Assignment: History and Physical of a 65 year man with Hypertension

Assignment: History and Physical of a 65 year man with Hypertension

Assignment: History and Physical of a 65 year man with Hypertension

create a fictitious patient within the population you selected for the assignment in Topic 4 and complete the three parts of the assignment for your patient, as outlined below.

Part 1: Risk Factors, Quality Indicators, and CAM:

Identify the following regarding the health of your fictitious patient:

Risk factors associated with the patient’s demographics.
Complementary and alternative medicines (CAM).
Quality indicators specific to the patient.
Part 2: History and Physical

ORDER A CUSTOMIZED, PLAGIARISM-FREE Assignment: History and Physical of a 65 year man with Hypertension HERE

Good News For Our New customers . We can write this assignment for you and pay after Delivery. Our Top -rated medical writers will comprehensively review instructions , synthesis external evidence sources(Scholarly) and customize a quality assignment for you. We will also attach a copy of plagiarism report alongside and AI report. Feel free to chat Us

Develop a history and physical (H&P) examination for the fictitious patient chosen. In previous courses in the program, you have used this subjective, objective, assessment, and plan format to document H&P examinations. Refer to the “History and Physical Note” template to complete this assignment.

Part 3: Model or Plan of Care

Develop a model or plan of care for the patient population pertinent to the above-mentioned patient. This could include community or health system programs as an approach or what seems appropriate. Incorporate the 6 components of the chronic care model in your model or plan of care.

Self-management support
Community resources
Health system
Delivery system design
Decision support
Clinical information systems
General Requirements

You are required to cite three to five sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

A Sample Of This Assignment Written By One Of Our Top-rated Writers

History and Physical Note Template

Chief Complaint or Reason for Consult: “My BP has been high.”

History of Present Illness (HPI):

P.D is a 65-year-old AA male who presents with a chief complaint of an elevated BP. He states that in the past week, his BP has been above 140/90, with the highest at 162/100 and the lowest at 144/94. The patient is worried that his condition could be worsening since he does not miss medications and he has been on a low-sodium diet. He states that his BP has previously been controlled below 140/90, and the last time it surpassed that was almost a year ago. In addition to taking his hypertension medications, he uses garlic, Omega-3 Fatty Acid, and Green Tea supplements, which have helped to lower his BP. Besides, he reports that he occasionally experiences pounding headaches at the occipital region, which he associates with elevated BP. He denies having visual or neurological disturbances.  

Past Medical History: Hypertension- diagnosed at 57 and has been controlled for two years. Hyperlipidemia was diagnosed five years ago.

Past Surgical History: History of Appendectomy in 2009.

Family History: The patient’s father had HTN and diabetes; he died from stroke at 82 years. The mother died from a heart attack at 86 years. The paternal grandfather had HTN and stomach cancer; he died from cancer complications at 79.

Social History: P.D is a retired high-school teacher and currently manages his hotel business alongside his wife. He has been married for 33 years and has three children, 32, 29, and 24. He currently lives with his wife in a middle-income neighborhood in Jackson County, TN. He has a history of alcohol use and tobacco smoking, which he quit five years ago following advice from his PCP to control his BP. He denies ever using illicit drugs. His hobbies include watching soccer and reading magazines. He denies having any difficulties performing activities of daily living.

Allergies: No medication or food allergies.

Home Medications: OTC Tylenol 500 mg PRN (when experiencing headaches).

Hospital Medications: HCTZ 25 mg PO OD; Vasotec 20 mg PO OD; Atorvastatin 20 mg PO OD.

 Review of Systems:

• CONSTITUTIONAL: Denies fever, weight loss/gain, chills, general body weakness, or generalized fatigue.
• EYES: Denies vision changes, eye pain, double vision, blurred vision, eye redness, or excessive tearing. Last eye exam- 3 years ago.
• EARS, NOSE, and THROAT: Denies ear pain, ear discharge, tinnitus, or hearing loss. Denies facial pain/tenderness, sore tongue, sore throat, hoarse voice, bleeding gums, or tooth cavities. Last dental exam- 12 months ago.
• CARDIOVASCULAR: Denies palpitations, edema of lower limbs, productive cough, chest pain or pressure, SOB on exertion, fatigue, or lips cyanosis.
• RESPIRATORY: Negative for cough, sputum production, pleuritic chest pain, wheezing, or SOB.
• GASTROINTESTINAL: Denies nausea, vomiting, regurgitation, epigastric pain, distension, flatulence, abdominal pain, diarrhea, or constipation.
• GENITOURINARY: Denies urinary frequency/urgency, dysuria, incontinence, changes in urine color, or blood in the urine.
• MUSCULOSKELETAL: Negative for muscle pain or tenderness, joint pain or stiffness, joint deformities, back pain, or limitations in movement.
• INTEGUMENTARY: Negative for rashes, discoloration, bruises, lacerations, or lesions.
• NEUROLOGICAL: Positive for occipital headaches. Negative for muscle weakness, dizziness, fainting, black spells, or tingling/ burning sensations
• PSYCHIATRIC: Denies anxiety, mood symptoms, sleep disturbances, or suicidal thoughts.
• ENDOCRINE: Negative for increased urine production, excessive hunger, acute thirst, excessive sweating, or cold/heat intolerance.
• HEMATOLOGIC/LYMPHATIC: Denies bruising, bleeding, history of anemia, or swollen lymph nodes.
• ALLERGIC/IMMUNOLOGIC: Negative for hives, rashes, or frequent illnesses.

Physical Exam:

• GENERAL APPEARANCE: Black male patient in his mid-60s, well-nourished, calm, and in no distress. The client is well-groomed and appropriately dressed.
• VITAL SIGNS: BP- 154/98 mmHg (1^st reading) 150/96 mmHg (2^nd reading); RR-20b/min; HR-94b/min; Temp- 98.4F; SPO2- 98%

WT-; HT-; BMI-

• HEENT: Head: Normocephalic and symmetrical. Eyes: Sclera is white; Conjunctiva is pink; no excessive tearing; PERRLA. Ears: Tympanic membranes are patent, transparent and shiny. Nose: Patent nostrils and nasal septum; No rhinorrhea or epistaxis. Mouth: Pink and moist mucous membranes; Tongue is mid-line, pink, and non-inflamed; Two missing teeth; No bleeding gums or tooth cavities. Throat: Tonsillar glands are non-erythematous
• NECK: Symmetrical; Full ROM; Trachea is mid-line; Thyroid gland is normal.
• CHEST: Chest rises and falls in unison during respiration; Respirations are smooth.
• LUNGS: Lungs are clear on auscultation bilaterally. No rhonchi, wheezes, or rales.
• HEART: No edema or neck veins distension; S1 and S2 normal on auscultation. No gallop sounds, bruits, or systole were heard.
• BREASTS: Symmetrical; No skin color changes, nipple discharge, breast tenderness, masses, or lumps.
• ABDOMEN: The abdomen is round, soft, and moves up and down on respiration. No bruits; BS normoactive on all quadrants. No hepatomegaly or splenomegaly on percussion. No tenderness, masses, guarding, or organomegaly.
• GENITOURINARY: [Male]. Normal male genitalia. No penile plaques or genital skin lesions. The testicles are descended bilaterally with no masses or tenderness. The perineum is patent.
• RECTAL: [Male]. No rectal fissures; Intact sphincter tone; Prostate is smooth, non-tender, and with no nodules.
• EXTREMITIES: Capillary refill time- 2 secs. No bluish discoloration or edema.
• NEUROLOGIC: Normal gait and posture are normal. Muscle strength- 5/5; DTRs are intact; CNs II-XII are intact.
• PSYCHIATRIC: Coherent speech and thought process. No delusions, hallucinations, obsessions, homicidal, or suicidal thoughts were noted.
• SKIN: Dark, warm, and well-perfused skin with good turgor. No discoloration, rashes, bruises, fresh scars, or lesions were noted.
• LYMPHATICS: Lymph nodes are non-palpable.

Laboratory and Radiology Results: No diagnostic tests have been ordered at this time.

Differential Diagnosis:

Essential Hypertension: Hypertension is characterized by systolic blood pressure (SBP) of 140 mm Hg or above, a diastolic blood pressure (DBP) of 90 mm Hg or more, or both (Unger et al., 2020). The patient has essential hypertension based on his history of HTN and BP levels above 140/90 mm Hg.

Resistant Hypertension: Resistant HTN is described as blood pressure that remains above the desired goal despite concurrent administration of three antihypertensive agents from different classes (Carey et al., 2018). Patients have persistently high BP levels. Although the patient’s BP levels have persistently elevated in the past week, Resistant HTN is unlikely since he had previously achieved BP control.

Uncontrolled Hypertension: A patient with uncontrolled hypertension lacks blood pressure control due to poor medication adherence or an inadequate treatment regimen (Cherfan et al., 2020). The patient had previously achieved controlled HTN with BPs below 140/90, which makes uncontrolled hypertension an unlikely diagnosis.

Geriatric or Ethical Considerations:

The American Society of Hypertension/International Society of Hypertension (ASH/ISH) guidelines recommend that patients of African Ancestry be treated as follows: First-line drugs to be CCB or Thiazide diuretic; 2^nd-line to include the 1^st line drug plus ARB or ACEI; 3^rd line to be a combination of CCB plus ACEI or ARB plus thiazide diuretic (Unger et al., 2020). Thus the patient’s current antihypertensive medication may require an increase in dosage or a drug added to the therapy regimen.

References

Carey, R. M., Calhoun, D. A., Bakris, G. L., Brook, R. D., Daugherty, S. L., Dennison-Himmelfarb, C. R., … & White, W. B. (2018). Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension, 72(5), e53-e90.

Cherfan, M., Vallée, A., Kab, S., Salameh, P., Goldberg, M., Zins, M., & Blacher, J. (2020). Unhealthy behaviors and risk of uncontrolled hypertension among treated individuals-The CONSTANCES population-based study. Scientific Reports, 10(1), 1-12. https://doi.org/10.1038/s41598-020-58685-1

Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N. R., Prabhakaran, D., … & Schutte, A. E. (2020). 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension, 75(6), 1334–1357. doi: 10.1097/HJH.0000000000002453