Interactive Hypertension Case Study
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TOPIC 02: Patient Information

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Detailed Patient Information
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Lesson Splash, Page 1
Splash
Lesson Overview, Page 2
Overview
Topic 01: Overview of Patient, Page 3
Patient
Topic 02: Detailed Patient Information, Page 4
Patient Information
Lesson Summary, Page 5
Lesson Summary
4 of 5

Detailed Patient Information

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Past Medical HistoryFamily HistoryPhysical ExaminationLaboratory FindingsSocial HistoryDiagnosis
Medical history with stethoscope
Medical history with stethoscope
  • Appendectomy 30 years ago
  • Peptic ulcer disease 10 years ago
  • Type 2 diabetes mellitus for 10 years
  • Gout
Filling the Family History section in the medical history questionnaire
Filling the Family History section in the medical history questionnaire
  • Father had hypertension; died of myocardial infarction at age 55.
  • Mother had diabetes mellitus and hypertension; died of cerebrovascular accident at age 60.
Medical manometer, stethoscope and cardiogram.
Medical manometer, stethoscope and cardiogram.
  • Height 69 in, weight 90 kg
  • BP: 140/89 mm Hg (left arm), 138/82 mm Hg (right arm)
  • Pulse: 84 beats/minute, regular
  • Funduscopic examination: mild arterial narrowing, sharp discs, no exudates or hemorrhages
Blood in test tube, stethoscope and investigation form on table
Blood in test tube, stethoscope and investigation form on table
  • Blood urea nitrogen: 24 mg/dL
  • Serum creatinine: 1.1 mg/dL
  • Glucose: 95 mg/dL
  • Potassium: 4.0 mEq/L
  • Total cholesterol: 201 mg/dL
  • High-density lipoprotein cholesterol: 30 mg/dL
  • Triglycerides: 167 mg/dL
  • Urinalysis: within normal limit (no proteinuria)
  • Electrocardiogram and chest radiograph: mild left ventricular hypertrophy
Smoking and drinking, whiskey and cigarettes.
Smoking and drinking, whiskey and cigarettes.
  • Tobacco: 35 pack years
  • Alcohol: 1 pint of vodka/week
  • Coffee: 2 cups/day
Stage 1 Hypertension