History

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)

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