Hypertension Soap Note

Hypertension Soap Note, is a note with data about the patient, which is composed or introduced in a particular request, which incorporates certain segments for patients. Hypertension Soap Note Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work, and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy-paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Get assignment help from our qualified homework doers. We deliver quality and plagiarism-free papers within your set deadline. Use our professional writing service and receive: ✓High-Quality Papers ✓Plagiarism Free papers ✓Punctual Delivery ✓24/7 Support  

[av_buttonrow alignment=’center’ button_spacing=’5′ button_spacing_unit=’px’ av_uid=’av-hucrf’ admin_preview_bg=”]
[av_buttonrow_item label=’ Order a Quality and Plagiarism-Free Paper from Us’ link=’manually, https://assignmentessaytyper.com/order/’ link_target=” size=’small’ label_display=” icon_select=’yes’ icon=’ue82d’ font=’entypo-fontello’ color=’theme-color’ custom_bg=’#444444′ custom_font=’#ffffff’ av_uid=’av-awjpf’][/av_buttonrow_item]

 

Hypertension soap note practice scenarios

Example:

PATIENT INFORMATION

  • Name Mr. W.S.
  • Age: 65-year-old
  • Sex: Male
  • Source: Patient
  • Allergies: None
  • Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
  • PMH: Hypercholesterolemia
  • Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
  • Surgical History: Appendectomy 47 years ago.
  • Family History: Father- died 81 does not report information
  • Mother-alive, 88 years old, Diabetes Mellitus, HTN
  • Daughter-alive, 34 years old, healthy
  • Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

SUBJECTIVE:

  • Chief complain: “headaches” that started two weeks ago
  • Symptom 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). The 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. soap note example
  • The patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

ROS:

  • CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as described above. Denies changes in LOC. Denies a 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: The patient denies shortness of breath, cough or hemoptysis.
  • Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
  • dyspnea.
  • Gastrointestinal: Denies abdominal pain or discomfort.Denies flatulence, nausea, vomiting or
  • diarrhea.
  • 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

  • CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.
  • General appearance: 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 a 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 present 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 distention or organomegaly noted on palpation. soap note for myocardial infarction
  • COPD soap note: hypertension Soap Note Musculoskeletal:No pain to palpation. Active and passive ROM within normal limits, no stiffness.

Integumentary:intact, no lesions or rashes, no cyanosis or jaundice.

Assessment

Essential (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.

Differential diagnosis:

  • Ø Renal artery stenosis(ICD10 I70.1)
  • Ø Chronic kidney disease(ICD10 I12.9)
  • Ø Hyperthyroidism (ICD10 E05.90)

Plan

cardiac soap note example;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.

These basic laboratory tests are:

  • CMP
  • Complete blood count
  • Lipid profile
  • Thyroid-stimulating hormone
  • Urinalysis
  • Electrocardiogram

Ø Pharmacological treatment:

The treatment of choice, in this case, would be:

Thiazide-like diuretic and/or a CCB

  • Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

Ø Non-Pharmacologic treatment:

  • Weight loss
  • A 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 nutrition/dietary information.
  • Daily blood pressure monitoring 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.
  • The patient was educated on the 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 all hypertension hpi template

Follow-ups/Referrals

  • Evaluation with PCP in 1 week for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.
  • No referrals needed at this time.

What is a SOAP Note? Hypertension Soap Note

  • A SOAP note is data about the patient, which is composed or introduced in a particular request, which incorporates certain segments. Cleanser notes are utilized for confirmation notes, clinical chronicles and different reports in a patient’s graph. Numerous emergency clinics utilize electronic clinical records, which regularly have layouts that plug data into a SOAP note position. Most human services clinicians including medical caretakers, physical and word related specialists and specialists use SOAP notes. As a medications understudy, you likewise need to utilize a SOAP note group.
  • The reason for a SOAP note is to have a standard organization for sorting out patient data. On the off chance that everybody utilized an alternate organization, it can get confounding while investigating a patient’s diagram. A SOAP note comprises of four areas including abstract, goal, appraisal and plan.

What Each Section of a SOAP Note Means (Hypertension Soap Note)

  • Each area of a SOAP note requires certain data, including the accompanying:
  • Abstract: SOAP takes note of all beginning with the emotional area. This alludes to abstract perceptions that are verbally communicated by the patient, for example, data about manifestations.
  • It is viewed as abstract in light of the fact that there isn’t an approach to quantify the data. For instance, two patients may encounter a similar kind of torment. One patient may report it as the most noticeably terrible torment of their life while another may state it was just moderate agony.
  • While thinking about what to remember for the abstract segment of your SOAP notes recall the memory helper OLDCHARTS. Each letter represents an inquiry to consider while archiving manifestations. Think about the accompanying:
  1. – Onset: Determine from the patient when the manifestations previously began.
  2. – Location: If torment is available, area alludes where of the body harms.
  3. – Duration: How long has the torment or side effect been experienced for?
  4. – Character: Character alludes to the kind of agony, for example, cutting, dull or hurting.
  5. – Alleviating factors: Determine in the event that anything diminishes or dispenses with manifestations and on the off chance that anything aggravates them.
  6. – Radiation: notwithstanding the primary wellspring of torment, does it transmit anyplace else?
  7. – Temporal examples: Temporal example alludes to whether indications have a set example, for example, happening each night.
  8. – Symptoms related: notwithstanding the main objection, decide whether there are different indications.
  • Objective: The second segment of a SOAP note includes target perceptions, which means factors you can gauge, see, hear, feel or smell. This is where you ought to incorporate crucial signs, for example, heartbeat, breath and temperature. Data from a physical test including shading and any disfigurements felt ought to likewise be incorporated. Consequences of indicative tests, for example, lab work and x-beams can likewise be accounted for in the target area of the SOAP notes.
  • Appraisal: The following segment of a SOAP note is evaluation. An appraisal is the determination or conditions the patient has. In certain cases, there might be one clear finding. In different cases, a patient may have a few things wrong. There may likewise be different occasions where a conclusive analysis isn’t yet made, and more than one potential finding is remembered for the evaluation.
  • Plan: The last area of a SOAP note is the arrangement, which alludes to how you are going to address the patient’s concern. It might include requesting extra tests to preclude or affirm an analysis. It might likewise incorporate treatment that is recommended, for example, prescription or medical procedure. The arrangement may likewise incorporate data for self-care and statements including bed rest and days off work.
  • Instructing on best practice utilization of the SOAP group is remembered for huge numbers of the Global Pre-Meds specialist shadowing programs for pre-drug and pre-wellbeing understudies (see subtleties).

Tips for Using SOAP (Hypertension Soap) Note Format during Rounds

  • The SOAP note organization may appear to be very included, and it tends to be. However, utilizing the configuration doesn’t need to be overpowering. Truth be told, utilizing a set configuration is intended to make things simpler and better composed. Remember, you might be composing SOAP notes for diagramming purposes, yet you will likewise utilize it as a guide when you are doing an oral introduction on a patient.
  • There are a few things you can never really SOAP notes successfully and present your cases during clinical rounds in a skilled way.
  • Compose intensive notes you can allude to during adjusts. You can’t hope to recall explicit things about every patient, for example, lab esteems and fundamental signs. It is worthy to allude to your notes.
  • Before you compose your notes, sort out your musings. For instance, you don’t have to compose everything in a similar request the patient announced it. Take a couple of moments and consider what you have to incorporate and in what request you need to compose.
  • Preclude contributory data. You will have enough data to report and including data, which isn’t applicable to the circumstance doesn’t help. For instance, on the off chance that you tolerant reports they don’t have torment, you don’t have to cite their accurate proclamation.
  • Recall you are composing and introducing your case for other medicinal services experts not the overall population. It might be worthy to utilize clinical phrasing as a rule. On the off chance that your notes will be a piece of the patient’s lasting record, ensure you realize what shortened forms are satisfactory. In the event that you are simply writing to have something to reference when you present a case, you whatever shortened forms you pick.
  • While introducing your case, focus on around five minutes. On the off chance that you are succinct and efficient, you ought to have the option to introduce a case in around five minutes. Get ready to respond to questions, and in the event that you don’t have the foggiest idea about the appropriate response, don’t make it up.
  • Take a full breath. Introducing cases during rounds can be somewhat upsetting, particularly from the start. Be that as it may, utilizing the SOAP configuration can help. Take a full breath, and before you realize it introducing cases will turn out to be natural.

Get assignment help from our qualified homework doers. We deliver quality and plagiarism-free papers within your set deadline. Use our professional writing service and receive: ✓High-Quality Papers ✓Plagiarism Free papers ✓Punctual Delivery ✓24/7 Support  

[av_buttonrow alignment=’center’ button_spacing=’5′ button_spacing_unit=’px’ av_uid=’av-hucrf’ admin_preview_bg=”]
[av_buttonrow_item label=’ Order a Quality and Plagiarism-Free Paper from Us’ link=’manually, https://assignmentessaytyper.com/order/’ link_target=” size=’small’ label_display=” icon_select=’yes’ icon=’ue82d’ font=’entypo-fontello’ color=’theme-color’ custom_bg=’#444444′ custom_font=’#ffffff’ av_uid=’av-awjpf’][/av_buttonrow_item]