(Student Name)
\nMiami Regional University
\nDate of Encounter:
\nPreceptor\/Clinical Site:
\nClinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C<\/p>\n
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)<\/p>\n
PATIENT INFORMATION
\nName: Mr. DT
\nAge: 68-year-old
\nGender at Birth: Male
\nGender Identity: Male
\nSource: Patient
\nAllergies: PCN, Iodine
\nCurrent Medications:
\n\u2022\tAtorvastatin tab 20 mg, 1-tab PO at bedtime
\n\u2022\tASA 81mg po daily
\n\u2022\tMulti-Vitamin Centrum Silver
\nPMH: Hypercholesterolemia
\nImmunizations: Influenza last 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online-year, tetanus, and hepatitis A and B 4 years ago.
\nPreventive Care: Coloscopy 5 years ago (Negative)
\nSurgical History: Appendectomy 47 years ago.
\nFamily History: Father- died 81 does not report information
\nMother-alive, 88 years old, Diabetes Mellitus, HTN
\nDaughter-alive, 34 years old, healthy
\nSocial History: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
\nSexual Orientation: Straight
\nNutrition History: Diets off and on, Does not each seafood
\nSubjective Data:
\nChief Complaint: \u201cheadaches\u201d that started two weeks ago
\nSymptom analysis\/HPI:
\nThe patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159\/100, 158\/98 and 160\/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.<\/p>\n
Review of Systems (ROS)
\nCONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures.
\nHEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
\nRESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
\nCARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
\ndyspnea.
\nGASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
\ndiarrhea.
\nGENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting\/stopping stream of urine or incontinence.
\nMUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
\nSKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.<\/p>\n
Objective Data:
\nVITAL SIGNS: Temperature: 98.5 \u00b0F, Pulse: 87, BP: 159\/92 mmhg, RR 20, PO2-98% on room air, Ht- 6\u20194\u201d, Wt 200 lb, BMI 25. Report pain 2\/10.<\/p>\n
GENERAL APPREARANCE: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE\/LE strength 5\/5.
\nHEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,. Lids non-remarkable and appropriate for race.<\/p>\n
Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.
\nCARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.
\nRESPIRATORY: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
\nGASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation
\nMUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits, no stiffness.
\nINTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.<\/p>\n
ASSESSMENT:
\nMain Diagnosis
\nEssential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156\/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015 – Research Paper Writing Help Service). Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease (Domino et al,. 2017).<\/p>\n
Differential diagnosis:
\n\uf0d8\tRenal artery stenosis (ICD10 I70.1)
\n\uf0d8\tChronic kidney disease (ICD10 I12.9)
\n\uf0d8\tHyperthyroidism (ICD10 E05.90)
\nPLAN:<\/p>\n
Labs and Diagnostic Test to be ordered:
\n\u2022\tCMP
\n\u2022\tComplete blood count (CBC)
\n\u2022\tLipid profile
\n\u2022\tThyroid-stimulating hormone (TSH)
\n\u2022\tUrinalysis with Micro
\n\u2022\tElectrocardiogram (EKG 12 lead)<\/p>\n
Pharmacological treatment:
\n\u2022\tHydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.
\n\u2022\tLisinopril 10mg PO Daily<\/p>\n
Non-Pharmacologic treatment:
\n\u2022\tWeight loss
\n\u2022\tHealthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat
\n\u2022\tReduced intake of dietary sodium: <1,500 mg\/d is optimal goal but at least 1,000 mg\/d reduction in most adults
\n\u2022\tEnhanced intake of dietary potassium
\n\u2022\tRegular physical activity (Aerobic): 90\u2013150 min\/wk
\n\u2022\tTobacco cessation
\n\u2022\tMeasures to release stress and effective coping mechanisms.
\nEducation
\n\u2022\tProvide with nutrition\/dietary information.
\n\u2022\tDaily blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP
\n\u2022\tInstruction about medication intake compliance.
\n\u2022\tEducation of possible complications such as stroke, heart attack, and other problems.
\n\u2022\tPatient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R\/U.C. Answered all pt. questions\/concerns. Pt verbalizes understanding to all
\nFollow-ups\/Referrals
\n\u2022\tFollow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy.
\n\u2022\tNo referrals needed at this time.<\/p>\n
References
\nCodina Leik, M. T. (2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
\nISBN 978-0-8261-3424-0
\nDomino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
\n(25th ed.). Print (The 5-Minute Consult Series).<\/p>\n
-research paper writing service<\/p>\n","protected":false},"excerpt":{"rendered":"
(Student Name) Miami Regional University Date of Encounter: Preceptor\/Clinical Site: Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name: Mr. DT Age: 68-year-old Gender at Birth: Male Gender Identity: Male Source: Patient Allergies: PCN, Iodine Current Medications: \u2022 Atorvastatin tab […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1348,2496,1345,2493,2494,2492,2495,1347],"tags":[2428,1648,1572,2473,2498,1966,2497],"class_list":["post-7908","post","type-post","status-publish","format-standard","hentry","category-best-nursing-assignment-writing-service","category-best-nursing-essay-writing-service","category-cheap-online-nursing-essays-writing","category-companies-that-edit-nursing-papers","category-online-nursing-essay-writing-service","category-professional-nursing-writing-services","category-sample-essay-for-nursing","category-write-my-nursing-paper-online","tag-bsn","tag-medical-research-papers","tag-msn","tag-msn-essays","tag-nursing-essay-writers","tag-nursing-essays","tag-nursing-writing-service"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/7908","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/comments?post=7908"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/7908\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/media?parent=7908"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/categories?post=7908"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/tags?post=7908"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}