Case study and history of hypertension

Case study and history of hypertension History of Present Illness: Mr. AS is an 85 year old Caucasian male with a past history of hypertension and chest pain who currently presents to us with dementia and complaints of not knowing how he got here. Our patient was diagnosed with hypertension at the age of 40 and developed chest pain at the age of 45 when he was told he needed a pace maker. The pace maker was placed and he has had no heart complications since then. At the age of 55 our patient was diagnosed with dementia which he lived with independently at home until two years ago when he had a stroke. He was admitted to ALF on April 28, 2009 where he was told that he had a stroke and could not walk. Mr. AS has been staying at the facility since admission. Our patient currently denies any chest pain, headaches or vision changes. Mr. AS does complain of a cough that becomes productive at times with clear sputum. He stopped smoking 20 years ago and has a 160 pack year history. He also states that he thinks he hears himself wheezing at times. Mr. AS states that his legs don’t allow him to walk anymore and that the exercises that are done with the walker hurt his arms. He states that he has feeling in his legs but that movement is the problem. Mr. AS stated during the interview that he has accepted the fact that he will not be able to walk again and that he is content with his life as long as he can breathe and talk. Our patient also stated that he has problems remembering recent events and is better at remembering events that occurred during his childhood. Past Medical History: Hypertension at the age of 40 which is controlled with medication. Chest pain at the age of 45 which was fixed with the placement of a pacemaker. Dementia was diagnosed at the age of 55 Stroke at the age of 83 Appendectomy at the age of 10 due to an appendicitis Inguinal hernia repair at the age of 10 Current Medications Mirtazapine 15mg PO QD for depression Namenda 10mg PO Bid for treatment of alzheimer ’s symptoms Allopurinol 300mg PO QD for hyperuricemia Aspirin 81mg PO QD for general health and relief of minor pain Certavite antioxidant 18mg PO QD to prevent vitamin deficiency and undernutrion Loratadine 10mg PO QD for allergies Nifedipine 90mg PO QD for treatment of hypertension and angina Metoprolol tartrate 25mg PO QD for treatment of hypertension and angina Nasal decongestant 0.05% SP 2 sprays for each nostril Bid for allergies Omeprazole 20mg PO Bid for gastroesophageal reflux Aricept 10mg PO QD for dementia associated with alzheimer’s Tamsulosin HCl 0.4mg PO QD for benign prostatic hyperplasia Zolpidem Tartrate 5mg PO QD for help sleeping Acetaminopen 500mg PO every 6 hours for high temperature Allergies No known allergies Family History: Grandma had TB, patient could not remember cause or time of death and chart did not contain any information. Information about the mother and father could not be obtained by the patient or the c hart. Information about siblings could not be obtained by the patient or the chart. Patient states that he has one son who has back pain and is overweight. No other information could be provided by the patient or the chart. Patient states that he has no grandchildren Married twice and both deceased, cause unknown by patient and not stated in chart. Family members will need to be contacted to obtain more information on history of cancer, hypertension, heart disease, diabetes mellitus, or psychological illnesses. Social: