course material

1. case discussion(SOAP NOTE) – My Nursing Assignment
TITLE: NASAL FRACTUREEXAMPLE: SOAP NOTE Soap Note # Main Diagnosis ( Exp: H&P
Note #3 DX: Hypertension)Student NameMiami Regional UniversityDate of
Encounter:Preceptor/Clinical Site:Clinical Instructor: Dr. Rafael Camejo Soap Note # Main
Diagnosis ( Exp: Soap Note #3 DX: Hypertension)PATIENT INFORMATIONName: Mr.
DTAge: 68-year-oldGender at Birth: MaleGender Identity: MaleSource: PatientAllergies:
PCN, IodineCurrent Medications: · Atorvastatin tab 20 mg, 1-tab PO at bedtime· ASA 81mg
po daily· Multi-Vitamin Centrum SilverPMH: HypercholesterolemiaImmunizations:
Influenza last 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 report information Mother-alive, 88 years old, Diabetes
Mellitus, HTNDaughter-alive, 34 years old, healthySocial History: No smoking history or
illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired,
widow, he lives alone.Sexual Orientation: StraightNutrition History: Diets off and on, Does
not each seafood Subjective Data:Chief Complaint: “headaches” that started two weeks
agoSymptom analysis/HPI:The patient is 65 years old male who complaining of episodes of
headaches and on 3 different occasions blood pressure was measured, which was high
(159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two
weeks ago and sometimes it is accompanied by dizziness. He states that he has been under
stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness
of breath, nausea or vomiting.Review of Systems (ROS)CONSTITUTIONAL: Denies fever or
chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizziness as describe
above. Denies changes in LOC. Denies history of tremors or seizures. HEENT: HEAD: Denies
any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred
vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal
drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty
swallowing.RESPIRATORY: Patient denies shortness of breath, cough or
hemoptysis.CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal
nocturnaldyspnea.GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies
flatulence, nausea, vomiting ordiarrhea.GENITOURINARY: Denies hematuria, dysuria or
change in urinary frequency. Denies difficulty starting/stopping stream of urine or
incontinence.MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or
snapping sound.SKIN: No change of coloration such as cyanosis or jaundice, no rashes or
pruritus.Objective Data:VITAL SIGNS: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg,

2. RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 2/10.GENERAL
APPREARANCE: The patient is alert and oriented x 3. No acute distress noted.
NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation
intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.HEENT: Head:
Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes:
No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No
nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate.
Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses
no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,.
Lids non-remarkable and appropriate for race.Neck: supple without cervical
lymphadenopathy, no jugular vein distention, no thyroid swelling or
masses.CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted.
Capillary refill < 2 sec.RESPIRATORY: No dyspnea or use of accessory muscles observed. No
egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents
and clear bilaterally on auscultation.GASTROINTESTINAL: No mass or hernia observed.
Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and
aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or
organomegaly noted on palpationMUSKULOSKELETAL: No pain to palpation. Active and
passive ROM within normal limits, no stiffness.INTEGUMENTARY: intact, no lesions or
rashes, no cyanosis or jaundice.ASSESSMENT:Main DiagnosisEssential (Primary)
Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg),
classified as stage 2. Once the organic cause of hypertension has been ruled out, such as
renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is based
on the clinical evaluation through history, physical examination, and routine laboratory
tests to assess risk factors, reveal identifiable causes and detect target-organ damage,
including evidence of cardiovascular disease (Domino et al,. 2017).Differential diagnosis:Ø
Renal artery stenosis (ICD10 I70.1)Ø Chronic kidney disease (ICD10 I12.9)Ø
Hyperthyroidism (ICD10 E05.90)PLAN:Labs and Diagnostic Test to be ordered:· CMP·
Complete blood count (CBC)· Lipid profile· Thyroid-stimulating hormone (TSH)· Urinalysis
with Micro· Electrocardiogram (EKG 12 lead)Pharmacological treatment: ·
Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. · Lisinopril 10mg PO
DailyNon-Pharmacologic treatment: · Weight loss· Healthy diet (DASH dietary pattern): Diet
rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of
saturated and trans l fat· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but
at least 1,000 mg/d reduction in most adults· Enhanced intake of dietary potassium·
Regular physical activity (Aerobic): 90–150 min/wk· Tobacco cessation· Measures to
release stress and effective coping mechanisms.Education· Provide with nutrition/dietary
information.· Daily blood pressure monitoring log at home twice a day for 7 days, keep a
record, bring the record on the next visit with her PCP· Instruction about medication intake
compliance. · Education of possible complications such as stroke, heart attack, and other
problems.· Patient was educated on course of hypertension, as well as warning signs and
symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt.
questions/concerns. Pt verbalizes understanding to allFollow-ups/Referrals· Follow up

3. appointment 1 weeks for managing blood pressure and to evaluate current hypotensive
therapy.· No referrals needed at this time.ReferencesDomino, F., Baldor, R., Golding, J.,
Stephens, M. (2017). The 5-Minute Clinical Consult 2017(25th ed.). Print (The 5-Minute
Consult Series).Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive
Review (2nd ed.). ISBN 978-0-8261-3424-0NOTE: PLEASE APA FORMAT OF THE
REFERENCE, AND ORIGINAL