Patient initials and age: MD,47
Chief complaint: Patient states he is, “following up on my high blood pressure.”
History of present illness: Mr. D is following up from a visit 3 months ago in which he was noted to have possible hypertension. Today’s blood pressure is 140/92, which is an improvement from previous visit with a blood pressure of 154/100. Patient is a marathon runner. He states he exercises daily by running 6+ miles a day. He denies any current stressors in his life. He also denies any chest pain or palpitations. He states he cannot tell when his blood pressure is high. He does not check his blood pressure at home. He does have a familial history of hypertension of both the mother and father. He states he “tries to eat well,” but does enjoy salty foods. He also states he used to drink many energy drinks and now has tried to cut back on those. He has never taken any medication for hypertension. He also denies taking routine NSAIDs or OTC cold or sinus medications.
Past medical history:
1. Hypertension: October 2012
2. Sinus bradycardia 1st degree AV block: October 2012
Family history:
1. Father: living, hypertension, hyperlipidemia, arthritis, cardiac stents
2. Mother: living, hypertension, hyperlipidemia, hypothyroidism
3. Younger sister: living, no known medical history
Social history:
1. Denies any tobacco use
2. Reports occasional social alcohol use
3. Denies any elicit drug use
4. Enjoys running and participating in marathons
5. Denies currently being sexually active
6. Played basketball in college
Medications:
1. Multivitamin OTC, 1 P.O. daily
2. Fish oil OTC, 1 gram, P.O. daily
Immunizations:
1. Influenza: October 2012
2. Tetanus: patient cannot recall date, states has been within past 10 years.
3. Patient cannot recall any other previous immunizations
Allergies:
1. No known drug, food, or environmental allergies.
Review of systems:
General: denies any fever, chills, sweats, or fatigue. Does report a 20+ pound weight loss over past year. Patient relates this to increased exercise over the past year.
Integumentary: does report having a benign cyst removed last year to his anterior scalp. He states it has healed up without complications. Denies any changes to skin, dry skin, abrasions, bruising, changes to hair or nails.
HEENT: denies any headaches, dizziness, changes in vision, blurry vision, ear pain, hearing difficulties, nasal drainage, changes or difficulty with smell, sore throat, changes in taste, or dental complaints. Patient states he annually sees ophthalmologist.
Lymphatic: denies any swollen or painful lymph nodes.
Lungs/chest: denies any difficulty breathing, shortness of breath, cough, sputum, wheezing, does not recall last chest x-ray, and states all previous PPDs have been negative.
Cardiac: denies any chest pain, shortness of breath, palpitations, edema, claudication, or ever seeing a cardiologist. Reports family history hypertension, hyperlipidemia, and cardiac stents. Only cardiac testing he has had was his last office visit with EKG.
Gastrointestinal: denies any reflux, nausea, vomiting, abdominal pain, diarrhea, constipation, changes in bowel habits, blood in stool, or gall stones. Patient has never had colonoscopy.
Endocrine: denies any intolerance to heat or cold, thyroid enlargement, unplanned weight changes, polydipsia, polyuria, polyphagia, changes in face or body hair, changes to skin, or problems with sexual activity. Does report routine self-testicular exams. Does have a family history of hypothyroidism.
Genitourinary: denies any changes in urinary habits, changes in urine flow or color, problems starting or stopping stream, testicular pain, and history of STIs, UTIs, or kidney stones.
Musculoskeletal: denies any pain, stiffness, heat, or swelling of the bones or joints. Denies any muscle pain. Does state he alternates his running routes between pavement and softer surfaces to prevent tension on his joints.
Neurological: denies any tingling, numbness, paresthesias, syncope, dizziness, tremors, or seizures.
Psychiatric: denies any history of depression, mood swings, nervousness, suicidal thoughts, or difficulty with concentration.
OBJECTIVE DATA:
Vital signs: temperature: 97.7, heart rate: 44, blood pressure: 140/90, respirations: 18, pain level: “0/10.”
Physical exam:
General: patient is a 39 year old white male, appearing of stated age.
Mental status: A/Ox3, appropriate affect, pleasant with conversation. Does not appear anxious. Appropriate responses to questions.
Integumentary: Noted 1” scar to the mid-anterior scalp. Skin turgor WNL, no abrasions bites or lacerations noted to exposed skin. Skin dry and warm with no noted erythema. Hair is distributed evenly over scalp. Nails appear normal without clubbing, splitting, or pitting. No swelling.
HEENT: head is normocephalic and symmetrical. Facial features are symmetrical, noted scar to the mid-anterior portion of the scalp. (No eye exam performed because patient sees ophthalmologist yearly and is without visual complaints today). Tympanic membranes clear and intact bilaterally, minimal cerumen build up, no pineal pain. (No Weber or Rhinne tests performed since patient without any hearing complaints or history of problems with ears or nervous system). No nasal swelling externally or internally, no polyps, turbinates, drainage, crusting, or tenderness (sense of smell not tested due to patients presenting symptoms not related to smell and without any nasal trouble). Oropharynx is without erythema, drainage, exudates. Detention appears intact without gingival swelling. Soft palate rises when patient says, “ahh,” uvula is midline. Positive gag reflex (taste was not assessed since patient denies any oral complaints or problems with taste).
Lymphatic system: no lymphadenopathy.
Lungs/chest: chest is symmetrical, respirations are even, nonlabored and with ease. Lungs resonant to percussion posteriorly. Lungs are clear to auscultation without wheezes, rhonchi, or rales (Tactile fremitus was not performed due to patient without respiratory complaints or history of respiratory illness).
Cardiac/vascular: normal S1 and S2, regular rate and rhythm, no murmurs, gallops, carotid or abdominal bruits, JVD, clicks, snaps, heaves, or thrills. PMI is palpated at the 5ICS, midclavicular line. 2+ radial, carotid, and dorsalis pedal pulses bilaterally. No noted swelling, varicosities, coolness, or pallor or lower extremities. EKG from 10/2012 shows sinus bradycardia with 1st degree AV block at a rate of 46.
Abdomen: soft, nontender, flat, nondistended, positive bowel sounds x4 quadrants, no pulsations, hepatomegaly, spleenomegally, or masses (percussion of liver span and CTA tenderness was not performed due to patient not having previous history or current complaints regarding liver, kidneys, or urinary tract).
Male genitalia, anus, and rectum: these areas where not assessed since patient denies any complaints in these areas, states he performs self-testicular exams, and denies any changes to urinary stream, starting and stopping urinary flow, bowel habits, or changes in stool. Also patient has no known previous medical history regarding these areas.
Musculoskeletal system: body parts appear symmetrical, spine appears with straight alignment without any curving. Positive ROM of upper and lower extremities without pain, fasiculations, or spasms. Normal muscle mass and tone. No noted crepitus, tenderness, or swelling of joints.
Neurological: patient’s gait appears symmetrical without any difficulties. Cranial nerves, balance, sensory function, and DTRs were not assessed this visit since patient has no known history of neurological deficits, family history of nervous system disorders, and no complaints in these areas.
ASSESSMENT:
Nursing diagnosis:
1. Knowledge deficit related diet and nutrition.
All-inclusive medical diagnoses for this visit:
1. Stage 1 Hypertension
2. Sinus bradycardia with 1st degree AV block
Co-existing medical diagnosis:
1. Weight loss (20+ lbs in a year)
2. History of anterior scalp cyst removal
Differential diagnoses:
1. Anxiety
2. “white coat syndrome”
PLAN:
Diagnostic plan:
1. Follow up in 3 months with a CBC, CMP, lipid panel, uric acid level, UA, and EKG.
2. Will check TSH prior to next visit due to family history.
3. Obtain records of initial cardiology visit prior to returning to clinic.
4. Consider chest x-ray prior to next visit to rule out any heart failure.
Treatment Plan:
1. Refer to cardiology for monitoring of sinus bradycardia with 1st degree AVB.
2. Continue current OTC fish oil and MVI
3. If BP continues to be elevated despite diet moderation, consider starting medical management such as a thiazide-type diuretic or ACE-inhibitor.
Education Plan:
1. Diet moderation: decrease sodium intake and continuing to reduce caffeine intake. Provided education regarding DASH diet.
2. Patient encouraged to return in 3 months with blood pressure log of home readings
3. Discussed with patient exercise safety.
Chief complaint: Patient states he is, “following up on my high blood pressure.”
History of present illness: Mr. D is following up from a visit 3 months ago in which he was noted to have possible hypertension. Today’s blood pressure is 140/92, which is an improvement from previous visit with a blood pressure of 154/100. Patient is a marathon runner. He states he exercises daily by running 6+ miles a day. He denies any current stressors in his life. He also denies any chest pain or palpitations. He states he cannot tell when his blood pressure is high. He does not check his blood pressure at home. He does have a familial history of hypertension of both the mother and father. He states he “tries to eat well,” but does enjoy salty foods. He also states he used to drink many energy drinks and now has tried to cut back on those. He has never taken any medication for hypertension. He also denies taking routine NSAIDs or OTC cold or sinus medications.
Past medical history:
1. Hypertension: October 2012
2. Sinus bradycardia 1st degree AV block: October 2012
Family history:
1. Father: living, hypertension, hyperlipidemia, arthritis, cardiac stents
2. Mother: living, hypertension, hyperlipidemia, hypothyroidism
3. Younger sister: living, no known medical history
Social history:
1. Denies any tobacco use
2. Reports occasional social alcohol use
3. Denies any elicit drug use
4. Enjoys running and participating in marathons
5. Denies currently being sexually active
6. Played basketball in college
Medications:
1. Multivitamin OTC, 1 P.O. daily
2. Fish oil OTC, 1 gram, P.O. daily
Immunizations:
1. Influenza: October 2012
2. Tetanus: patient cannot recall date, states has been within past 10 years.
3. Patient cannot recall any other previous immunizations
Allergies:
1. No known drug, food, or environmental allergies.
Review of systems:
General: denies any fever, chills, sweats, or fatigue. Does report a 20+ pound weight loss over past year. Patient relates this to increased exercise over the past year.
Integumentary: does report having a benign cyst removed last year to his anterior scalp. He states it has healed up without complications. Denies any changes to skin, dry skin, abrasions, bruising, changes to hair or nails.
HEENT: denies any headaches, dizziness, changes in vision, blurry vision, ear pain, hearing difficulties, nasal drainage, changes or difficulty with smell, sore throat, changes in taste, or dental complaints. Patient states he annually sees ophthalmologist.
Lymphatic: denies any swollen or painful lymph nodes.
Lungs/chest: denies any difficulty breathing, shortness of breath, cough, sputum, wheezing, does not recall last chest x-ray, and states all previous PPDs have been negative.
Cardiac: denies any chest pain, shortness of breath, palpitations, edema, claudication, or ever seeing a cardiologist. Reports family history hypertension, hyperlipidemia, and cardiac stents. Only cardiac testing he has had was his last office visit with EKG.
Gastrointestinal: denies any reflux, nausea, vomiting, abdominal pain, diarrhea, constipation, changes in bowel habits, blood in stool, or gall stones. Patient has never had colonoscopy.
Endocrine: denies any intolerance to heat or cold, thyroid enlargement, unplanned weight changes, polydipsia, polyuria, polyphagia, changes in face or body hair, changes to skin, or problems with sexual activity. Does report routine self-testicular exams. Does have a family history of hypothyroidism.
Genitourinary: denies any changes in urinary habits, changes in urine flow or color, problems starting or stopping stream, testicular pain, and history of STIs, UTIs, or kidney stones.
Musculoskeletal: denies any pain, stiffness, heat, or swelling of the bones or joints. Denies any muscle pain. Does state he alternates his running routes between pavement and softer surfaces to prevent tension on his joints.
Neurological: denies any tingling, numbness, paresthesias, syncope, dizziness, tremors, or seizures.
Psychiatric: denies any history of depression, mood swings, nervousness, suicidal thoughts, or difficulty with concentration.
OBJECTIVE DATA:
Vital signs: temperature: 97.7, heart rate: 44, blood pressure: 140/90, respirations: 18, pain level: “0/10.”
Physical exam:
General: patient is a 39 year old white male, appearing of stated age.
Mental status: A/Ox3, appropriate affect, pleasant with conversation. Does not appear anxious. Appropriate responses to questions.
Integumentary: Noted 1” scar to the mid-anterior scalp. Skin turgor WNL, no abrasions bites or lacerations noted to exposed skin. Skin dry and warm with no noted erythema. Hair is distributed evenly over scalp. Nails appear normal without clubbing, splitting, or pitting. No swelling.
HEENT: head is normocephalic and symmetrical. Facial features are symmetrical, noted scar to the mid-anterior portion of the scalp. (No eye exam performed because patient sees ophthalmologist yearly and is without visual complaints today). Tympanic membranes clear and intact bilaterally, minimal cerumen build up, no pineal pain. (No Weber or Rhinne tests performed since patient without any hearing complaints or history of problems with ears or nervous system). No nasal swelling externally or internally, no polyps, turbinates, drainage, crusting, or tenderness (sense of smell not tested due to patients presenting symptoms not related to smell and without any nasal trouble). Oropharynx is without erythema, drainage, exudates. Detention appears intact without gingival swelling. Soft palate rises when patient says, “ahh,” uvula is midline. Positive gag reflex (taste was not assessed since patient denies any oral complaints or problems with taste).
Lymphatic system: no lymphadenopathy.
Lungs/chest: chest is symmetrical, respirations are even, nonlabored and with ease. Lungs resonant to percussion posteriorly. Lungs are clear to auscultation without wheezes, rhonchi, or rales (Tactile fremitus was not performed due to patient without respiratory complaints or history of respiratory illness).
Cardiac/vascular: normal S1 and S2, regular rate and rhythm, no murmurs, gallops, carotid or abdominal bruits, JVD, clicks, snaps, heaves, or thrills. PMI is palpated at the 5ICS, midclavicular line. 2+ radial, carotid, and dorsalis pedal pulses bilaterally. No noted swelling, varicosities, coolness, or pallor or lower extremities. EKG from 10/2012 shows sinus bradycardia with 1st degree AV block at a rate of 46.
Abdomen: soft, nontender, flat, nondistended, positive bowel sounds x4 quadrants, no pulsations, hepatomegaly, spleenomegally, or masses (percussion of liver span and CTA tenderness was not performed due to patient not having previous history or current complaints regarding liver, kidneys, or urinary tract).
Male genitalia, anus, and rectum: these areas where not assessed since patient denies any complaints in these areas, states he performs self-testicular exams, and denies any changes to urinary stream, starting and stopping urinary flow, bowel habits, or changes in stool. Also patient has no known previous medical history regarding these areas.
Musculoskeletal system: body parts appear symmetrical, spine appears with straight alignment without any curving. Positive ROM of upper and lower extremities without pain, fasiculations, or spasms. Normal muscle mass and tone. No noted crepitus, tenderness, or swelling of joints.
Neurological: patient’s gait appears symmetrical without any difficulties. Cranial nerves, balance, sensory function, and DTRs were not assessed this visit since patient has no known history of neurological deficits, family history of nervous system disorders, and no complaints in these areas.
ASSESSMENT:
Nursing diagnosis:
1. Knowledge deficit related diet and nutrition.
All-inclusive medical diagnoses for this visit:
1. Stage 1 Hypertension
2. Sinus bradycardia with 1st degree AV block
Co-existing medical diagnosis:
1. Weight loss (20+ lbs in a year)
2. History of anterior scalp cyst removal
Differential diagnoses:
1. Anxiety
2. “white coat syndrome”
PLAN:
Diagnostic plan:
1. Follow up in 3 months with a CBC, CMP, lipid panel, uric acid level, UA, and EKG.
2. Will check TSH prior to next visit due to family history.
3. Obtain records of initial cardiology visit prior to returning to clinic.
4. Consider chest x-ray prior to next visit to rule out any heart failure.
Treatment Plan:
1. Refer to cardiology for monitoring of sinus bradycardia with 1st degree AVB.
2. Continue current OTC fish oil and MVI
3. If BP continues to be elevated despite diet moderation, consider starting medical management such as a thiazide-type diuretic or ACE-inhibitor.
Education Plan:
1. Diet moderation: decrease sodium intake and continuing to reduce caffeine intake. Provided education regarding DASH diet.
2. Patient encouraged to return in 3 months with blood pressure log of home readings
3. Discussed with patient exercise safety.