Identifying and Managing Hypertension Effectively
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above., Denies changes in LOC. Denies history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Objective Data:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.
Identifying and Managing Hypertension Effectively
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.
Neck: The neck appears supple, and importantly, there is no cervical lymphadenopathy. Additionally, there is no jugular vein distention, and no thyroid swelling or masses are present.
CARDIOVASCULAR: Heart sounds, specifically S1 and S2, are regular in rate and rhythm. Furthermore, no murmur or gallop is noted. Capillary refill time is less than 2 seconds, indicating adequate perfusion.
RESPIRATORY: The patient shows no signs of dyspnea, and there is no use of accessory muscles observed during breathing. Moreover, upon examination, there is no egophony, whispered pectoriloquy, or tactile fremitus on palpation. Breath sounds are present and clear bilaterally upon auscultation.
GASTROINTESTINAL: No masses or hernias are observed during the examination. Upon auscultation, bowel sounds are present in all four quadrants, and there are no bruits over the renal and aorta arteries. Additionally, the abdomen is soft and non-tender, with no guarding, rebound tenderness, distention, or organomegaly noted on palpation.
MUSCULOSKELETAL: There is no pain upon palpation. Both active and passive range of motion are within normal limits, and importantly, no stiffness is present.
INTEGUMENTARY: The skin is intact, with no lesions or rashes noted. Furthermore, there is no evidence of cyanosis or jaundic