Hypertension Blood Pressure, Coursework Example

Chief Complaint: Confusion, headache, fatigue, and bloody nose

History of Present Illness: 42 year-old African American male who presents to the clinic and is experiencing nosebleeds, fatigue, headache, and mild confusion. He has experienced these symptoms intermittently over the past three days. He has had a nosebleed every day over the past three days, with the most severe and lengthy case occurring this past evening. He also finds it difficult to focus on his duties at work, to drive, and has obtained a ride to work from his wife. He is also experiencing difficulty sleeping and therefore, is fatigued and experiencing general malaise and exhaustion.

Medications: Lisinopril 20 mg / once daily

Lasix 40 mg / once daily

Esomeprazole 20 mg once daily

OTC Ibuprofen 200 mg as needed

Allergies: Sulfa; no known food allergies; experiences seasonal allergies in the spring months.

Past Medical History: Hypertension, occasional headache, seasonal allergies, frontal sinus problems.
Past Surgical History: No prior surgical history.

Personal/Social History: Is approximately 50 pounds overweight; smoked for 10 years but has not smoked in over 5 years; denies any form of drug use; drinks occasionally (average of 1-2 drinks per week); attempting to consume a low-sodium diet but is admittedly finding it difficult to “put down the salt shaker”; began a walking program two weeks ago and walks 3x/week for 30 minutes per session; works in the banking industry as a branch manager and admits to high stress on the job and periods of overtime; used to be an avid athlete in high school and college but quit sports after graduation.
Immunizations: Updated; flu shot approximately six months ago; DTAP three years ago.
Family History: Father had a history of hypertension and diabetes and currently lives in an assisted living facility; mother is deceased and had a history of breast cancer and heart disease, passed away from breast cancer in 2007; has two older sisters ages 45 and 48 and two younger brothers ages 39 and 37; is married with two children, ages 12 and 8.

Review of Systems:

General: overweight by approximately 50 pounds; weight gain has been gradual and is not recent; no fever; experiencing fatigue, headache, and confusion

Skin: no visible rashes, bumps, itching, sores; skin is dry, especially the hands and elbows

Throat: no sore throat is identified and no hoarseness of the voice

Neck: supple; no visible lymphadenopathy or thyromegaly

Respiratory: No coughing, wheezing, poor breath sounds, or other indicators

Cardiovascular: No chest pain, palpitations, shortness of breath; mild edema in the feet and ankles; hypertension is controlled using medication and diet; has a home blood pressure machine and takes readings every Sunday

Gastrointestinal: has experienced acid reflux when consuming Italian and Mexican foods, as well as with coffee; no nausea or vomiting, mild constipation and no diarrhea

Endocrine: No history of diabetes or other conditions; last HgB A1C reading was within the normal range and was 10 months ago

Objective Data:

T: 36.8 Celsius (oral) BP 255/163; P 102; RR; 17; wt. 108 kg (no BMI measurement)

In general, appearance is overweight and fatigued

Skin: no rashes or bumps observed

Head: atraumatic and normocephalic

Ears: no drainage observed; tympanic membranes are of normal color

Nose: no nasal discharge; deviated septum; mild sinus tenderness

Respiratory: normal respiration; no wheezing or diminished breath sounds; no rales

Abdominal: non-distended and soft; non-tender; no masses evident and bowel sounds are normal

Neuro: gait is slow but steady; fairly alert but experiences periods of confusion

Labs: Glucose 114; hemoglobin A1C 14.6, triglycerides 140

Assessment (Differential Diagnosis)

Diagnosis 1: Hypertensive crisis (systolic/diastolic reading, medications, headache, fatigue, confusion, nosebleeds) (American Heart Association, 2012)

Differential Diagnosis #2: Hypertension with hypertensive crisis: This is a result of extremely high systolic/diastolic readings that lead to specific symptoms (American Heart Association, 2012). The most recent BP reading was 255/163.

Differential Diagnosis #2: Anxiety Disorder: these conditions occur as a result of heightened anxiety in patients due to stressors or other factors that impact wellbeing (Yates, 2012). Anxiety disorders include panic disorder, social phobias, and post-traumatic stress disorder (Yates, 2012).

Differential Diagnosis #3: Amphetamine toxicity: this is caused by the abuse of amphetamines, including those found in over-the-counter diet pills (Handly, 2012). Headache and disorientation are common, along with agitation and chest pain (Handly, 2012). The patient did not present with chest pain and does not appear to have any other symptoms of amphetamine abuse.

Differential Diagnosis #4: Medications: A combination of medications may lead to complications and side effects (FDA, 2013). Prescribing Lasix and Lisinopril may contribute to an excessive reduction of blood pressure in some patients, particularly when dosing is too high; however, this is not the case in the presenting patient.

Plan:

1. Admission to the hospital for immediate IV medication administration and routine monitoring to assess any possible organ or system damage (Hopkins, 2013).
2. Administer Clevidipine via IV infusion 1mg/h and titrate for 90 second intervals; incease up to 8mg/h until BP is reduced to a normal range (Hopkins, 2013).
3. Upon stabilization, remove IV drip and administer oral medications.
4. Health Promotion: Restrict salt intake and the consumption of high fat foods. Take all medications in a timely manner and as prescribed by the physician. Monitor blood pressure at home daily for 30 days. Drink fluids and eliminate caffeinated coffee and all carbonated beverages. Increase exercise to 5 days per week/45 minutes per day. Work only the scheduled amount of hours and limit overtime as much as possible. No alcohol until BP crisis is stabilized.
5. Disease prevention: follow up with physician in 7 days if BP readings do not stabilize. Follow up in 30 days if BP readings are consistently lower. Reevaluate medications in 30 days and determine if a different course of action is required.

Reflection Notes

For this patient, I am in agreement with the plan of care that has been established. The patient requires immediate hospitalization to stabilize his blood pressure and to eliminate the hypertensive crisis as quickly as possible. The administration of medication via IV drip is a critical requirement. It is necessary for the patient to be monitored closely for the first 24 hours to ensure that his BP is stabilized at a normal level and remains normal for a period of time. Furthermore, hospitalization is necessary to ensure that there is no organ, system, or neurological damage from the hypertensive crisis. After stabilizing his BP, he should be prepared for discharge and should be closely evaluated by his physician in the outpatient setting. Most importantly, his medications should be adjusted accordingly so that there is a much lower risk of a repeat hypertensive crisis. In addition, the patient should adhere to the required diet restrictions and improved exercise regimen as closely as possible to reduce his risk of another event. His stress levels are critical in maintaining normal BP; therefore, he should evaluate the level of stress in his job and make all possible efforts to alleviate his stress levels as best as possible to achieve the best possible outcomes.

References

American Heart Association (2014). What are the symptoms of high blood pressure? Retrieved from

http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/SymptomsDiagnosisMonitoringofHighBloodPressure/What-are-the-Symptoms-of-High-Blood-Pressure_UCM_301871_Article.jsp

Food and Drug Administration (2013). Drug interactions: what you should know. Retrieved from http://www.fda.gov/drugs/resourcesforyou/ucm163354.htm

Handly, N. (2012). Amphetamine toxicity clinical presentation. Medscape, retrieved from http://emedicine.medscape.com/article/812518-clinical

Yates, W.R. (2012). Anxiety disorders. Medscape, retrieved from http://emedicine.medscape.com/article/286227-overview