Blood Pressure Case Study: Urgent Care Clinic

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Chief Complaint: "I need to get my blood pressure medicine refilled."
Mr. S is a 56 year-old male who presents to the Urgent Care Clinic with a request to refill his blood pressure medication. He states that he is leaving town for a week in the morning for his son's wedding in Florida and did not realize he only had 1 blood pressure pill left. It is 5PM and his doctor's office is closed for the day.
Upon further inquiry you find his blood pressure is 175/105 and he is complaining of feeling a little lightheaded and slight headache. He states he thinks it is because it was hot and he's been outside all day.
Patient denies dyspnea, orthopnea, syncope, palpitations, or cough.
Smokes 1 PPD.
PMI
Positive h/o HTN (diagnosed 5 years ago). Negative h/o DM or hypercholesterolemia. No childhood illnesses. Tonsillectomy at age 5.
Family History: Father-HTN, MI age 60, Bypass surgery post MI, still living; Mother--HTN, DM, still living
1. What additional information would you want to collect? What important risk factors does this patient have? …show more content…
I would need to make sure I assessed whether these symptoms were acute or whether he had been experiencing these for some time. Lightheadedness and headache are signs and symptoms of elevated blood pressure and could also indicate a larger problem. He stated that he was taking blood pressure medicine and that he needed a refill but I would want to know when his last cardiologist appointment was. I would also want to know the last time his medication type or dosage was changed. These are both important because it appears that his current blood pressure medication is not working and he is not achieving a therapeutic effect. His current BP is 175/105 which is elevated and needs to be brought

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