Posted: May 1st, 2022

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

Should use the pattern template on your cleaning soap be aware, maintain this template for if you begin clinicals.

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Comply with the MRU Cleaning soap Be aware Rubric as a information

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Flip it in Rating should be lower than 50% or is not going to be accepted for credit score, should be your personal work and in your personal phrases. You may resubmit, Last submission can be accepted if lower than 50%. Copy paste from web sites or textbooks is not going to be accepted or tolerated. I need help writing my essay – research paper see School Handbook with regards to Educational Misconduct Assertion.

Using tempates is pleased with regards of Flip it in, however the Affected person Historical past, CC, HPI, The Evaluation and Plan ought to be of your personal work and individualized to your made up affected person.

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(Scholar Title)

Date of Encounter:
Preceptor/Scientific Website:
Scientific Teacher: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C

Cleaning soap Be aware # Principal Analysis ( Exp: Cleaning soap Be aware #three DX: Hypertension)

PATIENT INFORMATION
Title: Mr. DT
Age: 68-year-old
Gender at Beginning: Male
Gender Identification: Male
Supply: Affected person
Allergy symptoms: PCN, Iodine
Present Drugs:
• Atorvastatin tab 20 mg, 1-tab PO at bedtime
• ASA 81mg po day by day
• Multi-Vitamin Centrum Silver
PMH: Hypercholesterolemia
Immunizations: Influenza final 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online-year, tetanus, and hepatitis A and B four years in the past.
Preventive Care: Coloscopy 5 years in the past (Unfavorable)
Surgical Historical past: Appendectomy 47 years in the past.
Household Historical past: Father- died 81 doesn’t report info
Mom-alive, 88 years previous, Diabetes Mellitus, HTN
Daughter-alive, 34 years previous, 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
Diet Historical past: Diets on and off, Doesn’t every seafood
Subjective Knowledge:
Chief Criticism: “complications” that began two weeks in the past
Symptom evaluation/HPI:
The affected person is 65 years previous 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 seen the issue began two weeks in the past and typically it’s accompanied by dizziness. He states that he has been beneath stress in his office for the final month. Affected person denies chest ache, palpitation, shortness of breath, nausea or vomiting.

Evaluate of Programs (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 damage, 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, issue 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 issue 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 power 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 acceptable 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 tissue 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 gentle 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:
Principal Analysis
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 – Research Paper Writing Help Service). Analysis relies on the medical analysis by way of historical past, bodily examination, and routine laboratory checks to evaluate threat elements, 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)
 Continual kidney illness (ICD10 I12.9)
 Hyperthyroidism (ICD10 E05.90)
PLAN:

Labs and Diagnostic Take a look at to be ordered:
• CMP
• Full blood rely (CBC)
• Lipid profile
• Thyroid-stimulating hormone (TSH)
• Urinalysis with Micro
• Electrocardiogram (EKG 12 lead)

Pharmacological therapy:
• Hydrochlorothiazide tab 25 mg, Preliminary dose: 25 mg orally as soon as day by day.
• Lisinopril 10mg PO Day by day

Non-Pharmacologic therapy:
• Weight reduction
• Nutritious diet (DASH dietary sample): Weight loss plan wealthy in fruits, greens, complete grains, and low-fat dairy merchandise with diminished content material of saturated and trans l fats
• Decreased consumption of dietary sodium: <1,500 mg/d is perfect objective however not 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 info.
• Day by day blood stress monitoring log at house twice a day for 7 days, maintain a document, deliver the document on the subsequent go to along with her PCP
• Instruction about remedy consumption compliance.
• Schooling of attainable problems 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/issues. Pt verbalizes understanding to all
Comply with-ups/Referrals
• Comply with up appointment 1 weeks for managing blood stress and to guage present hypotensive remedy.
• No referrals wanted presently.

References
Codina Leik, M. T. (2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay). Household Nurse Practitioner Certification Intensive Evaluate (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).

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