Charting Assignment 2 Total Points 25 Joanis A 59 Year Old A

Charting Assignment 2 Total Points 25joanis A 59 Year Old Afri

Joan, a 59-year-old African American female, presents with elevated blood pressure reading of 168/90, morning headaches, and sensations of rapid heartbeat. She reports experiencing headaches at least twice weekly upon waking, episodes of lightheadedness, chest tightness that resolved before coming to the clinic, and a feeling that her heart is beating too fast. She has not been seen by a healthcare provider in about two years and is unaware of any previous hypertension diagnosis. Her family history includes a father who died from a heart attack and a mother with heart failure. Joan smokes two packs of cigarettes daily, leads a sedentary lifestyle outside work, and consumes 2-3 beers 4-5 times weekly, with increased intake on weekends. She is married, and her oldest son recently died in a car accident two months prior. She does not take prescription medications but uses an over-the-counter multivitamin and a daily aspirin for potential cardioprotective effects. Vital signs: BP 168/92 after 20 minutes, pulse 114, respirations 20, temperature 98.2°F, height 6'2", weight 255 lbs, BMI 33. Physical exam reveals signs of age compared to her stated age, no jugular venous distention, strong heart sounds with a systolic murmur at the left sternal border, tender right upper quadrant, but otherwise normal findings.

Sample Paper For Above instruction

Introduction

Hypertension remains a prevalent health concern, especially among African American populations who tend to develop hypertension at earlier ages and often with more severity. The case of Joan, a 59-year-old African American woman presenting with elevated blood pressure and related symptoms, underscores the importance of comprehensive assessment, diagnosis, and management of hypertension and associated cardiovascular risks. This paper discusses key clinical questions, differential diagnoses, diagnostic procedures, and management strategies for Joan, grounded in evidence-based practice.

1. Key Questions and Rationale

To deepen understanding of Joan's condition, the following questions are critical:

1. Have you experienced similar headaches or symptoms like dizziness or palpitations before? This helps determine if her symptoms are chronic or episodic, which guides the differentiation between hypertensive crises and chronic hypertension.
2. Do your headaches or lightheadedness correlate with specific activities or times of day? Understanding the timing can help assess whether her symptoms are related to blood pressure fluctuations or other causes like stress or sleep issues.
3. How would you rate your stress levels, especially after recent family loss? Elevated stress can acutely increase blood pressure and contribute to symptoms such as headaches and palpitations, indicating the need for psychosocial assessment.
4. What is your typical diet, particularly salt intake? Diet influences blood pressure, especially in African American populations where salt sensitivity is common.
5. Have you noticed any swelling, chest pain, or changes in your vision? These questions screen for end-organ damage from hypertension or other cardiac issues like heart failure.

These questions are grounded in evidence indicating that stress, lifestyle, and symptom timing can influence hypertension management (Whelton et al., 2018).

2. Differential Diagnoses

1. Essential Hypertension — Given her elevated BP readings, sedentary lifestyle, high BMI, smoking, and family history, primary hypertension is most probable. Her persistent BP over multiple readings supports this diagnosis. It is supported by her African American background, which correlates with earlier and more severe hypertension (Fang et al., 2017).
2. Secondary Hypertension due to Renal Dysfunction — Her right upper quadrant tenderness and normal spleen/kidney assessment challenge this, but renal issues can still present without overt signs. Her elevated BP warrants renal evaluation to exclude underlying causes (Calhoun et al., 2018).
3. Hypertensive Heart Disease — The systolic murmur and her symptoms suggest possible early cardiac involvement. Nonetheless, her physical exam shows no JVD or pulmonary edema, making overt hypertensive cardiomyopathy less likely currently. It warrants assessment but is less probable at this stage.

In conclusion, essential hypertension remains the likely diagnosis, but secondary causes must be ruled out through further testing.

3. Diagnostic Procedures

Ordering targeted diagnostic tests is crucial. First, obtain multiple outpatient BP measurements or ambulatory blood pressure monitoring to confirm hypertension (Whelton et al., 2018). Second, laboratory studies should include serum electrolytes, serum creatinine, BUN, fasting lipid profile, and fasting blood glucose for cardiovascular risk assessment and to rule out secondary causes like renal dysfunction or endocrine disorders.

An EKG is recommended to evaluate for left ventricular hypertrophy or arrhythmias, especially given her symptoms of palpitations and elevated heart rate. An echocardiogram can provide structural and functional cardiac information, particularly assessing for hypertrophy or valvular disease. Additionally, a urinalysis helps detect proteinuria or renal disease.

These evaluations form part of a comprehensive approach to confirm or exclude secondary hypertension, assess target organ damage, and guide management (Fang et al., 2017).

4. Diagnosis and Management Plan

Based on available data, the working diagnosis is primary (essential) hypertension with early signs of target organ involvement. The intervention includes pharmacologic therapy—initially, antihypertensive agents like thiazide diuretics, ACE inhibitors, or calcium channel blockers—as evidence suggests their efficacy in African Americans (Calhoun et al., 2018). Non-pharmacological measures should emphasize lifestyle modifications:

• Smoking cessation programs
• Dietary counseling to reduce salt intake and promote DASH (Dietary Approaches to Stop Hypertension) diet
• Weight loss strategies targeting BMI reduction
• Regular physical activity, aiming for at least 150 minutes of moderate exercise per week
• Stress management interventions and mental health support, considering recent family loss

Health promotion also involves educational sessions about medication adherence, blood pressure monitoring, and recognizing symptoms of hypertensive emergencies. Referral to a cardiologist or hypertension specialist may be indicated if blood pressure remains uncontrolled.

5. Physical Examination and SOAP Note Rationale

The physical examination should be comprehensive, with emphasis on cardiovascular assessment, including auscultation for murmurs, JVP measurement, peripheral pulses, and signs of hypertensive target organ damage like retinal changes or signs of heart failure. Fundamental examinations such as abdominal palpation, extremity assessment, and neurological evaluation are also essential.

The SOAP note should document:

• Subjective: Chief complaints, history of present illness, family history, lifestyle factors (smoking, alcohol), psychosocial factors, symptoms experienced.
• Objective: Vital signs, physical exam findings including cardiovascular and abdominal assessments, BMI, and any neurologic signs.
• Assessment: Primary diagnosis of essential hypertension, with differential diagnoses considered.
• Plan: Diagnostic tests ordered, pharmacologic therapy selected, lifestyle modifications, patient education, follow-up schedule, and referrals.

Employing this structured approach ensures comprehensive documentation that guides treatment decisions and facilitates continuity of care, supported by evidence indicating the importance of detailed assessment in hypertension management (Whelton et al., 2018).

References

• Calhoun, D. A., Jones, D., Textor, S., Goff, D. C., Murphy, T. B., & Smith, S. C. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology, 71(19), e127-e248.
• Fang, J., Madhavan, S., & Alderman, M. H. (2017). Race differences in hypertension awareness, treatment, and control: The National Health and Nutrition Examination Survey, 2011–2014. American Journal of Hypertension, 30(8), 780–786.
• Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., & Dennison Himmelfarb, C. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension, 71(6), e13–e115.
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