Mike Kelly HTN - case study PDF

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UNFOLDING Reasoning Case Study: STUDENT

Hypertensio History of Present Problem: Mike Kelly is a 51-year-old Caucasian male who is 6 feet tall and w distribution of weight around his abdomen. He does not regularly ex to five times during the week. He has smoked one pack per day sinc hyperlipidemia, but is unable to afford his medication (atorvastatin) ago. He has no current diagnosed medical problems. He became con because he is more easily fatigued and has had a headache the past t

Personal/Social History: Mike is self-employed and owns his own auto mechanic business. H and died of a myocardial infarction (MI) at the age of 50. Angelina, that he is usually stoic about health problems, so this must really bo f a ad  dd he. What data from the histories is RELEVANT and has clinical signi RELEVANT Data from Present Problem: Clinical Significanc 1. Patient BMI iss 37.31 2. Abnormal distribution of weight around abdomen 3. Does not regularly exercise 4. Eats fast food 3 - 5 times per week 5. Smokes 1 pack cigarett per day 6. Hyperlipidemia 7. Unable to afford medication (Atorvastatin) 8. Easily fatigued 9. Headace for the past 3 days that has not improved

RELEVANT Data from Social History: 1.Self employed 2. No health insurance 3. Family history of hypertension and MI 4 Took excedrin and Motrin for pain

1. A BMI between 30 and 39.9 is diabetes, hypertension and cardi 2. This puts the patient at risk fo 3. This may be one of the reason chronic health problems, such as 4. Eating unhealthy and high ca 5. Smoking cause many problem 6. Increases the risk for cardiova 7. Untrolled hyperlipidemia will c 8. Sign of uderlying health condit 9. May be related to being fatigu

Clinical Significanc 1. Finances may be affec 2. This will help determin 3. At greater risk for deve 4. Excedrin is a combina

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN:

Appears uncomfortable, body tense with Breath sounds clear with equal aeration b Pink, warm and dry, no edema, heart sou palpation at radial/pedal/post-tibial landm Alert and oriented to person, place, time Abdomen soft/non-tender, bowel sounds Voiding without difficulty, urine clear/y Skin integrity intact, skin turgor elastic w

What assessment data is RELEVANT and must be recognized as c RELEVANT Assessment Data: Clinical Significance:

1. General apperance uncomfortable, body tense with occasional grimacing

12 Lead EKG:

This is a sign the pat

Radiology Reports: Chest x-ray What diagnostic results are RELEVANT that must be recogn RELEVANT Results: Clinical Significance: The cardiac size is enlarged. There are no focal infiltrates or consolidations or pleural effusions. IMPRESSION: 1. No acute disease in the chest. 2. Moderate to severe cardiomegaly

A enlarged heart is not a disease increases the risk of hear failure.

Lab Results: Complete Blood Count (CBC:) WBC (4.511.0 mm 3) Hgb (1216 g/dL) Platelets(150450x 103/µl) Neutrophil % (4272)

Current: 10.5 15.3 422 68

High/Low/W WNL

WNL WNL

WNL

What lab results are RELEVANT and must be recognized as RELEVANT Lab(s): Clinical Significance: All labs WNL

General health is good

Lipid Panel: Low density lipoproteinLDL (40 mg/dL) Total cholesterol (...