reserved for Expert_Researcher
Health and Physical Assessment Form
| Name (Initials): | Date: | Time: 09:45 am | ||
| CA | Age: 68 | Sex: female | ||
| SUBJECTIVE Data | ||||
| Chief Complaint (CC): “My blood pressure is higher than normal and headaches”
| ||||
| History of Present Illness (HPI): Patient 68 years old female with Atherosclerosis of aorta, Hypertensive heart disease, Chronic Atrial Fibrillation, Diabetes Mellitus type II, and Mixed hyperlipidemia. The patient is coming today to manage her blood pressure. Patient complains of uncontrol blood pressure over the last week, denies any pain or aggravating factors. | ||||
| Medications: Atenolol 50 mg tablet, one tablet every 12 hours for Essential Hypertension and Chronic Atrial Fibrillation Xarelto 20 mg tablet, one table with food once a day for Chronic Atrial Fibrillation GlipiZIDE 5 mg tablet, one table every 12 hours with meal for Diabetes Mellitus type II Simvastatin 40 mg tablet, one table at bedtime for Hyperlipidemia and Atherosclerosis of Aorta Omeprazole 20 mg tablet, once a day for Gastro-esophageal reflux disease No over the counter medications Medication Intolerances: None
| ||||
| Past Medical History (PMH) Atherosclerosis of aorta, Essential Hypertension, Pulmonary Hypertension, Chronic Atrial Fibrillation, Diabetes Mellitus type II, Peripheral Vascular disease, Mixed hyperlipidemia and Gastro-esophageal reflux disease. Allergies (Drugs, Food, and Environmental): None Tobacco, alcohol, or illicit drug use in the past: Caffeine use 1-2 times a day, denies tobacco or alcohol use.
Chronic Illnesses/Major traumas: Atherosclerosis of aorta Essential Hypertension Pulmonary Hypertension Atrial Fibrillation Diabetes Mellitus type II Hyperlipidemia Gastro-esophageal reflux disease. History of any illness: Childhood: Tonsillectomy, chicken pox, and mumps. Adult: Atherosclerosis of aorta, Essential Hypertension, Pulmonary Hypertension, Chronic Atrial Fibrillation, Diabetes Mellitus type II, Peripheral Vascular disease, Mixed hyperlipidemia and Gastro-esophageal reflux disease. Ob/Gyn: Nulligravida, Hysterectomy Psychiatric: None Hospitalizations/Surgeries: Tonsillectomy during childhood Hysterectomy 35 years ago TEE with cardioversion 2015
| ||||
| Family History None | ||||
| Social History Patient is a widow, nulligravida who lives with his younger sister. Consume caffeine 1-2 times a day, currently smoker and denies drugs or alcohol use. | ||||
| ROS | ||||
| General Denies any recent weight or energy levels changes. No fatigue or sleep disturbance.
| Cardiovascular No chest pain or palpitation, denies shortness of breath or swelling in the extremities.
| |||
| Skin Denies lesion, rashes or discoloration, nor bleeding or bruises.
| Respiratory No SOB or productive cough. Denies TB exposure or symptoms. Currently smoker.
| |||
| Eyes Denies blurred vision, vision deficits or any use of corrective lenses or glasses. | Gastrointestinal Denies constipation, or diarrhea, no abdominal discomfort, normal appetite. | |||
| Ears No pain, vertigo or discharge, denies any hearing change. | Genitourinary/Gynecological Continent to urine, denies pain or hematuria, normal urine flow, no sexual active. | |||
| Nose/Mouth/Throat Denies nasal discharge/bleed, smell or sinus problems. No mouth dryness, dentures or lesion. No swallowing difficulty, sore throat, or inflamed glands.
| Musculoskeletal No muscle pain, swelling or fractures. Denies stiffness or spasticity. | |||
| Breast Denies discharge, pain, lumps or masses. | Neurological Denies paresthesia, unsteady gait, or weakness. No dizziness or loss of consciousness, Memory intact. Occasional headaches, worsen with high blood pressure. | |||
| Heme/Lymph/Endo No temperature intolerance, swollen glands, changes in appetite, thyroid imbalance. Confirms history of diabetes. | Psychiatric No sleep disturbances, suicidal ideation, or depression or anxiety. Denies abuse of substances. | |||
| OBJECTIVE Data | ||||
| Weight 196 lb BMI 31.6 kg/m2 | Temp 98.6 | BP 168/83 mm/HG | ||
| Height 66 in | Pulse 87/ min | Resp 17/ min | ||
| General Appearance Well developed, well nourished, and well groomed, no deformities, no acute distress, normal gait and posture. | ||||
| Skin Warm and moist without suspicious lesions. Nail beds pink without clubbing. | ||||
| HEENT Head: normocephalic and atraumatic Eyes: Pupils equal, round and reactive to light and accommodation. EMO’s intact. Acuity 20/20 (R); 20/20 (L). Ears: ear canals without redness, pain or irritation, tympanic membranes clear, pearly and intact. Neck: trachea at midline, negative for masses, no thyromegaly, no jugular veins distention, no cervical lymphadenopathy Nose: Pink mucosa, no epistaxis, septum at midline, no tenderness in the maxillary or frontal sinuses. Throat: no lesion, swelling or bleeding gums. no tonsils. Pharynx erythematous. | ||||
| Cardiovascular S1 and S2 normal, PMI non-displaced. No murmurs or rubs. 2+ carotid pulse bilaterally, no bruits. Capillary refill 3 seconds. No peripheral edema noted. | ||||
| Respiratory Normal appearance, symmetrical chest wall expansion, trachea at midline, expiratory wheezing, resonant and clear. | ||||
| Gastrointestinal Soft, non-tender, active bowel sounds present x4, tympanic, no rebound, no guarding, and no organomegaly.
| ||||
| Breast No masses, no discharge, axillae without masses. | ||||
| Genitourinary No assessed
| ||||
| Musculoskeletal Full range of motion and normal appearance of all joints of upper and lower extremities. No pedal edema, normal gait. | ||||
| Neurological Alert and oriented x3, Cranial nerves II-XII intact. Normal gait, no motors deficits or sensibility noted. No papiledema. Clear and coherent speech. | ||||
| Psychiatric Alert and oriented, normal mood, no paranoid nor delusional, speech not pressured, normal sequence. | ||||
| Lab Tests Urinalysis-pending CBC-pending BMP-pending Lipid panel-pending TSH, free T3, free T4-pending Hemoglobin A1c-pending Wet prep - pending
| ||||
| Special Tests EKG- Shows persistent Atrial Fibrillation with normal ventricular response at 87 bpm. Renal Doppler ultrasound- order Mammogram screening Bone Density
| ||||
|
Differential Diagnoses and Diagnosis | ||||
| Differential Diagnoses
Final Diagnosis: Essential Hypertension (decompensated) I10 Other obesity due to excess calories E11.42 Atherosclerosis of aorta I 70.0 Other secondary pulmonary hypertension I 27.2 Chronic atrial fibrillation I 48.2 Diabetes Mellitus type II without complications E11.9 Mixed hyperlipidemia E78.2 Gastro-esophageal reflux disease without esophagitis K 21.9 Encounter for Mamogramm screening Encounter for osteoporosis Z13.820 Body mass index (BMI) 31.0-31.9, adult | ||||
| Plan/Therapeutics | ||||
Others: Continue with current medications. Referral to Cardiologist for decompensated Essential Hypertension. Preventive Medicine: Education provided: Low cholesterol/sodium diet Remains physically active Drink plenty of fluid Prevent falls Follow up in two weeks
| ||||
|
Evaluation of patient encounter | ||||
| Strengths: interview process, recalling subjective data, stablishing professional relationship with the patient. Weakness: differential diagnosis, documentation, complete head to toe assessment To improve my weakness, I will enrich my knowledge about disease process, practice more the documentation and complete patient assessment. | ||||
Lisinopril is an ACE inhibitor that works on essential hypertension by blocking angiotensin converting enzyme, thus reducing angiostensin II production. Angiostensin II is responsible for controlling BP naturally by constricting and narrowing blood vessels to increase BP. By reducing its production, blood vessels widen and relax to reduce BP. The drug is used in diabetics because it reduces blood vessels constriction in the kidney to improve overall kidney function. This reduces the high risk of kidney issues that may develop in diabetics. More so, through this mechanism, it improves the function of other organs to reduce major cardiovascular events, coronary heart disease and stroke risk by 20-30% in diabetics who are at risk of these conditions. It is associated with a reduction of all-cause mortality in diabetics (Cruickshank, 2012).
Essential hypertension has a highly complex and multi-factorial pathophysiology. Most often, changes in renal, vascular and cardiac function are responsible for arterial pressure increase that eventually leads to established hypertension. Increase in cardiac output, which mediates arterial pressure increase, is attributed to increase in stroke volume and heart rate. Dysfunction of vascular endothelial cell also because reduced relaxing factors derived from endothelium, such as prostacyclin, nitric oxide, as well as, endothelium-derived hyperpolarizing. It may also cause high production of thromboxane A2 among other contracting factor. This also goes for increase signaling pathway activity related to contraction of vascular smooth muscle, including protein kinase C, Rho kinase and [Ca (2+)] that increase vasoconstriction. Over time, the excessive vasoconstriction and vascular relaxation cause increased arterial pressure and peripheral vascular resistance, especially as a person ages. Factors causing changes in the way kidney regulates fluid cause water and salt retention that in return cause increase in cardiac output and plasma volume leading to arterial pressure increase. More so, when rennin-angiotensin system is activated to raise angiotensin II levels, generally vasoconstriction occur and at other times kidney vasoconstriction occur cause water and salt retention that eventual cause arterial pressure increase. Essential hypertension is often asymptomatic until it develops to become serious. At this time, the patient may display malignant hypertension, which is dangerous and serious with symptoms such as confusion, vomiting and headache. A patient may also experience complications such as heart disease without being aware they have hypertension (Cruickshank, 2012).
As per BMI, obesity is considered having a BMI greater or equal to 30. When offering patient education to facilitate obesity prevention, focus should be on educating the patient to maintain a healthy BMI of 18.5 to a BMI of <25, which is considered within normal limits. Interventions should be on controlling all factors that mediate obesity, such as stress, lack of physical activity and poor dietary habit. Hence, focus is on teaching the patient how to manage stress, engage in regular physical activity and eat health while observing portions (Center for Disease Control and Prevention, 2017).
References
Center for Disease Control and Prevention. (2017). Defining adult overweight and obesity. Retrieved from https://www.cdc.gov/obesity/adult/defining.html
Cruickshank, J. M. (2012). Essential hypertension. London, LND: PMPH-USA.
