- ****54 y/o male with past medical history of HTN taking lisionopril but medication not working on bp. *******
- Subjective: What details did the patient provide regarding his or her personal and medical history?
- Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
- Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
- Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
- Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
Expert Solution Preview
Introduction: The following is an analysis of a case study involving a 54-year-old male with a history of HTN and uncontrolled blood pressure despite taking lisinopril. The case study provides an opportunity to evaluate the patient’s personal and medical history, conduct a physical assessment, provide a diagnosis, and develop a treatment plan.
Answer:
Subjective: The patient reported a medical history of hypertension and was taking lisinopril, but it was not effectively managing their blood pressure.
Objective: During the physical assessment, the patient was found to have elevated blood pressure. There were no significant physical exam findings; however, the patient displayed signs of stress and anxiety.
Assessment: The differential diagnosis includes uncontrolled hypertension (ICD-10 code: I10), chronic kidney disease-related hypertension (ICD-10 code: I12.9), and secondary hypertension (ICD-10 code: I15.1). The primary diagnosis is uncontrolled hypertension due to the patient’s history of hypertension and their current elevated blood pressure measurement.
Plan: The diagnostic plan includes a blood test to assess for underlying kidney disease and secondary hypertension. The treatment plan includes lifestyle modifications, such as exercise and dietary changes, to manage hypertension along with adding a calcium channel blocker, amlodipine, to the patient’s medication regime as an alternative. The patient should also be monitored through regular follow-up appointments to evaluate the effectiveness of the treatment.
Reflection notes: The “aha” moment is recognizing that despite typical management with lisinopril, the patient’s blood pressure remained elevated. In the future, it would be helpful to consider other medication options sooner in this type of patient and implement non-pharmacologic interventions alongside medication treatment.
