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Subjective Information:

Pertinent Positives:

• Patient is a 65-year-old female presenting with a request to check her blood pressure.
• She experienced dizziness yesterday.
• Blood pressure reading at a pharmacy was 189/112.
• Dizziness resolved after taking a shower.
• Denies significant medical history, recent stress, tobacco, alcohol use, NSAIDs, and recent medications.
• Family history includes diabetes and hypertension in her sister, coronary artery disease in maternal grandfather, and breast cancer in maternal grandmother.

Pertinent Negatives:

• Denies lightheadedness, dizziness, nausea, vomiting, headache, chest pain, shortness of breath, blurred vision, increased stress, and use of tobacco or alcohol.
• No history of elevated blood pressure.
• Denies symptoms commonly associated with high blood pressure (headache, visual changes, etc.).
• Denies various symptoms across multiple systems (fatigue, fever, chills, malaise, night sweats, weight changes, skin issues, respiratory symptoms, cardiovascular symptoms, gastrointestinal symptoms, genitourinary symptoms, musculoskeletal symptoms, neurological symptoms, endocrine symptoms, psychiatric symptoms).

Missing Information:

• Detailed dietary habits.
• Physical activity level.
• Detailed history of previous blood pressure measurements.
• Information on hydration status.
• Evaluation for potential orthostatic hypotension.

Objective Information:

Pertinent Positives:

• Blood pressure reading at the office is 129/86.
• All vital signs are within normal limits.
• General appearance indicates the patient is well-nourished and appears her stated age.
• Comprehensive physical examination reveals no abnormalities.

Pertinent Negatives:

• No signs of acute distress.
• Normal findings across all systems reviewed (skin, HEENT, neck, cardiovascular, respiratory, gastrointestinal, genitourinary, peripheral vascular, musculoskeletal, neurological, psychiatric).

Missing Information:

• Orthostatic blood pressure measurements to evaluate for orthostatic hypotension.
• Detailed dietary and lifestyle assessment.
• Recent lab work to assess kidney function, electrolytes, and glucose levels.

Differential Diagnosis

1. Primary Hypertension: Given the significantly elevated blood pressure reading at the pharmacy and the patient’s family history of hypertension, primary hypertension is a likely diagnosis.
2. Secondary Hypertension: Although the patient denies recent medication use and has no known medical history, secondary causes of hypertension (such as renal artery stenosis, primary aldosteronism, or pheochromocytoma) should be considered, especially given the significant elevation in blood pressure.
3. Transient Hypertensive Episode: The elevated blood pressure could be a transient response to an acute stressor or an error in measurement technique. The patient’s current blood pressure reading is within normal limits, indicating that the high reading may have been an isolated event.

Plan

For Primary Hypertension:

1. Lifestyle Modifications:
   • Diet: Encourage a diet low in sodium and rich in fruits, vegetables, whole grains, and low-fat dairy products. Recommend the DASH diet (Sacks et al., 2001).
   • Physical Activity: Advise at least 150 minutes of moderate-intensity aerobic activity per week (Whelton et al., 2017).
   • Weight Management: Maintain a healthy weight with a BMI between 18.5 and 24.9 (Whelton et al., 2017).
   • Alcohol Moderation: Limit alcohol intake to no more than one drink per day for women (Whelton et al., 2017).
   • Smoking Cessation: If applicable, provide resources for smoking cessation.
2. Medication:
   • If blood pressure remains elevated, initiate antihypertensive medication such as a thiazide diuretic, ACE inhibitor, or calcium channel blocker, following current guidelines (Whelton et al., 2017).
3. Monitoring:
   • Schedule follow-up appointments to monitor blood pressure and assess the effectiveness of lifestyle modifications and medication.
   • Consider home blood pressure monitoring to provide additional data and ensure accurate readings.
4. Referral:
   • If secondary hypertension is suspected, refer to a cardiologist and/or nephrologist for further evaluation and management.
5. Patient Education:
   • Educate the patient on the importance of adhering to lifestyle modifications and medications.
   • Discuss potential symptoms of hypertensive emergencies and when to seek immediate medical attention.

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