Soapnote

Name:   PS

Pt. Encounter Number: 234

Date:  14/10/20

Age:  45

Gender:  Male 

SUBJECTIVE 

CC:

HPI:   

Mr. PS paid a visit to the clinic for a follow up of his HTN. He stated to experience a persistent chest pain with an earlier angina. Feels discomfort is his chest while stretching. In his early 20s, the patient also had CAD. He denies edema and walks daily as he says it. He also suffered from Hypercholesterolemia.

Medications:

Taking atenolol 150gm per day, ASA 325mg per day and Lisinopril 20gm daily,  

PMH 

Allergies:   NKDA

Medication Intolerances: Not any

Chronic Illnesses/Major traumas: High blood pressure 

Hospitalizations/Surgeries: None   

Family History 

Both of his folks who are as yet alive experience the ill effects of hypertension, hyperlipidemia. The mother likewise has hypothyroidism. The dad also has joint pain and cardiac stent. The younger sister who is also alive has no known medicinal history.   

Social History 

The patient reports his wellbeing to be "really great". He never smoked and confessed to drinking 1 six-pack of alcohol each month. In a monogamous marriage but has no children. When working outside, he is physically active.

ROS 

General  

He is a 45-year-old American man well-groomed and presentable  

Cardiovascular 

chest pain, no edema  

Skin 

Had no rashes or lesions

Respiratory 

Shortness of breath, wheezing and difficulty in breathing 

Eyes 

Visual changes of any kind, corrective lenses and blurring.

Gastrointestinal  

Denied abdominal pain, denied nausea and diarrhea  

Ears 

Discharge, ringing in ears, loss of hearing and ear pain 

Genitourinary/Gynecological 

Burning during urination

Nose/Mouth/Throat 

Nose: No discharge, no obstruction, septum not deviated.

Mouth: Complete set of upper and lower dentures.

Throat: Pharynx not injected any exudates.   

Musculoskeletal 

No muscle, back pain, denies stiff joint

Breast 

N/A 

Neurological 

Denies history of stroke, seizures or continuous/weakening cerebral pain; Denies tremors.

Heme/Lymph/Endo 

denies lymphadenopathy

Psychiatric 

Denies inconvenience concentrating, apprehension, tension, or panic attack. Denies trouble falling or staying unconscious. Want to hurt oneself and others, frequent misery, hearing voices and denies mood changes. Inordinate life stress, memory misfortune, denies bad dreams.

In the family, there will be no deaths for family or a close companion.

OBJECTIVE 

Weight 65kg       BMI  28.7

Temp 98.2

BP  152/92

Height 5’10’,

Pulse 17

Resp 72

General Appearance 

Alert, anxious, appears younger than age.

Skin 

The skin is intact, clean, dry, warm and brown. No lesions or rashes that is well-known.

HEENT 

Head: Atraumatic, symmetric and normocephalic. There is no presence of hernia around the neck and the trachea. 

Eye: non-inflamed eyes. The covering of the eye is bilaterally aligned with the eyelids. 

Ears: the absence of exudation. The ear is bilaterally aligned with side appearance. Both the skin and the ear look healthy. 

Nose: no presence of lesions. The mucous membrane is moist and pink. 

Throat: front sinus and maxillary are tender to palpation. The gap response is sensitive. Both tongue and uvula lie in the middle line—no exudating tonsils. Mucus is scant and thick.

Cardiovascular 

he dismisses the presence of any chest pain, dismisses asthma, palpitations, no edema, claudication, or regularly observing a cardiologist. The patients report that his family has a history of cardiac stents, hyperlipidemia and blood pleasure.

Respiratory 

Symmetrical chest wall expansion. Normal respiratory effort. Clear to auscultation BL.

Gastrointestinal 

No hepatosplenomegaly. Abdomen soft, nontender. Abdomen obese; BS active in all the four quadrants.   

Breast 

N/A 

Genitourinary 

No CVA tenderness noted; bladder is palpable and non-distended.

Musculoskeletal 

Right lower leg crack (football, non-dislodged) 1991.Occasional agony the two knees, which he ascribes to long periods of playing sports and not to a horrendous accident. Denies other orthopedic damage or arthralgia

Neurological  

Gait appears symmetrical, proper cranial nerves, had balance

Psychiatric 

He provides correct and desired answers to the questions. Very pleasant with any conversation, denies anxiety.

Lab Tests 

Serum Glucose-123

Urinalysis- pending review

CBC and differential- pending review

CMP-pending review  

Special Tests 

Diagnosis 

Differential diagnosis  

· After conducting a thorough diagnostic test with the patient, she noticed that she had inadequate information on proper nutrition. The priority diagnosis was likewise noted to stage 1 hypertension. Another differential diagnosis observed during the follow-up session was uneasiness, Diabetes, Heart murmur, and Hyperlipidemia (Mayo Clinic, 2018).

 Final diagnosis 

· Essential Hypertension (American Heart Association, 2017)

PLAN in Plan:   

· Further testing - The patient was first referred to cardiology to screen the sinus bradycardia

· Medication - He was prescribed to use Angiotensin-converting enzyme (ACE) inhibitors such as Zestril, captopril. Beta-blockers were also recommended to reduce the workload of the heart

· Education - The client should be educated on the importance of eating a balanced diet and increasing her physical activity. She should minimize taking fatty, salty, and fried foods. She should be visiting the clinic regularly to check her blood pressure and other underlying conditions. In the following month, she should be recording her daily blood pressure on a journal and continue taking current medications.

· Nonmedication treatments - Since the hypertension was in its first stage, the patient was encouraged to continue taking OTC fish oil and MVI (American Heart Association, 2017). He was additionally encouraged to adjust the way of life that is gone for lessening glucose. Different methodologies were suggested to incorporate a decrease in sodium consumption, increased routine physical exercise, and moderating liquor intake, carefully following the Dietary (MacGill, 2018) Approaches to Stop Hypertension. (DASH) eating plan and following weight reduction techniques. 

· Follow-up - In the next four weeks, the patient will follow up with a nurse to continually check her diet programs, blood pressure, exercise activities, and recheck of renal function labs.

Evaluation of patient encounter 

It was an exciting and satisfactory experience with my patient. I dint experience challenges while examining my patient because she understood all my questions, and as far as she could possibly understand, she answered them clearly.