Kristy's Hypertension: A Case Study

Sarah Jennings is a 45 years old female, 5 feet 6inches tall, 130lbs. Today she came in to see Dr. Wallace for 3-month appointment. She has been diagnosed with hypertension, diabetes, and cholesterol. Due her cholesterol medication she was asked to come in to get her liver function checked. During her visit today she mentioned to the doctor she has had knee pain for the past few days. It started after she tripped while hiking last week. Sarah also suffers with bipolar disorder, but she has been doing well with the anti-depressant she is on. She is a very sweet, tiny, determined lady who is trying her best to keep up with all her health issues. She has changed her diet and has been good with exercising daily.

The patient was last seen in the office in February. Please see that note for complete details. She has several issues she would like to discuss today. She tells me that she has really been under a lot of stress of late. She had been caring for her sister, who has uterine cancer. In addition, her husband 's brother recently died, and there have been issues regarding a property they co-owned. She sold her house in New York and is now renting a house here in Portsmouth. She feels all that she has been doing is moving and cleaning. She feels that she is a little bit settled, however and is hoping that she can get back to her normal regimen. She has not been walking as much as typical, and she would like to lose a couple of pounds and plans to get back into that, as well as her physical therapy exercises that she has been doing for her neuropathy.

General Health State (present weight – gain or loss, reason for gain or loss, amount of time for gain or loss; fatigue, malaise, weakness, sweats, night sweats, chills ): She currently weighs 110lbs. No weight loss. She is well developed and nourished. No distress. States she has always been healthy, other than occasional constipation.

Current Medical Information Kaylea’s medical providers include: Dawn Sorenson (primary doctor, PRN), Dr. Grazyna Piekos-Sobezqk (pediatric endocrinologist, PRN), Trina Hart (clinical therapist, sees weekly), and Ashley Valdovinos (high needs case manager, CFTS). Kaylea is a “type 1 diabetic with uncontrolled diabetes due to stealing food”. Her last A1C was

S.M. has been reading a lot of health promoting activities via magazines and books and has started to adapt them. She has never consumed alcohol and smoked her life. She visits the dentist twice a year and primary care physician once a year. Her last physical exam was December 18th, 2016. She visits her ophthalmologist every once a year. S.M. is up to date on all her screening exams such as mammograms. She said that she does not do self-breast exams because she doesn’t know how to perform them. Her medical history includes a hypertension, femur fracture at the age of twenty-four, and cataract. She told me that two years ago, May of 2015, she had corrective surgery to treat the cataract in India. S.M. manages her hypertension through medication, exercise, and diet. She states that she takes Valsartan (Diovan) 80 mg once a day for hypertension. She said that she is soon going to purchase a blood pressure machine so she can monitor her blood pressure daily. She says she knows what hypertension is through what the doctor tells her, but express the desire to learn more about it and its detrimental affects it can have on her health in the

Lisa is 5’4’’ tall and weighs 140 pounds. She has not been hospitalized recently and she does not have any chronic medical conditions. She explains that she does not have any health conditions that keep her from participating in activities that she does enjoy. She explains that she does not practice preventative health measures. Lisa does not have a regular physician. Lisa rated her health as a 7.2 because she believes she eats healthy. However, she is concerned because she has not been to the doctor since her twins were born eight years ago. Lisa’s health history is “excellent” because she has not had any issues since the last time she went to the doctor which was eight years ago. She states that she does not get sick easily. She explains that medical bills are very expensive and she does not believe it is necessarily important. Lisa explains that

Ms.[Name] returns today. She relays that she is doing well. She is having troubles with her weight, as we discussed it.

At today visit she is accompanied by her daughter Judy, She is awake, alert and pleasant. The daughter reports that the patient has a poor appetite, does not want to eat the facility food but eats well she takes the patient home to visit. The patient had a weight loss of 2lbs in the last month. The daughter reports that the patient had colon resection in the past as a result she has soft stool. The daughter reports that the patient sleeps most

M. H. states that she is generally in good overall health. No cardiac, respiratory, endocrine, vascular, musculoskeletal, urinary, hematologic, neurologic, genitourinary, or gastrointestinal problems.

At today’s visit she is accompanied by her husband. She is awake, alert and oriented times one. She denies pain, chest pain, and shortness of breath. The husband reports that the patient appears stable at this time, but she is not eating as much as she used to. She reports that she is able to dress herself, feed herself and shower herself. The husband reports that it is increasing difficulty to get her to her doctor appointment and that she wonder at time. No acute distress noted. KPS 50%.

Consumer stated that her meeting with “KM” benefit specialist was “very good”. Consumer stated that her week was “ok”. Consumer reported that she is happy that her brother will be discharge from the hospital as of tomorrow. Consumer stated that she hopes that her brother will deal with his issues differently after his experience with the inpatient hospitalization. Consumer stated that she takes her medications as prescribe and that she does not have any side effect other than feeling “little tired” during the day. CM explained to consumer that she may experience some side effect with her medications in the beginning. Consumer stated that she is aware of that and that she understands that she has to wait for another couple of weeks before considering changing any of her medications.

The nurse has to focus on the eyes system and blood circulation system. This is because the patient has pain in the right eye, and also he has been hypertension.

Per grandmother, the client’s pregnancy, and delivery were normal. The grandmother recalls that Keisha’s developmental milestones were reached appropriately, including basic motor skills such as crawling, walking and fine motor skills such as writing. According to the client, she experienced an accident when she was nine years old. The accident affected her brain causing her to experience a coma for more than a month. It took her several months of rehabilitation to be able to return back to school. Keisha reports fatigue and/or loss of energy very often. Even after sleeping for more than twelve hours per day she feels tired every morning. She has been feeling this way for more than three years. Furthermore, the client reports that she has poor appetite, eating one or two meals per day. Due to her decrease in appetite the client reports that she lost about ten pounds since last year. Keisha mentions that her appetite has decreased since she started high school. Per client, her father abused drugs when he was younger, which included heroin and crack. She is unaware if father continues abusing drugs. Per client, her mother did not abuse any drugs while she was alive. The client reports no allergies, traumas or chronic diseases affecting her

Patient education programme designed to improve self-care in hypertension management (nurse-led education session plus patient information booklet)

Mrs. A (pseudonym) is an 83-year-old Samoan female of Christian religion who was admitted to an urban hospital on 02/04/15 by GP referral. She came in with chest pain associated with productive cough and shortness of breath (SOB) on exertion. She also complained of having recurrent episodes of vomiting mixed with saliva and fatigue. She has a history of asthma, hypertension, type 2 diabetes mellitus on Metformin and double incontinence due to a long-standing history of intermittent constipation. Her chest computed tomographic (CT) revealed right lower lobe opacity indicating pulmonary consolidation, which means that her right lower lung has accumulated exudates in the alveoli that would have normally been filled by gas, indicative of bacterial pneumonia. Furthermore, a sputum gram stain sample collected from Mrs. A showed gram-positive bacteria, which is also a characteristic of pneumonia. Her blood tests revealed a high haemoglobin count, which may be caused by an underlying lung disease, as well as high white blood cell count confirming the presence of infection. Considering all diagnostic results, Mrs. A was diagnosed with right lower lobe bacterial pneumonia.