SOAP Note For Hypertension Discussion Paper

SOAP Note For Hypertension Discussion Paper

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SOAP Note

Patient information

Patient initials:  M.K        Age: 53           Race: Hispanic       Gender: male

S.

CC:” Can I have my blood pressure checked?”

HPI: M.K, a 53-year-old Hispanic male, stepped in to get his blood pressure checked. He added that he had checked his blood pressure two weeks before to his visit in a mall near his office, and the measurement of 144/105 mmHg really startled him. He has been having inexplicable headaches and chest discomfort for the past 8 weeks, which he rates as a 7/10, and the pain intensifies when he falls asleep. He had presumed the symptoms were typical and had not sought medical attention. He denies having history of syncope, dyspnea, or edema, but admit to having nosebleeds and fatigue in the last month. SOAP Note For Hypertension Discussion Paper

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Medication: Metformin HCL 850 P0 taken once daily.

Allergies: no known drug or food allergies

PMHX: Diabetes, well managed by Glucophage XR

Past surgical history: none reported.

Family history: Father (83-y/o): diabetes type 2. Mother (77 y/o): hypertension. Maternal grandfather (deceased): hypertension. Maternal grandmother (deceased): breast cancer. Maternal grandfather (deceased): stroke. Elder brother (59 y/o): Asthma.

Social history: M.K, a Hispanic patient, was born in the Georgian city of Macon at the age of 53. He’s a full-time instructor at a local college. He is married to a single lady who works as a nurse, and they have three college-age children. He reported smoking more frequently and drinking alcohol on weekends. He reported going to gymnastics twice a week with his wife for fitness. He is financially secure and has insurance. Reported living in a safe neighborhood, wearing a seat belt, and never using a phone or driving while under the influence of alcohol. Consumes a nutritious diet high in fruits and vegetables. SOAP Note For Hypertension Discussion Paper

ROS

General: No fevers, chills, but significant weight gain reported.

HEENT: Reported severe headache and dizziness. Denies loss of hearing, and sinusitis. Reported frequent nosebleed, denies sinusitis, and frequent sore throat.

Cardiovascular: Reported chest pain and dyspnea. Denies irregular heartbeats, heart murmur, and pain in the feet.

Respiratory: Denies SOB, and chronic cough

GI: Denies decrease in appetite, heartburn, nausea, vomiting, or diarrhea.

GU: Denies pain, or burning with urination, urinary urgency and frequency.

Msk: Denies muscle weakness, joint swelling, or any orthopedic injuries.

Neurologic: Reported unexplained headache, and dizziness, denies muscle spasm, and fainting.

Psychiatric: Denies depression or anxiety. Denies homicidal ideation.

Endocrine: Denies heat or cold intolerances, increases in thirst, and decreases in sexual desire.

Skin/lymph/heme: Denies skin redness, rash, or changes in skin color.

O.

PE

VTS: BP 154/105 left arm, sitting using regular adult cuff. Wt.: 203lb Ht.: 5’6 T.: 37.8 RR: 20 P: 80 Sp02: 98%

General: A&Ox3, appear mildly distress. Well-nourished. Appear his stated age.

HEENT; normocephalic and atraumatic. Hair is normal in texture; visual acuity 20/20, sclera non-icteric. EOMI, PERRLA, no sign of nystagmus. Snares patent bilaterally. Hearing intact with good acuity.  No buccal nodule noted. Carotid pulse 2+ bilaterally without bruit.

Cardiovascular: Heartbeat irregular, no murmur, SI and S2 heard and are of normal intensity.

Respiratory: Chest wall is symmetric and non-tender. No signs of respiratory distress noted., lungs sound is clear without rales. Resonance is normal upon percussion.

Skin: Warm and dry. Normal texture

Abdomen: Soft and symmetrical without distention. Bowel sounds are normoactive. No masses noted.

Extremities: Atraumatic with tenderness. No swelling noted. Muscle strength 5/5 bilaterally. Capillary refill >3sec.

Neuro: Cranial nerve intact. Sensation intact bilaterally.  Memory and thought process intact.

Psychiatric: He is oriented to place and time, no abnormal affect noted.

Assessment: SOAP Note For Hypertension Discussion Paper

Lab test and result

CBC: result pending

TSH test: result pending

Chest Xray: result pending

Diagnosis

Differential diagnosis

Essential Hypertension

This is the most common type of hypertension, affecting millions of people worldwide. This condition often develops gradually over time and is more common in men than in women. While its etiology is unknown, genetic and environmental factors are thought to play a role in its pathogenesis. Essential hypertension causes blood pressure to rise significantly above normal levels (Saxena et al.,2018)SOAP Note For Hypertension Discussion Paper . Common symptoms of essential hypertension include headaches, dizziness, fatigue, and difficulty breathing, all of which were present in the patient’s case. Furthermore, the patient’s ancestry and lifestyle may be factors in this diagnosis.

Congestive heart Failure

This is a complicated clinical condition in which the heart is unable to fully pump to suit the body’s metabolic demands. This condition can be caused by coronary artery disease, hypertension, vulvar heart disease, or cardiomyopathies (Porumbs et al.,2020)SOAP Note For Hypertension Discussion Paper . CHF symptoms include overall weariness, hard breathing, and chest discomfort. It was also linked to right hypochondrial discomfort, persistent cough, weight gain, loss of appetite, and edema, none of which were present in the case scenario.

Chronic Kidney Disease

Chronic kidney failure (CKF) is a long-term gradual reduction in kidney function. It can be caused by a variety of diseases, including diabetes, hypertension, and glomerulonephritis. CKF can cause a variety of major health issues, including anemia, bone disease, and cardiovascular disease. CKF normally develops over time, however it can emerge unexpectedly in persons who have never had any previous kidney issues (Gichoni et al.,2018). It is characterized by weariness, chest discomfort, elevated blood pressure, headache, and dizziness. This might be a diagnosis since the patient has high blood pressure and is diabetes. However, this condition is also accompanied with additional symptoms such as shortness of breath, weight loss, and unconsciousness, which were not present in the M.K clinical presentation.

Primary diagnoses: Essential hypertension

P.

Lab test: Patient cholesterol and creatinine levels need to be tested.

Medication: Give Prinivil 10mg PO to be taken once daily for six weeks more so before bedtime (Gujjarlamudi et al.,2018).

Patient education: The patient must be thoroughly counselled on lifestyle changes including avoiding alcohol intake, minimizing salt intake, and using DAS diet on consistent basis. He must be advised on monitoring his blood pressure on a regular. The patient must be encouraged to adhere to prescription for better result.

Follow-up: After 6 weeks of therapy, the patient must report back to the clinic for further assessment.

Referral: in case of any complication, the patient should be referred to the cardiologist, and nephrologist for further intervention SOAP Note For Hypertension Discussion Paper .

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References

Saxena, T., Ali, A. O., & Saxena, M. (2018). Pathophysiology of essential hypertension: an update. Expert review of cardiovascular therapy, 16(12), 879-887.

Porumb, M., Iadanza, E., Massaro, S., & Pecchia, L. (2020). A convolutional neural network approach to detect congestive heart failure. Biomedical Signal Processing and Control, 55, 101597.

Gichoni, P. (2018). Evaluation of Therapy Adherence Among Patients With End Stage Renal Disease at Kenyatta National Hospital (Doctoral dissertation, University of Nairobi).

Gujjarlamudi, H. B., Jose, A., & Dupaguntla, R. (2018). Cost analysis of ACE inhibitors and ARBs used in essential hypertension. Asian Journal of Pharmacy and Pharmacology, 4(3), 275-279 SOAP Note For Hypertension Discussion Paper