NR 509 Advanced Physical Assessment – Case Study: Primary
Hypertension
Patient Presentation:
A 57‑year‑old Hispanic male, overweight, construction worker, smoker. He presents to the clinic
after an elevated blood pressure of 170/92 mm Hg was noted at a community health fair. He is
otherwise asymptomatic and is seeking follow‑up evaluation.
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I. Subjective Data (History of Present Illness)
- Chief Complaint: “My blood pressure was high at the health fair, so they told me to see a
doctor.”
- Onset: Discovered incidentally today; patient unaware of prior high readings.
- Location: Not applicable (asymptomatic).
- Duration: Unknown; likely chronic.
- Character: No chest pain, palpitations, dyspnea, dizziness, or headaches.
- Aggravating/Relieving Factors: None.
- Timing: Not applicable.
- Severity: Not applicable.
Review of Systems (ROS)
- Constitutional: Denies fever, chills, fatigue, unintentional weight loss.
- Cardiovascular: Denies chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea,
lower extremity edema.
- Respiratory: Denies dyspnea on exertion, cough, wheezing.
, - Neurological: Denies headaches, visual changes, transient weakness, or numbness.
- Renal/Urinary: Denies hematuria, nocturia, dysuria.
- Endocrine: Denies polyuria, polydipsia.
- Musculoskeletal: Occasional low back pain from work, no joint swelling.
Past Medical History (PMH)
- Hypertension: None known.
- Diabetes: None known.
- Hyperlipidemia: None known.
- Cardiovascular disease: None.
- Kidney disease: None.
Past Surgical History (PSH)
- None.
Medications
- None.
Allergies
- No known drug, food, or environmental allergies.
Social History
- Occupation: Construction worker (physical labor, outdoor work, often lifting heavy materials).
- Smoking: 1 pack per day for 35 years (35 pack‑year history).
- Alcohol: Occasional beer (2–3 per week).
- Illicit drugs: Denies.
Hypertension
Patient Presentation:
A 57‑year‑old Hispanic male, overweight, construction worker, smoker. He presents to the clinic
after an elevated blood pressure of 170/92 mm Hg was noted at a community health fair. He is
otherwise asymptomatic and is seeking follow‑up evaluation.
---
I. Subjective Data (History of Present Illness)
- Chief Complaint: “My blood pressure was high at the health fair, so they told me to see a
doctor.”
- Onset: Discovered incidentally today; patient unaware of prior high readings.
- Location: Not applicable (asymptomatic).
- Duration: Unknown; likely chronic.
- Character: No chest pain, palpitations, dyspnea, dizziness, or headaches.
- Aggravating/Relieving Factors: None.
- Timing: Not applicable.
- Severity: Not applicable.
Review of Systems (ROS)
- Constitutional: Denies fever, chills, fatigue, unintentional weight loss.
- Cardiovascular: Denies chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea,
lower extremity edema.
- Respiratory: Denies dyspnea on exertion, cough, wheezing.
, - Neurological: Denies headaches, visual changes, transient weakness, or numbness.
- Renal/Urinary: Denies hematuria, nocturia, dysuria.
- Endocrine: Denies polyuria, polydipsia.
- Musculoskeletal: Occasional low back pain from work, no joint swelling.
Past Medical History (PMH)
- Hypertension: None known.
- Diabetes: None known.
- Hyperlipidemia: None known.
- Cardiovascular disease: None.
- Kidney disease: None.
Past Surgical History (PSH)
- None.
Medications
- None.
Allergies
- No known drug, food, or environmental allergies.
Social History
- Occupation: Construction worker (physical labor, outdoor work, often lifting heavy materials).
- Smoking: 1 pack per day for 35 years (35 pack‑year history).
- Alcohol: Occasional beer (2–3 per week).
- Illicit drugs: Denies.
