Soap Note Hypertension

Hypertension

Instructions

Must use the sample template for your soap note, keep this template for when you start clinicals.

Late Assignment Policy

Assignments turned in late will have 1 point taken off for everyday assignment is late, after 7 days assignment will get grade of 0 (zero). No exceptions

Follow the MRU Soap Note Rubric as a guide

Use APA format and must include minimum of 2 Scholarly Citations.
Please see College Handbook with reference to Academic Misconduct Statement.

The use of tempates is ok with regards to Turn it in, but the Patient History, CC, HPI, The Assessment (including subjective and objective information) and Plan should be of your own work and individualized to your made up patient.

Solution

 

(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

 

Soap Note # ____   Main Diagnosis: Hypertension

 

PATIENT INFORMATION

Name: A.F.

Age: 58 years.

Gender at Birth: Male.

Gender Identity: Male gender.

Source: White.

Allergies: No food allergies. Develops skin rushes when he consumes penicillin.

Current Medications:

• Tylenol to manage early morning headache and chest pain.

PMH: A.F. was diagnosed with pneumonia 6 years ago. He was hospitalized due to the condition but recovered after treatment. He denies a history of other medical conditions.

Immunizations: He received all immunizations as scheduled. He recently received COVID-19 Pfizer vaccine.

Preventive Care: A.F. undergoes a medical check-up annually. During such visits, he ensure that he obtains screening for chronic illnesses such as hypertension, diabetes, and cancer. His last visit to a physician for check-up was 11 months ago.

Surgical History: Has not undergone a surgical operation before.

Family History: Mother is alive while father is dead. His father died at the age of 75 years due to complications of hypertension. The mother was diagnosed with type 2 diabetes and hypertension 2 years ago and 5 years ago respectively. His wife and children are normal.

Social History: Happily married with four children. Two of his children are working while the other two are still in college. A.F. is a trained accountant and is currently employed in a nearby cement factory. He smokes 5 sticks of cigarettes per day and drinks alcohol, mostly over the weekend. He does not engage in physical exercise. The only time he is able to walk long distance is when he is going to work.

Sexual Orientation: Male gender.

Nutrition History:  His typical diet comprises of red meat eaten four days a week. He normally consumes grilled chicken and fried potato chips for lunch while at work. He enjoys eating cheese over the weekend while at home. He occasionally consumes fruits and vegetables.

 

Subjective Data:

Chief Complaint: “I have a crushing chest pain, early morning headache, and fatigue.”

Symptom analysis/HPI:

The patient is a 58-year-old white male who has reported to the clinic complaining of a crushing chest pain, early morning headache, and fatigue. These symptoms started a month ago and have worsened in the recent weeks. The chest pain worsens during exercise and when the patient is performing heavy tasks. Rest relieves the chest pain. The chest pain does not radiate to other tissues but it is just concentrated around the chest. The patient reports other symptoms which occur occasionally including vision changes, nausea, vomiting, and buzzing in both ears. He is currently using Tylenol to manage early morning headache.

Review of Systems (ROS)

CONSTITUTIONAL: Patient denies a recent change in body weight. Reports nausea and vomiting.

NEUROLOGIC: Reports early morning headache. Denies body weakness.

HEENT: Reports early morning headache. Reports occasional vision changes. Reports buzzing in both ears. No nasal problems reported. Denies mouth ulcers. Denies difficulty swallowing.

RESPIRATORY: Reports shortness of breath, especially when chest pain occurs.

CARDIOVASCULAR: Reports crushing chest pain. Reports tightness of the chest.

GASTROINTESTINAL: Denies stomachache. Denies constipation. Reports vomiting.

GENITOURINARY: Denies issues with the genitals. Denies pain in the pelvic region. Denies a burning sensation during urination.

MUSCULOSKELETAL: Denies pain in the joints. Denies general body weakness.

SKIN: Denies skin redness, skin itchiness, or rashes.

Objective Data:

VITAL SIGNS: BP: 140/95 (sitting), RR: 19, Temperature: 37.3, Height: 5 feet 02 inches, Wt: 86 kg (overweight).

 

GENERAL APPREARANCE: A.F. is neatly dressed and looks healthy. He appears disturbed by the chest pain and is bending forward in an attempt to relieve the pain.

NEUROLOGIC: Sensation is intact bilaterally. His motor function not defective. Speech is clear and coherent.

HEENT:

• Head: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.
• Eyes: Conjunctivae are clear without exudates or hemorrhage. Sclera is non-icteric. EOM are intact, PERRLA. Eyelids are normal in appearance without swelling or lesions.
• Ears: The external ear and ear canal are non-tender and without edema. The canal is clear without discharge. The tympanic membrane is normal in appearance.
• Nose: Nasal mucosa is pink and moist. The nasal septum is midline. Nares are patent bilaterally.
• Throat: Oral mucosa is pink and moist with good dentition. Tongue is without lesions and with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is normal in appearance without tonsillar edema or exudates.

CARDIOVASCULAR: Irregular heart rhythm. Gallop and murmur present.

RESPIRATORY: No wheezing. The chest wall is without deformity. Chest wall is non-tender. No signs of trauma. Evidence of shortness of breath observed.

GASTROINTESTINAL: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars.

MUSKULOSKELETAL: Sensation to the upper and lower extremities is normal bilaterally. No discomfort is noted with flexion, extension, and side-to-side rotation of the cervical spine, full range of motion is noted. Capillary refill is less than 3 seconds in all extremities.

INTEGUMENTARY: Skin is warm, dry and intact without rashes or lesions. Nail Beds pink with no cyanosis or clubbing.

 

ASSESSMENT:

Patient A.F. came to the clinic c/o of a crushing chest pain, early morning headache, and fatigue. A.F. states that these symptoms started a month ago and have worsened in the recent weeks. The patient denies radiation of the chest pain to other body organs. Subjective findings that have been used to make a diagnosis include; a crushing chest pain, early morning headache, fatigue, a chest pain that worsens during exercise and when the patient is performing heavy tasks but relieves with rest. Other symptoms that support diagnosis include vision changes, nausea, vomiting, and buzzing in both ears. The patient is overweight, has a family history of hypertension, consumes alcohol and cigarettes, does not engage in physical exercise, his typical diet comprises mainly of red meat, grilled chicken, fried potato chips, cheese, and he rarely eats fruits and vegetables. On objective examination, I noted a blood pressure of 140/95 (sitting), weight of 86 kg (overweight), irregular heart rhythm, gallop, and heart murmur. These findings indicate the presence of a heart-related chest pain.

Main Diagnosis

• Essential (primary) hypertension
• ICD-10 code:  I10

 

The ICD-10 code for Essential (primary) Hypertension is I10. This code is applied to individuals who meet the criteria for hypertension alone without evidence of any other comorbid conditions such as kidney disease and heart disease (American Academy of Family Physicians, 2020).

Differential diagnoses

– Aortic valve stenosis

– Coronary artery disease

– Chest wall pain

PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

• – Ambulatory monitoring of blood pressure over a 24-hour period.
• – Electrocardiogram
• – Chest x-ray
• – Echocardiogram
• – Stress Test
• – Lab tests: Urinalysis, complete blood count (CBC), and lipid profile

Pharmacological treatment:

–Initiate BP-lowering therapy with two first-line agents of different classes. First line agents (different classes) for hypertension include; thiazide diuretics (e.g. chlorthalidone), calcium channel blockers (e.g. amlodipine), and angiotensin-converting enzyme inhibitors (e.g. lisinopril), or angiotensin receptor blockers (e.g. losartan) (Mayo Clinic, 2021).

Non-Pharmacologic treatment:

-Enroll the patient in a weight loss program.

-Stick to a heart-healthy diet.

-Develop a structured exercise program for the patient to help increase physical activity.

-Recommend potassium supplements.

-Reduce sodium intake.

-Limit alcohol and cigarette consumption (American Academy of Family Physicians, 2018).

Education

Educate the patient to;

• Eat a heart-healthy diet with less salt, reduced red meat, reduced grilled chicken, reduced fried potatoes, reduced cheese, and increased fruits and vegetables.
• Get regular physical activity
• Maintain a healthy weight or lose weight
• Limit the amount of alcohol and cigarettes consumed
• Avoid stress
• Adhere to medications (American Academy of Family Physicians, 2018; Mayo Clinic, 2021).

Follow-ups

–The patient should report to the clinic after one month for evaluation and monitoring.

Referrals; Refer the patient to;

-Cardiologist, Nutritionist, Physiotherapist, Psychologist, Physiotherapist, and Endocrinologist.

 References

American Academy of Family Physicians. (2018). High blood pressure: ACC/AHA releases updated guideline. https://www.aafp.org/afp/2018/0315/p413.html

American Academy of Family Physicians. (2020). How to document and code for hypertensive diseases in ICD-10. https://www.aafp.org/fpm/2014/0300/p5.html

Mayo Clinic. (2021). High blood pressure (hypertension). https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/diagnosis-treatment/drc-20373417