L. S., a 75-year-old man, presents to a holistic care specialist for evaluation of his worsening health state. L. S., who is a retired employee, was diagnosed with hypertension 2 years ago. Following a course of treatment with antihypertensive medications, he felt better and did not make any attempts to continue treatment. He does not have any chronic disease and has not experienced any severe infections recently.
He has been noticing worsening headaches over the past few weeks. At first, he only noticed them in the morning, after doing his everyday routine in the garden. Now he has worsening symptoms of a headache in the second part of the day. The patient tried to spend more time sleeping and taking a rest, but the headaches did not disappear. His recent headaches appear to be the same symptoms of hypertension he had in the past.
In general, the headache is felt like pressure at the back of the head. The typical pain is described as 6-7/10 on the pain scale and lasts for half an hour. It occurs several times per day. A few days ago, he had a more severe headache after experiencing some stress. The pain went up to 8/10 and lasted for 2 hours. It was accompanied by altered vision and light-headedness.
The patient’s concerns, if asked, are worsening hypertension and the possibility of experiencing a stroke. His dad died from a stroke.
The patient smokes cigarettes and has a rare glass of wine. He has never used drugs. He drinks four cups of coffee per day (increased over baseline). His eating habits are not healthy. He prefers greasy food and products containing a lot of sugar. He eats fruits and vegetables rarely. He has a hard time following a special diet for people with hypertension and finds it very stressful. He is not doing sports and fails to do regular exercises meant to improve his health status.
He is not emotionally stable and finds it difficult to cope with stressful situations. He has a positive environment and has not experienced any serious shock recently. He has never had mental problems.
He believes in the long-term efficacy of medications and does not regard a healthy lifestyle as an effective cure. He does not put much trust in his doctor’s advice to increase physical activity in order to reduce the symptoms of hypertension. He tends to take more medications instead of giving up his actual bad habits and changing his everyday routine.
He values a good state of health that enables him to live a normal usual life. He focuses on the general feeling of well-being, rather than on analyzing distinct symptoms caused by different health issues.
L.S. retired 15 years ago. While working, he was constantly under pressure and had to work overtime. Being on a pension, he does not experience stress often. He is married and has 2 children and 3 grandchildren. He lives with his wife, the younger son, and his family. His family members are concerned about his unhealthy lifestyle and frequent symptoms of hypertension.
He has been involved in the local church community for many years. He regularly visits church with his family members and enjoys doing community productions.
His personal health goals include maintaining good conditions and being able to lead his usual lifestyle. He wants to decrease the negative influence of hypertension and improve his well-being.
L. S. has repeated symptoms of hypertension, which can present a risk of a heart attack or a stroke (Cheung, Lam, Lau, Man, & Ong, 2007, p. 69). He does not follow the basic recommendations for the prevention of hypertension. He is emotionally unstable though he is not exposed to serious stressful situations. His mental condition is good. He is actively seeking help and appears worried by his symptoms.
Reference
Cheung, B., Lam, K., Lau, C., Man, Y., & Ong, K. (2007). Prevalence, awareness, treatment, and control of hypertension among United States adults 1999–2004. Hypertension, 46(1), 69-75.