Hypertension Patient Case Longitudinal Case Study For StudentsMarch 9, 2009 Print-friendly version Email this article
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 |
|
1 |