NGR6201L Focused SOAP Note Hypertension PDF

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Focused SOAP Template

Student Name: Michele Niedermeyer Course: NGR6201L Care of the Adult I Practicum Assignment: SOAP Note: Hypertension Date: October 2, 2020

SUBJECTIVE:

C/C: “I’ve had a couple high blood pressure readings at home and bloody nose x 3 days” HPI: 35 y/o male presents to clinic stating his home blood pressure readings have been running high. Systolic number on 2 instances have been over 200 and 235 this month. Patient, also, stated he has had 3 nose bleeds this past week at random times in the day at work lasting a few minutes. He applied pressure and leaned forward for the nose bleed to stop. He does landscaping for a living so he is exposed to the environment and heat. No complaints of congestion, or blowing nose hard, but has had itchy eyes, but will wash face to take dirt/grass/pollen several times day and is relieved of these irritants to eyes. He states he does blow his nose but does not feel he blows too hard. Denies fever, chills, or night sweats. He has no other health complaints, is active with the landscaping job and has an 8-month old baby and his weight has been the same. He stated he has decreased drinking alcohol to 1-2 drinks a month and has incorporated healthier meals such as grilled chicken and salads. Review of Systems: Constitutional: denies fever, chills, night sweats, weight loss, change in appetite, fatigue, no change in strength or exercise tolerance. Skin: no color changes, no rashes, no suspicious lesions.

Head: denies, headaches, visual changes, redness, or drainage, no vertigo, no injury. Eyes: itchy eyes due to landscaping, normal vision, no diplopia, no tearing, no scotomata, no pain. Ears: denies tinnitus, hearing loss, drainage, no bleeding, no vertigo Nose: epistaxis three times in one week, denies nasal drainage, redness, tenderness, no coryza, no obstruction. Mouth and Throat: denies sore throat, edema, difficulty swallowing, hoarseness, no dental difficulties, no gingival bleeding, no use of dentures. Neck: denies neck pain, no stiffness, no tenderness or edema, no noted masses. Chest/Cardiovascular: denies chest pain, palpitations, dizziness, peripheral edema. Respiratory: denies coughing, wheezing, dyspnea Breasts: denies pain, masses, discharge Gastrointestinal: denies abdominal pain, nausea, vomiting, diarrhea, constipation Endocrine: denies loss of appetite, excessive thirst, urination, heat or cold intolerance Hematological: denies bruising, blood clots, or history of blood transfusions Lymphatics: denies enlarged or tender lymph nodes Genitourinary: denies dysuria, urinary frequency or urgency, hematuria Musculoskeletal: denies redness, tenderness, edema to joints or muscles

Peripheral: denies pain or edema to bilateral upper or lower extremities Integumentary: denies rash, hives, dry skin, lesions Neurological: denies numbness, tingling, or confusion Psychiatric: denies depression, mood swings, irritability, anxiety, or sleep disturbance PMH/PSH: (+) Chlamydia 1/4/2019 Fam Hx: Pt not raised by biological parents; pt does not know familial PMH. Social Hx: Works full time as landscaper. Married with an 8month-old son. Drinks 1-2 alcoholic beverages a month. Former smoker 5/8/2018 and denies drug use. Meds: New start 9/10/20-Edarbi 40mg PO Take ½ tablet once a day. Allergies: NKA Immunizations: Influenza vaccination received today Preventative Care: PHQ-9 done today. Eye exam 2017, EKG 5/8/2018: sinus Bradycardia-Horizontal axis for age. OBJECTIVE Physical Examination: Vital Signs: T: 98.0F; P: 54; RR: 16; 1st BP: 150/84; 2nd BP 131/86 Ht: 61in; Wt: 199.3lbs BMI: 37.62 Labs/procedures: 1/2019: A1c: 5.5, LDL: 99, HDL: 49, Triglycerides: 180, Cholesterol: 189, GFR: 113, TSH: 3.65 Labs drawn today 9/10/2020 CBC, CMP, lipid panel, TSH, HbA1c, microalbumin

General Appearance: Well appearing, groomed, and dressed appropriately in work attire, in no acute distress and is cooperative with my exam. Skin: Normal, no rashes, no lesions noted. HEENT: Normocephalic and atraumatic. Bilateral tympanic membranes are pearly gray with good cone of light, without erythema, bulging, or retraction noted, boney landmarks are visible. Bilateral ear canals are free from drainage. Pupils are equal, round, and reactive to light accommodation, extra ocular movement intact, free from drainage and redness. Conjunctiva clear. Oral mucosa is moist, no pharyngeal edema or erythema, uvula is midline, tonsils are 1+ bilaterally, no drainage noted. Nose is symmetrical, vessels dilated in bilateral nares with clear drainage noted with patent nares. Neck: Supple. No lymphadenopathy noted. No thyromegaly or jugular vein distention. No goiter noted. Respiratory: Respirations are non-labored, symmetrical chest wall expansion, and without chest wall tenderness. Lung sounds are clear to auscultation, no rhonchi, wheezes, or rales noted. Cardiovascular: Apical pulse is palpable. Heart is of regular rate and rhythm, no murmurs, gallops, or rubs noted. S1 and S2 are normal. No thrills or bruits are present. No edema of upper or lower extremities. Musculoskeletal: No joint deformities noted. No erythema, warmth, tenderness, or effusion noted. Active range of motion of joints, gait is steady. Gastrointestinal: Abdomen is normal shape, soft, no pain upon palpation. No splenomegaly or hepatomegaly noted. Bowel sounds are normoactive in all 4 quadrants. Genitourinary: Not examined.

Integumentary: Skin is of color to ethnicity, warm, and dry. No rash, hives or lesions noted. Neurologic: A&O x3, normal speech, no tremors or ataxia, no cerebellar signs or symptoms, no motor or sensory deficit, normal gait. Psychiatric: Content, affect congruent to mood and appropriate. ASSESSMENT:

Problem List (Dx#1): Epistaxis (R04.0) (CPT: 99213) Differential Dx: Acute sinusitis, Vasomotor rhinitis, Nasal Foreign Bodies Rationale: Dilation of the vessels in the nose, especially in the Kiesselbach’s plexus, produces swelling and can cause congestion, but this patient stated he was not congested and that is why he felt it could be his blood pressure being elevated. Pt displayed localized dilation in the nares suggesting localized epistaxis instead of a systemic issue. Forced nose blowing or excessive use of nasocorticosteroids can be a trigger. The patient is not presenting symptoms of the other differential diagnoses at this time. Dx#2: Essential Hypertension (I10) (CPT:99213) Differential Dx: Secondary Hypertension, Chronic kidney disease, Hypothyroidism Rationale: Patient had 2 separate instances of elevated systolic blood pressure at home, at rest, with 3 nose bleeds, which warrants treatment for essential hypertension. The patient is not presenting symptoms of the other differential diagnoses at this time. PLAN:

Dx #1: Epistaxis (R04.0) (CPT: 99213)

Treatment: Saline nasal irrigation given to patient to help reduce drainage and rinses away irritants and allergies. Diagnostics: None today. Education: In order to prevent repeated nose bleeds, patient educated to take precautions on not forcefully blow his nose, wear mask to keep environmental debris from going up nose as patient is a landscaper. Educated patient on use of saline nasal irrigation (gave patient lavage), the importance of not using tap water or if patient would rather use daily, OTC Ocean nasal spray is recommended. Referrals: None at this time. Follow-up: Follow-up in 4 weeks or PRN if symptoms worsen.

DX#2: Essential Hypertension (I10) (CPT:99213) Treatment: One-month supply of Edarbi 40mg PO Take ½ tablet once a day. Continue monitoring home blood pressure checks and gave pt blood pressure logs to take home, Diagnostics: Blood pressure re-check at end of visit of 131/86. Education: Pt was educated on optimal BP control and risks of uncontrolled HTN. Recommended reduction of salt intake/DASH diet, medication adherence, exercise and weight loss, and stress reduction. Educated on side effects of blood pressure medication of low blood pressure and dizziness. Printed education in Spanish was given to patient to reinforce verbal education. Referrals: None at this time. Follow-up: Follow-up in 4 weeks and bring BP logs from home for review or PRN if symptoms worsen.

Clinical Decision Making:

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Labs drawn today 9/10/2020 CBC, CMP, lipid panel, TSH, HbA1c, microalbumin. Labs drawn to check for possible chronic kidney disease, anemia or hypothyroid which can all elevate blood pressure. Blood pressure re-check at end of visit of 131/86. Everyone experiences various symptoms when dealing with high blood pressure. This patient felt his nose bleeds could be a sign of elevated blood pressure. Regular monitoring via a BP log at home can actually show his baseline and can provide valuable information regarding effective BP medication titration. Challenges experienced would be some communication of technical terms as patient’s main language is Spanish. Used a Spanish nurse to assist with technical terms. I did print out instructions for nasal lavage and medication for hypertension in Spanish for patient to take home as well. One key takeaway from this patient case is I was able to use an otoscope for the first time and see dilated vessels in person rather than from the internet, so I found this to be a great learning experience. I do not feel I would anything differently. Interviewing this patient was easy despite having a language barrier. Patient understood everything I said other than some medical terminology when answering the PHQ-9 questionnaire. To also make sure the patient understood education, I went and printed patient education leaflets in his primary language to assist him when at home. In this case, one insightful way to better my practice in the future is to take a medical Spanish course for NPs, Physicians and Pas. I went and looked up one course to help me. https://www.medicalspanish.com/courses/npsand-physicians.html...