(Scholar Identify)
Miami Regional College
Date of Encounter:
Preceptor/Scientific Website:
Scientific Teacher: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C
Cleaning soap Word # Important Prognosis ( Exp: Cleaning soap Word #three DX: Hypertension)
PATIENT INFORMATION
Identify: Mr. DT
Age: 68-year-old
Gender at Beginning: Male
Gender Id: Male
Supply: Affected person
Allergy symptoms: PCN, Iodine
Present Medicines:
• Atorvastatin tab 20 mg, 1-tab PO at bedtime
• ASA 81mg po each day
• Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza final 2018-year, tetanus, and hepatitis A and B four years in the past.
Preventive Care: Coloscopy 5 years in the past (Unfavorable)
Surgical Historical past: Appendectomy 47 years in the past.
Household Historical past: Father- died 81 doesn’t report info
Mom-alive, 88 years outdated, Diabetes Mellitus, HTN
Daughter-alive, 34 years outdated, wholesome
Social Historical past: No smoking historical past or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Diet Historical past: Diets on and off, Doesn’t every seafood
Subjective Information:
Chief Criticism: “complications” that began two weeks in the past
Symptom Assessment/HPI:
The affected person is 65 years outdated male who complaining of episodes of complications and on three completely different events blood strain was measured, which was excessive (159/100, 158/98 and 160/100 respectively). Affected person seen the issue began two weeks in the past and generally it’s accompanied by dizziness. He states that he has been underneath stress in his office for the final month. Affected person denies chest ache, palpitation, shortness of breath, nausea or vomiting.
Overview of Programs (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weak spot or weight reduction. NEUROLOGIC: Headache and dizziness as describe above. Denies modifications in LOC. Denies historical past of tremors or seizures.
HEENT: HEAD: Denies any head damage, or change in LOC. Eyes: Denies any modifications in imaginative and prescient, diplopia or blurred imaginative and prescient. Ear: Denies ache within the ears. Denies lack of listening to or drainage. Nostril: Denies nasal drainage, congestion. THROAT: Denies throat or neck ache, hoarseness, issue swallowing.
RESPIRATORY: Affected person denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest ache, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies belly ache or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies issue beginning/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or ache. Denies listening to a clicking or snapping sound.
SKIN: No change of coloration akin to cyanosis or jaundice, no rashes or pruritus.
Goal Information:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’four”, Wt 200 lb, BMI 25. Report ache 2/10.
GENERAL APPREARANCE: The affected person is alert and oriented x three. No acute misery famous. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to particular person, place, and time. Sensation intact to bilateral higher and decrease extremities. Bilateral UE/LE energy 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visible acuity and extraocular eye actions intact. No nystagmus famous. Ears: Bilateral canals patent with out erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly grey with sharp cone of sunshine. Maxillary sinuses no tenderness. Nasal mucosa moist with out bleeding. Oral mucosa moist with out lesions,. Lids non-remarkable and acceptable for race.
Neck: supple with out cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or lots.
CARDIOVASCULAR: S1S2, common charge and rhythm, no murmur or gallop famous. Capillary refill < 2 sec.
RESPIRATORY: No dyspnea or use of accent muscle groups noticed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
GASTROINTESTINAL: No mass or hernia noticed. Upon auscultation, bowel sounds current in all 4 quadrants, no bruits over renal and aorta arteries. Stomach gentle non-tender, no guarding, no rebound no distention or organomegaly famous on palpation
MUSKULOSKELETAL: No ache to palpation. Lively and passive ROM inside regular limits, no stiffness.
INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.
ASSESSMENT:
Important Prognosis
Important (Major) Hypertension (ICD10 I10): Given the signs and hypertension (156/92 mmhg), categorised as stage 2. As soon as the natural reason behind hypertension has been dominated out, akin to renal, adrenal or thyroid, this prognosis is confirmed (Codina Leik, 2015). Prognosis relies on the scientific analysis by historical past, bodily examination, and routine laboratory checks to evaluate danger elements, reveal identifiable causes and detect target-organ harm, together with proof of heart problems (Domino et al,. 2017).
Differential prognosis:
Renal artery stenosis (ICD10 I70.1)
Persistent kidney illness (ICD10 I12.9)
Hyperthyroidism (ICD10 E05.90)
PLAN:
Labs and Diagnostic Check to be ordered:
• CMP
• Full blood rely (CBC)
• Lipid profile
• Thyroid-stimulating hormone (TSH)
• Urinalysis with Micro
• Electrocardiogram (EKG 12 lead)
Pharmacological remedy:
• Hydrochlorothiazide tab 25 mg, Preliminary dose: 25 mg orally as soon as each day.
• Lisinopril 10mg PO Day by day
Non-Pharmacologic remedy:
• Weight reduction
• Nutritious diet (DASH dietary sample): Eating regimen wealthy in fruits, greens, entire grains, and low-fat dairy merchandise with diminished content material of saturated and trans l fats
• Diminished consumption of dietary sodium: <1,500 mg/d is perfect objective however a minimum of 1,000 mg/d discount in most adults
• Enhanced consumption of dietary potassium
• Common bodily exercise (Cardio): 90–150 min/wk
• Tobacco cessation
• Measures to launch stress and efficient coping mechanisms.
Schooling
• Present with diet/dietary info.
• Day by day blood strain monitoring log at residence twice a day for 7 days, maintain a file, carry the file on the subsequent go to together with her PCP
• Instruction about medicine consumption compliance.
• Schooling of doable issues akin to stroke, coronary heart assault, and different issues.
• Affected person was educated on track of hypertension, in addition to warning indicators and signs, which might point out the necessity to attend the E.R/U.C. Answered all pt. questions/considerations. Pt verbalizes understanding to all
Observe-ups/Referrals
• Observe up appointment 1 weeks for managing blood strain and to judge present hypotensive remedy.
• No referrals wanted at the moment.
References
Codina Leik, M. T. (2014). Household Nurse Practitioner Certification Intensive Overview (2nd ed.).
ISBN 978-Zero-8261-3424-Zero
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Scientific Seek the advice of 2017
(25th ed.). Print (The 5-Minute Seek the advice of Sequence).
-research paper writing service
