J.W. is a pleasant, 56-year-old male who presents to the office for a one month follow up on Blood Pressure and lab results. Patient’s lab results are within normal range except Lipid panel and HAIC. Patient’s blood pressure is elevated after checking it in the office BP 168/102. Patient decided to follow conservative approach including lifestyle modifications, low fat diet, gradual exercise program to lower his BP on last office visit. Despite making some lifestyle modification such as cutting down alcohol, salt intake, and walking 3 times a week, Blood Pressure is still elevated, and home BP logs also show elevated Blood pressure. Patient is going to need medication along with lifestyle modifications to manage his blood pressure.
Denies blurred vision, headaches, nosebleeds, chest pain, chest pressure, irregular heartbeat, fatigue, vertigo, syncope, increased sensitivity to cold, recent weight changes, edema, pain in bilateral lower extremities and muscle weakness. He also denies visual disturbances, excessive urination, excessive hunger, excessive thirst, numbness or tingling in hands and feet, sweating, dry skin, and nausea. Patient reported his work-related stress is well managed. He also reported history of allergies and get symptoms such as sinus pressure, watery eyes, and sneezing. Patient takes Sudafed and starts doing nasal irrigation that helps. He is concerned about his high blood pressure and is willing to get started on Blood pressure medication.
Mother – Died at age 74 of Stroke and had Diabetes
Father – Deceased at age of 60 of Heart Attack
Sister – Age 46 has Hypertension
Brothers – Age 54 has Diabetes and Hypertension
Occupation: Works as a Production Manager for local light Industry, Sedentary Job
Living Situation: Lives at home with his wife. Married for 30 years to the same woman. Has 3 daughters living at home. Feels safe at home
Childhood illnesses: None
Accidents or Injuries: None
Serious or Chronic Illnesses: Denies having any health problems
Medications: Pseudoephedrine OTC prn for allergies 2-3 times a month
ROS: Denies fever, chills, night sweats, weight changes, headaches, blurred vision, fatigue, changes in mentation or memory, chest pain, or pressure, palpitations, shortness of breath, muscle weakness or cramps, pedal edema, urinary problems.
Vital Signs: T 98.6, P 88 regular, R 20, BP 168/102, Height: 6’0” Weight: 247 BMI 33.5 Obesity
Heart: The external chest is normal and symmetric. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. S1, S2 heard. Regular rate and rhythm. No murmurs, gallops, or rubs. No Cartoid bruit or renal bruit. No edema.
Diagnostic Test and Results
Lab Tests Results: Cholesterol 230, Triglyceride 170, HDL 52, LDL 144. UA shows trace Protein
Blood Chemistry (K+, Cl-, Na+, BUN/Cr, AST, Alk Phos) and Liver Function studies WNL
- Hypertension (I10)
- Hyperlipidemia (E78.5)
- Diabetes Mellitus Type 2 (E11.9)
- Obesity (E66.9)
- Situational Stress (Z73.3)
- Hypothyroidism (E03.9)
- Renal Artery Stenosis (I70.1)
- Chronic Kidney Disease (N18.9)
- Hypothyroidism (E03.9)
- Liver Disease (K76.9)
- Metabolic Syndrome (E88.81)
Diabetes Mellitus Type 2 (E11.9):
- Prediabetes (R73.09)
- Cushing Syndrome (E24.9)
- Pancreatic Insufficiency (K86.81)
- Overweight (E66.3)
- Metabolic Syndrome (E88.81)
- Binge Eating Disorder (F50.81)
- Adjustment disorder (F43.20)
- Post-Traumatic Stress Disorder (F43.11)
- Acute Stress Reaction (F43.0)
Treatment: Medication and Diet and Lifestyle modifications
- Hydrochlorothiazide 12.5 mg oral 1 Tab Daily (Philip et al., 2021)
- Rosuvastatin 20 mg PO Daily
- Aspirin 81 mg PO Daily
Education: This medicine is used to treat high blood pressure. It lowers the risk of strokes and heart attacks in patients with high blood pressure (Di Palo & Barone, 2020). Patient has high blood pressure BP 168/102 which puts him in stage 2 hypertension category (Philip et al., 2021). Goal is to have SBP less than 120 and DBP less than 80.
Diet and Lifestyle Modifications:
- Reduce sodium intake, follow DASH diet. Cut down processed foods or fast foods
- Weight loss
- Increase activity: Engage in aerobic exercise at least 30 mins daily at least three times per week (Valenzuela et al., 2020). Aerobic exercises include walking, jogging/running, tennis, basketball, swimming or biking for 30 minutes or longer 3 days a week.
- Referral sent for Nutritionist/Dietician, follow up with them
- Enhanced intake of dietary Potassium
- Monitor blood pressure readings at home and keep the log. Bring the log next time
Diagnostics: comprehensive metabolic panel (CMP), Lipid Panel screening along with other labs in 3 months
Follow-up plan: 4 weeks for evaluation of medication adherence and assess for need for medication adjustments. Bring your blood pressure reading log with you. May consider adding Amlodipine 5 mg if Blood pressure is still elevated during the next visit. Will do labs in 3 months and review the results. Notify provider sooner if you experience any side effects, chest pains or shortness of breath.
|Nova Southeastern University Medical Clinic Florida |
Patient Name: J. W. Date: 04/11/2022
Take: 1 Tablet Daily
Di Palo, K. E., & Barone, N. J. (2020). Hypertension and heart failure. Heart Failure Clinics, 16(1), 99–106. Web.
Philip, R., Beaney, T., Appelbaum, N., Gonzalvez, C. R., Koldeweij, C., Golestaneh, A. K., Poulter, N., & Clarke, J. M. (2021). Variation in hypertension clinical practice guidelines: A global comparison. BMC Medicine, 19(1), 1–13. Web.
Valenzuela, P. L., Carrera-Bastos, P., Gálvez, B. G., Ruiz-Hurtado, G., Ordovas, J. M., Ruilope, L. M., & Lucia, A. (2020). Lifestyle interventions for the prevention and treatment of hypertension. Nature Reviews Cardiology, 18(4), 251–275. Web.