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Hypertension Patient Case
Longitudinal Case Study For Students

March 9, 2009

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Page 1Hypertension

Hypertension

Thomas McEwan is a 51 year old black male diagnosed with hypertension 3 years ago. Thomas visits your pharmacy and enrolls in your hypertension care program. You are to work with Tom to manage his hypertension and prevent complications.

To communicate with Thomas, send him an e-mail.

CC: "I've been getting headaches lately. I lost my job as a machinist and as old as I am, I am not ready to try and find a new job".

HPI: TM is a 51-year-old African American man with a three year history of HTN.

PMH: HTN; Bilateral Renal Arterial Stenosis (RAS), and chronic pain.

FH: Divorced, 1 unmarried child, mother deceased ~ 10 yrs ago of unknown cause, father (83 years old), w/a, h/o CABG x 3.

SH: + tobacco use; 1-2 packs a day for 35 years, + EtOH (socially, 1-3 drinks/night), (-) exercise, diet consists of food prepared at work and mostly prepackaged or canned foods at home.

Meds: Multivitamin 1 QD, Neurontin 100 mg TID, Furosemide 40 mg 1 PO QD.

ALL: Fish

PE:

Gen: WD, mildly obese, BM in NAD; 5'11", 193lbs, BP 160 mmHg/96 mmHg, HR 85

HEENT: NC/AT, EOMI, PERRLA, (-) JVD, nasopharynx clear

CV: S1, S2, regular

Lungs: + bilateral BS, no RRW

Abdomen: + BS, NT, central obesity

Ext: (-) C/C/E

Neuro: A and O X 3/3, strength 5/5

Laboratory Results
Lab Value
Na+ (mEq/L) 143
K+ (mEq/L) 4.2
Cl- (mEq/L) 108
CO2 (mEq/L) 27
BUN (mg/dL) 22
SCr (mg/dL) 2.5
Glucose (mg/dL) 142

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