Topic: HYPERLIPIDEMIA

Directions

Please include:

  1. Demographic information of the patient
  2. Chief complain.
  3. History of present illness. Fallowing the mnemonic old chart: Onset/Location/Duration/Character/Alleviating-Aggravating factors/Temporal pattern/Severity. Additional symptoms and previous treatment if known.
  4. Medical history: PMH, FMH, SMH.
  5. Social history, employment, habits, physical activity, allergies and medications taken. For these six elements include a concise statement about the impact of such findings for potential outcomes with in-text citations as required.
  6. Review of systems.
  7. As part the objective component include: Vital signs, body measurements.
  8. Physical examination with pertinent normal findings, normal variations and abnormalities. Characterization of pain or discomfort (if present) and psychological status.
  9. Completed or known diagnostic tests with results supporting or ruling outa medical diagnosis.
  10. Diagnosis. Include a rationale and in-text citation supporting your diagnosis. Are there possible etiologies? What’s the reasoning behind it?(Include citations as required).
  11. Differential diagnosis. Include three ruled out diagnoses with in-text citations supporting your ideas.
  12. Treatment with rationales per therapeutic option. Describe the goals, priorities and education provided. Include a citation per therapeutic option and education.
  13. New orders for diagnostic testing. Include rationale and one citation per order.
  14. Follow ups and referrals if required.
  15. Finish the case with a paragraph justifying a theoretical perspective supporting your management approach.

PLEASE NOT PLAGIARISM, NEED BE ORIGINAL AND UNIQUE.

USE 5 PAGES

3-4 REFERENCES NO OLDER THAN 5 YEARS 

NEED IT FOR Thursday, JANUARY 20, 2022

REVIE OF SYSTEM

Constitutional: No fever, severe weight loss, normal appetite, no generalized weakness.

Neurologic: Denies headache, tremors, seizures or gait imbalance, denies tics or numbness in lower extremities, no dizziness, no visual disturbances, slow speech and no behavior problems at this moment.

HEENT: Denies odontalgia, sore throat, hoarseness, ear pain/pruritus or hearing loss, report unable to swallow

Respiratory: Report shortness of breath, denied cough or chest pain.

Cardiovascular: No chest pain on anterior left hemi thorax, palpitations or intermittent claudication, no petechial or unexpected bleeding.

Gastrointestinal: Denied abdominal pain, vomit, diarrhea constipation.

Genitourinary: Denied bowel and bladder incontinent, no dysuria, polyuria, nocturia or oligura

Skin: Upon PE no redness on the body, no petechia, no rash, skin warm.

Musculoskeletal: Denied Pain, inflammation, redness

Objective

Vital Signs: BP: 142/88 mmHg, RR: 16’, HR: 83’, Temp: 97.3 F, SatO2: 99%, Weight:

178 pounds, height: 5’10”, BMI: >25

Neurologic: AAOx3, no central or peripheral focal neurological deficit, gross sensation, muscle tone and grip strength diminish, gait disturbances, unable to examine Romberg, Kernig’s test and Brudzinski’s signs.

HEENT: EOMs intact, PERRLA, no redness or discharge noted in the ear canal, pearly and no bulging tympanic membrane bilaterally, no jugular veins distention, no neck mass or enlarged lymph nodes. No white/yellow plaques or ulcers noted on palate, uvula or tonsils, no erythema noted on oropharynx. Normal results obtained after performing Rinne and Weber tests.

Cardiovascular: No murmurs, no collateral circulation, no edema, carotid, apical, radial femoral and pedal pulses present and strong, no carotid murmur bilaterally.

Respiratory: No cyanosis, rhonchi or crackles noted vesicular murmur present

bilaterally.

Gastrointestinal: Oral cavity with no lesions suggestive of malignancy, wet oral mucosa, abdomen soft, non-tender, non-distended, no hernias, no organomegaly, continent bladder and bowel movements daily.

Genitourinary: No genitalia pain, urine 2000 ml daily, continent, urine yellow, no odor.

Musculoskeletal: Muscle mass tonic, no weak, deformity, pain or other.

Intertegumentary: Skin dry, warm, no petequiae, rash or any other.

Assessment

ICD-10 I10 Essential (primary) hypertension

PlRIMARY DIAGNOSIS

Essential (primary) hypertension : Blood pressure is the force that a person’s blood exerts against the walls of their blood vessels. This pressure depends on the resistance of the blood

REVIE OF SYSTEM

Constitutional: No fever, severe weight loss, normal appetite, no generalized weakness.

Neurologic: Denies headache, tremors, seizures or gait imbalance, denies tics or numbness in lower extremities, no dizziness, no visual disturbances, slow speech and no behavior problems at this moment.

HEENT: Denies odontalgia, sore throat, hoarseness, ear pain/pruritus or hearing loss, report unable to swallow

Respiratory: Report shortness of breath, denied cough or chest pain.

Cardiovascular: No chest pain on anterior left hemi thorax, palpitations or intermittent claudication, no petechial or unexpected bleeding.

Gastrointestinal: Denied abdominal pain, vomit, diarrhea constipation.

Genitourinary: Denied bowel and bladder incontinent, no dysuria, polyuria, nocturia or oligura

Skin: Upon PE no redness on the body, no petechia, no rash, skin warm.

Musculoskeletal: Denied Pain, inflammation, redness

Objective

Vital Signs: BP: 142/88 mmHg, RR: 16’, HR: 83’, Temp: 97.3 F, SatO2: 99%, Weight:

178 pounds, height: 5’10”, BMI: >25

Neurologic: AAOx3, no central or peripheral focal neurological deficit, gross sensation, muscle tone and grip strength diminish, gait disturbances, unable to examine Romberg, Kernig’s test and Brudzinski’s signs.

HEENT: EOMs intact, PERRLA, no redness or discharge noted in the ear canal, pearly and no bulging tympanic membrane bilaterally, no jugular veins distention, no neck mass or enlarged lymph nodes. No white/yellow plaques or ulcers noted on palate, uvula or tonsils, no erythema noted on oropharynx. Normal results obtained after performing Rinne and Weber tests.

Cardiovascular: No murmurs, no collateral circulation, no edema, carotid, apical, radial femoral and pedal pulses present and strong, no carotid murmur bilaterally.

Respiratory: No cyanosis, rhonchi or crackles noted vesicular murmur present

bilaterally.

Gastrointestinal: Oral cavity with no lesions suggestive of malignancy, wet oral mucosa, abdomen soft, non-tender, non-distended, no hernias, no organomegaly, continent bladder and bowel movements daily.

Genitourinary: No genitalia pain, urine 2000 ml daily, continent, urine yellow, no odor.

Musculoskeletal: Muscle mass tonic, no weak, deformity, pain or other.

Intertegumentary: Skin dry, warm, no petequiae, rash or any other.

Assessment

ICD-10 I10 Essential (primary) hypertension

PlRIMARY DIAGNOSIS

Essential (primary) hypertension : Blood pressure is the force that a person’s blood exerts against the walls of their blood vessels. This pressure depends on the resistance of the blood