05 Oct Case Study CC: “I would like my blood pressure checked.”

Case Study

CC: “I would like my blood pressure checked.”

 

HPI: 65 y/o F presents to the facility as a new patient requesting her blood pressure be checked. She was feeling dizzy yesterday, and she went to the pharmacy’s electric cuff and her blood pressure was found to be 189/112. She stated once she got home and took a shower the dizziness resolved on its own. She has no significant medical history. At this time, she denies any lightheadedness, dizziness, nausea, vomiting, headache, chest pain, shortness of breath or blurred vision. Has never had elevated blood pressure in the past. She denies increase stress, tobacco or ETOH use. She has not been using NSAIDs and has not been on any recent medications. She described the dizziness as constant, did not notice if movement made it worse. Did not feel like the room was spinning and denies feeling unsteady on her feet. She denies headache, weakness, visual changes, ear pain/fullness, numbness or tingling. This has never happened before.

 

 

 

PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS: denies any medical, surgical or hospitalizations history

 

Allergies: No known allergies.

 

MEDICATIONS: None; denies herbal supplements or OTC medications.

 

FAMILY HISTORY / PERSONAL HISTORY: Mother died from MVA at the age of 55. Never knew her father. Sister (68) is morbidly obese with a PMH of diabetes and HTN. Maternal grandmother died at age 58 breast cancer. Maternal grandfather died at age 78 due to CAD.

 

Health Promotion: She has not been to the family doctor in 5 years, will seek urgent care if feeling ill.

 

 

 

 

 

ROS:

 

General: Patient denies fatigue, fever, chills, malaise, night sweats, unexplained weight loss or weight gain, loss of appetite, difficulty sleeping.

 

Skin: No changes in skin, rash, itching, nail deformity, hair loss, moles, open areas, or bruising.

 

HEENT: Denies headaches or hx of vertigo. Denies loss of vision or blurry vision. No complaints of ear drainage or pain. Denies nasal congestion, sinus pain, facial pressure or rhinorrhea Denies sore throat. Denies difficulty swallowing

 

Neck: Denies lumps, pain, or swollen glands

 

Respiratory: Denies cough, wheezing, or shortness of breath. Cardiovascular: Denies chest pain, palpitations, dyspnea, or orthopnea.

 

Gastrointestinal: Denies abdominal pain. Denies nausea, vomiting, diarrhea, constipation. Last bowel movement was today.

 

Genitourinary: No CVA tenderness, dysuria or hematuria. Peripheral vascular: Denies pain or swelling in extremities

 

Musculoskeletal: Denies pain on bones, muscles, and joint. Denies joint swelling, stiffness, weakness, or joint or back pain. Normal ROM

 

Neurological. Denies any behavioral changes or difficulty of concentrating. Denies fainting, seizures or motor sensory loss. Denies headache. Pt c/o one episode of dizziness yesterday that resolved with shower. Dizziness was not aggravated by any factors. She denies room spinning or feeling unsteady on

 

 

 

her feet.

 

Endocrine: Denies increase thirst or urination. Denies thyroid enlargement or tenderness, no unexplained weight gains or loss.

 

Psychiatric. Denies suicidal ideation, depression, mood swings, or hallucinations.

 

 

 

 

 

Objective:

 

VS: Temp- 98.4 F (oral), BP- 129/86, HR- 71, 99% on room air, Resp 18, Height- 5’7″, Weight- 135 lbs.; BMI 21.1.

 

General Appearance: Affect and facial expression appropriate to situation, patient well-nourished and appears stated age. Does not appear in acute distress.

 

Skin: Skin warm, dry and intact. No lesions present.

 

HEENT: Normocephalic. Normal conjunctiva. PERRLA. Tympanic membranes pearly gray, intact, with visible ossicles. Oral mucosa moist. No pharyngeal erythema or exudate noted. Thyroid palpable, no nodules or enlargement noted.

 

Neck: Supple, trachea midline, non-tender, no JVD. No lymphadenopathy.

 

CV: Regular rate and rhythm, S1/S2. No murmur, Chest wall non-tender. No deformity noted on the chest.

 

Lungs: Lungs are clear to auscultation and equal bilaterally, symmetrical chest expansion; respirations are regular and non-labored.

 

Gastrointestinal: Abdomen is soft, non-tender, non-distended. Bowel sounds present in all quadrants. No guarding, no rebound, no hepatosplenomegaly

 

Genitourinary No CVA tenderness or suprapubic pain.

 

Peripheral vascular: Peripheral pulses normal and equal in all extremities. No edema noted on extremities.

 

Musculoskeletal: Normal active ROM, gait steady.

 

Neurological: Alert and oriented to person, place, time and situation. CN II-XII intact, PERRLA, EOM intact. Deep tendon reflexes +2. Cerebellar assessment intact. Strength in all extremities 5/5. Fine motor skills and sensory intact. Psychiatric: Appropriate mood and affect. Cooperative.

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