Health Assessment  Paper

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25 yrs

Hispanic White

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Health Assessment  Paper

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Reliable historian

Marital status: single

Living conditions: Lives with the parents and siblings

Occupation: Works as an accountant at a local mall

Education: BSc Economics and Finance and CPA 4

Hobbies: Watching movies, dancing, hiking, and music.

Social support: supportive parents and siblings and a local church. Active in the church as a youth leader

Indication: Essential hypertension

Class: Antihypertensives, Calcium channel blockers: Dihydropyridine calcium channel blockers.

Action: Nifedipine blocks calcium channels in blood vessels and the SA of the heart, delaying cells hence slowing the entry of calcium into these cells during the depolarization phase. Preventing the entry of calcium ions into cells prevents vasoconstriction and promotes vasodilation in the periphery and coronary circulation. Thus, it reduces total peripheral resistance. Blood pressure is a function of cardiac output and total peripheral resistance. Reducing peripheral resistance reduces blood pressure (Khan et al., 2019).

Common and Major S&E: General malaise, headache, flushing, heat sensation, dizziness, lightheadedness, nausea, diarrhea, constipation, stomach pain, increased micturition, labored breathing (relaxing respiratory muscles), and leg cramps. Danger signs/ those requiring medical attention include worsening angina, palpitations, edema of the extremities, gastric pain, and jaundice. These signs could because by damage to vital organs.

Patient Education: Do not change the dose without the doctor’s advice, take the medication same time every day to avoid forgetting (set alarms or reminders if possible), maintain strict adherence to medication dosage and frequency as prescribed (non-adherence leads to fatal side effects. Report any danger signs such as dark tarry stools, allergic reactions (hives, rashes, runny nose), worsening chest pain, tremors, mood changes, severe constipation, and SOB (Khan et al., 2019)

Hair/Nails: Denies hair loss or excess hair, has strong nails, and denies yellow nails, pain, or infection

Ears: Denies otorrhea, drainage, hearing loss, tinnitus, or vertigo

Eyes: Denies blurry vision, pain, dryness, itchiness, or photophobia

Nose: Denies epistaxis, loss of smell, stuffiness, pain, drainage sneezing, erythema, or sinus pain

Throat/mouth: Denies pain, stuffiness, cough, mouth lesions, pain, gum bleeding or pain, hoarseness, or sire throat

peripheral vascular: Denies leg pain, claudication, edema, masses, wounds

Nails: Pink nail bed, symmetrical nails, no discoloration, clubbing, pitting, or cyanosis. Cap refill <1 sec

Eyes: Visual acuity 20/20 bilaterally, PERRLA with direct and consensual light reflexes bilaterally, sclera white, clear conjunctiva, lens clear, lacrimal apparatus soft, no drainage

Nose: Nasal septum intact and midline, pink mucosal, no lesions, rashes, polyps, or erythema. Non-tender sinuses. No nasal drainage

Throat: Ovule midline, non-inflamed tonsils, gag reflex present. Pharynx pink and moist

Mouth: Pink lips, no lesions, rashes, or sores. Sense of taste intact, symmetrical tongue movement, gum strong and well attached, not edematous

Teeth: No missing dentition, no dental caries

Perip vascular: Peripheral pulses: brachia. Radial, tibial, dorsalis pedis, and temporal pulses 78

CN I- Differentiates smells, CN I, Olfactory, intact

CN II- Distant and near vision (Snellen and Rosenbaum) OD 20/20. OS 20/20, OU 20/20, CN II, Optic, intact bilaterally

CN III- Completes the six cardinal points eye movement without nystagmus, corneal light reflex positive, cover-uncover test negative, CNIII, Oculomotor, intact

CN IV: Completes the 6 EOMIs 1, CN IV, Trochlear, Intact

CN V: Identifies correctly sharp and dull touch, bilateral temporal and masseter muscle contractions, CN V, Trigeminal, intact bilaterally

CN VI: Completes the 6 EOMIs with no nystagmus, CLR symmetric, cover-uncover test negative for deviation or mvt. CN VI Abducens, intact

CN VII: patient frowns, smiles, wrinkles, opens moth, exposes teeth, puffs cheeks, raises eyebrows, moves lips, closes eyelids against resistance, all facial movements symmetrical, with conscious manipulation. CN VII, Facial, intact bilaterally

CN VIII: Whisper tests with “Fruit salad” from two feet positive. CN VII, Acoustic Vestibulocochlear, intact bilaterally

CN IX & CN X: Uvula and soft palate rise on phonation symmetrically, gag reflex present, no dysphagia or hoarseness, distinguishes bitter from sour. CN IX Glossopharyngeal and CN X Vagus, intact.

CN XI: Symmetrical trapezium and sternocleidomastoid muscles contraction with strong muscle tone. CN XI, spinal accessory, intact

CN XII: symmetric tongue movement with appreciable muscle tone, reactive to passive resistance

Intact coordination, rapid alternating rhythmic movement, deep tendon reflexes intact, negative Babinski bilaterally CN XII, hypoglossal intact.

Post-Traumatic Stress Disorder

Heart disease- 151.9

Mild Depression F32.0

Diagnostics: Hypertension and anxiety management

Medications/Treatments: Cognitive behavioral therapy, Sertraline 25mg Daily, PO, Paroxetine 20mg PO OD, and Nifedipine 30mg PO OD.

Education: According to the guideline, hypertensive patients should ensure their BMI is between 18 and 25. Smoking and alcohol cessation intake is also a priority in hypertension management. Take drugs at the same time to avoid missing dosages. Regularly measure your blood pressure. Regulate your salt intake, take adequate water regularly exercise for hypertension and weight management.

Follow-up: Patient follow-up every three months is integral for evaluating the effectiveness of current therapy, assessing complications, and replenishing management drugs. The anxiety CBT sessions (talk sessions and group therapy) every two weeks.

Referrals: Group therapy for effective CBT. Community anxiety groups

Prevention Plan: Alcohol intake cessation. Jogging three days a week, avoiding snacks and junk foods. Exercises such as jogging or bike riding are good for cardiac rehabilitation.

Well-controlled hypertension does not require further interventions or change in therapy. The patient’s hypertension is within targets hence the need for continued therapy. The ACCC/AHA/AAPA/ABC… 2018 guidelines recommend exercises such as yoga, swimming, cycling, and jogging 2-3 days a week for hypertensive patients, moderating caffeine, reducing salt intake, smoking cessation, and weight loss (Whelton et al., 2018). Salt regulation is vital in renal function and controlling blood volume. Regulating salt intake helps relieve unnecessary stress on the blood volume regulations. It also recommends whole grains, polyunsaturated fats, vegetables rich in nitrates rich in minerals. Some foods, such as snacks, contain too much sugar, leading to weight gain and temporary blood pH shifts, negatively impacting hypertension management (Whelton et al.,m 2018). Increased weight in hypertensive patients also leads to other complications such as renal injury and type II diabetes. Patient collaboration is important in hypertension management hence the need for comprehensive patient education. These measures are also easily ignored. Emphasizing their importance to these patients will ensure their implementation.

PTSD and CPTSD present with disabling thoughts and uncontrollable flashbacks of the events, which are not present in our patient. The thoughts appear with or without the triggers, while the anxiety arises only when our client travels. Unlike anxiety, mild depression presents with a depressed mood, unlike our client. Hopelessness and feeling of unworthiness present in depression are absent in our client. Hence, anxiety is the correct diagnosis for our client. Heart disease presents with several symptoms, primarily chest pain, tightness or discomfort, and shortness of breath, absent in our client. The client has a history of hypertension for which she receives treatment, making it our primary diagnosis.

According to the NICE guideline (2019), cognitive behavioral therapy is the treatment of choice and the first-line treatment for anxiety and anxiety disorders. It entails controlled exposure to anxiety triggers and alleviates adverse conditions and maladaptive behaviors. Sertraline and Paroxetine are the FDA-approved first-line medications for anxiety disorders (Stefan et al., 2019). SSRIs inhibit the reuptake of serotonin in the brain and reduce anxiety symptoms. SSRIs are well tolerated and are effective in long-term and short-term management, and thus they are recommended in anxiety disorders (Strawn et al., 2019). Combining psychotherapy and pharmacotherapy produces better management, drug adherence, and better patient adherence. According to Straw et al. (2019), these interventions also target different cognitive and somatic anxiety symptoms hence their superimposed benefits.

Hypertension is essentially high blood pressure resulting from increased peripheral resistance or cardiac output. Blood pressure depends on cardiac output and total peripheral resistance. Cardiac output depends on fluid volume, majorly affected by renal clearance and blood pH. Poor renal clearance leads to fluid overload, hence increased cardiac preload, which increases blood pressure. Blood volume and pH changes control the capillary fluid shift. High blood volume and low pH cause fluid movement to the interstitial pH spaces, leading to generalized edema. Low blood volume and high pH lead to fluid shift; thus, dehydration for compensation, blood shunting to vital organs, decreased peripheral pulse and skin turgor, and prolonged capillary refill (hypotension). Peripheral resistance is caused by narrowing blood vessels such as aortic stenosis and atherosclerotic plagues. Other conditions also lead to fibrous invasion of inner vessel muscles hence poor contractility (Ali & Bakris, 2019). Medications target decreasing the blood volume (thiazides, loop diuretics, ARBs, and ACEIs) while other drugs such as beta-blockers and calcium channel blockers target peripheral resistance and cardiac contractility. These drugs restore homeostasis hence the absence of these manifestations in well-controlled hypertension.

Anxiety causes stress, physical conditions, genetic predisposition, environmental factors (car accident for this patient), or substance abuse. The brain amygdala determines the significance of stimuli and stores emotional memories (Munir et al., 2019). The amygdala efferent pathways from its central nucleus travel to other brain regions such as the parabrachial nucleus (dyspnea and hyperventilation), dorsomedial nucleus of vagus nerve hence parasympathetic nervous stimulation (eye tearing, frequent or urination urge, digestion, and defecation urge), and the lateral hypothalamus leading to sympathetic nervous stimulation hence apprehension, shakiness (manifested in our patient), nervousness, agitation, muscle tension, poor digestion/indigestion (possible cause of decreased appetite in our client) and increased heart rate (Munir et al., 2019). Thus, shakiness and excessive worry before traveling are manifestations of anxiety. Managing anxiety early will help prevent the development of generalized anxiety disorder to post-traumatic stress disorder. Thus, active management with pharmacologic and non-pharmacologic interventions is integral.

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