An Introduction to the History of Psychology, Exams of Nursing

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FELIPE GARCIA 57 YEAR OLD REASON FOR ENCOUNTER HIGHBLOOD PRESSURE LATEST CASE 2025

HISTORY

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:

1. Lifestyle Modifications: o Low-sodium, DASH diet.

- 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.

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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.