Soap note
(Student Name)
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C
Soap Note # ____ Main Diagnosis ______________
PATIENT INFORMATION
Name: O.R
Age: 52
Gender at Birth: Male
Gender Identity: Male
Source:
Allergies: Penicillin
Current Medications:
·
PMH: Hypercholesterolemia,
Immunizations: Updated according to the patient age.
Preventive Care:
Surgical History: None
Family History: Father- alive, 81 years old with coronary artery bypass 5 years ago, HTN
Mother- alive, 78 years old with Diabetes Mellitus, HNT
Social History: Alcoholic beverage social celebrations, ,He is currently a truck driving
Sexual Orientation: Straight
Nutrition History:
Subjective Data:
Chief Complaint: I have severe headache early morning
Symptom analysis/HPI: The patient is a 52-year-old man who complains of symptoms of hypertension, such as severe headache early morning. This patient complained of a worsening of his symptoms one week ago.. He said he recently gained weight because he is truck driving and he is no have time for practice exercise... Blood pressure was measured and increased on 3 different occasions (155/93 mmHg, 145/92 mmHg, 140/90 mmHg, respectively). This confirms that the patient has his own clinical crisis, which in this case is hypertension.
The patient is …
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )
CONSTITUTIONAL: Denies loss of consciousness. Denies seizure, tremors. Denies change in vision /blurred vision. Pt states recently gained weight.
NEUROLOGIC: Patient states severe headache early morning. He denies seizures, tremors, loss of consciousness and change in vision /blurred vision.
HEENT: HEAD: Denies any head injury or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. No scleral icterus Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Negative for nosebleed nasal. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. Moist mucous membranes. No cervical lymphadenopathy. EARS: Patient denies pain, tinnitus, vertigo, discharge
RESPIRATORY: Patient states shortness of breath. Patient denies cough or hemoptysis. Lungs clear to auscultation bilaterally, no accessory muscle use. Patient denies cough, sputum, hemoptysis, night sweats.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea. Regular rate and rhythm. No murmur. No JVD, he denies edema, previous myocardial infarction, claudication, thromboses, thrombophlebitis
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhea. Abdomen soft, non-tender and non-distended. No palpable masses. Denies constipation, intolerance for any class of food, dysphagia, heartburn, hematemesis, denies any change in stool color or contents, hemorrhoids or history of ulcer.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. Denies flank or suprapubic pain, denies incontinence, denies STIs.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound. Denies myalgia. Patient states right knee pain. Patient denies muscle weakness. Denies joints stiffness, restriction of motion, swelling, redness, heat or bony deformity
SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Denies excessive sweating or abnormal nail or hair growth.
PSYCHIATRIC: Denies depression, difficulty concentration, nervousness. Patient denies sleep disturbance. Denies suicidal thoughts, irritability.
Objective Data:
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 96/min, BP: 145/92 mmHg, RR 32/min, PO2-98% on room air, Ht- 5’11”, Wt 205 lb, BMI: 28.6.
Report pain: headaches 4/10.
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. Deep tendon reflex response +2.
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 < 2 sec.
RESPIRATORY: Tachypnea, however, there is not contraction of accessory muscles observed or retraction of supraclavicular fossa. There is not pursed-lib breathing or a prolonged expiratory phase. There is mild retraction of intercostal muscle bilaterally. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
GASTROINTESTINAL: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation
MUSKULOSKELETAL: There is pain to palpation right knee. Active and passive ROM within normal limits, no stiffness. There is not effusion. There are not infection signs. Upper extremities within normal limits.
INTEGUMENTARY: intact, no lesions or rashes, no cyanosis or jaundice.
ASSESSMENT:
(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)
Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)
Main Diagnosis
(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.
Differential diagnosis (minimum 3)
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PLAN:
Labs and Diagnostic Test to be ordered (if applicable)
Labs and Diagnostic Test to be ordered:
· Stress test
· Complete blood count (CBC)
· Fasting Lipid profile
· Thyroid-stimulating hormone (TSH)
· Ambulatory Blood Pressure Monitor
· Electrocardiogram (EKG 12 lead)
· Echocardiogram
· Urinalysis (Albumin Excretion)
· Chest-X-Ray
ASSESSMENT:
Main Diagnosis
· ICD10-I10). Hypertension is the term used to describe high blood pressure. Hypertension is an important public health problem and one of the leading risk factors for morbidity and mortality from cardiovascular diseases and is the most common cause of primary care visits. Hypertension among the adult population is increasing, and its complications account for 9.4 million annual deaths around the word. (Saka, M., 2020)
Hypertension however, there are different factors associated to hypertension such as increasing age, male sex, being married, low educational level, unemployment, poor economic situation, sedentary lifestyle, lack of regular physical exercise, and increasing body mass index. Secondary hypertension is caused by another pathology such as kidney problem (arteries narrowing), adrenal disease (Pheochromocytoma, primary aldosteronism or Conn’s disease, Cushing syndrome), thyroid problem (hyperthyroidism), Hyperparathyroidism and sleep apnea. (James P.A., 2015
Differential diagnosis:
· Sleep Apnea (ICD10 G47.30). Sleep apnea and Hypertension are two conditions well known associated. The association was found to be more evident in young to middle-aged men (<50 years old). Apnea is defined as the absence of inspiratory airflow for at least 10 seconds. Normal sleep is important to decrease stress and protect central nervous system and cardiovascular system. Sleep-disordered breathing or sleep apnea is a disease frequently associated with arterial hypertension. Sleep apnea has consequences that include abnormal arterial blood oxygen level decreasing parasympathetic system and increased sympathetic activity, all of which are harmful for cardiovascular system. There is also a potential role of mineralocorticoid hormones (aldosterone) produced by cortex of the adrenal gland. Its function is regulation of water and electrolytes balance in the body. Hyperaldosteronism is significantly associated with sleep apnea and Hypertension. Treatment of sleep apnea with oral appliance devices and with aldosterone antagonists decrease sympathetic activity and improve blood pressure. (Zhao, E. C., 2018) (Lombardi, G., 2018)
· E05. 80 Hyperthyroidism: Hypothyroidism and hypertension have similarity symptoms to rapid heart rate, elevated blood pressure, and hand tremors. You may also sweat a lot and develop a low tolerance for heat. Hyperthyroidism can cause more frequent bowel movements, weight loss, and, in women, irregular menstrual cycles. (Lights, 2019)
· I21.9 Heart Attack Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes – or it may go away and then return. It can feel like uncomfortable pressure, squeezing, fullness or pain. Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. Shortness of breath. This can occur with or without chest discomfort. Other signs. Other possible signs include breaking out in a cold sweat, nausea or lightheadedness. (heart.org, n.d.)
Pharmacological treatment:
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg PO bid.
· Lisinopril 20mg PO qd
· Ecotrin 325mg: 1 Tab PO qd
Non-Pharmacologic treatment:
· Weight loss. BMI no more then 24.9
· Healthy diet: Implement “DASH dietary pattern”. Diet rich in fruits, vegetables, whole grains, low-fat dairy products, poultry, fish, legumes, non-tropical vegetable oils, and nuts; and limiting intake of sweets, sugar-sweetened beverages, and red meat.
· Reduced intake of dietary sodium: Limiting intake no more than 2600mg/d however <1,500 mg/d is optimal goal.
· Alcohol intake should be no more than two drinks/day for men and one drink/day for women.
· Enhanced intake of dietary potassium
· Regular moderate aerobic physical activity 3 to 4 times/week: 90–150 min/wk or 40 minutes/session.
· Measures to release stress and effective coping mechanisms.
· Patients with hypertension and obstructive sleep apnea should use continuous positive airway pressure to lower blood pressure.
Education
· Provide with nutrition/dietary information.
· Provide tobacco cessation interventions for those who use tobacco products.
· Daily self-measure blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP. The patient should performe this activity daily with or without additional support such as education, counseling, telemedicine, home visits, Web-based logging.
· Instruction about medication intake compliance.
· Education of possible complications such as stroke, heart attack, and other problems.
· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all
· Guide the patient and family on health status (diagnosis, procedures).
· Provide family interaction according to the patient's condition.
· Assist in using relaxation techniques and defense mechanisms.
· Offer emotional support for management of difficulty sleeping
· monitor your health condition.
· Establish and maintain adequate nurse-patient relationship to provide productive communication.
· Use of therapeutic communication techniques aimed at the patient expressing their worries and concerns.
· Offer medication and support therapy for the remission of symptoms and signs
Follow-ups/Referrals
· Follow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy.
· No referrals needed at this time.
References
Codina Leik, M. T. (2018). Family Nurse Practitioner Certification Intensive Review. New York: Springer Publishing Company. ISBN 978-0-8261-3424-0
James, PA., Oparil, S., Carter, BL., et al. (2015). Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) [published correction appears in JAMA.311(5):507–520.
Lombardi, C., Pengo, M. F., & Parati, G.(2018). Systemic hypertension in obstructive sleep apnea. Journal of Thoracic Disease, S4231-S4243.
Saka, M., Shabu, S., & Shabila, N. (2020). Prevalence of hypertension and associated risk factors in older adults. Eastern Mediterranean Health Journal, 26(3),268-275.
Valentina, L., Neal, S. (2019). Pathophysiology. The biologic basis for disease in adult and children. St.louis-Missouri: Elsevier.
Zhao, E. C. (2018). Association between Sleep Apnea Hypopnea Syndrome and the Risk of Atrial Fibrillation: A Meta-Analysis of Cohort Study. BioMed Research International.
heart.org. (n.d.). Warning Signs of a Heart Attack. Retrieved from heart.org: https://www.heart.org/en/health-topics/heart-attack/warning-signs-of-a-heart-attack Lights, V. (2019, March 22). Hyperthyroidism. Retrieved from healthline: https://www.healthline.com/health/hyperthyroidism Lombardi, C. (2018). Systemic hypertension in obstructive sleep apnea. Journal of Thoracic Disease, S4231-S4243.