University of Miami Region

Meeting Date: 15/December/ 2021

Site of Clinic: MSN5600L Class

Instructor: Patricio Bidart

Soap Note: Hypertension

INFORMATION about Patient

Designation:

Age: 50

Gender: Female

Basis: patient

Antipathies: blue band and peanut

Present Medications:

 Once a day, take 500mg and one tablet of PO

 At bedtime, take one tablet PO and 20mg Atorvastatin

PMH: Hypercholesterolemia

Immunizations: Last four years, Hepatitis B and A

History of Surgery: Thirty years ago, she underwent Appendectomy

Family History: Mother died, and father alive and ninety years old but doesn't provide any data.

Social History: The patient is catholic by religion and a widow who lives with her daughter. She
is neither smoker nor an alcoholic, nor does she have any history of drugs.
Sexual Orientation: straightforward

Nutrition History: low diet of fats and carbohydrates

Subjective Data:

Chief Complaint: The client complained of head pains that began fourteen days ago

Sign analysis: The female patient is fifty years old and complains of head pains. Blood was
measured on three diverse occasions, and the pressure was high (160/100, 158/99, and
159/99). The patient realized that the problem began fourteen days ago, and the head pains
are conveyed by shakiness. She reiterates she has been stressed at her place of work for the
last thirty days. She refutes vomiting and chest pains.

Review of Systems (ROS)

CONSTITUTIONAL: the patient refutes chills. There are no signs of weight loss.

NEUROLOGIC: episodes of head pains accompanied by dizziness as described above. Refutes

changes in LOC.

HEENT: The patient denies any form of injury on neither the head nor the pain. There are no
changes in vision or hearing.

Nose: absence of destruction of neither nose nor nasal discharge

Throat: no difficultness in swallowing

RESPIRATORY: Nonappearance of the smallness of breath

CARDIOVASCULAR: absence of pains in the chest nor tachycardia

GASTROINTESTINAL: no abdominal pain nor discomfort. Absence of bleeding from the rectum

GENITOURINARY: no burning sensation during urination and incontinence

MUSCULOSKELETAL: absence of snapping, neither sound nor pain

SKIN: absence of jaundice or cyanosis

Objective Data:

VITAL SIGNS: temperature 97.4 degrees; BP 122/71 and BMI 30, 160/100, on room air PO2 is
99%. Report on pain is 0/10

OVERALL APPEARANCE: The female client is keen and well-displayed x 3. The absence of critical
stress was reported. Both lower and upper extremities are intact.
NEUROLOGIC: keen, LE/UE strength is 5/5. The lower and upper extremities sensation intact.

HEENT: non-tender and symmetric, the maxillary sinuses lack tenderness

Eye: movement of the eye is intact

Nose: The mucosa of the nasal is moist, and no signs of bleeding

Neck: no absence of thyroid swelling or detention of jugular vein

CARDIOVASCULAR: the rate is regular with the absence of gallop. Refill of the capillary is less
than two seconds

RESPIRATORY: No usage of muscles from the accessory system. Absence of ego phony. Sounds
of breath are clear on auscultation

GASTROINTESTINAL: absence of hernia. No-tender and soft abdomen. The four quadrants
experience bowel sounds.

MUSCULOSKELETAL: nonappearance of tremor and both lively and inert ROM that lie within
the normal units

INTEGUMENTARY: Absence of jaundice or rashes.

ASSESSMENT:

The 50-year-old female has Hypertension (ICDC 10l10): from the signs and the high blood levels
averaging 158/100mmhg. The hypertension is at stage II. Ruling out the biological cause of high
blood pressure like adrenal thyroid makes it easier to confirm the diagnosis.

Main Diagnosis

The high blood levels averaging at 160/100 indicate the presence of hypertension. This is
through a series of lab tests.

Differential diagnosis

 stenosis of renal artery

 Kidney infection (ICD10l12.9)
 Hyperthyroidism

PLAN:
The clinical evaluation helps establish the diagnosis through continuous lab testing and physical
examination to help ascertain the risk factors involved. It also helps identify the damaged organ
in line with the presence of cardiovascular infection(Domino et al., 2017).

Basic laboratory Tests

 Comprehensive blood count

 The shape of the lipid

Pharmacological treatment:

The options of treatment for this scenario will be:

A CBB

25MG of hydrochlorothiazide to be administered once

Non-Pharmacologic treatment: loss of weight, diet plenty of fruits and products that have
fewer fats

Education: offer good nutrition/diet

They monitor blood pressure while at home thrice a day for two weeks and maintain a record
of the activities. The record is to be used in the next visit.

Provide education on other possible complications like stroke

Referrals

Evaluating with PCP in seven days for controlling the blood pressure and assessing the existing
hypotensive rehabilitation

Two weeks appointments

Call if there is any adverse reaction

Work Cited

Domino, F, Baldor, R, Golding, J., Stephens M. (2017). The 5-minute clinical 2017(25th edition.)
print(the 5-minute consult series)