Unit 5: Case Presentation #1:

A New Paradigm Application

.....The following case is designed to help you visualize how the new paradigm might be implemented when assisting a client with potential hypertension. Review the following client data, then consider how you would answer the questions provided. When you are ready, compare your plan of care with that of the authors'.

Subjective Infomation:

  • Alex L. 38 y/o white male. Presents to your primary care office for a pre-employment physical.
  • Health maintenance: non-smoker, 1-2 beers twice a month, plays in a racquetball league 2 nights a week, wears seat belt. Last physical 2 years ago. No history of restricted dieting, weight-cycling, or recent weight loss/gain.
  • Eating pattern (a typical 24 hour period):
    • 7 AM: Cheese Danish, 2 cups coffee
    • Noon: Big Mac, large order fries, large Coke
    • 3PM: Large apple
    • 6 PM: Grilled BBQ chicken, baked potato with butter, asparagus, water
    • 9PM: Apple pie ala mode, milk
  • Social history: married x14 years, 2 school-age children, +family and social support, +stress related to recent unemployment secondary to corporate merger.
  • Past medial history: appendectomy @ age 18 without complications, last Td @ 36 y/o
  • Family history: father deceased age 48 with MI, mother L&W age 60 with Type 2 diabetes
  • Medications: Tylenol 3-4 times/mo for HA
  • NKDA
  • ROS: unremarkable

     

Objective Information:

  • Ht: 70"
  • Wt: 189 lbs
  • BMI: 27
  • BP: 158/92 recheck 154/90
  • P: 86
  • R: 14
  • HEENT: WNL
  • Lungs: CTAB
  • Heart: RRR without murmur
  • Peripheral vascular: WNL
  • Abdomen: WNL
  • Neuro: WNL
  • MS: WNL

    As a provider, what are you concerned about?

    What are you reassured by?

    What other information would be necessary?

Assessment:

What are your primary diagnoses?

Plan:

What is your plan of care?

 

To view how the authors would use the new paradigm approach to assist this client, click "next" below.

 

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© Spring 1998