Laura Cady
Case Study for NP students
Dale Jones, a 28-year-old black male, presents to the clinic complaining of headache, dizziness, fatigue,
and mild peripheral edema. He has not seen a healthcare provider in 8 years. Weight: 240 lbs.; Height
5’10”; waist-to-hip ratio > 2:1. He rates his headache 8/10 and describes it as a constant, throbbing
pressure distributed evenly over the top of his head. He rates his pain 8/10. His symptoms are worse in
the morning than in the evening. Tylenol and Ibuprofen help some; pain is 5-6/10 after medication. He
thinks he may have “blood pressure problems like his father.” Denies chest pain, injuries, physical
trauma, or recent illness. His family history is positive for hypertension, coronary artery disease, and
Type II Diabetes. Vital signs: HR 96, BP 160/86, RR 20, SpO2 98%.
Psychosocial: sells insurance, occasionally feels stressed from work.
Diet & Lifestyle: sedentary, frequently eats at local fast food restaurants. Denies tobacco use.
Occasionally consumes alcohol.
Physical Exam:
General: Alert & oriented to person, place, and time. Appropriately dressed & groomed with good
hygiene. Calm & cooperative.
Mental status: Oriented x3, speech appropriate, clear.
HEENT: normocephalic, without deformities, no evidence of trauma. Hair with normal distribution &
texture. Eyelids, sclera, and conjunctiva normal. A few xanthosis nodules near inner canthus/eyelid
margins. PERRLA, EOM full, no cataracts, fundoscopic exam WNL. Ears w/normal appearing pinnae &
auditory canals, tympanic membrane pearly gray, glistening, w/o retraction or bulging, normal light
reflex, hearing intact. Nose without deformity, patent nares, pale pink, moist mucosa, normal turbinates,
no deviation of septum or polyps noted. No tenderness to palpation of frontal or maxillary sinuses or
nares. Reports occasional sinus pressure and clear nasal drainage. Buccal and tongue mucosa pink and
moist. No lesions were noted under the tongue or inside the mouth. Teeth are in good repair, and there
is no evidence of gum disease. Tonsils not enlarged or red, oropharynx patent. Thyroid midline, no
enlargement or nodularity present. No palpable lymph nodes in the neck or supraclavicular fossa. No
cervical masses. Trachea midline. Acanthosis nigricans noted around base of neck, underarms, and
posterior fossa of knees.
Breasts, Axilla, Epitrochlear nodes: deferred.
Cardiovascular: Carotids w/+3 pulses, no bruits. No JVD. Cardiac PMI in 5th intercostal space at
midclavicular line. No parasternal lift or abnormal pulsations. S1&S2 present w/normal quality. No
murmurs, gallops, or clicks were noted. +2 peripheral pulses, normal rate & rhythm.
Chest & Lungs: clear in upper & lower fields. No fremitus. No pectus excavatum or carinatum present.
Normal respiratory pattern, inhalation & expiration full without use of accessory muscles. A-P diameter
2:1. No deformities of thorax seen.
Abdomen: Normal bowel sounds, soft, nondistended, nontender. Liver, kidneys, spleen not palpable.
Aortic pulsation palpable within normal limits.
Back: no scoliosis, kyphosis, or lordosis seen. No CVA tenderness.
Case Study for NP students
Dale Jones, a 28-year-old black male, presents to the clinic complaining of headache, dizziness, fatigue,
and mild peripheral edema. He has not seen a healthcare provider in 8 years. Weight: 240 lbs.; Height
5’10”; waist-to-hip ratio > 2:1. He rates his headache 8/10 and describes it as a constant, throbbing
pressure distributed evenly over the top of his head. He rates his pain 8/10. His symptoms are worse in
the morning than in the evening. Tylenol and Ibuprofen help some; pain is 5-6/10 after medication. He
thinks he may have “blood pressure problems like his father.” Denies chest pain, injuries, physical
trauma, or recent illness. His family history is positive for hypertension, coronary artery disease, and
Type II Diabetes. Vital signs: HR 96, BP 160/86, RR 20, SpO2 98%.
Psychosocial: sells insurance, occasionally feels stressed from work.
Diet & Lifestyle: sedentary, frequently eats at local fast food restaurants. Denies tobacco use.
Occasionally consumes alcohol.
Physical Exam:
General: Alert & oriented to person, place, and time. Appropriately dressed & groomed with good
hygiene. Calm & cooperative.
Mental status: Oriented x3, speech appropriate, clear.
HEENT: normocephalic, without deformities, no evidence of trauma. Hair with normal distribution &
texture. Eyelids, sclera, and conjunctiva normal. A few xanthosis nodules near inner canthus/eyelid
margins. PERRLA, EOM full, no cataracts, fundoscopic exam WNL. Ears w/normal appearing pinnae &
auditory canals, tympanic membrane pearly gray, glistening, w/o retraction or bulging, normal light
reflex, hearing intact. Nose without deformity, patent nares, pale pink, moist mucosa, normal turbinates,
no deviation of septum or polyps noted. No tenderness to palpation of frontal or maxillary sinuses or
nares. Reports occasional sinus pressure and clear nasal drainage. Buccal and tongue mucosa pink and
moist. No lesions were noted under the tongue or inside the mouth. Teeth are in good repair, and there
is no evidence of gum disease. Tonsils not enlarged or red, oropharynx patent. Thyroid midline, no
enlargement or nodularity present. No palpable lymph nodes in the neck or supraclavicular fossa. No
cervical masses. Trachea midline. Acanthosis nigricans noted around base of neck, underarms, and
posterior fossa of knees.
Breasts, Axilla, Epitrochlear nodes: deferred.
Cardiovascular: Carotids w/+3 pulses, no bruits. No JVD. Cardiac PMI in 5th intercostal space at
midclavicular line. No parasternal lift or abnormal pulsations. S1&S2 present w/normal quality. No
murmurs, gallops, or clicks were noted. +2 peripheral pulses, normal rate & rhythm.
Chest & Lungs: clear in upper & lower fields. No fremitus. No pectus excavatum or carinatum present.
Normal respiratory pattern, inhalation & expiration full without use of accessory muscles. A-P diameter
2:1. No deformities of thorax seen.
Abdomen: Normal bowel sounds, soft, nondistended, nontender. Liver, kidneys, spleen not palpable.
Aortic pulsation palpable within normal limits.
Back: no scoliosis, kyphosis, or lordosis seen. No CVA tenderness.
