Subjective DataDemographic Data:S.B., 55-year-old African American female. Married. Works asa Registered Nurse. Information via patient interview. Appears to be a reliablesource of information.Chief Complaint/Concern:High blood pressure finding 2 days ago.History of Present Illness:Went to dentist office for a tooth extraction and wastold that her blood pressure was high. Remembers the top number “was in the160s.”Dentist then instructed patient to see her PCP about her blood pressure.Patient gets occasional headaches at the front of her head and eye sockets thatbegan about 6 months ago. Headaches are relieved by Tylenol and rest and seemto be worse during periods of stress. Noticed a weight gain of about 5 poundsover the last week. No nosebleeds, nausea, fatigue, weakness, or chest pain.Currently not taking any medications for high blood pressure.Past Medical History:General Health:Overall, feels healthy. No health complaints.Adult Hospitalization:No hospitalizations or surgeries.Childhood Diagnosis:1.Seizure at 3 y/o. One time event. No cause found.Current Diagnoses:1.Hypercholesterolemia – diagnosed in 2019, is prescribed medication, butadmits to forgetting to take it, so she only takes it about three times perweek.Serious Injuries:No serious injuries.Immunizations:Received 2021 flu shot, received 2 doses of COVID-19 in April andMay 2021, negative TB test in 2020. All childhood vaccinations up to date, tetanuscurrent, Hep B series completed, MMR current. No recent travel out of thecountry.Current Medications:B-complex vitamin supplement by mouth daily (unsure of doses).D vitamin supplement 1000 IU by mouth daily.Acetaminophen 650 mg by mouth as needed for headaches.Atorvastatin 40 mg by mouth daily.Allergies:No latex, medication, food, or seasonal allergies.
