History of Present Illness:

44 y/o F w/ PMHx hypertension presents to urgent care for blood pressure check as her “blood pressure has been high for the past 4 days”.  According to patient, she has been logging her blood pressure at home daily for the past four days noting a SBP > 150 and a DBP > 90 during each read. She was prescribed 10 mg amlodipine PO daily x2 years ago at urgent care but has been unable to schedule an appointment with PCP to establish  continuity of care. She refills her prescriptions three months at a time at Nao Medical Crown Heights and adheres to daily regimen as prescribed. Patient reports headache, dizziness, and overall “not feeling well” which has been preventing her from getting out of bed. Endorses one episode of palpitations lasting 15 minutes 2 days ago in which she was woken up in the middle of the night and had trouble falling back asleep. Patient also c/o a 6/10 non-radiating, dull, intermittent RT sided lower back pain starting yesterday which she reported was worse in the morning and gradually improved throughout the day. Patient states that she has had had previous episodes of elevated BP while on 10 mg amlodipine but was never symptomatic. Of note patient expressed that she has recently been experiencing a lot of stress as she works full time, attends school part-time, and has been “arguing” with her son and daughter at home “more than usual recently”. Denies blurry vision, chest pain, changes in urine color,  changes in glasses prescription, abdominal pain, intrascapular pain, dysuria, hematuria, extremity weakness, or illicit drug use.

Past Medical History:

Hypertension

Asthma

Eczema

Past Surgical History:

Patient has no surgical history

Medications:

Amlodipine Besylate 10 mg PO daily for Hypertension

Allergies:

NKDA

Family History:

Mother alive and well, history of HTN and DM

Father alive and well, no known medical problems

25-year-old daughter, alive and well with no medical problems

18-year-old son, alive and well with no medical problems

Social History:

K.W. is a 44 y/o F living in a home in Brooklyn, New York with her two children and husband. 

Habits – Patient denies any hx smoking, EtOH consumption, or illicit drug use

Travel – no recent travel

Diet – patient states she tends to skip breakfast, will have a heavy lunch consisting of “some carb and protein” and for dinner will eat whatever her husband saves for her.

Exercise – goes to the gym once or twice a week if her schedule allows

Sleep – sleeps about 6 hours a night but will sometimes wake up in the middle of the night and has trouble going back to sleep.

Safety measures – practices seatbelt safety measures

Sexual Hx – sexually active with her husband only

Occupation – real estate manager

Review of Systems:

General: Denies fever, chills, night sweats, fatigue, weakness, loss of appetite, recent weight gain or loss

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

Head:  Admits headache. Denies vertigo, head trauma, unconsciousness, coma, fracture

Eyes: Patient uses glasses and contact lenses for myopia. Denies visual disturbances, fatigue, lacrimation, photophobia, pruritus, last eye exam February 2024 normal.

Ears: Denies deafness, pain, discharge, tinnitus, use of hearing aids

Nose/Sinuses: Denies discharge, epistaxis, obstruction, congestion

Mouth and throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures, last dental exam December 2022 normal.

Neck: Denieslocalized swelling/lumps, stiffness/decreased range of motion

Breast: Denies lumps, nipple discharge, pain, last mammogram No

Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

Cardiovascular system: Admits HTN, palpitations. Denies chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur

Gastrointestinal system: Denies changes in appetite, intolerance to foods, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool. Patient has not had colonoscopy.  

Genitourinary: Denies urinary frequency, changes to color of urine, incontinence, dysuria, nocturia, urgency, oliguria, polyuria

Sexual history: Sexually active? (Yes) sexual partners (husband). Denies anorgasmia, hx of sexually transmitted infections, contraception

Menstrual and Obstetrical: date of last normal period:  March 24, 2024, menarche: 13 years old. Interval between periods  ~26-28 days, duration and amount of flow: lasting about 5-6 days, changes pads every 6-8 hours but does not fill up pad, 2-3 pads/24 hours. Denies dysmenorrhea, menorrhagia, premenstrual symptoms, postcoital bleeding, vaginal discharge, dyspareunia, or break-through bleeding

G:2 T:2 P:0 A:0 L:2

Musculoskeletal System: Admits RT sided lower back pain. Denies muscle/joint pain, deformity or swelling, redness, arthritis

Peripheral Vascular System: Denies intermittent claudication, coldness of trophic changes, varicose veins, peripheral edema, color change

Hematologic System: Denies hx anemia, easy bruising or bleeding, lymph node enlargement, hx DVT/PE

Endocrine System: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous System: Denies seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)

Psychiatric: admits feeling anxious. Denies depression/sadness, obsessive compulsive disorder. have you ever seen a mental health professional? No. Medications? None

Physical:

General: Patient appears clean & well groomed, alert & oriented to time, place, and person. Has good posture and appears to be a reliable source of information. Appears stated age and is not in acute distress.

Vital Signs:       

Temperature: 98.7

O2 Sat: 98

Height: 65 inches

Weight: 175 lbs

BMI: 29.12

Respiratory Rate: 16

Heart Rate: 81

Blood Pressure:

LT Arm Sitting: 163/108

LT Arm Standing: 149/100

LT Arm Lying Down: 150/94

Hair, Head, and Face:

Hair is of average quantity and distribution. Brown in color with silky texture and no sign of lice or nits.

Head is normocephalic & atraumatic. Face is symmetrical with no signs of drooping, swelling, or trauma.

Skin, and Nails:

The skin is warm and moist with good texture and turgor. Non-icteric with no swelling or signs of ecchymosis.

Nails do not exhibit digital clubbing, capillary refill less than 2 seconds in upper extremities.

Eye:

The eyes are symmetrical OU. Conjunctiva is pink, sclera is white, the pupils and iris are round. There is no exophthalmos OU.

The patient’s visual fields intact OU. PERRLA, EOMs intact with no nystagmus, strabismus, or signs of lid lag. Near point of convergence test is unremarkable.

Red reflex intact OU. Optic disc yellow, sharp, with disc to cup 0.5 OU. No AV nicking, copper wiring, hemorrhages, soft/hard exudates, or neovascularization in any of the four quadrants OU. Macula is yellow with no granulation or degeneration OU.

Ear:

Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. No cerumen noted AU, no foreign bodies externally AU. TM’s pearly white/intact with light reflex in good position, cone of light is present AU. No foreign bodies, discharge, effusions, perforations, or erythema AU

Mouth and Pharynx:

The lips are pink with no signs of blisters, fissuring, or cyanosis.

The buccal mucosa is pink and well hydrated.

The tongue is pink and covered in papillae with no signs or leukoplakia.

The hard palate is continuous, with no bony deformities, or bleeding.

Oropharynx is well hydrated, there is no tonsillar adenopathy, the uvula is pink, moist, and midline.

Neck, Thyroid, and Lymph Nodes:

The trachea is midline without masses or scars, it is supple and non-tender to palpation. The thyroid is consistent in size and shape and non-tender to palpation. The lymph nodes are freely mobile and non-tender.

Cardiac:

S1 and S2 are normal. No murmurs, S3, or S4 sounds on auscultation. No S2 split or friction rubs present.

Thorax and Lung:

Respirations are unlabored without use of any accessory muscles. Lungs are clear to auscultation bilaterally.

Cranial Nerves:

CN I- X11 are intact

Peripheral Neurologic Exam:

No atrophy, tics, tremors, or fasciculation. Strength 5/5 throughout.  Romberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Mental Status Exam:

Patient is well appearing, good hygiene and neatly groomed. Patient is alert and oriented to name, date, time, and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgement, cognition, memory, and attention intact.

DDx:

1. Hypertensive Urgency
2. New Onset Anxiety Disorder
3. Hyperthyroidism
4. Medication Failure secondary to incorrect dosage or non-adherence 
5. Descending Aortic Dissection

EKG:

Rate – 77 BPM

PR Interval – 154 msec

QT/QTc – 398/427 msec

QRSD – 88 msec

P Axis – 56

QRS Axis – 56

T Axis – 40

Urinalysis:

Leukocytes – Negative

Nitrites – Negative

Uro – 2

Protein – 30

pH – 5

Blood – 10

Specific Gravity – 1.020

Ketones – Negative

Bilirubin – Negative

Glucose – Negative

Bloodwork:

CBC, CMP, Comprehensive Thyroid Panel, Lipid Panel, HgB A1C, Urine Cx

Assessment:

            K.W. is a 44 y/o F w/ PMHx hypertension presenting to urgent care for blood pressure check. She lives in Brooklyn New York with her husband, daughter, and son. For the past four days, she has been experiencing headache, dizziness, and one episode of palpitations which woke her up from her sleep and lasted 15 minutes. As per patient, she logs her blood pressure daily and noticed her blood pressure has been elevated the past four days (>150/90 for each reading). She also developed a 6/10 non-radiating, dull, intermittent RT sided lower back pain starting yesterday which she reported was worse in the morning and gradually improved throughout the day. Patient reports feeling more stressed out than usual as she has been arguing with her children in the last week. Physical exam was unremarkable, and labs/EKG did not demonstrate any acute concerning findings. Based on the clinical history and physical exam findings, the plan should be focused on managing the patient’s hypertension with a primary care provider to prevent hypertensive emergency.

Plan:

#HTN

• Continue with logging daily blood pressure readings
• Continue taking Amlodipine Besylate 10 mg PO daily
• Add and ACEi or ARB for optimal hypertension control
• If symptoms persist, worsen, or blood pressure continues to increase, go to the emergency room

#Stress

• Offer Psych services provided by Nao Medical Center

#PCP follow-up

• Create a referral for PCP that the patient can create an appointment with

#proteinuria/hematuria

• Evaluate for nephrolithiasis; patient c/o colicky RT LBP

Patient Education:

“Because you have a history of elevated blood pressure despite taking the amlodipine, we want to add a new medication that you will take on top of the one you are already taking now. This should help bring your blood pressure down and may resolve some of the symptoms you have been experiencing if they are due to your blood pressure. Because you expressed that you’ve been experiencing some trouble in the home, we want to offer some of the Psych services provided by our clinic. Our professionals can help you learn new techniques for mitigating the stress associated with what is going on in the home, at work, and at school. Finally, since you expressed that you haven’t been able to attend any of the follow-up appointments we’ve created for you, we’re going to create a PCP referral so that you can create your own appointment at a time that is more convenient for you. That way you will have someone who can monitor your blood pressure and try other medication if necessary.”