Assignment 2 Soap 2 Dx HTN Follow The MRU SOAP Note Rubric

Assignment 2 Soap 2 Dx Htn Follow The Mru Soap Note Rubric As A Gui

Assignment 2 Soap 2 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

Title: Comprehensive SOAP Note for Hypertension Management Following MRU Guidelines

The purpose of this paper is to demonstrate the ability to create a comprehensive SOAP note for a patient diagnosed with hypertension (HTN), following the MRU SOAP note rubric as a structured guide. The SOAP note is essential in clinical documentation, reflecting a systematic approach to patient assessment, diagnosis, and management. This narrative will encompass a detailed patient history, chief complaint (CC), history of present illness (HPI), assessment, and plan, all individualized to a hypothetical patient with hypertension.

The patient, Mr. John Doe, is a 55-year-old male presenting for a routine check-up. His history reveals a background of elevated blood pressure readings over the past few months, with occasional headaches and dizziness. He reports a sedentary lifestyle, high sodium diet, and a family history of hypertension. No previous diagnosis of hypertension has been documented, and he denies chest pain, palpitations, or shortness of breath at present. His current medications are over-the-counter NSAIDs for occasional joint pain. The patient’s lifestyle factors, including smoking status and alcohol intake, are also assessed and documented, emphasizing the importance of modifiable risk factors in hypertension management.

The Chief Complaint (CC) is: "I want to get my blood pressure checked because I’ve been feeling some headaches."

The History of Present Illness (HPI) details the onset, duration, and characteristics of symptoms, noting that the patient reports intermittent headaches, often dull and located around the temples, occurring mainly in the afternoons. He reports occasional dizziness during standing and a feeling of heaviness in the chest but denies chest pain, palpitations, or vision changes. The symptom pattern is consistent with hypertensive fluctuations without evidence of hypertensive crisis.

The assessment involves reviewing vital signs, including blood pressure readings of 150/95 mm Hg, as well as other physical examination findings such as BMI, cardiovascular examination, and neurological assessment. Laboratory tests, including serum electrolytes, lipid profile, and renal function tests, are ordered to evaluate end-organ involvement and comorbid conditions. Risk stratification based on the patient's age, family history, and lifestyle factors guides the management plan.

The plan emphasizes lifestyle modifications, including dietary sodium restriction, weight management, exercise, smoking cessation, and moderation of alcohol intake. Pharmacologic therapy may be initiated if blood pressure remains above target levels after lifestyle interventions, incorporating antihypertensive agents such as ACE inhibitors or thiazide diuretics, aligned with current guidelines. Patient education about medication adherence, monitoring blood pressure at home, and follow-up appointments is also highlighted. The documentation adheres strictly to the MRU SOAP note rubric, ensuring clarity, individualization, and clinical relevance.

In conclusion, creating a detailed, individualized SOAP note following the MRU guidelines enhances clinical reasoning, promotes consistent documentation, and improves patient care for those with hypertension. The integration of evidence-based practices and careful assessment ensures optimal management tailored to the patient's specific needs.

References

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• Whelton, P. K., Carey, R. M., Aronow, W. S., et al. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASP/CNS guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology, 71(19), e127-e248.
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• Vasan, R. S., Beiser, A. S., Seshadri, S., et al. (2001). Residual lifetime risk for developing hypertension in young adults at fixed levels of systolic blood pressure: the Framingham Heart Study. JAMA, 285(11), 1440–1447.
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• Viera, A. J., & Whelton, P. K. (2015). Blood pressure measurement techniques: strategies for accuracy. The Journal of Family Practice, 64(11), 653-660.