IHUMAN CASE STUDY HARVEY HOYA CC: HIGH BLOOD PRESSURE, 57 YEARS MALE

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IHUMAN CASE STUDY HARVEY HOYA CC: HIGH BLOOD PRESSURE, 57 YEARS MALE Patient Information: Name: H.H. Age: 57 Sex: _Male Race: _Hispanic SUBJECTIVE DATA Chief Complaint (CC): “High ... blood pressure”. History of Present Illness: Pt. is a 57 y/o Hispanic who presents to the clinic with complaints of elevated blood pressure. The pt. states that a local health professional at a local health clinic was concerned by the elevated blood pressure, and advised him to see a doctor. He admits that he has been informed about his elevated blood pressure before, but has remained uncontrolled. Associated symptoms include intermittent headaches rating 3-4/10, and described as dull. He also reports problems with sleeping due to snoring. The patient has been diagnosed with gastritis in the past managed with medication. Current Medications: ibuprofen 800 mg 3 times per day for headaches, omeprazole every morning for gastritis Allergies: None Pertinent PMHx: patient denies any previous pertinent health history Soc Hx: Patient smoke a pack of cigarette a day, hx. of ETOH occasionally, mostly on weekends. Patient can afford to co-pay for the clinic visits and medications. Fam Hx: Father 62, dead, stroke; mother alive diabetes; grandmother alive, diabetes; grandfather dead at 52 due to heart attack. Brother and paternal uncle hx. of diabetes. History questions asked: 1. How can I help you today? 2. How is your overall health? 3. How severe is your high blood pressure? 4. Does your problem with high blood pressure come and go? 5. Have you lost or gained weight unintentionally gained or lost weight? 6. Are you taking any prescription medications? 7. Have you ever been hospitalized? 8. Are your immunizations up to date? 9. Do you have any allergies? 10. Do you have heart disease and/or have ever had a heart attack? 11. Have you had problems with high blood pressure before? 12. Are you worried about your health? 13. Hove you changed your caffeine intake? 14. Have you had more pressure at work? 15. Do you have night sweats? 16. Have you recently fainted? 17. Tell me about your current or past medical problems you have had? 18. When did your headaches start? 19. Do you have any symptoms that occur at the same time as your headache? 20. How long does your headache last? 21. Do you have any awareness or warning symptoms that occur before the headache begins? 22. What treatments have you had for your headache? 23. How severe (1-10 scale) is your headache? 24. What does the pain in your headache feel like? 25. Do you have any pain in your abdomen? 26. Do you presently have heartburn, a food or acid taste in your mouth? 27. Do you have a history of lower GI bleed? [Show More]

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