GOOD SAMARITAN COLLEGES

PATIENT PERSONAL DATA

Name: XXXXXXXXXXX

Age: 62 Sex:Female

MEDICAL HISTORY: Diabetes, Hypertension, Breast Cancer

Past Medical History: Hypertension

History of Present Illness: Elevated Blood Pressure

PHYSICAL ASSESSMENT
BODY PARTS ASSESSED DESCRIBE YOUR OBSERVATION ON THIS COLUMN
GENERAL APPEARANCE
A. Hygiene Good
B. Interaction/behavior Good
C. Facial expression Good
D. Posture A bit altered due to age
E. Attention span Gets bored quickly
F. Level of cooperation Good
HEAD:
A. Size/Shape Normal
B. ROM
- Head control
Normal
- Head posture Normal
C. Color of Hair Black but whites are present
FACE:
A. Appearance Wrinkled
B. Symmetry Normal
C. Movement Normal

EARS:
a.Discharges Not present
a. Lesion Not present
Internal :
a. Discharges
Not Present
b. Lesion
Not present
c. Excoriation
Not present
d. Presence foreign body
Not present
e. Hearing acuity
- Reaction to noise
In good condition
MOUTH:
a. Lips Shows a light cracks
b. Tongue Has a white appearance
c. Buccal mucosa Have minimal black spots
d. Gums Gums are red and healthy
e. Teeth
-number of teeth
32
-Location of teeth
Complete
g. Throat/tonsils
In normal size
NOSE/SINUSES:
a. Structure and patency of nares Normal, Good Condition
b. Discharges Not present
c. Tenderness Not present
NECK:
a. Mobility Normal
b. Cervical lymph nodes Not present
c. Swelling Not present
d. Tenderness Not present

SKIN:
A. color Normal
B. odor None
C. lesion None
D. moisture Normal
E. temperature 37.2
F. texture Soft because it is too loose
G. turgor Normal
H. edema None
THORAX/LUNGS:
a. shape Nornal
b. respiratory effort Slight Effort
c. breath sounds There are some slight crackles
BREAST:
a. shape Normal
b. symmetry Normal
c. color Normal
d. discharges None
e. lesion None
f. masses None
g. tenderness Not present
HEART
a.rate 92
b.rhythm IRREGULAR

ABDOMEN:
a. shape A bit big due to low metabolism
b. bowel sounds Normal
c. masses/tenderness None
d.
Bowel movement Normal (as client stated)
(skip questions about genital/anus unless
specified by the patient.
 MUSCULOSKELETAL SYSTEM
-Upper extremities
a. ROM
Normal
b. Symmetry
Normal
c. shape
Normal
d. Posture
Slightly hunch backed due to age
e. Fracture
Normal
f. Bone deformity
None
g. Size/strength muscle
Normal
-Lower extremities
a. Symmetry
b. Shape Normal
c. Movement Normal
d. position Slightly slow
e. Fracture Normal
f. Bone deformity None
g. ROM None
h. Size and strength muscle Normal
-Spinal Alignment Normal
a. spine
b.posture Normal
Hunch backed due to age
NEUROLOGIC SYSTEM
a. Cerebral function Normal
b. Cranial nerve function Normal
c. Deep tendon/superficial reflexes Normal
d. balance and coordination Normal
e. sensory function Normal
f. motor function Normal

1V.DIAGNOSIS OF THE PATIENT

1. pathophysiology-research about the diagnosis of the patient

- The pathophysiology of hypertension involves the impairment of renal pressure natriuresis, the

feedback system in which high blood pressure induces an increase in sodium and water excretion by the
kidney that leads to a reduction of the blood pressure. A doctor can diagnose hypertension by checking
your blood pressure. It is a very simple test that takes only a few minutes. Usually, an inflatable upper
arm cuff with a gauge is used. Your doctor or another medical professional will slide the blood pressure
cuff to just above your elbow on your bare arm.

2. Signs and symptoms of the disease and correlate with the complaints made by the patient during
interview and assessment

- include early morning headaches, nosebleeds, irregular heart rhythms, vision changes, and buzzing in
the ears. Severe hypertension can cause fatigue, nausea, vomiting, confusion, anxiety, chest pain, and
muscle tremors. The patient stated that she experiences dizziness especially when it is hot and makes
her vision a bit blurry.
V. MANAGEMENT OF THE DISEASE

1. Diagnostic test

Blood tests. Blood tests are often done to check your levels of potassium, sodium, creatinine, blood
glucose, and total cholesterol and triglycerides, among others, A urine test (urinalysis), Ultrasound of
your kidneys, Electrocardiogram (ECG or EKG).

2. Pharmacological

Diuretics, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), beta-
blockers, and calcium channel blockers are among the first-line drugs used to treat hypertension (CCBs).

3. complementary

Research results show that some psychological and/or physical practices, such as relaxation techniques
and yoga, may help reduce blood pressure in people with hypertension.

4. other specific treatment

Unfortunately, there is no cure yet for primary HBP. Healthy lifestyle habits can help keep your HBP
under control. But you'll likely need medication eventually to keep your blood pressure in a safe range.
Secondary hypertension is caused by another health condition.

Prepared by: submitted to:

HANNAH REYEEN PASCUAL Mrs. ALMA GEMMA C. MANUZON, RN

Student /BSN 3 Instructor