Student Name Miami Regional University Date Of Encoun 880943 ✓ Solved

Student Namemiami Regional Universitydate Of Encounterpreceptorcli

(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 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

Review of Systems (ROS) CONSTITUTIONAL : Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC : Headache and dizziness as describe above. Denies changes in LOC. Denies history of tremors or seizures. HEENT : HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. RESPIRATORY : Patient denies shortness of breath, cough or hemoptysis. CARDIOVASCULAR : No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea. GASTROINTESTINAL : Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. GENITOURINARY : Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. MUSCULOSKELETAL : Denies falls or pain. Denies hearing a clicking or snapping sound. SKIN : No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data: VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10. GENERAL APPREARANCE : The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5. HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions. Lids non-remarkable and appropriate for race. Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses. CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill

Sample Paper For Above instruction

Hypertension is a prevalent chronic condition characterized by elevated blood pressure levels that increase the risk of cardiovascular morbidity and mortality. Proper assessment, diagnosis, and management are crucial in preventing severe complications such as stroke, myocardial infarction, and renal failure. This paper discusses the comprehensive approach to evaluating a 68-year-old male patient presenting with new-onset headaches and elevated blood pressure readings, emphasizing evidence-based strategies for diagnosis and treatment.

The initial step in managing this patient involves a thorough collection of subjective data, including detailed history and review of systems (ROS). The chief complaint of headaches, described as episodic over two weeks, accompanied by dizziness and elevated blood pressure readings (from 158/98 mmHg to 160/100 mmHg), forms the basis for suspicion of hypertension. Importantly, the patient reports stress at work, which can transiently elevate blood pressure levels (American Heart Association [AHA], 2018). Objective findings, including vital signs—BP of 159/92 mmHg, HR of 87 bpm, and BMI of 25—support the necessity for further evaluation.

Comprehensive physical examination, including neurological, cardiovascular, respiratory, abdominal, and extremity assessments, reveals no immediate signs of hypertensive end-organ damage. The patient’s neurological assessment demonstrates grossly intact cranial nerves and sensation, with motor strength of 5/5 bilaterally, indicating no focal deficits. Cardiovascular and respiratory examinations are unremarkable, with clear breath sounds and regular heart rhythm, which are essential in ruling out secondary causes of hypertension. The absence of retinopathy or other physical signs does not exclude hypertension but underscores the need for laboratory diagnostics.

The diagnosis of essential hypertension is supported by clinical findings and the exclusion of secondary causes such as renal artery stenosis, chronic kidney disease, and hyperthyroidism. Laboratory tests, including comprehensive metabolic panel (CMP), complete blood count (CBC), lipid profile, thyroid-stimulating hormone (TSH), and urinalysis, are ordered based on evidence-based guidelines (Whelton et al., 2018). An electrocardiogram (EKG) assesses for cardiac hypertrophy or ischemic changes, which can guide management decisions (James et al., 2014).

Management of hypertension encompasses both pharmacologic and non-pharmacologic strategies, aligning with guidelines from the American College of Cardiology/American Heart Association (2017). Pharmacologic therapy initiated with hydrochlorothiazide 25 mg daily and lisinopril 10 mg daily targets blood pressure reduction via mechanisms such as diuresis and inhibition of the renin-angiotensin-aldosterone system. Evidence indicates that thiazide diuretics and ACE inhibitors effectively lower blood pressure and reduce cardiovascular risks (Chobanian et al., 2017).

Non-pharmacological interventions include lifestyle modifications, vital in managing hypertension. Dietary recommendations follow the DASH (Dietary Approaches to Stop Hypertension) pattern, emphasizing increased intake of fruits, vegetables, and low-fat dairy while reducing sodium intake below 1,500 mg/day (Sacks et al., 2001). Weight loss, physical activity of at least 90 minutes weekly, smoking cessation, and stress management are critical components supported by robust evidence (Appel et al., 2011). Patient education emphasizes the importance of blood pressure monitoring at home, medication adherence, and awareness of hypertensive emergencies, aligning with patient-centered care principles.

Follow-up is scheduled within one week to evaluate the efficacy of initiated therapies and adherence, aligning with the evidence that early follow-up improves blood pressure control (Whelton et al., 2018). No immediate referrals are necessary as the patient shows no signs of end-organ damage or secondary hypertension during the initial assessment.

In conclusion, a systematic approach integrating careful history, physical examination, targeted laboratory testing, and a comprehensive management plan is essential in effectively controlling hypertension. Such strategies have been demonstrated to reduce long-term cardiovascular risks and improve patient outcomes, emphasizing the importance of evidence-based practice in primary care settings.

References

  • American Heart Association. (2018). Understanding blood pressure readings. https://www.heart.org
  • Chobanian, A. V., Bakris, G. L., Black, H. R., et al. (2017). Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). JAMA, 289(19), 2560–2572.
  • Craig Whelton, P., Carey, R. M., Aronow, W. S., 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 in adults. Journal of the American College of Cardiology, 71(19), e127–e248.
  • James, P. A., Oparil, S., Carter, B. L., et al. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults. Hypertension, 63(4), 878–885.
  • Sacks, F. M., Svetkey, L. P., Vollmer, W. M., et al. (2001). Effects on blood pressure of reduced dietary sodium and the DASH diet. New England Journal of Medicine, 344(1), 3–10.
  • American College of Cardiology/American Heart Association. (2017). Hypertension guidelines. https://www.acc.org
  • Domino, F., Baldor, R., Golding, J., & Stephens, M. (2017). The 5-Minute Clinical Consult (21st ed.).
  • Codina Leik, M. T. (2015). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
  • Leik, M. C. (2014). Family Nurse Practitioner Certification Intensive Review. F.A. Davis Company.
  • Additional peer-reviewed articles and guidelines from reputable sources to support evidence-based recommendations.

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