Comprehensive Hypertension (HTN) Case Study

This is not a real patient chart. The names and data have been created.

Patient Chart

Patient Name: John Edward Miller
Date of Birth: 06/21/1956
Age: 68
Gender: Male
Medical Record Number: 20250315
Date of Admission: 03/15/2025
Primary Care Provider: Dr. Rachel Stevens

Chief Complaint (CC)

"I’ve been feeling dizzy and lightheaded lately, and my blood pressure has been higher than usual."

History of Present Illness (HPI)

John Miller is a 68-year-old male with a 20-year history of hypertension, who presents with complaints of dizziness and lightheadedness. He reports that for the past few weeks, his blood pressure readings at home have been higher than usual, despite taking his prescribed antihypertensive medications. He states that he feels lightheaded, especially when standing up from a sitting position, and has occasionally experienced headaches at the back of his head. He denies chest pain, shortness of breath, or palpitations.

He has been non-adherent with his medication regimen at times, particularly missing doses due to forgetfulness. Additionally, he has not had regular follow-up appointments for blood pressure monitoring.

Past Medical History (PMH)

  • Hypertension – diagnosed 20 years ago, poorly controlled in recent months
  • Type 2 Diabetes Mellitus – diagnosed 10 years ago, controlled with Metformin
  • Hyperlipidemia – diagnosed 5 years ago, managed with Atorvastatin
  • Obesity – BMI of 32 (overweight)
  • Gastroesophageal Reflux Disease (GERD) – diagnosed 5 years ago, managed with Omeprazole

Surgeries & Procedures

  • Cholecystectomy (20 years ago)
  • Left knee arthroscopy (7 years ago)

Allergies

  • Penicillin – Rash
  • Aspirin – Gastrointestinal upset

Medications

  • Amlodipine 5 mg daily for hypertension
  • Metformin 1000 mg twice daily for diabetes
  • Atorvastatin 20 mg nightly for hyperlipidemia
  • Omeprazole 20 mg daily for GERD

Family History (FH)

  • Father: Deceased, 72, with a history of hypertension, heart disease, and stroke
  • Mother: Alive, 88, with a history of hypertension and osteoarthritis
  • Brother: Alive, 64, with a history of hypertension and type 2 diabetes
  • Paternal Grandfather: Died of a myocardial infarction at age 70

Social History (SH)

  • Smoking: Former smoker, quit 10 years ago (20 pack-years)
  • Alcohol: Occasional drinker (2-3 drinks per week)
  • Drug Use: Denies illicit drug use
  • Occupation: Retired mechanic, previously employed for 40 years
  • Living Situation: Lives alone, independent in activities of daily living

Review of Systems (ROS)

  • General: Dizziness, lightheadedness, no weight loss or fatigue
  • Cardiovascular: Occasional headaches, no chest pain or palpitations
  • Respiratory: No shortness of breath or cough
  • Gastrointestinal: No nausea, vomiting, or abdominal pain
  • Neurological: Occasional dizziness, no focal deficits or visual changes
  • Musculoskeletal: No joint pain or swelling

Physical Assessment Findings

Vital Signs:

  • Temperature: 98.7°F (37.1°C)
  • Heart Rate: 82 bpm, regular
  • Respiratory Rate: 18 breaths/min
  • Blood Pressure: 168/98 mmHg (right arm, sitting position)
  • Oxygen Saturation: 97% on room air
  • Height: 5'4"
  • Weight: 192 lbs.

General Appearance: Overweight male, alert and oriented, but appears slightly fatigued
Cardiovascular: Regular rate and rhythm, no murmurs or gallops, no jugular venous distention
Respiratory: Clear to auscultation bilaterally, no wheezes or crackles
Abdomen: Soft, non-tender, no hepatomegaly or splenomegaly
Neurological: Alert and oriented, no focal deficits, negative for dizziness with lying down, positive for dizziness when standing up (orthostatic hypotension)
Extremities: No edema, pulses 2+ bilaterally

Laboratory Results

Basic Metabolic Panel (BMP)

Test Result Reference Range
Sodium (Na) 140 mEq/L 135-145 mEq/L
Potassium (K) 4.2 mEq/L 3.5-5.1 mEq/L
Chloride (Cl) 102 mEq/L 98-107 mEq/L
Bicarbonate (HCO₃) 24 mEq/L 22-28 mEq/L
Blood Urea Nitrogen (BUN) 15 mg/dL 7-20 mg/dL
Creatinine (Cr) 1.1 mg/dL 0.6-1.2 mg/dL
Glucose (fasting) 92 mg/dL 70-99 mg/dL

Complete Blood Count (CBC)

Test Result Reference Range
White Blood Cell Count (WBC) 6.5 x10³/µL 4.0-11.0 x10³/µL
Hemoglobin (Hgb) 14.0 g/dL 12.0-16.0 g/dL
Hematocrit (Hct) 42% 36-46%
Platelets (Plt) 240 x10³/µL 150-450 x10³/µL

Lipid Panel

Test Result Reference Range
Total Cholesterol 210 mg/dL < 200 mg/dL
Low-Density Lipoprotein (LDL) 130 mg/dL < 100 mg/dL
High-Density Lipoprotein (HDL) 45 mg/dL > 40 mg/dL
Triglycerides 160 mg/dL < 150 mg/dL

Coagulation Studies

Test Result Reference Range
Prothrombin Time (PT) 12.0 seconds 11-13.5 seconds
International Normalized Ratio (INR) 1.1 0.8-1.1
Activated Partial Thromboplastin Time (aPTT) 30 seconds 25-35 seconds

Thyroid Function Tests

Test Result Reference Range
TSH (Thyroid Stimulating Hormone) 2.1 µIU/mL 0.4-4.0 µIU/mL
Free T4 1.1 ng/dL 0.8-1.8 ng/dL

Urinalysis

Test Result Reference Range
pH 6.0 4.5-8.0
Protein Negative Negative
Glucose Negative Negative
Ketones Negative Negative
Blood Negative Negative
Specific Gravity 1.015 1.005-1.030