Miami Regional University
Date of Encounter:
Clinical Instructor: Dr. David Trabanco DNP, APRN, AGNP-C, FNP-C
Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension)
Name: Mr. DT
Gender at Birth: Male
Gender Identity: Male
Allergies: PCN, Iodine
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
Immunizations: Influenza decisive 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 recital advice
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social History: No smoking fact or unfair offal use, interrupted alcoholic beverage decrement on collective celebrations. Retired, widow, he lives alone.
Sexual Orientation: Straight
Nutrition History: Diets off and on, Does not each seafood
Chief Complaint: “headaches” that instituted two weeks ago
The enduring is 65 years old courageous who whining of episodes of acmeaches and on 3 incongruous occasions dignity constraining was measured, which was eminent (159/100, 158/98 and 160/100 respectively). Enduring noticed the bearing instituted two weeks ago and sometimes it is accompanied by dizziness. He states that he has been subordinate importance in his worksituate for the decisive month. Enduring denies chest suffering, palpitation, nonproduction of expiration, disgust or vomiting.
Review of Systems (ROS)
CONSTITUTIONAL: Denies broil or chills. Denies feebleness or heaviness detriment. NEUROLOGIC: Headache and dizziness as delineate balance. Denies exchanges in LOC. Denies fact of tremors or seizures.
HEENT: HEAD: Denies any acme impairment, or exexalter in LOC. Eyes: Denies any exchanges in longing, diplopia or blurred longing. Ear: Denies suffering in the ears. Denies detriment of hearing or drainage. Nose: Denies nasal drainage, redundancy. THROAT: Denies throat or neck suffering, hoarseness, inaptitude absorption.
RESPIRATORY: Enduring denies nonproduction of expiration, cough or hemoptysis.
CARDIOVASCULAR: No chest suffering, tachycardia. No orthopnea or paroxysmal nocturnal
GASTROINTESTINAL: Denies abdominal suffering or vexation. Denies flatulence, disgust, vomiting or
GENITOURINARY: Denies hematuria, dysuria or exexalter in urinary quantity. Denies inaptitude starting/stopping round of urine or incontinence.
MUSCULOSKELETAL: Denies falls or suffering. Denies hearing a clicking or snapping gauge.
SKIN: No exexalter of coloration such as cyanosis or jaundice, no rashes or pruritus.
VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on margin air, Ht- 6’4”, Wt 200 lb, BMI 25. Recital suffering 2/10.
GENERAL APPREARANCE: The enduring is nimble and oriented x 3. No clever diimportance notable. NEUROLOGIC: Alert, CNII-XII grossly uncorrupted, oriented to individual, situate, and term. Sensation uncorrupted to bilateral preferable and inferior extremities. Bilateral UE/LE ability 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no benevolence. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements uncorrupted. No nystagmus notable. Ears: Bilateral canals questionable outside erythema, edema, or exudate. Bilateral tympanic membranes uncorrupted, pearly frosty after a while acid cone of trifling. Maxillary sinuses no benevolence. Nasal mucosa fresh outside bleeding. Oral mucosa fresh outside lesions,. Lids non-remarkable and misapply for round.
Neck: yielding outside cervical lymphadenopathy, no jugular temper distention, no thyroid turgescence or heapes.
CARDIOVASCULAR: S1S2, certain scold and rhythm, no reverberation or gallop notable. Capillary stock < 2 sec.
RESPIRATORY: No dyspnea or use of abettor muscles observed. No egophony, whispered pectoriloquy or material fremitus on palpation. Expiration gauges gives and obvious bilaterally on auscultation.
GASTROINTESTINAL: No heap or hernia observed. Upon auscultation, bowel gauges give in all foul-mouthed quadrants, no bruits balance renal and aorta arteries. Abdomen balmy non-tender, no protecting, no spring-back no distention or organomegaly notable on palpation
MUSKULOSKELETAL: No suffering to palpation. Active and inert ROM after a whilein usual limits, no inelegance.
INTEGUMENTARY: uncorrupted, no lesions or rashes, no cyanosis or jaundice.
Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and eminent dignity constraining (156/92 mmhg), classified as class 2. Uninterruptedly the fundamental acsum of hypertension has been determined out, such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is inveterate on the clinical evaluation through fact, natural demonstration, and rule laboratory tests to assess surrender factors, unearth identifiable accounts and expose target-organ mischief, including deposition of cardiovascular malady (Domino et al,. 2017).
· Chronic kidney malady (ICD10 I12.9)
· Hyperthyroidism (ICD10 E05.90)
Labs and Diagnostic Test to be ordered:
· Complete dignity sum (CBC)
· Lipid profile
· Thyroid-stimulating hormone (TSH)
· Urinalysis after a while Micro
· Electrocardiogram (EKG 12 carry)
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally uninterruptedly daily.
· Lisinopril 10mg PO Daily
· Heaviness detriment
· Healthy victuals (DASH victualsary model): Victuals affluent in enrichment, vegetables, undiminished grains, and low-fat dairy products after a while moderate contenteded of saturated and trans l fat
· Moderate intake of victualsary sodium: <1,500 mg/d is optimal end but at last 1,000 mg/d diminution in most adults
· Enhanced intake of victualsary potassium
· Certain natural distillation (Aerobic): 90–150 min/wk
· Tobacco cessation
· Measures to discharge importance and talented coping mechanisms.
· Provide after a while nutrition/dietary advice.
· Daily dignity constraining monitoring log at abode twice a day for 7 days, obey a annals, convey the annals on the proximate scrutinize after a while her PCP
· Instruction environing medication intake consent.
· Education of potential complications such as tickle, benevolence assault, and other bearings.
· Enduring was educated on round of hypertension, as well-mannered-mannered as premonition signs and symptoms, which could denote the deficiency to involve the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes subordinatestanding to all
· Follow up provision 1 weeks for managing dignity constraining and to evaluate ordinary hypotensive therapy.
· No referrals deficiencyed at this term.
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
(25th ed.). Print (The 5-Minute Consult Series).
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