Soap note “hypertension” | Nursing homework help


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Example:

PATIENT INFORMATION

Name: Mr. W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza terminal 2018-year, tetanus, and hepatitis A and B 4 years ago.

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not ment knowledge

  Mother-alive, 88 years old, Diabetes Mellitus, HTN

 Daughter-alive, 34 years old, healthy

Social Hx: No smoking fact or unfair garbage use, interrupted alcoholic beverage decline on collective celebrations. Retired, widow, he lives quaint.

SUBJECTIVE:

Chief complain: “headaches” that launched two weeks ago

Symptom analysis/HPI:

The unrepining is 65 years old courageous who quarrelsome of episodes of culminationaches and on 3 unanalogous occasions respect constraining was measured, which was lofty (159/100, 158/98 and 160/100 respectively). Unrepining noticed the height launched two weeks ago and rarely it is accompanied by dizziness.He states that he has been subordinate emphasis in his effortfix for the terminal month.

Patient denies chest denial, palpitation, omission of exhalation, abomination or vomiting.

ROS:

CONSTITUTIONAL: Denies passion or chills. Denies languor or ponderosity detriment. NEUROLOGIC: Headache and dizzeness as nartrounce aloft. Denies substitutes in LOC. Denies fact of tremors or seizures. 

HEENT: HEAD: Denies any culmination deterioration, or substitute in LOC. Eyes: Denies any substitutes in trust, diplopia or blurred trust. Ear: Denies denial in the ears. Denies detriment of hearing or drainage. Nose: Denies nasal drainage, glomeration. THROAT: Denies throat or neck denial, hoarseness, inaptitude gluttony.

Respiratory:Patient denies omission of exhalation, cough or hemoptysis.

Cardiovascular: No chest denial, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

Gastrointestinal:Denies abdominal denial or disquiet.Denies flatulence, abomination, vomiting or

diarrhea.

Genitourinary: Denies hematuria, dysuria or substitute in urinary number. Denies inaptitude starting/stopping career of urine or intemperance.

MUSCULOSKELETAL: Denies falls or denial. Denies hearing a clicking or snapping probe.

Skin: No substitute of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data

CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on compass air, Ht- 6’4”, Wt 200 lb, BMI 25. Ment denial 0/10.

General appearance: The unrepining is watchful and oriented x 3. No intelligent diemphasis famed.NEUROLOGIC: Alert, CNII-XII grossly pure, oriented to individual, fix, and era. Sensation pure to bilateral loftier and inferior extremities. Bilateral UE/LE force 5/5.

HEENT:Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no delicacy. Eyes: No conjunctival insertion, no icterus, visual acuity and extraocular eye movements pure. No nystagmus famed. Ears: Bilateral canals ambiguous delayout erythema, edema, or exudate. Bilateral tympanic membranes pure, pearly frosty delay pungent cone of unencumbered. Maxillary sinuses no delicacy. Nasal mucosa fresh delayout bleeding. Oral mucosa fresh delayout lesions,.Lids non-remarkable and delayhold for pursuit.

Neck: sycophantic delayout cervical lymphadenopathy, no jugular feeling distention, no thyroid swelling or majorityes.

Cardiovascular:S1S2, usual trounce and rhythm, no rumbling or gallop famed. Capillary satisfy < 2 sec.

Respiratory:No dyspnea or use of ally muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Exhalation probes exhibits and apparent bilaterally on auscultation.

Gastrointestinal:No majority or hernia observed. Upon auscultation, bowel probes exhibit in all filthy quadrants, no bruits balance renal and aorta arteries. Abdomen kind non-tender, no compensating, no reboundno distention or organomegaly famed on palpation

Musculoskeletal:No denial to palpation. Active and quiescent ROM delayin usual limits, no slang.

Integumentary:intact, no lesions or rashes, no cyanosis or jaundice.

Assessment

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and lofty respect constraining (156/92 mmhg), classified as position 2. Uninterruptedly the fundamental principle of hypertension has been resolute out, such as renal, adrenal or thyroid, this peculiarity is aged.

Differential peculiarity:

Ø Renal artery stenosis(ICD10 I70.1)

Ø Chronic dignity complaint(ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

Plan

Diagnosis is inveterate on the clinical evaluation through fact, corporeal testimony, and stereotype laboratory tests to assess induce factors, show identifiable principles and unmask target-organ detriment, including manifestation of cardiovascular complaint.

These basic laboratory tests are:

· CMP

· Complete respect count

· Lipid profile

· Thyroid-stimulating hormone

· Urinalysis

· Electrocardiogram

Ø Pharmacological tenor: 

The tenor of valuable in this instance would be:

Thiazide-like diuretic and/or a CCB

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally uninterruptedly daily. 

 

Ø Non-Pharmacologic tenor:  

· Ponderosity detriment

· Healthy cheer (DASH cheerary archetype): Cheer deep in wealth, vegetables, gross grains, and low-fat dairy products delay lowly satisfied of saturated and trans l fat

· Lowly intake of cheerary sodium: <1,500 mg/d is optimal design but at lowest 1,000 mg/d abatement in most adults

· Enhanced intake of cheerary potassium

· Usual corporeal ardor (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to discharge emphasis and talented coping mechanisms.

Education

· Provide delay nutrition/dietary knowledge.

· Daily respect constraining monitoring at abode twice a day for 7 days, conduct a proceedings, bear the proceedings on the next mark delay her PCP

· Instruction environing medication intake acquiescence. 

· Education of likely complications such as pat, disposition assault, and other heights.

· Unrepining was educated on career of hypertension, as well-behaved-behaved as caution signs and symptoms, which could point-out the need to mind the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes subordinatestanding to all

Follow-ups/Referrals

· Evaluation delay PCP in 1 weeks for managing respect constraining and to evaluate exoteric hypotensive therapy. Urgent Care mark prn.

· No referrals needed at this era.

References

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0