Soap Note
(Student Name)
Miami Regional University
Date of Encounter: September 25, 2021
Preceptor/Clinical Site: Medical Department
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # _Essential Hypertension___ Main Diagnosis __Hypertension___________
PATIENT INFORMATION
Name: Mr. K.V
Age: 50yrs
Gender at Birth: Male
Gender Identity: Male
Source: Medical-Surgical
Allergies: No known allergies.
Current Medications:
· 50mg of Losartan daily orally
· Daily Amlodipine PO 10mg
PMH: Adult illness – elevation in cholesterol levels.
Childhood illnesses – Acute tonsillitis, chickenpox, and mumps.
Immunizations: Hepatitis B and Influenza preventive vaccines 2015.
Preventive Care: Undergone screening for prostate cancer on July 20, 2020
Surgical History: The patient had his tonsils removed at the age of 14.
Family History: Mom:Heart attack and stroke , hypertension and high lipids.Dad: Hypertensive and arterial aneurysms . Grandparents and sibling have no known information.
Social History: Our client is employed full-time in a high-stress, high-demand profession. K.V is the father of two grown-up children. The client consumes up to three beers every evening, smokes cigarettes, and loves tobacco thrice per week. Dismisses ever using illegal drugs. K.V is self-sufficient in his Daily living activities and Instrumental activities. Takes FOUR meals per day AND snacks off between. Because his job is so demanding and taxing, he does not engage in physical activity. K.V has been interested in sex for 35 years with the same spouse.
Sexual Orientation: The patient is enduring less interest and attraction to the female gender with a remarkably lower sexual drive.
Nutrition History: He reports having had a weight gain in the past few years—no history of loss of appetite.
Subjective Data:
Chief Complaint: Regular medical checkup for Hypertension and has regular headaches and chest pains.
Symptom analysis/HPI: K.V., a 50-year-old Jewish man, goes to the urgent care every fortnight for a blood pressure exam. Guy adds that his blood pressure has so far been high for the past few months. He monitors his blood pressure on a regular basis and takes account of findings.
.He reports that the headaches and the chest pains have been persistent over the past few days. The chest pains and the headaches have been mild to moderate.
The patient is …The patient looks generally weak but walks comfortably on his own.
Review of Systems (ROS) (This section is what the patient says; therefore it should state Pt denies, or Pt states….. )
CONSTITUTIONAL: Denies fever, chills, fatigue, or weight gain/loss recently.
NEUROLOGIC: Dismisses symptoms such as dizziness, numbing, stinging, even unconsciousness.
HEENT: Mental fogginess, dizziness, visual disturbances, blurred eyesight, ringing, hearing problems, runny nose or discharge, hoarseness, or drains from the eyeballs are all denied. Reaffirms the occurrence of migraines sometimes. He is a spectacles wearer.
RESPIRATORY: On deny of cough, SOB, trouble respiration, or blood cough
CARDIOVASCULAR: No sudden severe pain in the chest, uneasiness, irregular heartbeat, or murmurs background. There is no evidence of tachycardia, night breathlessness, or swelling.
GASTROINTESTINAL: Pain with vomit, diarrhea, constipation, abdominal discomfort, or gastroesophageal reflux are all denied by the patient.
GENITOURINARY: reports No alterations in the patterns of the urinary system like urge incontinence or polyuria and hematuria.
MUSCULOSKELETAL: He refutes Pain in the joints or swelling
SKIN: client reports denies the presence of growths,itchy skin, dryness, flaking, and open sores.
Objective Data:
VITAL SIGNS: Heigth: 1.8 metres, Weight 241lbs, BMI: 34.6, HR: 79, BP: 185/88, RR: 15, Temp: 97.7, oral, O2 sat: 100% on room air.
GENERAL APPEARANCE:
As in the examination chair, he is sitting up straight. It appears to be at ease. The appearance appears to be age-appropriate. There was no odor from the body. Pampering and cleanliness are essential. The client is well-fed and responds to inquiries correctly.
NEUROLOGIC: A&O x4, cooperative. Mood and affect are appropriate. Remarkable bilaterally and symmetrical.
HEENT: The characteristics of the face are symmetrical. The Head has no atraumatic sign and is of normal size. His T.M.s are symmetrically normal and without any redness or swellings. There is no enlargement in the eardrum. The nasal cavity is distinct on both sides. There were no tumors found. The mucosal of the nose is pinkish, but there is no runny nose. There is no pain in the sinuses. There is no erythema or exudate in the oropharynx. The teeth are in fine condition, and the gums are healthy and not irritated.
CARDIOVASCULAR: no murmur in the tripple, rubbing, and galloping. Bilateral plus 2 in the radia and pedus pulses.
RESPIRATORY: L And A.P., the Chest wall is symmetrically notable. In all lung fields, there is CTA, absent SOB.
GASTROINTESTINAL: The belly is smooth and non-tender. There is no increase in the air, no lumps, and no hepatomegaly. The abdomen is a flat IN manner. Percussion is never dull. In all four quadrants, the bowel sounds sensible. There is no tenderness when it comes to protecting or rebounding.
MUSCULOSKELETAL: bears the weight. No clubs in the nails, no bluishness, or swelling. The strength of muscles is five over five in groups.
INTEGUMENTARY: partial dryness, but intactness is maintainable.No rash or lesion.Good turgor.No yellowing of skin or lightness.
ASSESSMENT:
(In a paragraph, please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came into our clinic c/o of ear pain. Pt states that the Pain started three days ago after swimming. Pt denies discharge etc.… on examination I noted this and that etc.)
The client didn’t have any complaints of Hypertension, though he was able to ascertain when it was elevated and how long thanks to continuous inspection. After some days of persistently high values, the client became suspicious and scheduled an evaluation. High blood pressure is known as the “fatal disease” since so many individuals have no indicators. Patients who have Hypertension for longer timeframes are more likely to have a heart attack and stroke. The clinician and I were frightened whenever the client mentioned that his mom died of a heart attack and his dad succumbed due to an infarct.
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
The volume of blood the heart circulates or the development of resistance to systemic arteries affects your blood pressure. Because not everybody gets hypertension complaints, few people might have migraines, difficulty breathing, or bloody noses. Basic (primary) high blood pressure and secondary high blood pressure (Heller, 2017) are the two main forms of Hypertension. Primary Hypertension is a type of high blood pressure that develops and has no known etiology. Secondary high blood pressure is caused by chronic sleep problems, renal disease, endocrine glands malignancies, thyroid dysfunction, inherited vascular anomalies, pharmaceuticals, illicit narcotics, or alcohol dependence. Aging, ethnicity, family medical history, becoming significantly overweight, sedentary lifestyle, cigarette usage, excessive salts, insufficient vitamins such as vitamin D, consuming liquor, anxiety excessively, and such chronic medical conditions are all potential causes for high blood pressure.
Differential diagnosis (minimum 3)
– Whenever ventilation is abruptly and regularly stopped throughout slumber, this is known as sleep apnea. Hypertension has already been linked to obstructive sleep apnea. Hypertension and sleep apnea are linked, and one can exacerbate the other. Obesity is common among people with sleep apnea and high blood pressure, and it has a role in both disorders. Sleep apnea is thought to effects 20–40% of hypertension cases.
– Kidney Arterial Stenosis involves abnormal constriction in one or more of the arteries that supply to the renal. Blood pressure increases when the vasculature contract, preventing appropriate circulation volumes in accessing both kidneys (American Heart Association, 2017). Hypertension is hard to treat, a slightly wider notice inside the arteries, increased protein thresholds inside the urinary, exacerbating renal function through hypertension treatment, electrolyte imbalances and inflammation in the hands and feet, and medicine heart failure are all signs and symptoms.
– When confronted with a stressful circumstance, the body releases adrenaline and cortisol into the bloodstream. The hormonal changes constrict veins and arteries and increase heart rate to prepare the body for the “physiological stress” instinct. Cardiac output is raised through tightening of veins and arteries and a rapid heartbeat. Some impacts of persistent stress on the body are currently less clear.
PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
· Complete blood count
· Urinalysis and profile of lipids
Pharmacological treatment:
–Amlodipine continuation 10milligramd Per Oral on a daily basis, up the Losartan up to 100milligrams orally daily, then start Clonidine as per need 0.1milligrams orally in Systolic >189, diastolic >98
Non-Pharmacologic treatment:
Diet Approach to Stopping Hypertension and low sodium alternatives brochures were given out. The diet plan (CardioSmart, 2015) is a moderate diet high in vegetables, greens, ordinary and non-milk, and even whole cereals. The meal is shown to lower the blood pressure possible in short as two weeks. The patient is instructed to exercise for half an hour at one vigorous speed four times each week. Activity can aid weight loss, lower your blood pressure, or reduce anxiety. “Frequent physical conditioning has already been demonstrated to reduce general tension, enhance and consolidating mood, induce sleep, and develop a positive self.
Education (provide the most relevant ones tailored to your patient)
The importance of daily checkups was emphasized, and the person’s quarterly test results were described in detail. The patient was informed about the dangers of Hypertension, and given his family tree of aneurysms and strokes, he was advised to treat his health seriously.
Follow-ups/Referrals: Transfer to a specialist if Hypertension remained high or reference to a nutritionist for cardiovascular nutrition were suggested, but most were postponed at this time. For a month, the patient must take his blood pressure twice a day and record it. Inside two fortnights, the client will return.
References
AACC. (2017, January 15). Hypertension. Retrieved from AACC: Lab Tests Online:https://labtestsonline.org/understanding/conditions/hypertension/start/3/
ADAA. (2016). Physical activity reduces stress. Retrieved from ADAA: Anxiety and Depression Association of American: https://www.adaa.org/understanding-anxiety/relatedillnesses/other-related-conditions/stress/physical-activity-reduces-st
American Heart Association. (2017, January 10). Managing stress to control high blood pressure. Retrieved from American Heart Association: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/MakeChangesThatMa tter/Managing-Stress-to-Control-High-BloodPressure_UCM_301883_Article.jsp#.WUSQiOjyuUk
CardioSmart. (2015, May 1). Sleep apnea and high blood pressure: A dangerous pair. Retrieved from CardioSmart: https://www.cardiosmart.org/news-and-events/2015/05/sleep-apneaand-high-blood-pressure-a-dangerous-pair
Heller, M. (2017, January 5). The DASH eating plan. Retrieved from The DASH Diet Eating Plan: http://dashdiet.org/default.asp Mayo Clinic. (2016, September 9). High blood pressure (Hypertension). Retrieved from Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/high-bloodpressure/basics/definition/con-20019580
Mayo Clinic. (2017, May 31). Renal artery stenosis. Retrieved from Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/renal-artery-stenosis/home/ovc-20320997
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