Case Study: Blood Pressure Recheck for Heather Nardone Chamberlain
(56 years) Chamberlain University || 100% Guaranteed Pass || complete
A+ Guide
Heather Nardone – Chamberlain
56 yo Female
5’5” (165cm)
188.0 lbs (85.5kg)
Reason for Encounter: Blood Pressure Recheck
Location: Outpatient clinic with laboratory
capabilities
Patient's name Heather Nardone Chamberlain, 56-year-old female, 5 feet 5 inches or 165 centimeter in
height, 188 pounds or 85.5 kilogram. Reason for encounter, blood pressure recheck. Location, outpatient
clinic with laboratory capabilities. History of present illness, blood pressure recheck. History of present
illness, this patient is a 56-year-old obese female patient with a primary medical history of hypothyroidism
who presents for a blood pressure recheck after attending a workplace health fair three weeks ago. Her blood
pressure reading at the health fair was 132.74 and the nurse asked her to follow up with a primary care
within four weeks for re-evaluation. She has not been taking her blood pressure at home and recently moved
to an area about five months ago but has not established care with a PCP. She reports consuming a high fat,
high salt diet, physically inactivity, and a family history of heart disease. She is asymptomatic and denies chest
pain, shortness of breath, light swelling, polio, polydipsia, polypagia, weakness, numbness, tingling, and
fatigue. For the review of systems, general denies fever, chills, weight loss, or night sweats. For HENT or neck,
no new blurry vision, hearing loss, sore throat, or swollen lymph nodes. For the cardiovascular, as per HPI,
denies syncope, presyncope, or palpitations. Respiratory denies cough or wheezing. Gastrointestinal denies
vomiting, constipation, or diarrhea. Genitourinary denies nocturia, dysuria, or hematuria. Musculoskeletal or
osteopathic structural examination denies muscle pain or joint swelling. Neurologic, as per HPI, denies
syncope or lightheadedness. Indigumentary or breast, no rashes, echemosis, or lesions. Psychiatric reports
slight stress due to work, and watching grandchildren denies depressed or anxious mood. Endocrine, as per
HPI, denies heat or cold intolerance. Hematologic or lymphatic denies easy bruising or bleeding. Allergic or
immunologic denies recent itching or hives. For past medical history, hypothyroidism diagnosed 80 years
ago. Obese BMI diagnosed 10 years ago. Two children delivered full-term, spontaneous vaginal delivery
without complications. For hospitalization or surgeries, laparoscopic myomectomy 12 years ago, no
complications, and tolerated anesthesia well. For medication, levothyroxine, 75 microgram PO daily, take 30
minutes before breakfast. Allergies, no known drug allergies.
Preventive health, annual wellness checks, last visit 10 months ago, attended health fair three weeks ago for
screenings. Annual dental cleanings, last visit eight months ago, wears reading glasses, last eye exam 14
, months ago. Colonoscopy, last completed four years ago, no abnormalities. Last pap smear two years ago, no
abnormalities. Last mammogram one year ago, no abnormalities. Completes monthly breast exams.
Immunizations, all vaccinations are up to date. Received seasonal influenza vaccine, declined COVID-19
vaccine. Family history, mother, 77 years old, hypothyroidism, fibroids, uterine cancer. Father, disease at 66
year old, coronary heart disease, hyperlipidemia, hypertension, died from heart attack. Children, son, 26 year
old, no health problems. Son, 30 years old, no health problems. Maternal grandmother, unknown. Maternal
grandfather, diseased at 72 years old, atrial fibrillation. Paternal grandmother, unknown. Paternal
grandfather, unknown. Social history, tobacco, non-smoker, alcohol, drinks one day per week, consumes two
to three glasses of wine. Diet, denies. Activity, sedentary lifestyle, is not physically active. Travel, no recent
travel. Sleep, no problems of falling or staying asleep. Stressors, managing grandchildren and work. Living
situation, leaves alone, divorce. Support system, children and friends. Occupation, insurance claim adjuster.
Finances, budgeted. Exposures, none. Life planning has living well.
Physical exam. Height, 65 inches. Weight, 188 pounds. BMI, 31.3. Cognitive status, ANO times 4. Temperature,
37.1 degrees Celsius or 98.8 Fahrenheit Oral pulse, 83 beats per minute. Rhythm, regular. Strength, normal.
Blood pressure, left, 118 over 72. Right, 118 over 72. Assessment, normal tensive. Pulse pressure, normal.
Respiration, 18 beats or breaths per minute. Rhythm, regular. Effort, unlabored. SPO2, 99%. General, alert
and oriented. Appropriate attention and dress. Obese body habitus. HENT or neck. Eyes, visual acuity. Right
eye, OD, 20 over 20. Left eye, OS, 20 over 20. Eyelids without ptosis, erythema, or swelling. Yellow waxy
appearing lesions above medial bilateral eyes. Bilateral conjunctiva, pink without discharge. Bilateral cornea
with light gray rings. Fundoscopic exam, red reflex bilaterally. Optic disc sharp, no AV nicking or cotton wall
spots noted. Neck, thyroid mobile without masses. Tenderness, nodules or enlargement. Cardiovascular, no
carotid bruit. Non-displaced PMI, jugular venous pressure, less than 3 centimeter above sternum. Regular
rate and rhythm, no gallop, murmur, or friction rub. No leg swelling. Lower extremity, capillary refill less
than 2 seconds. Pedal pulses, positive 2, and symmetrical bilaterally. Chest or respiratory, regular respiratory
effort without accessory muscle usage. Clear breath
(56 years) Chamberlain University || 100% Guaranteed Pass || complete
A+ Guide
Heather Nardone – Chamberlain
56 yo Female
5’5” (165cm)
188.0 lbs (85.5kg)
Reason for Encounter: Blood Pressure Recheck
Location: Outpatient clinic with laboratory
capabilities
Patient's name Heather Nardone Chamberlain, 56-year-old female, 5 feet 5 inches or 165 centimeter in
height, 188 pounds or 85.5 kilogram. Reason for encounter, blood pressure recheck. Location, outpatient
clinic with laboratory capabilities. History of present illness, blood pressure recheck. History of present
illness, this patient is a 56-year-old obese female patient with a primary medical history of hypothyroidism
who presents for a blood pressure recheck after attending a workplace health fair three weeks ago. Her blood
pressure reading at the health fair was 132.74 and the nurse asked her to follow up with a primary care
within four weeks for re-evaluation. She has not been taking her blood pressure at home and recently moved
to an area about five months ago but has not established care with a PCP. She reports consuming a high fat,
high salt diet, physically inactivity, and a family history of heart disease. She is asymptomatic and denies chest
pain, shortness of breath, light swelling, polio, polydipsia, polypagia, weakness, numbness, tingling, and
fatigue. For the review of systems, general denies fever, chills, weight loss, or night sweats. For HENT or neck,
no new blurry vision, hearing loss, sore throat, or swollen lymph nodes. For the cardiovascular, as per HPI,
denies syncope, presyncope, or palpitations. Respiratory denies cough or wheezing. Gastrointestinal denies
vomiting, constipation, or diarrhea. Genitourinary denies nocturia, dysuria, or hematuria. Musculoskeletal or
osteopathic structural examination denies muscle pain or joint swelling. Neurologic, as per HPI, denies
syncope or lightheadedness. Indigumentary or breast, no rashes, echemosis, or lesions. Psychiatric reports
slight stress due to work, and watching grandchildren denies depressed or anxious mood. Endocrine, as per
HPI, denies heat or cold intolerance. Hematologic or lymphatic denies easy bruising or bleeding. Allergic or
immunologic denies recent itching or hives. For past medical history, hypothyroidism diagnosed 80 years
ago. Obese BMI diagnosed 10 years ago. Two children delivered full-term, spontaneous vaginal delivery
without complications. For hospitalization or surgeries, laparoscopic myomectomy 12 years ago, no
complications, and tolerated anesthesia well. For medication, levothyroxine, 75 microgram PO daily, take 30
minutes before breakfast. Allergies, no known drug allergies.
Preventive health, annual wellness checks, last visit 10 months ago, attended health fair three weeks ago for
screenings. Annual dental cleanings, last visit eight months ago, wears reading glasses, last eye exam 14
, months ago. Colonoscopy, last completed four years ago, no abnormalities. Last pap smear two years ago, no
abnormalities. Last mammogram one year ago, no abnormalities. Completes monthly breast exams.
Immunizations, all vaccinations are up to date. Received seasonal influenza vaccine, declined COVID-19
vaccine. Family history, mother, 77 years old, hypothyroidism, fibroids, uterine cancer. Father, disease at 66
year old, coronary heart disease, hyperlipidemia, hypertension, died from heart attack. Children, son, 26 year
old, no health problems. Son, 30 years old, no health problems. Maternal grandmother, unknown. Maternal
grandfather, diseased at 72 years old, atrial fibrillation. Paternal grandmother, unknown. Paternal
grandfather, unknown. Social history, tobacco, non-smoker, alcohol, drinks one day per week, consumes two
to three glasses of wine. Diet, denies. Activity, sedentary lifestyle, is not physically active. Travel, no recent
travel. Sleep, no problems of falling or staying asleep. Stressors, managing grandchildren and work. Living
situation, leaves alone, divorce. Support system, children and friends. Occupation, insurance claim adjuster.
Finances, budgeted. Exposures, none. Life planning has living well.
Physical exam. Height, 65 inches. Weight, 188 pounds. BMI, 31.3. Cognitive status, ANO times 4. Temperature,
37.1 degrees Celsius or 98.8 Fahrenheit Oral pulse, 83 beats per minute. Rhythm, regular. Strength, normal.
Blood pressure, left, 118 over 72. Right, 118 over 72. Assessment, normal tensive. Pulse pressure, normal.
Respiration, 18 beats or breaths per minute. Rhythm, regular. Effort, unlabored. SPO2, 99%. General, alert
and oriented. Appropriate attention and dress. Obese body habitus. HENT or neck. Eyes, visual acuity. Right
eye, OD, 20 over 20. Left eye, OS, 20 over 20. Eyelids without ptosis, erythema, or swelling. Yellow waxy
appearing lesions above medial bilateral eyes. Bilateral conjunctiva, pink without discharge. Bilateral cornea
with light gray rings. Fundoscopic exam, red reflex bilaterally. Optic disc sharp, no AV nicking or cotton wall
spots noted. Neck, thyroid mobile without masses. Tenderness, nodules or enlargement. Cardiovascular, no
carotid bruit. Non-displaced PMI, jugular venous pressure, less than 3 centimeter above sternum. Regular
rate and rhythm, no gallop, murmur, or friction rub. No leg swelling. Lower extremity, capillary refill less
than 2 seconds. Pedal pulses, positive 2, and symmetrical bilaterally. Chest or respiratory, regular respiratory
effort without accessory muscle usage. Clear breath
