Adult Health Case study Hypertension

Adult Health Case study Hypertension

Adult Health Case study

Hypertension

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%