Discussion post answer
critique the Soap note of the two people who posted before you. You must use clinical practice guidelines in your post. Your critique should identify at least one positive and one area for future growth.
150 words for each with one reference.
Student 1 CP
by Caroline Pena – Saturday, August 14, 2021, 4:31 PM
Number of replies: 0
Subjective:
The patient presents to the clinic for a wellness check. The Patient reports she has been taking natural supplements to control blood pressure. The Patient says her blood pressure was higher when she worked for this other company, but now her blood pressure is better.
Consult:
The Patient’s medical history: HTN
The Patient’s surgical history: no past surgery
The Patient’s social history: The Patient reports she does not smoke, has no alcohol or drugs.
Current medications: Lisinopril 40 mg take one tablet by mouth daily, over-the-counter beetroot, and celery seed.
Information obtained from other sources: no other sources
ROS:
Constitutional: no weakness, fatigue, fever, or night sweats.
Eyes: denies eye pain, vision disturbances, and eye pressure.
Ear: no pain, no hearing disturbances, tinnitus, or discharge.
Nose: no congestion or discharge, no bleeding, no pain.
Mouth and throat: denies cough. Denies painful or soar throat.
Neck: no swollen neck glands.
Respiratory: no cough, denies SOB and wheezing, no painful breathing.
Cardiac: No CP, denies SOB, denies palpitations and denies dizziness.
GI: no n/v/d, denies abd pain, cramping, and discomfort. No changes in bowel patterns, no blood in the stool.
GU: no urgency, frequency, burning with urination.
Musculoskeletal: No joint pain, stiffness, or muscle pain.
Hematologic: no bruising or bleeding.
Skin: no rash, irritations, or redness.
Neurology: no complaints of HA, numbness, tingling, dizziness, or lightheadedness. Denies tremors or involuntary movements.
Mental Health: denies depression and anxiety.
OBJECTIVE:
Patient’s vital signs B/P: 180/107, HR: 100, RR: 17, O2 SAT: 95, WT: 210LB, HT: 5’7″.
Patient’s blood pressure elevated, Patient asymptomatic. The Patient’s BMI is 32.89.
Physical Exam:
General: Well Nourished, Well Developed, Normal Orientation, Normal Alertness, No Distress
HEENT: Normal Cephalic, No Trauma, No Tenderness, Conjunctiva pink, Sclera anicteric, ears normal, neck supple, no JVD bruit or thyromegaly, throat normal
Heart: No bradycardia, No tachycardia, No thrills, No heave, Normal rhythm, No gallop, Normal heart.
Lungs: Normal Breathing pattern, Normal chest expansion, No wheeze, No rhonchi, No rales, Normal breathing sounds, Normal percussion note.
Abdomen: Normal symmetry, No mass, No palpable organs, No tenderness, Normal bowel sounds, No hernia, No ascites.
Neurological: Normal cognition, Normal judgment, No hallucination, Normal sensation, Normal reflexes, Normal reflexes, Normal gait.
Musculoskeletal: Normal gait, Normal joints, No joint pain, No backache, No fracture.
Psychiatric/mood: No anxiety, No depression, Cooperative behavior, Logical thoughts.
ASSESSMENT:
The patient presents to the clinic for a physical examination. The patient’s blood pressure is elevated. The patient has not been taking blood pressure medication Lisinopril as prescribed. The patient reports Lisinopril did not work before, but she is willing to give it another try.
Diagnoses: HTN due to elevated blood pressure 180/107 and a history of high blood pressure.
Prescribed Lisinopril 40 mg take one tablet by mouth daily, Carvedilol 6.25 mg take one tablet by mouth twice daily.
Plan:
Patient to take Lisinopril and Carvedilol.
Encourage the patient to engage in physical activity.
Patient to maintain 2000 mg sodium daily.
Encourage healthy foods and low sodium foods daily
Hypertension (High Blood Pressure) is the second leading cause of death in the United States. Individuals with high blood pressure may not exhibit any symptoms. During my clinical, I have noticed a trend in prehypertensive patients, and the patient’s diagnosed with hypertensive, their blood pressure is not well controlled. Health care providers can make a difference in providing patient support and education on the disease process of hypertension and how to manage and maintain it better. Health care providers can also follow evidence-based protocols created by the American Medical Association (“Hypertension medication treatment protocol,” 2020). Health care providers can utilize these protocols to prescribe recommended blood pressure medication. The American Heart Association website provides healthy eating and living recipes that can be shared with patients and their families (“American Heart Association,” 2021).
Reference
Student 2-
According to CDC, one of the top reasons for office visits include medication reasons that is includes unspecified as well as progress visit (CDC, 2017). Today I have a patient that is here for a follow up on his Amlodipine that was prescribed to him two weeks ago as well as his blood work and chest CT results.
Subjective:
Chief Complaints: Patient is here for two-week F/U on his blood pressure medication.
HPI: Patient comes in today. He has brought a log of his blood pressures and frequently he has blood pressure that is higher than 120 systolic. We discussed the recent study where risk reduction of a stroke by reducing the systolic blood pressure by 10 mmHg and thus the patient should strive for a blood pressure of 120/80 or below. He is currently on amlodipine 5 mg daily. He denies any ankle swelling. He was advised that the best time to take the amlodipine is at bedtime. The dose should be increased to 10 mg daily. In a couple of weeks, he should come back to the office to get his blood pressure rechecked. He also is known to have aortic calcification according to the low-dose CT done at Summit imaging. He is currently on atorvastatin. His LDL was 146. We will recheck in 3 to 4 months. He should follow-up thereafter. In case his blood pressure remains elevated in spite of increasing the dose of amlodipine, he should return to see a provider. All other blood work was normal.
ROS: Denies
Medical History: Kidney disease. Family History: Father: brain tumor
Social History: never. Alcohol history: denies
Medications: Taking Vitamin D3 125 MCG (5000 UT) daily, Atorvastatin 10 mg daily, Taking Amlodipine Besylate 10 MG nightly, Taking Fish Oil 1000 MG Capsule daily.
Objective: Vitals: BP 162/98 mm Hg, HR 66 /min, Ht 67 in, Wt 201 lbs, BMI 31.48 and Pain scale 0 1-10.
General Appearance: Well developed, well nourished, in no acute distress. HEAD: normocephalic, atraumatic. EYES: pupils equal, round, reactive to light and accommodation. EARS: normal. ORAL CAVITY: mucosa moist. THROAT: clear. NECK/THYROID: neck supple, full range of motion, no cervical lymphadenopathy. Skin: warm and dry, no suspicious lesions. HEART: regular rate and rhythm, S1, S2 normal, no murmurs. LUNGS: clear to auscultation bilaterally. ABDOMEN: soft, nontender, nondistended, bowel sounds present, normal. EXTREMITIES: no clubbing, cyanosis, or edema. NEUROLOGIC: motor strength normal upper and lower extremities, sensory exam intact.
Assessment: 1. Essential hypertension 2. Aortic calcification – CT done 6/2021 Summit imaging
Plan: 1. Essential hypertension- He is currently on amlodipine 5 mg daily. He does not have any ankle swelling. He was advised that the best time to take the amlodipine is at bedtime. The dose should be increased to 10 mg daily. In a couple of weeks, he should come back to the office to get his blood pressure rechecked. In case his blood pressure remains elevated in spite of increasing the dose of amlodipine, he should see a provider as well in addition to just having a nurse visit. 2. Aortic calcification- He is currently on atorvastatin. His LDL was 146. Recheck in 3 to 4 months should be ideal. He should follow-up thereafter.
“Contemporary data from over 100 countries suggest that on average, less than 50% of adults with hypertension receive BP-lowering medication, with few countries performing better than this and many worse. This is despite the fact that a difference in BP of 20/10 mm Hg is associated with a 50% difference in cardiovascular risk” (Unger et al., 2020).
CDC (2017). Ambulatory care use. Retrieved from: https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf
Thomas Unger, Claudio Borghi, Fadi Charchar, Nadia A. Khan, et al. (6 May, 2020). 2020 International society of hypertension practice guidelines. Retrieved from: https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.120.15026
The post Discussion post answer critique the Soap note of the two people who appeared first on PapersSpot.
