Running head: CASE STUDY ANALYSIS
1
Case Study Analysis: Hypertension
Name
Liberty University
,CASE STUDY ANALYSIS 2
Case Study Analysis: Hypertension
CC: “My daughter is a CNA and says I need to see a doctor for a check-up.”
HPI: GKC is a 61 YO Caucasian male who presents to his new family practice
physician for evaluation of his medical problems. He has no particular
complaints today. He states he occasionally has problems with sinus
allergies and “picked up some Sudafed at Wal-Mart.”
PMH: Hypertension for approximately 8 yrs. No history of CAD or DM.
FH: Father died of acute MI at age 73; mother died of lung cancer at age
69; brother (age 68) has HTN and hyperlipidemia; and younger sister
(age 55) has no known medical problems.
SH: He has been married for 39 years and has one son and daughter (in
their 20s) who are healthy. He quit smoking a pipe about 6 years
ago. He states his alcohol intake is 6–8 drinks/week. He is retired
and enjoys walking around the neighborhood with his wife 1–2
times per week. He does not pay attention to what he eats. He
enjoys a “good ole Southern diet” and adds salt to his food. He
denies ever being placed on any diet due to his medical conditions.
Allergies: NKDA
Medication History: Hydrochlorothiazide/triamterene 25/37.5 mg QD x 8 years
Sudafed 60 mg Q6 hours prn sinus drainage
Aleve 1 to 2 tablets QD PRN joint pain
Physical Exam: Gen–A&O, obese Caucasian man in NAD
VS–Average BP 155/86, HR 55, RR 16, T 98.6, Ht. 6’0,” Wt. 255 lbs.
HEENT–TM’s clear throughout and no drainage, EOMI; funduscopy
shows arteriolar narrowing
Lungs–few basilar crackles; no wheezing
Heart–RRR (slow), normal S1 and S2
Abd–Soft and ND; mildly tender in suprapubic area, no masses, bruits
Rectal/GU–Prostate 1+ (enlarged); prostate benign. Heme (-) stool
, CASE STUDY ANALYSIS 3
Ext–No clubbing, cyanosis, or edema.
Lab Results: Na–136 mEq/ml K–3.8 mEq/ml
Cl–98 mEq/ml HCO3–29 mEq/ml
BUN–22 mg/dl Glucose–181 mg/dl
HbA1c–8.5% TCHOL–262 mg/dl
LDL–180 mg/dl TGs–275 mg/dl
HDL–35 mg/dl AST–32 U/I
ALT–30 U/I Alk Phos–38 U/I
SCr – 1.0 mg/dl
1
Case Study Analysis: Hypertension
Name
Liberty University
,CASE STUDY ANALYSIS 2
Case Study Analysis: Hypertension
CC: “My daughter is a CNA and says I need to see a doctor for a check-up.”
HPI: GKC is a 61 YO Caucasian male who presents to his new family practice
physician for evaluation of his medical problems. He has no particular
complaints today. He states he occasionally has problems with sinus
allergies and “picked up some Sudafed at Wal-Mart.”
PMH: Hypertension for approximately 8 yrs. No history of CAD or DM.
FH: Father died of acute MI at age 73; mother died of lung cancer at age
69; brother (age 68) has HTN and hyperlipidemia; and younger sister
(age 55) has no known medical problems.
SH: He has been married for 39 years and has one son and daughter (in
their 20s) who are healthy. He quit smoking a pipe about 6 years
ago. He states his alcohol intake is 6–8 drinks/week. He is retired
and enjoys walking around the neighborhood with his wife 1–2
times per week. He does not pay attention to what he eats. He
enjoys a “good ole Southern diet” and adds salt to his food. He
denies ever being placed on any diet due to his medical conditions.
Allergies: NKDA
Medication History: Hydrochlorothiazide/triamterene 25/37.5 mg QD x 8 years
Sudafed 60 mg Q6 hours prn sinus drainage
Aleve 1 to 2 tablets QD PRN joint pain
Physical Exam: Gen–A&O, obese Caucasian man in NAD
VS–Average BP 155/86, HR 55, RR 16, T 98.6, Ht. 6’0,” Wt. 255 lbs.
HEENT–TM’s clear throughout and no drainage, EOMI; funduscopy
shows arteriolar narrowing
Lungs–few basilar crackles; no wheezing
Heart–RRR (slow), normal S1 and S2
Abd–Soft and ND; mildly tender in suprapubic area, no masses, bruits
Rectal/GU–Prostate 1+ (enlarged); prostate benign. Heme (-) stool
, CASE STUDY ANALYSIS 3
Ext–No clubbing, cyanosis, or edema.
Lab Results: Na–136 mEq/ml K–3.8 mEq/ml
Cl–98 mEq/ml HCO3–29 mEq/ml
BUN–22 mg/dl Glucose–181 mg/dl
HbA1c–8.5% TCHOL–262 mg/dl
LDL–180 mg/dl TGs–275 mg/dl
HDL–35 mg/dl AST–32 U/I
ALT–30 U/I Alk Phos–38 U/I
SCr – 1.0 mg/dl
