Chief Complaint
“I have been having headaches recently, especially in the morning, and swelling in my legs all day.”
History of Present Illness
J.K. is a 50 year old white female presenting to her PCP with an increase in headaches and edema. She reports elevated blood pressure for several years and a stable weight, which is considered obese.
Past Medical History
Tonsillectomy at age 5
Cesareans at age 29, 34, and 35
Blood transfusion post-Cesarean at age 35
Pertinent Family History
Father died of MI at age 40
Mother is alive with HTN at age 72
Brother is alive with HTN and CV disease at age 49
Sister is alive with hypothyroidism at age 45
Pertinent Social History
Full-time nurse in the local hospital
Sedentary lifestyle
Hobbies include scrapbooking and photography of her children
Enjoys cooking – Southern style with lots of fried food
Occasional alcohol
Non-smoker
Drinks a lot of caffeinated, carbonated beverages
Allergies
Sulfates
Morphine
Dilaudid
Codeine
Medications
Atorvastatin – 20 mg h.s.
Focused Physical Exam
Weight and Height:
260 lbs
5’7″
BMI 39.5 (NIH, 2013)
Last Several Blood Pressures (left arm):
135/99
145/100
155/89
Headaches:
Adult onset
Bilateral location – temporal
Daily – lasting hours
Starts in the morning and lasts throughout the day – better in the evening
Throbbing sensation
Lab Values and Exam Findings
The following were normal:
CBC
Complete urinalysis
Potassium, calcium, creatinine, uric acid
Fasting blood glucose, Hemoglobin A1c
The following are as listed:
HDL – 30 mg/dL
LDL – 250 mg/dL
TG – 200mg/dL
No sign of retinopathy
S1 and S2 easily heard with no murmurs
No signs of S3 or S4
Abdominal exam showed no masses or bruits
Synchronous radial and femoral pulses
ECG showed normal sinus rhythm
Chest x-ray showed no cardiomegaly
(Ball, Dains, Flynn, Solomon, & Stewart 2015; UCentral, 2014)