Posted: May 1st, 2022

Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)

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Utilizing tempates is happy with regards of Flip it in, nevertheless the Affected particular person Historic previous, CC, HPI, The Analysis and Plan should be of your private work and individualized to your made up affected particular person.

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(Scholar Title)

Date of Encounter:
Preceptor/Scientific Web site:
Scientific Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C

Cleansing cleaning soap Remember # Principal Assessment ( Exp: Cleansing cleaning soap Remember #three DX: Hypertension)

PATIENT INFORMATION
Title: Mr. DT
Age: 68-year-old
Gender at Starting: Male
Gender Identification: Male
Provide: Affected particular person
Allergy signs: PCN, Iodine
Current Medicine:
• Atorvastatin tab 20 mg, 1-tab PO at bedtime
• ASA 81mg po daily
• Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza ultimate 2018-year, tetanus, and hepatitis A and B 4 years previously.
Preventive Care: Coloscopy 5 years previously (Unfavorable)
Surgical Historic previous: Appendectomy 47 years previously.
Family Historic previous: Father- died 81 would not report data
Mother-alive, 88 years earlier, Diabetes Mellitus, HTN
Daughter-alive, 34 years earlier, healthful
Social Historic previous: No smoking historic previous or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Weight loss program Historic previous: Diets on and off, Would not each seafood
Subjective Data:
Chief Criticism: “problems” that started two weeks previously
Symptom analysis/HPI:
The affected particular person is 65 years earlier male who complaining of episodes of problems and on three completely completely different occasions blood stress was measured, which was extreme (159/100, 158/98 and 160/100 respectively). Affected particular person seen the difficulty started two weeks previously and usually it is accompanied by dizziness. He states that he has been beneath stress in his workplace for the ultimate month. Affected particular person denies chest ache, palpitation, shortness of breath, nausea or vomiting.

Consider of Applications (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weak level or weight discount. NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies historic previous of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in imaginative and prescient, diplopia or blurred imaginative and prescient. Ear: Denies ache inside the ears. Denies lack of listening to or drainage. Nostril: Denies nasal drainage, congestion. THROAT: Denies throat or neck ache, hoarseness, challenge swallowing.
RESPIRATORY: Affected particular person denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest ache, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies abdomen ache or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies challenge starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or ache. Denies listening to a clicking or snapping sound.
SKIN: No change of coloration comparable to cyanosis or jaundice, no rashes or pruritus.

Objective Data:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report ache 2/10.

GENERAL APPREARANCE: The affected particular person is alert and oriented x three. No acute distress well-known. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to specific particular person, place, and time. Sensation intact to bilateral larger and reduce extremities. Bilateral UE/LE energy 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, seen acuity and extraocular eye actions intact. No nystagmus well-known. Ears: Bilateral canals patent with out erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray 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 heaps.
CARDIOVASCULAR: S1S2, frequent cost and rhythm, no murmur or gallop well-known. Capillary refill < 2 sec.
RESPIRATORY: No dyspnea or use of accent muscle tissue observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen light non-tender, no guarding, no rebound no distention or organomegaly well-known on palpation
MUSKULOSKELETAL: No ache to palpation. Vigorous and passive ROM inside common limits, no stiffness.
INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.

ASSESSMENT:
Principal Assessment
Essential (Main) Hypertension (ICD10 I10): Given the indicators and hypertension (156/92 mmhg), categorised as stage 2. As quickly because the pure rationalization for hypertension has been dominated out, comparable to renal, adrenal or thyroid, this Assessment is confirmed (Codina Leik, 2015). Assessment depends on the medical Assessment by means of historic previous, bodily examination, and routine laboratory checks to judge menace components, reveal identifiable causes and detect target-organ hurt, along with proof of coronary heart issues (Domino et al,. 2017).

Differential Assessment:
 Renal artery stenosis (ICD10 I70.1)
 Continuous kidney sickness (ICD10 I12.9)
 Hyperthyroidism (ICD10 E05.90)
PLAN:

Labs and Diagnostic Check out 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 quickly as daily.
• Lisinopril 10mg PO Day-to-day

Non-Pharmacologic remedy:
• Weight discount
• Nutritious eating regimen (DASH dietary pattern): Weight reduction plan rich in fruits, greens, full grains, and low-fat dairy merchandise with diminished content material materials of saturated and trans l fat
• Decreased consumption of dietary sodium: <1,500 mg/d is ideal goal nevertheless not lower than 1,000 mg/d low cost in most adults
• Enhanced consumption of dietary potassium
• Frequent bodily train (Cardio): 90–150 min/wk
• Tobacco cessation
• Measures to launch stress and environment friendly coping mechanisms.
Education
• Current with vitamin/dietary data.
• Day-to-day blood stress monitoring log at home twice a day for 7 days, preserve a doc, ship the doc on the next go to alongside along with her PCP
• Instruction about treatment consumption compliance.
• Education of attainable issues comparable to stroke, coronary coronary heart assault, and completely different points.
• Affected particular person was educated on observe of hypertension, along with warning indicators and indicators, which could level out the need to attend the E.R/U.C. Answered all pt. questions/points. Pt verbalizes understanding to all
Adjust to-ups/Referrals
• Adjust to up appointment 1 weeks for managing blood stress and to guage current hypotensive treatment.
• No referrals needed presently.

References
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Consider (2nd ed.).
ISBN 978-Zero-8261-3424-Zero
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Scientific Search the recommendation of 2017
(25th ed.). Print (The 5-Minute Search the recommendation of Assortment).

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