Week 4 you are learning many concepts, the one we will be focusing on with this

Week 4 you are learning many concepts, the one we will be focusing on with this discussion board is appropriate prescribing of medication to the older adult. As Nurse Practitioner, we have the responsibility of deciding if a medication is warranted, which drug is the best to prescribe and how much/often. It is also our responsibility to educate on the side effects of the medication and when to seek medical attention if it should occur. Finally, it is our responsibility to determine the effectiveness of our treatment that was prescribed, for example, is the patient’s glucose stable on Glucophage 500 mg BID PO or do we need to titrate up or down.
Initial Post Instructions:
Please critically evaluate the subjective and objective information provided to you in the attached file below.
The first part of the discussion board is to identify all pertinent positive and, negative information and list missing information.
Then create a differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.
Second part is to create a plan utilizing clinical practice guidelines for the priority diagnosis.
Be sure to utilize template, in-text citations and provide full reference citation at the end of the discussion.
Please use this document for your discussion response:
please use updated references
see below example please use in own words cover all aspect of assignment
Pertinent Positive
History of dizziness resolved by showering (yesterday)
Elevated BP of 189/112 during the feeling of dizziness yesterday
Elevated current BP: 129/86
Family history of Breast cancer, CAD, Diabetes with Hypertension
Has not been to the family doctor in 5 years, will seek urgent care if feeling ill.

Pertinent Negative
Significant medical history
Lightheadedness, dizziness, nausea, vomiting, headache, chest pain, shortness of breath and blurred vision
History of vertigo
History of elevated blood pressure
Increase stress
Use of Tobacco or ETOH
Use of NSAIDs or any recent medications
Use of herbal medicines
Feel like the room is spinning
Feel unsteady on her feet
Weakness, visual changes, ear pain / fullness
Numbness or tingling
Fatigue, Fever and chills
Night sweat
Unexplained weight loss or weight gain
Loss of appetite
Difficulty sleeping
Presence of rashes, itching, nail deformity, hair loss, moles, open areas or bruising
Nasal congestion, sinus pain, facial pressure or rhinorrhea
Sore throat
Difficulty swallowing
Cough and wheezing
Palpitations
Dyspnea
Orthopnea
Dysuria
Hematuria
Pain or swelling in the extremities
Bone pain
Muscle pain
Joint pain
Joint swelling, stiffness, weakness
Back pain
Behavioral changes
Difficulty concentrating
Fainting or motor sensory loss
Seizures
Increase thirst or urination
Thyroid enlargement or tenderness
Suicidal ideation
Depression
Mood swings
Hallucinations
Deformity on the chest
Murmur

See explanation.
Step-by-step explanation
Differential Diagnosis:
Primary hypertension
This means that there’s only present hypertension which is not caused by any other disease
The patient is not aware of the diseases that her parents because one died in MVA and she never knew the other. That is a big significant data that is missing because in maternal side, there’s a history of a cardiovascular disease that has a high percentage of getting passed down to different generations.
Hypertension’s signs & symptoms usually don’t show right away, a patient can be asymptomatic for years without ever knowing that her blood pressure has elevated. Patient might have experienced the first symptom yesterday which was dizziness.
Moreover, patient’s current blood pressure is still a bit elevated.
Secondary hypertension
This means that the hypertension is being caused by another disease that is reversible or manageable The only way to manage this is to manage first the other disease.
Age is a great risk factor for primary hypertension but also to a hundred of lists of other diseases such as renal failure, renal artery stenosis and more.
Since patient has not been to a doctor for 5 years, it’s also possible that she has developed another disease but still asymptomatic up until yesterday when she felt dizzy.
Patient reported that she relieved dizziness after taking a shower. There have been studies where taking a warm shower can lower blood pressure and is great for those with heart conditions. This may be the reason why her dizziness was relieved.
Malignant hypertension
This means an elevation in the blood pressure above 180 in systolic or above 120 in diastolic with an organ damage
This is a differential diagnosis since in the case study, no laboratory examination was done to the patient yet. So we have to rule out if the patient experienced a malignant hypertension yesterday since she also reported that she never had an elevated blood pressure.
Organ damages are mostly symptomatic but they can also be delayed.
It’s a medical emergency however, patient did not go to the hospital right after finding out what her blood pressure was.

References:

Hecht, M. (2019, December 20). Types and Stages of Hypertension. Healthline. https://www.healthline.com/health/types-and-stages-of-hypertension#other-types

Verzwyvelt, M. (2017, September 28). 10 Reasons to Take a Hot Bath or Shower | An Electric Instant Water Heater May Be Good for Your Health. Heatworks. https://blog.myheatworks.com/blog/10-reasons-to-take-a-hot-bath-or-shower
another example:The first part of the discussion board is to identify all pertinent positive and, negative information and list missing information.
Pertinent (+)
65 year-old female – patient is of geriatric age, where cardiovascular and neurologic accidents such as CAD and stroke are more prone to happen
(+) hx of constant dizziness with resolution upon bathing – this is a pertinent positive because this is a symptom of ischemic heart disease, although chest pain should come with the said condition
(+) hypertension with BP 189/112 – blood pressure is at level where hypertensive urgency vs emergency is considered, although the blood pressure was only taken once
(+) family hx of obesity, diabetes, hypertension, breast cancer, CAD – increased risk for the patient to also have the same familial diseases
(+) normal vital signs – patient is apparently well and normal vital signs indicate that the patient is not in distress and this is not an urgent matter that requires urgent intake of medications or any other therapeutic interventions
(+) well-nourished and appears stated age – patient is apparently well
Pertinent (-)
(-) lightheadedness, dizziness, nausea, vomiting, headache, chest pain, shortness of breath or blurred vision – these are all symptoms that could point out to ischemic heart disease, which is an important differential diagnosis for the patient
(-) hx of hypertension – patient is less likely to have any atherosclerotic accidents
(-) medical, surgical or hospitalizations – cause of dizziness is unlikely due to any previous procedures that could have caused any embolisms or any structural abnormalities
(-) fatigue, fever, chills, malaise, night sweats, unexplained weight loss or weight gain, loss of appetite, difficulty sleeping – presumptively rules out infection, malignancies, thyroid abnormalities
(-) headaches or hx of vertigo, loss of vision or blurry vision, fainting, motor sensory loss, increased thirst or urination – presumptively rules out stroke, diabetes
(-) no JVD – presumptively rules out congestive heart failure
Peripheral pulses normal and equal in all extremities – presumptively rules out congestive heart failure
(-) edema noted on extremities – presumptively rules out congestive heart failure
Missing information
History of falls – Has she had any instances where her head hit the ground or something hard?
Dietary habits – Does she like fatty food? Is she eating enough protein?
Lifestyle – How many times a week does she exercise? What are her usual activities of daily living?
Diabetes history – Had she been told by a medical practitioner that she was diabetic?
On anticoagulant therapy? – Has she been taking any warfarin/heparin prescribed by her doctor?
How exactly was the blood pressure taken? Were proper steps followed? – Did she take a 15-minute rest prior to taking her blood pressure? Was the cuff positioned properly? Did she repeat blood pressure taking after 10-15 minutes?
List differential diagnosis list with at least 3 possibly actual diagnosis based on your findings.
Rule out Hypertensive crisis
Hypertensive crises refer to patients with severe blood pressure elevations (systolic blood pressure ≥ 180 mm Hg or diastolic blood pressure ≥ 120 mm Hg), and can be further classified as:
Hypertensive emergency – severe elevation in blood pressure is accompanied by end-organ damage
Hypertensive urgency – severe elevation in blood pressure occurs without end-organ damage
Benign Paroxysmal Positional Vertigo
BPPV is an inner ear disorder manifested by repeated episodes of spinning sensation triggered by changes in head position relative to gravity.
BPPV results from a small crystal of calcium carbonate (canalith, otoconia) entering a semicircular canal, usually affecting the posterior canal but it can also affect the horizontal or anterior (superior) semicircular canals.
Suspect BPPV in patients with a history and physical exam consistent with repeated brief (seconds) episodes of vertigo immediately following changes in head position and without signs or symptoms of hearing loss or an underlying neurological disorder.
Vestibular neuronitis
Vestibular neuronitis is inflammation of the vestibular nerve leading to acute, spontaneous peripheral vertigo.
The exact cause of vestibular nerve inflammation is unknown, but it is potentially due to precedent or concurrent viral infection.
It most commonly affects the superior division of the vestibular nerve (reported in 55%-100% of patients), and less commonly affects the total vestibular nerve (reported in 15%-30% of patients) or rarely, the inferior division of the vestibular nerve (reported in up to 15% of patients).
Patients often present with sudden spontaneous vertigo, nausea/vomiting, unsteadiness, and oscillopsia (visual disturbance in which items in the visual field appear to oscillate).
Step-by-step explanation
Second part is to make a plan utilizing clinical practice guidelines for the priority diagnosis.
Distinguishing hypertensive urgency from emergency requires tests to evaluate cerebral, cardiovascular, renal, and hematological function and damage, including:
blood tests including electrolytes, blood urea nitrogen, creatinine, and complete blood count
cardiac biomarkers
urinalysis (for proteinuria or hematuria consistent with glomerular damage)
toxicology screen
electrocardiogram
careful examination of optic nerve for signs of intracranial hypertension (with pupillary dilation if needed)
Imaging based on clinical suspicion for specific conditions, including:
chest x-ray (for signs of left ventricular failure)
chest computed tomography or Doppler echocardiography in patients with unequal pulses or widened mediastinum on chest x-ray – to look for dissecting aortic aneurysm
head computed tomography in patients with signs and symptoms of neurologic abnormalities to evaluate for ischemic or hemorrhagic stroke, and subarachnoid hemorrhage
Consider an evaluation for secondary causes of hypertension.
After obtaining the patient’s complete history, do the following:
Perform risk stratification and determine proper treatment setting for patient
Obtain vital signs with blood pressure taken in both upper extremities
Perform fundoscopic exam to assess for papilledema, which suggests hypertensive encephalopathy
Screen for noncompliance or abrupt discontinuation of medications that cause rebound hypertension (such as beta-blockers, clonidine, and minoxidil) or alcohol withdrawal
Assess for illicit drug use that could precipitate a hypertensive crisis (such as cocaine, amphetamines, and phencyclidine)
Consider the following laboratory tests depending on the clinical presentation of the patient:
Electrolytes
Blood urea nitrogen
Creatinine
Coagulation studies
Fibrinogen
Urine toxicology screen
Urine pregnancy test
Urinalysis for proteinuria, red blood cells, and cellular casts
Cardiac enzymes
Brain natriuretic peptide
Consider urine protein or 24-hour urine test for catecholamines in select patients where there is concern for secondary hypertension
Consider complete blood count and peripheral blood smear to check for microangiopathic hemolytic anemia
Order electrocardiogram to check for myocardial ischemia, infarction, and/or signs of left ventricular hypertrophy
Determine in-house availability of subspecialists and need for consultation as dictated by specific end-organ involvements
Ensure start of IV (hypertensive emergency) or oral (hypertensive urgency) antihypertensives prior to departure from the emergency department if indicated
please use in own word! examples are answers and format