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An Introduction to the History of Psychology
Typology: Exams
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FELIPE GARCIA 57 YEAR OLD REASON FOR ENCOUNTER HIGHBLOOD PRESSURE LATEST CASE 2025
Here’s what I can include: Patient Information (Age, Weight, Height) Medical History (Past conditions, medications, family history) Symptoms & Diagnosis Treatment Plan Follow-up Recommendations
No varicose veins. Capillary refill <2 seconds (normal circulation). Skin warm and dry, no ulcers or lesions. Skin Examination: No rashes, lesions, or infections. No signs of diabetic skin changes. Musculoskeletal System: Normal range of motion in all joints. No joint swelling, tenderness, or deformities. No back pain or spinal tenderness. Assessment & Plan: Assessment:
Primary Diagnosis: Hypertension (High Blood Pressure). Risk Factors: Overweight, possible lifestyle factors (diet, physical activity). Patient Name: Felipe Garcia Age: 57 years Gender: Male Height: 5'7" (175 cm) Weight: 195.0 lbs (88.6 kg) BMI: 30.6 kg/m² (Overweight) Primary Concern: High Blood Pressure (Hypertension) General Appearance: Well-nourished, overweight middle-aged male. Appears calm and cooperative. No acute distress noted. Well-groomed, no signs of neglect or malnutrition.
Throat: No tonsillar swelling, no signs of infection. Neck Examination: No jugular venous distension (JVD). No carotid bruits (indicating no vascular obstruction). Thyroid gland is normal, no enlargement or nodules. Cardiovascular System: Heart rate regular, no murmurs, rubs, or gallops. No displaced point of maximal impulse (PMI). No peripheral edema or signs of heart failure. Peripheral pulses strong and symmetric bilaterally. No signs of deep vein thrombosis (DVT).
Respiratory System: Normal respiratory effort, no labored breathing. No use of accessory muscles. Lungs clear to auscultation bilaterally. No wheezing, crackles, or rhonchi. Abdominal Examination: Soft, non-tender, non-distended. No hepatosplenomegaly (enlarged liver or spleen). Bowel sounds present and normal. No masses or fluid accumulation (ascites). Plan:
- Patient education on hypertension and cardiovascular health provided. Neurological Examination: Alert and oriented (A&O ×3: person, place, time). Cranial nerves II-XII intact. No focal neurological deficits (no weakness, numbness, or tingling). Normal gait, coordination, and reflexes. Extremities & Peripheral Vascular System: No cyanosis, clubbing, or edema. No varicose veins. Capillary refill <2 seconds (normal circulation). Skin warm and dry, no ulcers or lesions. Skin Examination: No rashes, lesions, or infections.
No signs of diabetic skin changes. Musculoskeletal System: Normal range of motion in all joints. No joint swelling, tenderness, or deformities. No back pain or spinal tenderness. Assessment & Plan: Assessment: Primary Diagnosis: Hypertension (High Blood Pressure). Risk Factors: Overweight, possible lifestyle factors (diet, physical activity). Plan: 1.Lifestyle Modifications: o Low-sodium, DASH diet.
Primary Diagnosis: Hypertension (High Blood Pressure) – Stage 1 or 2 (Based on BP readings). Contributing Risk Factors: Age: 57 years (higher risk for hypertension). BMI: 30.6 kg/m² (overweight, increases cardiovascular risk). Possible Lifestyle Factors: High sodium intake, sedentary lifestyle, stress, or poor dietary habits. Potential Family History: If present, increases genetic predisposition to hypertension. Clinical Findings: Elevated Blood Pressure: 150/95 mmHg. No Acute Cardiovascular Symptoms: No chest pain, palpitations, or dizziness. No Signs of End-Organ Damage: No retinal changes, no signs of heart failure, normal neurological exam.
Differential Diagnoses: 1.Essential Hypertension (Primary Hypertension) – Most likely diagnosis, often linked to lifestyle, genetics, and aging. 2.Secondary Hypertension (less likely but needs evaluation): o Renal artery stenosis (kidney-related hypertension). o Hyperaldosteronism (hormonal imbalance). o Sleep apnea (linked to obesity and hypertension). o Medication-induced (NSAIDs, steroids, decongestants). General Appearance:
- Well-nourished, middle-aged male. - No acute distress observed. - Alert and oriented to person, place, and time.
- Regular rate and rhythm, no murmurs, rubs, or gallops. - No peripheral edema. - Peripheral pulses strong and symmetric. Respiratory Examination: - Clear breath sounds bilaterally. - No wheezing, rales, or rhonchi. Abdomen: - Soft, non-tender, no organomegaly. - No signs of fluid retention (ascites). Neurological Examination: - No focal deficits. - Normal gait and coordination. - Reflexes intact. Extremities: - No cyanosis, clubbing, or edema.
- Capillary refill <2 seconds. Assessment & Plan: - Primary Concern: Hypertension. - Plan: Lifestyle modifications, possible antihypertensive medication, follow-up in 2- 4 weeks.
_ Physical Examination Report Patient Name: Felipe Garcia Age: 57 years Gender: Male Height: 5'7" (175 cm) Weight: 195.0 lbs (88.6 kg) BMI: 30.6 kg/m² (Overweight)
- Temperature: 98.6°F (37°C) (Normal) - Oxygen Saturation (SpO2): 98% on room air
_ Head, Eyes, Ears, Nose, Throat (HEENT): - Head: Normocephalic, no lesions, no tenderness. - Eyes: No conjunctival pallor (rules out anemia). No jaundice. Fundoscopic exam shows no hemorrhages, papilledema, or hypertensive retinopathy. - Ears: No hearing loss, cerumen impaction, or discharge. - Nose: Nasal mucosa normal, no congestion or polyps. - Throat: No tonsillar swelling, no signs of infection.
Neck Examination:
- No jugular venous distension (JVD). - No carotid bruits (indicating no vascular obstruction). - Thyroid gland is normal, no enlargement or nodules.
_ Cardiovascular System: - Heart rate regular, no murmurs, rubs, or gallops. - No displaced point of maximal impulse (PMI). - No peripheral edema or signs of heart failure.