SOAP Notes - SOAP Note NUR 6041 Advanced Nurse Practicum 1 William Paterson University MSN-FNP PDF

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SOAP Note NUR 6041 Advanced Nurse Practicum 1 William Paterson University MSN-FNP...

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SOAP Notes #1

Christine Villamayor William Paterson University of New Jersey NUR 6041 Dr. Joanne Affinito September 20, 2021

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SUBJECTIVE Chief Complaint: High blood pressure History of Present Illness: Patient is a 32 y/o African American male who came in for a follow up visit for HTN management and treatment. He is tolerating thiazide diuretic and CCB’s. Patient reports his home BP readings are averaging in the 120’s/70’s, before treatment it was 130’s/80’s. Overall he feels better, no more occipital headache. Denies chest pain, shortness of breath. No leg edema. Admits to high stress working environment. Medications: 1. Hydrochlorothiazide 12.5mg 1 tablet PO OD #30 2 refills 2. Amlodipine 5mg 1 tablet PO OD #30 2 refills Allergies No allergy to medications No allergy to food No environmental allergies Primary Medical History: Primary hypertension diagnosed at age 32 – August 2021 Surgical History No significant surgical history Family History: Mother 56 Alive- Hypertension, T2DM, Hyperlipidemia Father 57 Alive- Hypertension, T2DM, Hyperlipidemia, CAD, COPD Brother 39 Alive- Hypertension, Obesity Sister 28 Alive- Obesity, Asthma Social History: Smoking- Non-smoker Alcohol 2-4 cans of beer weekly Drug- Marijuana stopped 20 years ago Occupation- Store Manager Review of Systems: Constitutional: Denies fatigue or weight gain HEENT Denies vision changes or nosebleeds Cardiovascular: Denies chest pain or palpitations.

3 Respiratory: Denies coughing or shortness of breath Gastrointestinal: Denies nausea, vomiting, diarrhea or constipation Musculoskeletal: Denies leg swelling or leg cramping OBJECTIVE Vital Signs: BP 128/79 PR 87 RR 18 O2sat 98%RA Temp 97.2 F Height 5Ft 7 inches Weight 180 Physical Examination: HEENT: Head NCAT. PERRLA. No AV nicking, hemorrhages, or papilledema Neck: Supple, No JVD, no carotid bruit Cardiovascular: Regular rate and rhythm, no S3 S4 Respiratory: Clear to auscultation bilaterally. No wheezes, rales, or ronchi. No snoring Gastrointestinal: No hepatomegaly, no splenomegaly, No renal bruit Musculoskeletal: No edema on bilateral lower extremities ASSESSMENT 1. Primary Hypertension (I10.0) 2. Overweight BMI 28.2 (Z68.42) Differential Diagnoses: 1. Renal Artery Stenosis (I70) 2. Obstructive Sleep Apnea (G47.33) 3. Hypothyroidism (E03.9) PLAN 1. CMP, Fasting glucose, lipid profile, TSH, HgbA1C, Urinalysis 2. Echocardiography 3. Lifestyle modification a. Diet- Dash and Mediterranean diet b. Exercise- Aerobic, dynamic resistance, and isometric resistance. c. Limit alcohol intake d. Stress management e. Weight loss goal BMI below 24.9 4. Return to office in 3 months.

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SLIDE 5 Renal Artery Stenosis

OSA — The sleep apnea syndrome is most commonly identified in obese men who snore loudly while asleep -Patients with obstructive sleep apnea often retain sodium and fail to respond optimally to antihypertensive drug therapy. Correction of the sleep apnea may improve blood pressure control and improve the response to antihypertensive drug therapy

AHA/ACC – American Heart Association/American College of Cardiology -released a scientific statement in 2021 which offers a new guidance in managing stage 1 HTN among patients with low ascvd risk

USPSTF- US Preventive Services Task Force Recommend to screen adults 18 above for hypertension

5 References Basile, J., MD, & Bloch, M. J., MD. (2021). Overview of hypertension in adults. UpToDate. Retrieved October 11, 2021, from https://www.uptodate.com/contents/overview-ofhypertension-in-adults?search=hypertension %20guidelines&source=search_result&selectedTitle=1~150&usage_type=default&displa y_rank=1 Goetsch, M. R., MD, Tumarkin, E., MD, Blumenthal, R. S., MD, & Whelton, S. P., MD. (2021, June 21). New guidance on blood pressure management in low-risk adults with stage 1 hypertension. American college of cardiology. https://www.acc.org/latest-incardiology/articles/2021/06/21/13/05/new-guidance-on-bp-management-in-low-riskadults-with-stage-1-htn Maganti, K., MD, FACC. (2019, April 29). Kep points from the 2019 ACC/AHA guidelines on the primary prevention of cardiovascular disease. American college of cardiology. https://www.acc.org/latest-in-cardiology/articles/2019/04/29/07/42/key-points-from-the2019-acc-aha-guidelines-on-the-primary-prevention-of-cvd Textor, S., MD. (2021). Evaluation of secondary hypertension. UpToDate. Retrieved October 11, 2021, from https://www.uptodate.com/contents/evaluation-of-secondary-hypertension? search=hypertension&source=search_result&selectedTitle=12~150&usage_type=default &display_rank=10...