 vaccination scheduling pending until vaccine is available.

Scheduled digital rectal exam for 01/2021.

Scheduled colonoscopy for 05/2023.

Instructions on daily foot care that includes inspecting feet daily for sores, ulcers, and abrasions, including the use of a mirror to check the soles of the feet.

Health Maintenance/Anticipatory Guidance:

Current Practice Guidelines

The primary prevention of hypertension should focus on exercise, obesity, and cardiovascular risk. Uncontrolled hypertension leads to organ damage. It is, therefore, vital to control hypertension and maintain a healthy lifestyle as emphasized by (Whelton et al., 2016). Improve opportunities for treatment and control of HTN. Health-care providers can help break down barriers to diagnosis and treatment of HTN (Dunphy & Winland-Brown, 2015). The key to HTN management is not only the reversal of HTN-related disease trends but also the prevention of target organ damage (Dunphy & Winland-Brown, 2015). It is important to educate the patient to stop alcohol consumption as well as smoking. For most patients with newly diagnosed HTN, therapeutic lifestyle changes should be tried for 1 month. If not effective in lowering the BP after 1 month, add pharmacological therapy. (Dunphy & Winland-Brown, 2015).

Current Practice Guidelines

Role of the Nurse Practitioner

The nurse practitioner should detect, refer and schedule follow up for the patient to better control his BP.

The nurse practitioner should also order diagnostic test and prescribe medication to manage the patient’s BP

Nurses complement and supplement physicians care for hypertension patients (Barnes, 2015)

Offer patient education and counselling services.

Also lead community-based research about hypertension

Nurses identify patient problems and resolve them accordingly.

Help with performance measurement and quality improvement.

The role of nurses in improving HBP control has expanded recently. The role of a nurse practitioner goes beyond problem identification. They also help resolve related issues. They play a vital role to complement the physician’s work by monitoring blood pressure. Nurses also detect, refer, and make follow-ups about clients. They provide vital education and counselling services for different patients.

References

Barnes, H. (2015, July). Nurse practitioner role transition: A concept analysis. In Nursing Forum (Vol. 50, No. 3, pp. 137-146).

Dunphy, L. M., Winland-Brown, J., Porter, B., & Thomas, D. (2015). Primary care: Art and science of advanced practice nursing. FA Davis.

Eidelson, S. (2019). Blood tests and other laboratory tests. Spineuniverse. https://www.spineuniverse.com/exams-tests/blood-tests-other-laboratory-tests

Gabb, G. M., Mangoni, A. A., Anderson, C. S., Cowley, D., Dowden, J. S., Golledge, J., ... & Schlaich, M. (2016). Guideline for the diagnosis and management of hypertension in adults—2016. Medical Journal of Australia, 205(2), 85-89.

Harvard Medical School (2019). New guidelines for high blood pressure diagnosis and treatment. Harvard Health Publishing. Retrieved from. https://www.health.harvard.edu/staying-healthy/new-guidelines-for-high-blood- pressure-diagnosis-and-treatment

References

Kumar, N., Khunger, M., Gupta, A., & Garg, N. (2015). A content analysis of smartphone–based applications for hypertension management. Journal of the American Society of Hypertension, 9(2), 130-136.

Labtests Online. (2018). Hypertension. https://labtestsonline.org/conditions/hypertension

Mientka, M. (2014). High blood pressure in middle age may hamper your memory and thinking. Medical Daily. https://www.medicaldaily.com/high-blood-pressure-middle- age-may-hamper-your-memory-and-thinking-later-287088.

SCAI (2014). Medications for treating high blood pressure (hypertension). http://www.secondscount.org/treatments/treatments-detail-2/medications-treating- hypertension-2#.X33r7mgzbIU