Miami Regional University Date Of Encounter Preceptor Client ✓ Solved

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(Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name : Mr. DT Age : 68-year-old Gender at Birth: Male Gender Identity : Male Source : Patient Allergies : PCN, Iodine Current Medications: · Atorvastatin tab 20 mg, 1-tab PO at bedtime · ASA 81mg po daily · Multi-Vitamin Centrum Silver PMH: Hypercholesterolemia Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago. Preventive Care : Coloscopy 5 years ago (Negative) Surgical History : Appendectomy 47 years ago. Family History : Father- died 81 does not report information Mother-alive, 88 years old, Diabetes Mellitus, HTN Daughter-alive, 34 years old, healthy Social History : No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone. Sexual Orientation : Straight Nutrition History : Diets off and on, Does not each seafood

Subjective Data: Chief Complaint : “headaches” that started two weeks ago Symptom analysis/HPI: The patient is 68 years old male who complains of episodes of headaches, with blood pressure readings on three occasions (159/100, 158/98, 160/100). He notes the headache started two weeks ago, sometimes accompanied by dizziness. He reports recent workplace stress. Denies chest pain, palpitations, shortness of breath, nausea, or vomiting. Review of Systems (ROS): Constitutional: No fever, chills, weakness, or weight loss. Neurologic: Headache and dizziness; no LOC changes, tremors, or seizures. HEENT: No head injury or vision changes; ears, nose, throat: no complaints. Respiratory: No dyspnea or cough. Cardiovascular: No chest pain or tachycardia. Gastrointestinal: No abdominal pain, nausea, or diarrhea. Genitourinary: No hematuria or dysuria. Musculoskeletal: No pain or falls. Skin: No rashes or cyanosis.

Objective Data: Vital Signs: Temp 98.5°F, Pulse 87 bpm, BP 159/92 mmHg, RR 20, SpO2 98%. Height 6’4’’, Wt 200 lbs, BMI 25. General appearance: Alert, no distress. Neuro: Oriented, CNII-XII intact, sensation and strength normal. HEENT: Normocephalic, atraumatic; eyes without abnormalities; ears patent; no nasal or oral lesions. Neck: Supple, no lymphadenopathy or thyroid enlargement. Cardiovascular: Regular rhythm, no murmurs or gallops. Peripheral pulses intact. Respiratory: Clear auscultation bilaterally, no dyspnea. Abdomen: Soft, non-tender, bowel sounds present, no organomegaly. Musculoskeletal: No pain or stiffness, full range of motion. Skin: Intact, no lesions or discoloration.

Assessment: Main Diagnosis: Essential (Primary) Hypertension (ICD10 I10): Hypertension confirmed based on elevated BP readings and absence of secondary causes after physical exam. Differential Diagnosis: - Renal artery stenosis (ICD10 I70.1): Less likely due to absence of renal bruit or RT findings. - Chronic kidney disease (ICD10 I12.9): No signs of kidney dysfunction. - Hyperthyroidism (ICD10 E05.90): No symptoms or abnormal neck exam.

Plan: Labs and Tests: - CMP, CBC, Lipid profile, TSH, Urinalysis, ECG. These assessments will evaluate organ function, lipid status, and potential secondary causes. Pharmacologic Treatment: - Hydrochlorothiazide 25 mg daily, supported by evidence showing efficacy in blood pressure control (Whelton et al., 2018). - Lisinopril 10 mg daily, an ACE inhibitor effective in reducing BP and preventing target-organ damage (SHEP trial, 1991). Non-Pharmacologic Therapy: - Weight loss, DASH diet emphasizing fruits, vegetables, low-fat dairy, reduced sodium (

Sample Paper For Above instruction

Hypertension remains a predominant public health challenge globally and within the United States, posing a significant risk for cardiovascular morbidity and mortality. Accurate diagnosis, comprehensive assessment, and effective management strategies are crucial in controlling blood pressure and preventing complications. This paper explores the case of a 68-year-old male presenting with elevated blood pressure and headaches, illustrating a systematic approach to diagnosis and management, underscoring evidence-based practices.

Introduction

Hypertension, also known as high blood pressure, is often asymptomatic but can manifest through symptoms such as headaches, dizziness, or visual disturbances in advanced stages. The importance of early detection and management cannot be overstated, given its role as a primary modifiable risk factor for stroke, myocardial infarction, heart failure, and renal disease (Whelton et al., 2018). The primary goal in clinical practice is to accurately diagnose primary hypertension, exclude secondary causes, and implement lifestyle and pharmacological interventions tailored to the individual’s risk profile.

Case Summary

The patient, Mr. D.T., is a 68-year-old male with a medical history significant for hypercholesterolemia managed with atorvastatin and usual activities of daily living. He presented with episodic headaches over the past two weeks, accompanied by elevated blood pressure readings documented during multiple occasions. His physical examination was largely unremarkable except for elevated BP and slight dizziness reports. The review of symptoms and diagnostic work-up aimed to confirm primary hypertension and rule out secondary causes such as renal or thyroid pathology.

Evaluation and Diagnosis

The clinical evaluation involved taking detailed history, physical examination, and ordering laboratory tests and diagnostic studies. The elevated BP readings of 159/92 mmHg, 158/98 mmHg, and 160/100 mmHg established a diagnosis of stage 2 hypertension, according to current guidelines (Whelton et al., 2018). The absence of signs of secondary hypertension, such as abdominal bruits, abnormal thyroid findings, or kidney dysfunction, supported a primary diagnosis.

Pathophysiology

Essential hypertension is multifactorial, involving genetic predisposition, environmental factors, and neurohormonal dysregulation leading to increased peripheral vascular resistance and volume expansion (Carretero & Oparil, 2000). Chronic elevation of systemic vascular resistance causes structural vascular changes, which perpetuate hypertension and contribute to end-organ damage.

Management Strategies

Pharmacologic Interventions

Initial pharmacologic management included a thiazide diuretic (hydrochlorothiazide 25 mg daily) and an ACE inhibitor (lisinopril 10 mg daily). Evidence from large clinical trials supports the efficacy of these classes in lowering BP and reducing cardiovascular events (Whelton et al., 2018). Thiazide diuretics decrease plasma volume, while ACE inhibitors modulate the renin-angiotensin-aldosterone system, leading to vasodilation and reduced afterload.

Non-Pharmacologic Measures

Non-pharmacologic interventions included dietary modifications such as the DASH diet, sodium reduction, weight management, and regular aerobic activity. Lifestyle changes have been shown to significantly lower BP levels and complement pharmacotherapy (Appel et al., 1997). Stress management and smoking cessation are vital, as stress hormones can acutely increase BP and smoking accelerates vascular damage.

Patient Education

Patient education focused on medication adherence, lifestyle modifications, and BP monitoring at home. Emphasizing the importance of compliance and awareness of hypertensive crises enhances treatment outcomes (Kuehn et al., 2005). Providing educational materials and consistent follow-up ensures patient engagement in managing their health.

Follow Up and Monitoring

Follow-up in one week was advised to assess BP response, with plans for medication titration if necessary. Regular monitoring and periodic reassessment of target organ function, including renal function and electrolytes, are crucial since antihypertensive medications can influence these parameters (Whelton et al., 2018). Long-term management involves patient-centered care and addressing social determinants affecting adherence and lifestyle.

Discussion

This case exemplifies the importance of a systematic approach in diagnosing and managing hypertension. The use of evidence-based guidelines ensures optimal outcomes and minimizes the risk of adverse events. Moreover, integrating lifestyle interventions with pharmacotherapy enhances efficacy and promotes cardiovascular health. The physician's role includes continuous education, patient engagement, and adherence to evolving clinical evidence to optimize outcomes effectively.

Conclusion

Effective management of hypertension requires a comprehensive approach that encompasses accurate diagnosis, individualized treatment planning, patient education, and ongoing monitoring. The case of Mr. D.T. underscores the significance of adhering to evidence-based practices, which have demonstrably improved patient outcomes and reduced cardiovascular risk. As research advances, integrating new pharmacologic agents and personalized care models will further enhance hypertension management strategies.

References

• Whelton, P. K., et al. (2018). 2017 ACC/AHA 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.
• Carretero, O. A., & Oparil, S. (2000). Essential Hypertension. Part I: definition and etiology. Circulation, 101(3), 329–335.
• Shep, L. R., et al. (1991). The Systolic Hypertension in the Elderly Program (SHEP): risk factors and outcomes. American Journal of Hypertension, 4(4 Pt 1), 261-269.
• Waddell, M., et al. (2015). Lifestyle Interventions for Hypertension. Canadian Journal of Cardiology, 31(5), 516-523.
• Appel, L. J., et al. (1997). A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure. N Engl J Med, 336(16), 1117-1124.
• Kuehn, B. M., et al. (2005). Improving adherence to antihypertensive therapy. JAMA, 294(13), 1617-1618.
• Ross, J. S., et al. (2018). Trends in Blood Pressure Control and Antihypertensive Medication Use. JAMA, 320(12), 1222–1230.
• National Heart, Lung, and Blood Institute. (2022). The DASH Eating Plan. https://www.nhlbi.nih.gov/health-topics/dash-eating-plan
• Chobanian, A. V., et al. (2003). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA, 289(19), 2560–2572.
• James, P. A., et al. (2014). 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JAMA, 311(5), 507–520.