Concept Map
Student Name: Jun Baek Instructor:Professor Stark
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References)
... [Show More] Medical, Surgical, Social History (1).
Medical History
Primary (Essential) Hypertension
Hypertension is defined as having a blood pressure that is consistently over 140 systolic and 90 diastolic which is confirmed on two visits. Hypertension has stages from normal which is less than 120 systolic and 80 diastolic, stage 1 which is 140 or a diastolic of 90, stage 2 which is systolic BP greater than or equal to 160 or diastolic BP greater than or equal to 100, and hypertension crisis happens when the blood pressure is over 180 systolic or diastolic over 120. There is another stage in between which is known as the prehypertension stage which is in between normal and stage 1. There is no clear known cause of primary hypertension and it is known as the idiopathic disorder. The patient’s blood pressure is 136/71 which signifies that the patient is in the stage 1 hypertension. (Copstead, L. E., & Banasik, J. L. (2005) p. 344).
Gastroesophageal reflux disease (GERD)
Gastroesophageal reflux disease (GERD) is a disease where the stomach acid frequently flows back into the esophagus which is the tube that connects the mouth to the stomach. The stomach acid, over time, irritates the lining of the esophagus. Patients often have symptoms of heartburn, regurgitation, chest pain, and dysphagia. These symptoms are more severe if there is a longer time in contact with the stomach acid. Different foods and medications can aggravate the stomach acid to be flown back to the esophagus causing GERD. (Copstead, L. E., & Banasik, J.
L. (2005) p. 724)
Osteoporosis
Osteoporosis is a bone disease that affects about 10 million people who are over 50 years old in the United States. Osteoporosis is the inability of the osteoblasts (makes bone cells) and the osteoclasts (absorbs bone cells) to keep up with the microtrauma that people go through every day. The bones in the body go through remodeling every day in order to combat the microtraumas that affect the bones of the body. During osteoporosis, the process of osteoblasts and osteoclasts are too “slow” in building up dense bone which is crucial for bone development. This results in brittle bones that are less dense which results in more frequent fractures. (Copstead, L. E., & Banasik, J. L. (2005) p. 1033)
Cerebrovascular accident
Cerebrovascular accident (CVA) happens when the brain does not receive the blood supply that it needs to function. This leads to the brain not receiving enough nutrients and oxygen which causes the part of the brain to die. This results in brain damage and loss of neurological function. Some symptoms may include facial droop, ataxia, sudden decrease in level of consciousness, and visual field deficits. The brain is a delicate organ that needs oxygenated blood constantly or else it will die. (Copstead, L. E., & Banasik, J. L. (2005) p. 906)
Surgical History
Patient has no known surgical history.
Social History
J.C is married, is a Christian, and is of Asian descent (Korean). He was a technician before he was admitted to Pacific Haven. Patient was unable to respond when asked about his habits of smoking, drinking, and illicit drug use. Pt has one son who seems to be his only family member. He has power of attorney and the son seems to make the medical decisions that his father (the patient) needs to make. Sexual history is unknown. It is unknown if the patient has been through abuse. Patient is disabled and requires assistance for ADLs.
Test Norms Date Current Value
WBC 4.0-10.5 1/7/19 10.0
RBC 4.38-5.62 1/7/19 2.99
Hemoglobin 13.5-16.9 1/7/19 9,7
Hematocrit 39.5-50.0 1/7/19 28.2
MCV 81.5-97.0 1/7/19 94.1
MCH 27.0-33.5 1/7/19 32.4
MCHC 32.0-35.5 1/7/19 34.5
RDW-CV 11.6-14.4 1/7/19 13.7
Platelet 150-400 1/7/19 316
MPV 7.2-11.7 1/7/19 8.0
Sodium 136-145 1/7/19 141
Potassium 3.5-5.1 1/7/19 4.2
Chloride 98-107 1/7/19 107
CO2 21-31 1/7/19 28
Electrolyte Balance 2-12 1/7/19 6
Glucose 85-125 1/7/19 110
BUN 7-25 1/7/19 32
Creatinine 0.7-1.3 1/7/19 1.0
GFR >59 1/7/19 >60
Calcium 8.6-10.3 1/7/19 8.8
Protein 6.0-8.3 1/7/19 5.6
Albumin 4.2-5.5 1/7/19 3.1
Alkaline Phosphate 34-104 1/7/19 67
AST 13-39 1/7/19 16
ALT 7-52 1/7/19 24
Bilirubin 0.0-1.4 1/7/19 0.3
Cholesterol <200 mg/dL
to 240 1/7/19 130
Triglycerides <150mg/mL
to 500 1/7/19 65
>40 1/7/19 60
<100 to >190 1/7/19 57
LDL 100 to 129 1/7/19 13
HDL >130 1/7/19 70 [Show Less]