This Assignment will assess your
ability to evaluate subjective and objective information in order to arrive at
an appropriate diagnosis and treatment plan for the patient.

Hypertension Case Study

C.D is a 55-year-old African
American male who presents to his primary care provider with a 2-day history of
a headache and chest pressure.

PMH

Allergic Rhinitis

Depression

Hypothyroidism

Family History

Father died at age 49 from AMI:
had HTN

Mother has DM and HTN

Brother died at age 20 from
complications of CF

Two younger sisters are A&W

Social History

The patient has been married for
25 years and lives with his wife and two children. The patient is an air
traffic controller at the local airport. He has smoked a pack of cigarettes a
day for the past 15 years. He drinks several beers every evening after work to
relax. He does not pay particular attention to sodium, fat, or carbohydrates in
the foods he eats. He admits to “salting almost everything he eats, sometimes
even before tasting it.” He denies ever having dieted or exercised.

Medications

Zyrtec 10 mg daily

Allergies

Penicillin

ROS

States that his overall health has
been fair to good during the past year.

Weight has increased by
approximately 30 pounds in the last 12 months.

States he has been having some
occasional chest pressure and headaches for the past 2 days. Shortness of breath
at rest, headaches, nocturia, nosebleeds, and hemoptysis.

Reports some shortness of breath
with activity, especially when climbing stairs and that breathing difficulties
are getting worse.

Denies any nausea, vomiting,
diarrhea, or blood in stool.

Self treats for occasional right
knee pain with OTC Ibuprofen.

Denies any genitourinary symptoms.

Vital Signs

B/P 190/120, HR 73, RR 18, T. 98.8
F., Ht 6’1”, Wt 240 lbs.

HEENT

TMs intact and clear throughout

No nasal drainage

No exudates or erythema in
oropharynx

PERRLA

Funduscopy reveals mild arteriolar
narrowing without nicking, hemorrhages, exudates, or papilledema

Neck

Supple without masses or bruits

Thyroid normal

No lymphadenopathy

Lungs

Mild basilar crackles bilaterally

No wheezes

Heart

RRR

No murmurs or rubs

Abdomen

Soft and non-distended

No masses, bruits, or organomegaly

Normal bowel sounds

Ext

Moves all extremities well

Neuro

No sensory or motor abnormalities

CN’s II-XII intack

DTR’s = 2+

Muscle tone=5/5 throughout

What you should do:

Develop an evidence-based
management plan.

Include any pertinent diagnostics.

Describe the patient education
plan.

Include cultural and lifespan
considerations.

Provide information on health
promotion or health care maintenance needs.

Describe the follow-up and
referral for this patient.

Prepare a 3–5-page paper (not
including the title page or reference page).

Assignment Requirements:

Before finalizing your work, you
should:

be sure to read the Assignment
description carefully (as displayed above);

consult the Grading Rubric to make
sure you have included everything necessary; and

utilize spelling and grammar check
to minimize errors.

Your writing Assignment should:

follow the conventions of Standard
English (correct grammar, punctuation, etc.);

be well ordered, logical, and
unified, as well as original and insightful;

display superior content,
organization, style, and mechanics; and

use APA 6th Edition format as
outlined in the APA Progression Ladder.