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NR 509 Week 5 iHuman Virtual Patient Encounter Attempt 3692802 - Anselmo Lopez

Chamberlain University Nursing NR 509 Advanced Physical Assessment Laci Peterson 7 pages
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History Notecard by Jessie Wood on case Anselmo Lopez Use this to collect your thoughts to develop a differential diagnosis list. Step 1: Write symptoms (Sx) you have identified in the appropriate column and row. Step 2: Characterize the symptoms using "OLDCARTS" (ie., Onset, Location, Characteristics...etc) in the HPI section. Step 3: Record your thoughts in the space labeled "What this means". Is the disease acute or chronic? Infectious or other?... Timing/treatments Hx Categories Sx= Sx= Sx= Sx= Sx= Sx= CC Provided How can I help you? Any other symptoms? HPI Onset/events Location Duration Characteristics Aggravating Reliving Severity What this means Attempt: 3692802 Report generated on 10/5/2025, 11:14:33 PM America/Denver Management Plan by Jessie Wood on case Anselmo Lopez Management plan: Diagnostic tests: ECG: 75bpm, regular rhythm CBC: unremarkable CMP: unremarkable TSH: unremarkable UA: unremarkable Medications: Hydrochlorothiazide 12.5mg PO once daily (Puckey.2024). Lisinopril 10mg PO once daily (Puckey, 2024). Suggested consults/referrals: Dietitian for education and pan for dietary modifications Client education: The client should be instructed to self-monitor their blood pressure before taking any medication at home to prevent excessive hypotension The client should be educated on smoking cessation as it can be a major risk factor for hypertension The client should be encouraged to increase exercise as regular exercise can prevent the onset of hypertensionThe client should avoid foods containing excess salt and follow a low-sodium, heart-healthy diet Caffeine and alcohol intake should be limited or avoided altogether as they can contribute to hypertension Encourage the client to follow up with their primary care provider when recommended and annually for age- appropriate screenings, immunizations, and general care as well as follow-up on hypertensive status Follow up: Follow up in one month with the clinician’s ofÏce for evaluation of hypertension and consider the titration of current medications or additional prescription(s) (Unger et. al., 2020). The patient should seek immediate health care either in the office or emergency department if experiencing chest pain, dizziness, heart palpitations, or intense headaches that may be signs of hypertensive-related complications (Unger et al., 2020). References Puckey, M. (2024). HCTZ. Drugs.com. https://www.drugs.com/lisinopril.html Puckey, M. (2024). Lisinopril. Drugs.com. https://www.drugs.com/lisinopril.html Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N.R., Prabhakaran, D., Ramirez, A., Schlaich, M., Stergious, G. S., Tomaszewski, M., Wainford, R. D., Williams, B., & Schutte, A. E. (2020). 2020 International society of hypertension global hypertension practice guidelines. AHA Journals. 75(6). https://doi.org/10.1161/HYPERTENSIONAHA.120.15026 Social History Category Data entered by Jessie Wood Social History Works as a construction worker Drinks alcohol occasionally (weekends) Smokes a pack a day since his 20s Review of Systems Category Data entered by Jessie Wood General Endorses weight gain throughout the years Denies chills, fever, weakness, fatigue, or appetite changes Integumentary / Breast Denies redness, rashes, or itchiness HEENT / Neck H: denies headache E: denies hearing loss and pain E: denies dryness and pain N: denies pain or drainage T: denies pain or difficulty swallowing Neck: denies pain Cardiovascular Denies palpations, chest pain, and shortness of breath Respiratory Denies chest pain,

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