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, shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis. He has a history of allergic rhinitis, depression and hypothyroidism. Patient has been married for 25 years and lives with his wife and two children, is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years, 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. He takes Zyrtec 10mg daily and is allergic to penicillin. Weight has increased by approximately 30 pounds in the last 12 months. B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs. Lungs with mild basilar crackles bilaterally, no wheezes.

·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.

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APA

1167 words