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HEENT: Reports posterior headaches with blurred vision that is worse in the morning. Denies history of headaches. Denies rhinorrhea, sore throat, or difficulty swallowing. Cardiac: Denies palpitations. Has been having chest pressure described as a heaviness. Respiratory: Denies cough but is having shortness of breath since started the chest pressure yesterday. GI: Denies nausea, vomiting, or abd pain. No changes in appetite. GU: Denies urgency or frequency. Musculoskeletal: Denies joint pain but does have chronic lower back pain. Denies leg weakness, numbness, or tingling or saddle anesthesia. Integumentary: Denies rash or lesions. Neuro: Reports posterior headache. Denies confusion, head trauma, or weakness. Physical Exam: VITAL SIGNS: BP: 225/105, Pulse: 85, Resp: 16, Temp: 98.5 F, SpO2 100% RA. Constitutional: Dressed appropriately, looks stated age. Obese. Neck: Supple with active range of motion. No thyromegaly. Cardiac: S1S2, No murmur/clicks/rubs. No edema. No JVD or JVP. BUN 47 Creatinine 2.83. EKG- Sinus rhythm with left ventricular hypertrophy. CT Brain without contrast- No mass, edema, hemorrhage, or hydrocephalus. CXR- The heart size is normal, the lung volumes are normal, and the pulmonary vessels are normal. No lobar consolidation or pleural effusion. Get the instant assignment help. Create a problem representation for the case study.
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