Case Presentation Rubric: Chief Complaint And Pertinent Hist ✓ Solved

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Case Presentation Rubricchief Complain And Pertinent History

CASE PRESENTATION RUBRIC Chief Complain and pertinent history-10% of total result Pertinent exam and Diagnosis-10% of total result Working diagnosis and supporting criteria 5% of total result Management plan 5% total result Epidemiological data-cited from literature-10% of total result Evidence based rationale for treatment (literature based)-10% of total result Analysis of self-care and family issues related to diagnosis and treatment plan-20% of total result Evaluation parameters to be used (or were used) to determine outcomes-10% of total result Identify major lessons learned and how it may affect your future practice-20% of total result.

Patient Initials: KL Pt. Encounter Number:1 Date:02/04/2021 Age: 61 Sex: Female Allergies: KNA Advanced Directives: NONE SUBJECTIVE CC: My blood pressure has been high lately.

61 y/o Hispanic female, who came to the consult complaining of high blood pressure readings at home during the past week. Patient states that usually the diastolic keeps higher than 140 mm/Hg, patient brought the list of the measures during the last week. Patient has four checking between mm/Hg, the systolic has been between 80 to 88 mm/Hg. Patient has previous medical history of HTN controlled with Lisinopril 5 mg PO daily. Client does not practice exercise or follows a healthy diet.

Current Medications: Losartan 50 mg PO daily for HTN. Essential Primary Hypertension. Mammogram: - 2018 negative. Nutrition history: - Low sodium diet. Developmental history: - Unremarkable. Pap Smear: - 2019 negative. Blood transfusions: - Denies. Hospitalizations: - Denies. Childhood Illnesses: - Chicken pox.

Family History: mother: Deceased at 83, Heart Attack, Hypertension, Stroke father: Alive, Hypertension sister (first): Alive, CHF brother (first): Alive, HTN, CVA Social History: Tobacco: Never smoker Alcohol: Do not drink alcoholic beverages Drug Abuse: Denies use of illicit drugs Safety: Household Smoke detector / Keep Firearms in home / Wear seatbelts Sexual Activity: Not sexually active Birth Gender: Female Others: Place of birth - Cuba.

General Denies fever, chills, fatigue or weight loss. Patient has good appetite and admits sleeping well. Cardiovascular Denies chest pain, syncope, lightheadedness, palpitations, lower extremities edema or claudication while walking. Skin Denies rash, redness, ecchymosis, skin breakdown, edema, ulcer or any other skin lesion. Respiratory Denies SOB, fever, cough, hemoptysis, wheezing or cyanosis. Eyes Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain.

Gastrointestinal Denies abdominal pain, nausea, vomiting, diarrhea, constipation or blood in stools. Ears Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain. Genitourinary/Gynecological Denies dysuria, nocturia, frequency, incontinence, hematuria, burning or kidney stones. Denies breast discomfort or abnormal discharge from the nipples.

SOAP NOTE Nose/Mouth/Throat Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain. Musculoskeletal Patient denies joint pain, weakness, muscle pain or stiffness. Breast Denies any symptoms Neurological Denies headache, weakness, seizure, dizziness, tremors, falls, numbness, paralysis or speech difficulty. Heme/Lymph/Endo Denies any symptoms Psychiatric Denies any symptoms of depression, anxiety, agitation, memory loss, forgetful, insomnia or hallucinations. Denies suicidal thoughts.

OBJECTIVE Weight 64.5 BMI Temp96.7 BP135/84 Height5’5 Pulse76 Resp19 PHYSICAL EXAMINATION General Appearance Patient is alert, awake, oriented x 3. Well developed, well nourished. No acute distress noted. No fevers. No weakness. Pleasant and cooperative during the examination. Head: Normocephalic, atraumatic. Skin Pink, intact, warm to touch, no rash, normal turgor and no abrasions.

HEENT Head: Normocephalic, atraumatic. Eyes: PERRL. Extraocular muscle movements intact. Sclera non-icteric. Conjunctiva clear. Nose: No external lesions, mucosae non-inflamed, septum is midline. Ears: Non-bulging and pearl bilateral TM’s. Canals free of cerumen. Throat: Mucosa non-inflamed, no tonsillar hypertrophy or exudate. NECK: No lymphadenopathy, No masses, midline trachea. No carotids bruit. No jugular venous distention. Proper ROM.

Cardiovascular Regular rate and rhythm. S1 and S2 present. No murmur rubs or gallops. No S3. PMI non-displaced. No lower extremity edema. Peripheral pulses present and strong. EKG shows sinus rhythm. Respiratory No respiratory distress, unlabored respiratory effort, no wheezing or rhonchi, no use of accessory muscles to breathe. Vesicular murmur present bilaterally. No cyanosis. Gastrointestinal Abdomen soft, non-tender, non-distended. No masses. Bowel sounds present in all 4 quadrants. Breast Soft, symmetric, no discoloration or abnormalities noted.

Genitourinary Gynecological exam deferred today by patient. No nodules felt on breasts. No skin changes or abnormal discharge from the nipples. Musculoskeletal No clubbing, no joint swelling. No diminished ROM. Conserved Neurological AAO x 3. No cranial nerves deficits. No tremors, no gait imbalance, rigidity or myoclonus. No seizure activity. Strength 5 + on BUE/BLE. Tendon reflexes are intact bilaterally. Psychiatric PSYCH: The patient is cooperative, no anxiety, no suicidal ideation, calmed. Affect appropriate. Good mood. No agitation or depression noted.

Lab Tests CMP, CBC, Lipid profile, Urinalysis. Special Tests Diagnosis · Primary Diagnosis- Differential diagnosis:
 Acute pyelonephritis: Patient doesn’t complaint of back pain, urgency, fever, malodorous urine, hematuria, chills, no PMHx of kidney stones or recent respiratory infections, which makes pyelonephritis a less likely diagnosis. Hypothyroidism : There isn’t generalized weakness, recent weight gain, cold intolerance, syncope, faintness, dry skin, anterior neck mass or pretibial edema, BMI is less than 25; which point far from Hypothyroidism diagnosis.

Hyperthyroidism: No tachycardia, no nervousness, no heat intolerance, no diarrhea, no insomnia, no, weight loss, no neck mass, no recent infections. All previously mentioned makes Hypothyroidism a less likely diagnosis. Primary diagnosis: 1) Essential (primary) hypertension (I10): High blood pressure (BP), or hypertension, is defined by two levels by 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines: (1) elevated BP, with a systolic pressure (SBP) between 120 and 129 mm Hg and diastolic pressure (DBP) less than 80 mm Hg, and (2) stage 1 hypertension, with an SBP of 130 to 139 mm Hg or a DBP of 80 to 89 mm Hg. Hypertension is the most common primary diagnosis in the United States. It affects approximately 86 million adults (≥20 years) in the United States and is a major risk factor for stroke, myocardial infarction, vascular disease, and chronic kidney disease.

PLAN Essential (primary) hypertension Pharmacological: Increase dose: Lisinopril 10 mg PO daily. Non-pharmacological: Low sodium diet. Exercise 15 minutes at least 6 times a week. Stress management or avoid stress. Continue monitoring blood pressure at home, document and bring log to the consult. Patient instructed to call/visit office if blood pressure higher then 140/90mm/Hg. Avoid high-sodium foods. Avoid eating: Smoked, cured, salted, and canned meat, fish, and poultry, ham, bacon, hot dogs, and luncheon meats, regular, hard, and processed cheese and regular peanut butter. Crackers with salted tops, and other salted snack foods such as pretzels, chips, and salted popcorn. Frozen prepared meals, unless labeled low sodium. Canned and dried soups, broths, and bouillon, unless labeled sodium-free or low-sodium. Canned vegetables, unless labeled sodium-free or low-sodium. French fries, pizza, tacos, and other fast foods. Pickles, olives, ketchup, and other condiments, especially soy sauce, unless labeled sodium-free or low-sodium.

FOLLOW UP: Follow up next week to review treatment effectiveness and laboratory results.

Paper For Above Instructions

The case presentation involves a 61-year-old Hispanic female patient, KL, who presented with elevated blood pressure readings. Her chief complaint was consistent with hypertension, with previous records noting diastolic pressures above 140 mmHg. The patient has a notable medical history of controlled hypertension, for which she has been taking Lisinopril. However, it is evident that she does not lead a lifestyle that contributes positively to her health objectives, failing to engage in regular physical exercise or adhere to a recommended diet.

Upon examination, the patient's current medication regime included Losartan, suggesting a recent adjustment to her treatment plan. Importance lies in recognizing that essential hypertension is a significant health concern that has possible long-term repercussions, including increased risk for myocardial infarction and stroke. Given these factors, the patient’s systemic health needs to be addressed comprehensively, considering pharmacological and non-pharmacological interventions.

The patient’s social history is relevant. She denies any substance abuse and maintains a stable living situation, though her diet and lack of physical activity raise concerns regarding how she manages her health. From a public health perspective, it is critical to highlight how lifestyle factors can exacerbate hypertension. To that end, advising her on dietary changes, particularly focusing on sodium intake, while promoting exercises like brisk walking for at least 15 minutes, six times a week is paramount.

Family history implies a predisposition to hypertension, accentuating the need for the patient to be diligent in her health management. Behavioral concerns arise from a family history that includes heart disease, stroke, and chronic hypertension. Her lack of adherence to lifestyle recommendations can create a cycle of health issues that may spiral out of control if not managed effectively.

In evaluating her clinical need for a non-pharmacological plan, the patient should be counseled on the potential benefits of stress management strategies. Life’s stressors can markedly affect blood pressure and overall well-being; mindfulness and coping mechanisms should be introduced in her treatment paradigm. Education around the potential dangers of high-sodium foods and processed diets, along with the guidance to keep a daily log of her blood pressure readings, would enhance her participation in self-care management.

The plan for her continued treatment should integrate regular follow-up appointments aimed at evaluating both the effectiveness of medication adjustments and the adherence to lifestyle changes. Laboratory tests including CBC, CMP, and lipid profiles will be critical in determining any underlying issues that may be contributing to her existing state of health.

Lessons learned from this case study provide critical insights into future practice. The continuous need to advocate for lifestyle change in chronically ill patients is paramount. Understanding each patient’s barriers to healthy living can sculpt tailored educational interventions and wellness strategies. Moreover, being aware that socioeconomic factors and support mechanisms play a role in patients' health decisions can guide better patient-centered care.

This case juxtaposes clinical guidelines against real-world patient behavior, underscoring each patient's unique journey through healthcare. An integrative approach to managing chronic diseases like hypertension must ideally orchestrate medication management with behavioral health practices and community resources.

References

• Biondi, B., & Cooper, D. S. (2018). Subclinical hyperthyroidism. New England Journal of Medicine, 378(25).
• Drake, M. T. (2018, September). Hypothyroidism in Clinical Practice. In Mayo Clinic Proceedings (Vol. 93, No. 9, pp.). Elsevier.
• Kolman, K. B. (2019). Cystitis and Pyelonephritis: Diagnosis, Treatment, and Prevention. Primary Care: Clinics in Office Practice, 46(2).
• Mancia, G. (2014). Hypertension: strengths and limitations of the JNC 8 hypertension guidelines. Nature Reviews Cardiology, 11(4), 189.
• Buttaro, T. M., & Sandberg_Cook, J. (2013). Primary care. A collaborative practice. St. Louis: Mosby, Inc.
• Grossman, S. C., & Porth, C. M. (2014). Porth's pathophysiology. Concepts of altered health states. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
• MD, L. B. (2012). Bates' guide to physical examination and history taking, 11th Edition. [VitalSource Bookshelf version]. Retrieved from ...
• American College of Cardiology. (2017). Hypertension Management. Retrieved from [insert URL]
• World Health Organization. (2019). Hypertension. Retrieved from [insert URL]
• Chobanian, A. V., Bakris, G. L., Black, H. R., et al. (2003). The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension, 42(6), 1206-1252.

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