(Pupil Title)
Date of Encounter:
Preceptor/Scientific Web site:
Scientific Teacher: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C
Soap Note # Foremost Prognosis ( Exp: Soap Note #three DX: Hypertension)
PATIENT INFORMATION
Title: Mr. DT
Age: 68-year-old
Gender at Start: 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 every 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 (Detrimental)
Surgical Historical past: Appendectomy 47 years in the past.
Household Historical past: Father- died 81 doesn’t report data
Mom-alive, 88 years outdated, Diabetes Mellitus, HTN
Daughter-alive, 34 years outdated, wholesome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
Vitamin Historical past: Diets on and off, Doesn’t every seafood
Subjective Knowledge:
Chief Grievance: “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The affected person is 65 years outdated male who complaining of episodes of complications and on three totally different events blood stress was measured, which was excessive (159/100, 158/98 and 160/100 respectively). Affected person observed the issue began two weeks in the past and generally it’s accompanied by dizziness. He states that he has been below stress in his office for the final month. Affected person denies chest ache, palpitation, shortness of breath, nausea or vomiting.
Overview of Methods (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weak point or weight reduction. NEUROLOGIC: Headache and dizziness as describe above. Denies adjustments in LOC. Denies historical past of tremors or seizures.
HEENT: HEAD: Denies any head harm, or change in LOC. Eyes: Denies any adjustments 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, problem swallowing.
RESPIRATORY: Affected person denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest ache, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies stomach ache or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies problem 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 corresponding to cyanosis or jaundice, no rashes or pruritus.
Goal Knowledge:
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 applicable 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 mass 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 delicate 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:
Foremost Prognosis
Important (Major) Hypertension (ICD10 I10): Given the signs and hypertension (156/92 mmhg), categorised as stage 2. As soon as the natural explanation for hypertension has been dominated out, corresponding to renal, adrenal or thyroid, this analysis is confirmed (Codina Leik, 2015). Prognosis relies on the scientific analysis by means of historical past, bodily examination, and routine laboratory exams to evaluate danger components, reveal identifiable causes and detect target-organ harm, together with proof of heart problems (Domino et al,. 2017).
Differential analysis:
· 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 every day.
· Lisinopril 10mg PO Every day
Non-Pharmacologic remedy:
· Weight reduction
· Nutritious diet (DASH dietary sample): Weight loss program wealthy in fruits, greens, complete grains, and low-fat dairy merchandise with lowered content material of saturated and trans l fats
· Lowered consumption of dietary sodium: <1,500 mg/d is perfect purpose however no less than 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 vitamin/dietary data.
· Every day blood stress monitoring log at house twice a day for 7 days, preserve a report, carry the report on the subsequent go to together with her PCP
· Instruction about treatment consumption compliance.
· Schooling of attainable issues corresponding 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
Comply with-ups/Referrals
· Comply with up appointment 1 weeks for managing blood stress 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 Collection).
-research paper writing service
