For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:
S =Subjective data: Patient’s Chief Complaint (CC).O =Objective data: Including client behavior, physical assessment, vital signs, and meds.A =Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.P =Plan: Treatment, diagnostic testing, and follow up
with epigastric pain x 6 days
complaint of knee pain x 3 days after a basketball
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EDUCATIONAL POWER POINT
TOPIC IS HYPERTENSION
https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health
Susan is a 30-year-old registered nurse who works in transitional care. She presents to employee health stating, “My back is killing me. I was helping to transfer a patient and he moved. I thought he was going to fall, so I twisted around to grab onto him and wrenched my back. The pain is terrible, and I can barely walk.” Susan is a healthy young adult, married with a 5-year old. daughter. She has no significant family history. Susan has a past medical history of fractured coccyx as a teenager when she fell during cheerleading practice; no sequelae. She has smoked one-half pack of cigarettes a day since age 15 but is trying to quit. Current medicines include medroxyprogesterone acetate (Depo Provera) injection for birth control every 13 weeks. She is supposed to take calcium, but states that she “always forgets, and it constipates me anyway.” Susan denies any change in bowel/bladder habits.
Mary is a 70-year-old widow with a history of osteoarthritis. She has been self-medicating with over-the-counter acetaminophen, either extra strength (500 mg/tablet) or arthritis strength (650mg/tablet) for over a year now. In addition to osteoarthritis, she also has osteoporosis and gastroesophageal reflux. She presents with the complaint of backache and right knee pain, aggravated by climbing stairs. She describes her knee pain as 8 on a scale of 1 to 10: “I can stand the back pain, but the knee is awful.” She lives alone but has two supportive daughters nearby. They take her shopping and help with housework. On good days, she goes to the senior center for lunch and socialization. She was doing exercises at the Senior Center but stopped due to her knee pain. She does not smoke or drink alcohol, except at birthday parties and celebrations. She denies any medication, food, or environmental allergies. In addition to the acetaminophen, medications include calcium with vitamin D, Protonix (pantoprazole), and an annual intravenous infusion of Reclast (zoledronic acid). She also has been taking a dietary supplement of glucosamine/chondroitin for 3 months. She recently had a complete physical examination with electrocardiogram and laboratory tests and was told that everything was “normal.”
In order to lower arterial blood pressure, antihypertensive drugs decrease cardiac output, total peripheral resistance or both. Diuretics, beta-blockers, and central adrenergic inhibitors decrease cardiac output. ACE inhibitors, angiotensin II antagonists, calcium antagonists, alpha-blockers, central adrenergic inhibitors, and after a delay also diuretics and beta-blockers decrease peripheral resistance (P; 2004). The cardiac stats of the hypertensive patient will affect which medication is given and how it will work for such patient. the indications for and criteria of treatment often must be adjusted according to the cardiac status of the patient. Thus, the presence of increased left ventricular (LV) wall thickness and mass in borderline hypertension may decide in favor of early treatment. The importance of systolic, as opposed to diastolic, blood pressure has been repeatedly stressed because of its closer relation to afterload and consequently of its more direct effects on cardiac performance (Adams et al., 2013). There are many cardiac factors that will affect the blood pressure, such as Reflex cardioadrenergic stimulation, which affect the increased output interfering with blood pressure control. Some side-effects that my apply are tachycardia, and coronary insufficiency, thus interfering with adequate therapy. Another sample is cardiac decompensation leading to further fluid retention and enhancing the increase in peripheral resistance. Reflex pressor effects coronary insufficiency leading to recurrent paroxysmal rises in blood pressure hypovolemia leading to orthostatic intolerance and vasovagal faints alterations in LV filling and relaxation, possibly leading to alterations in reflex blood pressure control (Adams et al., 2013). Many patients can become resistant to such medicines and will ultimately need to be reevaluated for cardiac and hemodynamic status.
Hypertension is termed when the blood pressure is above the normal range, that is 120/80mmHg. In older individuals, the blood pressure tends to be on the higher side usually due to the changes in blood vessel structure. In older individuals, of more than 60 years of age, a blood pressure of more than 140/90mmHg is considered hypertension (Adams et al., 2013). Many patients have hypertension and is goes unnoticed due to the fact they do not visit doctors or follow a poorly regimen with lack of exercise. Often stress can be another stressor to produce hypertension in adults. Renal failure also contributes to cardiac issues and hypertension as it is the second leading cause of renal failure with diabetes falling at number one in the world. Hypertension can damage the body for years producing damage and narrowing arteries, aneurysms. Coronary heart disease, enlarge disease, heart attack, etc. will damage the heart. TIA, and stroked will damage the brain. Kidneys and eyes as well as sexual conditions such as erectile dysfunction can occur due to untreated hypertension (Pruthi, 2023). High blood pressure usually is an ongoing condition that slowly causes damage over years if not treated, thus making yearly doctor visits and trying to live a healthy and less stressful life will always be beneficial to one’s health.
References
P; K. U. C. (2004, May 12). [pharmacological basis of antihypertensive drug therapy]. Praxis. https://pubmed.ncbi.nlm.nih.gov/15195836/
Adams, A. S., Uratsu, C., Dyer, W., Magid, D., O’Connor, P., Beck, A., Butler, M., Ho, P. M., & Schmittdiel, J. A. (2013, January 14). Health System factors and antihypertensive adherence in a racially and ethnically diverse cohort of new users. JAMA internal medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5105889/
Pruthi, S. (2023, November 28). How high blood pressure can affect the body. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure/art-20045868
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