due 3-24-23. NU610 Unit 3 Case Study

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Chief Complaint

The patient is being seen for an annual wellness exam.

History of Present Illness

The patient, Mrs. J, reports a history of hypertension for the past five years. She has been

managing the condition with medication that has effectively controlled her blood pressure

readings. However, in the past month, Mrs. J has been experiencing occasional headaches

and dizziness. Patient last recorded home reading yesterday was bp 139/85, pules 100 bpm.

According to Erkinovna (2021), these two symptoms are vital hallmarks of high blood

pressure.

Mrs. J reports that her blood pressure readings at home have been slightly elevated compared

to her usual readings. She denies any chest pain, shortness of breath, or difficulty breathing.

She also reports no changes in her urinary or bowel habits. Upon further questioning, Mrs. J

reports feeling more tired than usual and having difficulty sleeping. She attributes this to

increased stress in her personal life and family matters. She reports feeling overwhelmed and

anxious at times. However, research indicates that poor sleep quality can be associated with a

higher classification of hypertension; therefore, her condition may be severe (Mariana et al.,

2019).

Physical examination reveals her blood pressure is elevated at bp 135/82, pules 100 bpm

compared to her usual readings. No other significant findings are noted on examination. The

history suggests that, despite taking her current medications. Her raised blood pressure levels,

and increased stress may be responsible for her recent symptoms of headaches, light-

headedness, weariness, and trouble sleeping.

Mrs. J was advised to keep track/document of her blood pressure measurements and monitor

them at home reporting. She is advised to consume a low-sodium diet and frequent exercise

to help manage her blood pressure. Moreover, her provider advised her to adopt stress-

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reduction methods, including meditation and deep breathing exercises to control her stress

levels.

Pain Assessment

Mrs. J reports occasional headaches that have bothered her for the past month. She describes

the pain as a dull, throbbing sensation on both sides of her head. She rates the intensity of the

pain as a 5 out of 10 on a scale of 0 to 10, with 0 being no pain and 10 being the worst

possible pain. Mrs. J reports that the headaches usually last a few hours and occur once or

twice weekly. She notes that the headaches are more frequent in the afternoon and evening.

Headaches are currently being treated with importance in academia as their effect, especially

on intracranial hypertension, is not understood. However, it is a factor that significantly

impacts the quality of life for hypertension patients. She denies any visual disturbances or

nausea accompanying the headaches.

Allergies

No known allergies to medications or foods.

Not allergic to latex

Denies any history of allergic reactions.

No recent exposure to new medications or foods.

No known allergies to report.

Immunizations

Up to date on all vaccinations.

The patient received her last flu shot during the previous flu season.

The patient is current with her routine vaccinations and only requires her annual flu shot.

Medications

At-home medications: Amlodipine 5mg once per day and Hydrochlorothiazide 25mg once

per day for hypertension.

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Takes 600 mg over the counter acetaminophen for 3/10 occasional headache. Vitamin D (20

mcg once per day).

Hospitalization

No recent hospitalizations.

Past Medical History

For the previous five years, the patient has reported having hypertension. Her primary care

physician initially diagnosed and prescribed medication to treat her condition (Amlodipine

5mg once per day and Hydrochlorothiazide 25mg once per day for hypertension.

). She mentions sporadic headaches but denies experiencing any palpitations, shortness of

breath, or chest pain. During the previous two years, the patient has reported having

hyperlipidemia. She has been treated with dietary adjustments and increased physical

activity, among other lifestyle changes. She has never experienced a heart attack, stroke, or

coronary artery disease. The patient states that she has had osteoporosis for the past ten years.

She has been supplementing her vitamin D (20 mcg once per day) intake and doing weight-

bearing exercises to stop bone loss. She states that she has no prior history of bone fractures

or injuries. Asthma, chronic obstructive lung disease, thyroid disease, diabetes, and asthma

are denied.

Surgical History

The patient does not have a history of surgeries.

Previous Hospitalizations

The patient reports no previous hospitalizations or surgeries.

Gynecological/ mammogram/ wheelwomen’s exams History

The patient, who is 51 years old, reports going through menopause but says she has no recent

vaginal bleeding or discharge. Last pap smears two years ago and was unremarkable.

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Mammogram completed 3/10/22. The patient reports that last intercourse was one year ago

with her husband. She reports that she never experienced pelvic pain or discomfort.

Additionally, she reports two pregnancies and two vaginal births. She states that she has

never had any STIs or abnormalities. The patient states that she used contraceptives in the

past, this was the only birth control method, from her late 20s up to around age 45.

Family History (3 generations)

On the father's side of the family, the patient reports a positive family history of diabetes,

high cholesterol, and hypertension. Her paternal grandfather had a history of colon cancer

and also suffered from hypertension, diabetes, and high cholesterol. Both hypertension and

hypercholesterolemia were present in her paternal grandmother. Her father had a history of

hypertension, high cholesterol, and type 2 diabetes, and he died in an automobile accident at

58. While Mrs. J's sister has asthma, her brother is supposedly healthy.

Mrs. J reports a history of hypertension and excessive cholesterol on her mother's side of the

family. Her maternal grandmother had a history of high blood pressure and cholesterol and

died at 73 from a stroke. On the other hand, her maternal grandfather, who had a history of

hypertension and excessive cholesterol, suddenly away at the age of 78 from what was

thought to be a myocardial infarction. The 82-year-old grandmother of Mrs. J suffers from

hypertension and is still alive. The patient's responses align with the literature, highlighting

that a family history of hypertension increases an individual's risk of developing the condition

(Cuffee et al., 2021; Gando et al., 2018).

Social History

Mrs. J reports completing high school and attending some college courses but not completing

a degree. She reports working as a teacher for 30 years before retiring. Mrs. J reports that she

lives on a fixed income and has no significant financial concerns.

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Mrs. J reports being married for 45 years to her husband, who is also retired. They have two

adult children Samuel 30 and Ben 34 who are both married and living in other states. Mrs. J

reports having regular communication with her children through phone and video calls.

Mrs. J reports being an active member of a local church community and attending services

weekly. She reports no current tobacco or alcohol use and denies illicit drug use. Mrs. J

reports repots that she is a regular member of her Christian church and sings on the church

choir every Sunday.

Review of Systems

General: The patient reports occasional fatigue and difficulty sleeping due to work-

related stress.

Head: Reports headaches that occur monthly rated 3-4/10 and effectively managed

with 600 mg over the counter acetaminophen.

Ears: Mrs. J reports no difficulty hearing, ringing or noises in her ears, she state no

discharge or ear pain.

Eyes: Mrs. J reports episodes of blurred vision linked with reading and wears reading

glasses. Last eye exam 2/13/22.

Nose: Mrs. J reports no complain of obstruction, runny nose, or rhinitis.

Mouth: Mrs. J state she her last dental exam was 4/20/22 she has no dental problems,

changes in taste oral, wounds, or xerostomia.

Throat and Neck: Mrs. J reports no changes voice difficulty swallowing or sore

throat. She has no goiter or repots of hyper/hypothyroidism.

Respiratory: Mrs. J reports no history of bronchitis, pneumonia, or TB. Denies

difficulty breathing or uncontrollable cough.

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Cardiovascular: A history of hypertension and reports taking medications as

prescribed. Reports no palpitations occasional dyspnea on exertion.

No orthopnea paroxysmal nocturnal dyspnea or peripheral edema. No varicosities, no

pain in feet or hands. Denies blanchin in her fingertips in cold climates.

Gastrointestinal: She does not have any digestive troubles, GURD, deficulty

swallowing, unexplained vomiting or nausea, constipation. diarrhea, jaundice, or

bloody stools. Reports no liver or gallbladder disease.

Genitourinary: Denies flank pain, frequency, burning, and cloudy urine. Denies

history of recurrent urinary tract infections. Denies vaginal discharge and vaginal

itching. No history of sexually transmitted infections. Two pregnancy live birth via

vaginal deliveries.

Musculoskeletal: Mrs. J reports no history of gout, broken bones, or arthritis. No

reports of weakness. Exercise twice per week by walking one mile with church

friends.

Neurological: Denies episodes of vertigo, seizures, weakness, dizziness, numbness,

tingling in extremities or paralysis. Denies history of TBI or changes in memory

Skin, Hair, and Nails: Reports occasional dry skin predominantly in winter.

Psych: The patient reports feeling generally well emotionally and has no concerns

about their mental health. Mrs. J reports no history of depression, thoughts of harming

self or others.

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References

Cuffee, Y. L., Wang, M., Geyer, N. R., Saxena, S., Akuley, S., Jones, L., & Wilson, R. T.

(2021). Vitamin D and family history of hypertension in relation to hypertension

status among college students. Journal of Human Hypertension.

https://doi.org/10.1038/s41371-021-00577-6

Erkinovna, T. D. (2021). Modern understanding of the occurrence of cognitive impairments

in arterial hypertension and their correction. Asian journal of pharmaceutical and

biological research, 10(3).

Gando, Y., Sawada, S. S., Kawakami, R., Momma, H., Shimada, K., Fukunaka, Y., Okamoto,

T., Tsukamoto, K., Miyachi, M., Lee, I-Min., & Blair, S. N. (2018). Combined

association of cardiorespiratory fitness and family history of hypertension on the

incidence of hypertension: a long-term cohort study of Japanese males. Hypertension

Research, 41(12), 1063–1069. https://doi.org/10.1038/s41440-018-0117-2

Mariana, E. R., Zainab, A., & Amalia, M. (2019). Descriptive Quality of Sleep to Clients

with Hypertension. Indian Journal of Public Health Research & Development,

10(12), 1692. https://doi.org/10.37506/v10/i12/2019/ijphrd/192106