Assignment 1: Soap 1 Dx HTN Follow The MRU Soap Note Rubric

Assignment 1 Soap 1 Dx Htn Follow The Mru Soap Note Rubric As A Gui

Assignment 1 Soap 1 DX: HTN. Follow the MRU Soap Note Rubric as a guide. Use APA format and must include a minimum of 2 Scholarly Citations. Put through TURN-It-In (anti-Plagiarism program) must be your own work and in your own words. You can resubmit; copy-paste from websites or textbooks will not be accepted or tolerated. The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment and Plan should be of your own work and individualized to your made-up patient. Click link to open resource.

Paper For Above instruction

Introduction

Hypertension (HTN), also known as high blood pressure, is a prevalent chronic medical condition that significantly increases the risk of cardiovascular diseases such as stroke, myocardial infarction, and heart failure. Effective diagnosis and management are vital in reducing long-term health complications. This paper presents a comprehensive SOAP (Subjective, Objective, Assessment, and Plan) note for a fictional patient diagnosed with hypertension, adhering to the MRU SOAP note rubric and APA formatting standards. The narrative emphasizes individualized patient history, clinical presentation, assessment, and tailored management strategies, supported by scholarly literature.

Subjective

The patient is a 55-year-old African American male presenting for a routine health check-up. He reports a history of elevated blood pressure readings noted over the past year but has not been consistent with antihypertensive medications. He denies chest pain, shortness of breath, dizziness, or palpitations. The patient reports occasional headaches, especially in the mornings, and mild fatigue. He admits to a diet high in salt and processed foods, a sedentary lifestyle, and a weight of 230 pounds. His medical history includes borderline hypertension diagnosed two years ago. Family history reveals hypertension in both parents. The patient is a non-smoker and drinks alcohol socially. He is concerned about his health and seeks advice on managing his blood pressure effectively.

Objective

Vital signs reveal a blood pressure of 152/95 mm Hg, measured twice during the visit with a resting heart rate of 85 bpm. The patient's weight is 230 pounds with a height of 5 feet 9 inches, resulting in a BMI of 34.1 kg/m², classified as obese. Physical examination shows no abnormalities; cardiovascular assessment reveals regular rhythm without murmurs or gallops. Lung auscultation is clear, and no peripheral edema is noted. Laboratory tests including a basic metabolic panel and lipid profile are pending but are indicated for comprehensive evaluation. The patient’s blood pressure readings suggest uncontrolled hypertension requiring intervention.

Assessment

The clinical presentation and blood pressure measurements confirm a diagnosis of Stage 2 hypertension per current guidelines (American College of Cardiology, 2021). His risk factors include obesity, sedentary lifestyle, high salt intake, and family history. The absence of symptoms related to hypertensive emergencies is noted, but the persistent elevation poses risks for future cardiovascular events. The patient’s lifestyle factors significantly contribute to his hypertensive state. Given his background and clinical findings, a comprehensive management plan focusing on lifestyle modification and pharmacotherapy is indicated.

Plan

The management plan involves multiple components, starting with patient education on the significance of hypertension and lifestyle modifications. Dietary counseling emphasizes reducing salt intake, following the DASH diet, and increasing fruits, vegetables, and whole grains (Appel et al., 2011). An exercise regimen, aiming for at least 150 minutes of moderate-intensity activity weekly, is recommended. Weight management strategies are discussed to achieve a 5-10% weight loss, which can significantly reduce blood pressure (Jensen et al., 2014).

Pharmacotherapy is initiated with a thiazide diuretic, such as hydrochlorothiazide, as first-line treatment according to guidelines (Whelton et al., 2018). Blood pressure targets are set at

References

  • American College of Cardiology. (2021). 2017 AHA/ACC/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Journal of the American College of Cardiology, 71(19), e127–e248.
  • Appel, L. J., et al. (2011). Dietary approaches to prevent and treat hypertension: A scientific statement from the American Heart Association. Circulation, 123(24), 2892–2901.
  • Jensen, M. D., et al. (2014). 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults. Circulation, 129(25_suppl_2), S102–S138.
  • Whelton, P. K., et al. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure. Hypertension, 71(6), e13–e115.
  • James, P. A., et al. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults. JAMA, 311(5), 507–520.

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