Advanced Primary Care of Family Practicum I
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SOAPNOTE02042021.docx
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Patient Initials: KL |
Pt. Encounter Number:1 |
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Date:02/04/2021 |
Age: 61 |
Sex: Female |
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Allergies: KNA Advanced Directives: NONE
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SUBJECTIVE |
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CC: My blood pressure has been high lately. |
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61 y/o Hispanic female, who came to the consult complaining of high blood pressure readings at home during the past week. Patient states that usually the diastolic keeps higher than 140 mm/Hg, patient brought the list of the measures during the last week. Patient has four checking between 140-155mm/Hg, the systolic has been between 80 to 88 mm/Hg. Patient has previous medical history of HTN controlled with Lisinopril 5 mg PO daily. Client does not practice exercise or follows a healthy diet. She is AAO x 3, takes her own decisions, denies pain or any discomfort, denies visual or hearing issues, she is reporting good appetite and healthy sleeping, refers regular bowel movements and denies urinary discomfort.
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Current Medications:
Losartan 50 mg PO daily for HTN
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Essential Primary Hypertension Mammogram: - 2018 negative Nutrition history: - Low sodium diet Developmental history: - Unremarkable. Pap Smear: - 2019 negative Blood transfusions: - Denies Hospitalizations: - Denies Childhood Illnesses: - Chicken pox
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Family History: mother: Deceased at 83, Heart Attack, Hypertension, Stroke father: Alive, Hypertension sister (first): Alive, CHF brother (first): Alive, HTN, CVA
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Social History: Tobacco: Never smoker Alcohol: Do not drink alcoholic beverages Drug Abuse: Denies use of illicit drugs Safety: Household Smoke detector / Keep Firearms in home / Wear seatbelts Sexual Activity: Not sexually active Birth Gender: Female Others: Place of birth - Cuba
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ROS |
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General Denies fever, chills, fatigue or weight loss. Patient has good appetite and admits sleeping well.
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Cardiovascular Denies chest pain, syncope, lightheadedness, palpitations, lower extremities edema or claudication while walking.
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Skin Denies rash, redness, ecchymosis, skin breakdown, edema, ulcer or any other skin lesion.
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Respiratory Denies SOB, fever, cough, hemoptysis, wheezing or cyanosis.
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Eyes Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain.
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Gastrointestinal Denies abdominal pain, nausea, vomiting, diarrhea, constipation or blood in stools.
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Ears Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain.
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Genitourinary/Gynecological Denies dysuria, nocturia, frequency, incontinence, hematuria, burning or kidney stones. Denies breast discomfort or abnormal discharge from the nipples.
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SOAP NOTE
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Nose/Mouth/Throat Patient Denies headache, hearing loss, odontalgia, difficulty swallowing, blurred vision or facial pain.
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Musculoskeletal Patient denies joint pain, weakness, muscle pain or stiffness.
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Breast Denies any symptoms |
Neurological Denies headache, weakness, seizure, dizziness, tremors, falls, numbness, paralysis or speech difficulty.
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Heme/Lymph/Endo Denies any symtoms |
Psychiatric Denies any symptoms of depression, anxiety, agitation, memory loss, forgetful, insomnia or hallucinations. Denies suicidal thoughts.
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OBJECTIVE |
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Weight 64.5 BMI |
Temp96.7 |
BP135/84 |
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Height5’5 |
Pulse76 |
Resp19 |
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PHYSICAL EXAMINATION |
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General Appearance Patient is alert, awake, oriented x 3. Well developed, well nourished. No acute distress noted. No fevers. No weakness. Pleasant and cooperative during the examination. Head: Normocephalic, atraumatic.
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Skin Pink, intact, warm to touch, no rash, normal turgor and no abrasions.
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HEENT Head: Normocephalic, atraumatic. Eyes: PERRL. Extraocular muscle movements intact. Sclera non-icteric. Conjunctiva clear. Nose: No external lesions, mucosae non-inflamed, septum is midline. Ears: Non-bulging and pearl bilateral TM’s. Canals free of cerumen. Throat: Mucosa non-inflamed, no tonsillar hypertrophy or exudate. NECK: No lymphadenopathy, No masses, midline trachea. No carotids bruit. No jugular venous distention. Proper ROM.
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Cardiovascular Regular rate and rhythm. S1 and S2 present. No murmur rubs or gallops. No S3. PMI non-displaced. No lower extremity edema. Peripheral pulses present and strong. EKG shows sinus rhythm. EKG shows sinus rhythm.
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Respiratory No respiratory distress, unlabored respiratory effort, no wheezing or rhonchi, no use of accessory muscles to breathe. Vesicular murmur present bilaterally. No cyanosis.
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Gastrointestinal Abdomen soft, non-tender, non-distended. No mases. Bowel sounds present in all 4 quadrants.
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Breast Soft, symmetric, no discoloration or abnormalities noted |
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Genitourinary Gynecological exam deferred today by patient. No nodules felt on breasts. No skin changes or abnormal discharge from the nipples.
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Musculoskeletal No clubbing, no joint swelling. No diminished ROM. Conserved
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Neurological AAO x 3. No cranial nerves deficits. No tremors, no gait imbalance, rigidity or myoclonus. No seizure activity. Strength 5 + on BUE/BLE. Tendon reflexes are intact bilaterally.
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Psychiatric PSYCH: The patient is cooperative, no anxiety, no suicidal ideation, calmed. Affect appropriate. Good mood. No agitation or depression noted.
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Lab Tests |
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CMP, CBC, Lipid profile, Urinalysis.
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Special Tests |
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Diagnosis |
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· Primary Diagnosis- Differential diagnosis: Acute pyelonephritis: Patient doesn’t complaint of back pain, urgency, fever, malodorous urine, hematuria, chills, no PMHx of kidney stones or recent respiratory infections, which makes pyelonephritis a less likely diagnosis. Hypothyroidism: There isn’t generalized weakness, recent weight gain, cold intolerance, syncope, faintness, dry skin, anterior neck mass or pretibial edema, BMI is less than 25; which point far from Hypothyroidism diagnosis. Hyperthyroidism: No tachycardia, no nervousness, no heat intolerance, no diarrhea, no insomnia, no, weight loss, no neck mass, no recent infections. All previously mentioned makes Hypothyroidism a less likely diagnosis. Primary diagnosis:
1) Essential (primary) hypertension (I10): High blood pressure (BP), or hypertension, is defined by two levels by 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines: (1) elevated BP, with a systolic pressure (SBP) between 120 and 129 mm Hg and diastolic pressure (DBP) less than 80 mm Hg, and (2) stage 1 hypertension, with an SBP of 130 to 139 mm Hg or a DBP of 80 to 89 mm Hg. Hypertension is the most common primary diagnosis in the United States. It affects approximately 86 million adults (≥20 years) in the United States and is a major risk factor for stroke, myocardial infarction, vascular disease, and chronic kidney disease. PLAN Essential (primary) hypertension Pharmacological: Increase dose: Lisinopril 10 mg PO daily. Non-pharmacological: Low sodium diet. Exercise 15 minutes at least 6 times a week. Stress management or avoid stress. Continue monitoring blood pressure at home, document and bring log to the consult. Patient instructed to call/visit office if blood pressure higher then 140/90mm/Hg. Avoid high-sodium foods Avoid eating: Smoked, cured, salted, and canned meat, fish, and poultry, ham, bacon, hot dogs, and luncheon meats, regular, hard, and processed cheese and regular peanut butter. Crackers with salted tops, and other salted snack foods such as pretzels, chips, and salted popcorn. Frozen prepared meals, unless labeled low sodium. Canned and dried soups, broths, and bouillon, unless
labeled sodium-free or low-sodium. Canned vegetables, unless labeled sodium-free or low- sodium. French fries, pizza, tacos, and other fast foods. Pickles, olives, ketchup, and other condiments, especially soy sauce, unless labeled sodium-free or low-sodium. FOLLOW UP: Follow up next week to review treatment effectiveness and laboratory results.
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References Biondi, B., & Cooper, D. S. (2018). Subclinical hyperthyroidism. New England Journal of Medicine, 378(25), 2411-2419. Drake, M. T. (2018, September). Hypothyroidism in Clinical Practice. In Mayo Clinic Proceedings (Vol. 93, No. 9, pp. 1169-1172). Elsevier. Kolman, K. B. (2019). Cystitis and Pyelonephritis: Diagnosis, Treatment, and Prevention. Primary Care: Clinics in Office Practice, 46(2), 191-202. Mancia, G. (2014). Hypertension: strengths and limitations of the JNC 8 hypertension guidelines. Nature Reviews Cardiology, 11(4), 189.
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