L. Writing Assignment

REVIE OF SYSTEM

Constitutional: No fever, severe weight loss, normal appetite, no generalized weakness.

Neurologic: Denies headache, tremors, seizures or gait imbalance, denies tics or numbness in lower extremities, no dizziness, no visual disturbances, slow speech and no behavior problems at this moment.

HEENT: Denies odontalgia, sore throat, hoarseness, ear pain/pruritus or hearing loss, report unable to swallow

Respiratory: Report shortness of breath, denied cough or chest pain.

Cardiovascular: No chest pain on anterior left hemi thorax, palpitations or intermittent claudication, no petechial or unexpected bleeding.

Gastrointestinal: Denied abdominal pain, vomit, diarrhea constipation.

Genitourinary: Denied bowel and bladder incontinent, no dysuria, polyuria, nocturia or oligura

Skin: Upon PE no redness on the body, no petechia, no rash, skin warm.

Musculoskeletal: Denied Pain, inflammation, redness

Objective

Vital Signs: BP: 142/88 mmHg, RR: 16’, HR: 83’, Temp: 97.3 F, SatO2: 99%, Weight:

178 pounds, height: 5’10”, BMI: >25

Neurologic: AAOx3, no central or peripheral focal neurological deficit, gross sensation, muscle tone and grip strength diminish, gait disturbances, unable to examine Romberg, Kernig's test and Brudzinski's signs.

HEENT: EOMs intact, PERRLA, no redness or discharge noted in the ear canal, pearly and no bulging tympanic membrane bilaterally, no jugular veins distention, no neck mass or enlarged lymph nodes. No white/yellow plaques or ulcers noted on palate, uvula or tonsils, no erythema noted on oropharynx. Normal results obtained after performing Rinne and Weber tests.

Cardiovascular: No murmurs, no collateral circulation, no edema, carotid, apical, radial femoral and pedal pulses present and strong, no carotid murmur bilaterally.

Respiratory: No cyanosis, rhonchi or crackles noted vesicular murmur present

bilaterally.

Gastrointestinal: Oral cavity with no lesions suggestive of malignancy, wet oral mucosa, abdomen soft, non-tender, non-distended, no hernias, no organomegaly, continent bladder and bowel movements daily.

Genitourinary: No genitalia pain, urine 2000 ml daily, continent, urine yellow, no odor.

Musculoskeletal: Muscle mass tonic, no weak, deformity, pain or other.

Intertegumentary: Skin dry, warm, no petequiae, rash or any other.

Assessment

ICD-10 I10 Essential (primary) hypertension

PlRIMARY DIAGNOSIS

Essential (primary) hypertension : Blood pressure is the force that a person's blood exerts against the walls of their blood vessels. This pressure depends on the resistance of the blood vessels and how hard the heart has to work. CITATION

Differential Diagnosis

Steroids use: This is a common health problem mainly in adolescents, liver damage may often occur, and liver cancer is a risk, the heart is at risk for damage in a various ways. In response to excess steroid in the body, the heart muscle may enlarge just like any other muscle in the body, this enlargement, or hypertrophy, can lead to decreased pumping ability as well as changes in the electrical conduction system in the heart causing rhythm changes, palpitations, and potentially sudden cardiac death. As well, steroids may cause high blood pressure, increased cholesterol levels, and elevated blood sugars, all of which are risk factors for heart attack and stroke. CITATION

Pheochromocytoma: A pheochromocytoma is a rare, usually noncancerous (benign) tumor that develops in an adrenal gland. Usually, this type of tumor affects one of your two adrenal glands, but it can affect both. Signs and symptoms of pheochromocytomas often include: High blood pressure, heavy sweating, headache, rapid heartbeat (tachycardia), tremors, paleness in the face (pallor), shortness of breath (dyspnea). CITATION

Acute vasculitis: It is inflammation of your blood vessels. It causes changes in the blood vessel walls, including thickening, weakening, narrowing or scarring. These changes can restrict blood flow, resulting in organ and tissue damage. General signs and symptoms of vasculitis include: fever, headache, fatigue, weight loss, general aches and pains, night sweats, rash, nerve problems, such as numbness or weakness . CITATION