Loading...

Messages

Proposals

Stuck in your homework and missing deadline? Get urgent help in $10/Page with 24 hours deadline

Get Urgent Writing Help In Your Essays, Assignments, Homeworks, Dissertation, Thesis Or Coursework & Achieve A+ Grades.

Privacy Guaranteed - 100% Plagiarism Free Writing - Free Turnitin Report - Professional And Experienced Writers - 24/7 Online Support

Hypertension soap note

28/12/2020 Client: saad24vbs Deadline: 10 Days

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.






Example:


PATIENT INFORMATION


Name: Mr. W.S.


Age: 65-year-old


Sex: Male


Source: Patient


Allergies: None


Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime


PMH: Hypercholesterolemia


Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.


Surgical History: Appendectomy 47 years ago.


Family History: Father- died 81 does not report information


  Mother-alive, 88 years old, Diabetes Mellitus, HTN


 Daughter-alive, 34 years old, healthy


Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.


SUBJECTIVE:


Chief complain: “headaches” that started two weeks ago


Symptom analysis/HPI:


The 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.


ROS:


CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.


HEENT: 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.


Respiratory:Patient denies shortness of breath, cough or hemoptysis.


Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal


dyspnea.


Gastrointestinal:Denies abdominal pain or discomfort.Denies flatulence, nausea, vomiting or


diarrhea.


Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.


MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.


Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.


Objective Data


CONSTITUTIONAL: 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 pain 0/10.


General appearance: 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.


HEENT: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.


Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.


Cardiovascular:S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.


Respiratory: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.


Gastrointestinal: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 reboundno distention or organomegaly noted on palpation


Musculoskeletal:No pain to palpation. Active and passive ROM within normal limits, no stiffness.


Integumentary:intact, no lesions or rashes, no cyanosis or jaundice.


Assessment


Essential (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.


Differential diagnosis:


Ø Renal artery stenosis(ICD10 I70.1)


Ø Chronic kidney disease(ICD10 I12.9)


Ø Hyperthyroidism (ICD10 E05.90)


Plan


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.


These basic laboratory tests are:


· CMP


· Complete blood count


· Lipid profile


· Thyroid-stimulating hormone


· Urinalysis


· Electrocardiogram


Ø Pharmacological treatment:


The treatment of choice in this case would be:


Thiazide-like diuretic and/or a CCB


· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.




Ø Non-Pharmacologic treatment:


· Weight loss


· Healthy 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


· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults


· Enhanced intake of dietary potassium


· Regular physical activity (Aerobic): 90–150 min/wk


· Tobacco cessation


· Measures to release stress and effective coping mechanisms.


Education


· Provide with nutrition/dietary information.


· Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP


· Instruction about medication intake compliance.


· Education of possible complications such as stroke, heart attack, and other problems.


· Patient 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


Follow-ups/Referrals


· Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.


· No referrals needed at this time.


References


Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).


Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0

Homework is Completed By:

Writer Writer Name Amount Client Comments & Rating
Instant Homework Helper

ONLINE

Instant Homework Helper

$36

She helped me in last minute in a very reasonable price. She is a lifesaver, I got A+ grade in my homework, I will surely hire her again for my next assignments, Thumbs Up!

Order & Get This Solution Within 3 Hours in $25/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 3 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 6 Hours in $20/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 6 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 12 Hours in $15/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 12 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

6 writers have sent their proposals to do this homework:

A+GRADE HELPER
Top Essay Tutor
Helping Hand
University Coursework Help
Homework Guru
Writer Writer Name Offer Chat
A+GRADE HELPER

ONLINE

A+GRADE HELPER

Greetings! I’m very much interested to work on this project. I have read the details properly. I am a Professional Writer with over 5 years of experience, therefore, I can easily do this job. I will also provide you with TURNITIN PLAGIARISM REPORT. You can message me to discuss the detail. Why me? My goal is to offer services to you that are profitable. I don’t want you to place an order once and that’s it. For me to be successful, I need you to come back and order again. Give me the opportunity to work on your project. I wish to build a long-term relationship with you. We can have further discussion in chat. Thanks!

$105 Chat With Writer
Top Essay Tutor

ONLINE

Top Essay Tutor

I have more than 12 years of experience in managing online classes, exams, and quizzes on different websites like; Connect, McGraw-Hill, and Blackboard. I always provide a guarantee to my clients for their grades.

$115 Chat With Writer
Helping Hand

ONLINE

Helping Hand

I am an Academic writer with 10 years of experience. As an Academic writer, my aim is to generate unique content without Plagiarism as per the client’s requirements.

$110 Chat With Writer
University Coursework Help

ONLINE

University Coursework Help

Hi dear, I am ready to do your homework in a reasonable price.

$112 Chat With Writer
Homework Guru

ONLINE

Homework Guru

Hi dear, I am ready to do your homework in a reasonable price and in a timely manner.

$112 Chat With Writer

Let our expert academic writers to help you in achieving a+ grades in your homework, assignment, quiz or exam.

Similar Homework Questions

Burke and litwin model of organizational change - Magnesium and hydrochloric acid reaction - Anzac 75th anniversary $5 coin value - Peugeot 308 sw boot dimensions - The csirt is also known as the ir reaction team - The article " brother, Can you spare a cell?" - How to survive a plague putlocker - Learning about offenders’ characteristics - Every little hurricane essay - Economics of strategy 5th edition pdf - Writing binary formulas worksheet answers - What does the jabberwocky look like - Note that sometimes, particularly with Windows, Excel has a hard time performing calculations on the pivot table results. - Vlad the impaler family tree - Punchline algebra book b 12.12 answer key - Emperor of china self portrait of k ang hsi - Dia construction security plan worksheet - Ids 400 - Hyundai imax interior dimensions - Which of the following is true of emphasizing superordinate goals - Greek mythology travel itinerary - Graves and corcoran nursing informatics - The drawing shows a lower leg being exercised - The one minute entrepreneur pdf free download - Caleffi pressure reducing valve diagram - Jekyll and hyde summary - Present condition of the australian rainforest - WEEK5-Executive Practical Connection Activity-Data Science & Big Data Analy - Week 4 Discussion Forum: Cultural Inquiry and Values and Norms - A first amendment junkie pdf - Midalia steel flat bar - Reflection 7 - Myitlab excel chapter 2 grader project - Paper - Procurement Law - Shl numerical reasoning test answers pdf - Records management plan template - Quickbooks online student guide chapter - Labview xy graph real time - Native Spiritual Herbalist Traditional healer +27789489516 /Lost Love Spells Caster in Texas Dallas - Song of the jade lily discussion questions - Project: Scholar-Practitioner Project: Health Care Administration Leadership Theory - Research Methods in Accounting and Finance - Clinic plus shampoo advertisement - Virtualization - Dr gary martin hyfrecator - Thomas the daemon engine - The new colossus essay - Language devices in persuasive writing - Chapter 7 circular motion and gravitation test b answers - An advertisement claims that a particular automobile - Acme toy company prints baseball cards - 6 types of kingdoms - Analyzing asthma a statistics project - Which of the following accounts ordinarily appears in the post-closing trial balance - Hula hoop personal space activity - Corporate bar and grill bar rescue - Frm work experience example - My nissan maxima won t start - James redmond and amrit maghera - Delphi printer simulation scenario d - Nationbuilder in chief icivics answers - Paper on psychological bio psychology disorder (PTSD) - Week 7 nursing's - Dog obedience training brisbane southside - Math Roller Coaster Polynomial Assignment - How to make ionic equations - The Respiratory System - 9.1 cellular respiration an overview - What is a strong entity - British gas home appliance insurance - When should you use the strayer online library for research - N5 biology past papers - Fact families multiplication and division - I have a dream speech parallelism - First cirque du soleil show 1984 - Johns hopkins nursing evidence based practice research evidence appraisal tool - Lab 2 preparing a research report with a footnote - Queensland government information security classification framework - Difference between cbt and rebt - Assignment 1 lenscrafters case study - Moneygram roman program - Write a paragraph that evaluates the effectiveness of mortimer's style - 3.53 repeating as a fraction - How to show critical path in projectlibre - Bamboo reinforced concrete ppt - Zadie smith in conversation - Of mice and men essay questions and answers - Order 2263355: Read Instructions - Potassium bromide silver nitrate - What makes anne frank a hero - Pearson vue test centre leeds - Propose a mechanism for the following reaction - Thermoplastic composites manufacturing process - Aqa as grade boundaries 2013 - How to win capsim game - Assignment 8 - Fm mattsson mixer cartridge - William shakespeare father occupation - How to learn pig latin