SOAP (Nursing) Note on Dyspnea, Confusion, and Fatigue

Patient Initials: ____B.M__ Gender: M/F/Transgender: ___F_ Age: __38___ Race: __Black ___ Ethnicity __ African American __

Reason for Seeking Health Care: A 38-year-old African American woman was admitted because of dyspnea, confusion, and fatigue.

HPI: The patient had been well until 18 months before the current admission, when the blood pressure was noted to be 140/90 mm Hg during a routine appointment with her primary care physician. Therapy with oral contraceptive pills was discontinued, but the blood pressure was persistently elevated when measured at home and during subsequent clinical evaluations. Results of duplex ultrasonography of the bilateral renal arterial vasculature were average, as were levels of thyrotropin, plasma-free catecholamines, plasma metanephrines, and aldosterone. Transthoracic echocardiography revealed normal ventricular function, with no evidence of valvular disease or left ventricular hypertrophy; the interventricular septal wall thickness was 11 mm (normal range, 7 to 11). Lisinopril was administered, and the blood pressure decreased to 120/80 mm Hg.

Four weeks before the current admission, swelling of the legs, abdominal dis[1]tention, intermittent dyspnea on exertion, and fatigue developed, and the patient was evaluated in this hospitals emergency department. She reported a weight gain of 4.5 kg during the previous month, occasional episodes of confusion, and two episodes of burning chest pain during exercise that had lasted for 2 minutes each and were relieved with rest. On examination, the temperature was 36.8°C, the blood pressure was 180/110 mm Hg, the heart rate was 73 beats per minute, the respira[1]tory rate was 18 breaths per minute, and the oxygen saturation was 98%, while the patient was breathing ambient air. The weight was 66.9 kg; approximately five months earlier, it had been 67.1 kg at a clinic visit. The body-mass index (the weight in kilograms divided by the square of the height in meters) was 22. A systolic murmur (grade 2/6) was best heard at the left sternal border. The jugular venous pressure was estimated to be 10 cm of water. The abdomen was soft, non-tender, and slightly distended. There was trace nonpitting edema in the legs. The rest of the physical examination was ordinary. An electrocardiogram showed a normal sinus rhythm and left-axis deviation. A chest radiograph displayed a normal cardiac silhouette and small bilateral pleural effusions, with no opacities or pulmonary edema.

Allergies (Drug/Food/Latex/Environmental/Herbal): None

Current perception of Health: Fair

Past Medical History:

Major/Chronic Illnesses: The patient had a history of dysmenorrhea and endometriosis treated with a levonorgestrel-releasing intrauterine system. She had a history of palpitations not associated with evidence of arrhythmia.
Trauma/Injury: None
Hospitalizations: None

Past Surgical History: None

Medications: Oral contraceptive pills

Family History: The mother and sister had experienced miscarriages and venous thromboses. Maternal uncle experienced hypertrophic cardiomyopathy; no history of sudden cardiac death was reported.

Social history: The patient did not smoke tobacco, drink alcohol, or use illicit drugs. She worked as a lawyer and was married.

Lives: Condo Marital Status: Married Employment Status: Employed Current/Previous occupation type: Chef

Exposure to: ___Smoke_No_ ETOH _No_Recreational Drug Use ______No_________

Sexual orientation: Straight Sexual Activity: Active Contraception Use: Yes

Family Composition: Family

Health Maintenance

Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear

Exposures: None

Immunization HX: Influenza, Tetanus, Pneumovax

Review of Systems:

General: fatigue and confusion
HEENT: dizziness
Lungs: No symptoms
Cardiovascular: dyspnea
Breast: No symptoms
GI: No symptoms
Male/female genital: none
GU: No symptoms
Neuro: No symptoms
Musculoskeletal: weakness
Activity & Exercise: rare
Psychosocial: stress
Derm: No symptoms
Nutrition: prevalence of fat and fast food
Sleep/Rest: irregular
LMP: December 17
STI Hx: none

Physical Exam

BP: 140/90 mmHg TPR: 36.8°C HR: 73 bpm RR: 18 bpm Ht. 174.5 cm Wt. 66.9 BMI: 22
General: 38 years, African-American, female
HEENT: AT/NC
Neck: AT/NC
Lungs: CTA+P
Cardiovascular: PMI
Breast: Breast Mass
GI: Normal
Male/female genital: Normal
GU: Normal
Neuro: Normal
Musculoskeletal: Abdominal Mass
Derm: Normal
Psychosocial: Normal

Plan:

Differential Diagnoses
- Hypertension
Principal Diagnoses
- Hypertension

Plan

Diagnosis

Diagnostic Testing: Blood pressure test

Pharmacological Treatment: Lisinopril

The treatment of hypertension may be pharmacological, which involves using medication to lower blood pressure, or non-pharmacological, which consists in making lifestyle changes to reduce blood pressure. Lifestyle changes that may help to lower blood pressure include reducing salt intake, losing weight, eating a healthy diet, exercising regularly, and reducing stress. Medications that may be used to treat hypertension include angiotensin-converting enzyme inhibitors, beta-blockers, calcium channel blockers, and diuretics.

Referrals: Patients with hypertension should be referred for specialist assessment and treatment in the following cases:

If their blood pressure is consistently above 160/100 mmHg
There are signs or symptoms of target organ damage
There is a significant risk of target organ damage
There is an uncertain diagnosis
There is a need for specialist evaluation
There is a need for expert treatment
There are treatment complications.

Patients with hypertension should also be referred to a specialist if they have side effects from treatment, including severe hypotension, orthostatic hypotension, renal failure, or severe tolerability issues. Patients should also be referred if they have secondary hypertension, including renovascular hypertension, secondary to Cushings or Conns syndromes, primary aldosteronism, coarctation of the aorta, pheochromocytoma, or renal artery stenosis. Patients with refractory or difficult-to-control hypertension should be referred for specialist assessment and treatment. Patients with renal insufficiency or renal failure should be referred for expert evaluation and treatment. Pregnant or planning pregnancy patients should be referred for specialist assessment and treatment. Patients with a stroke or transient ischaemic attack (TIA) should be referred for specialist assessment and treatment. Patients with uncontrolled hypertension who are about to undergo surgery should be referred for specialist assessment and treatment.

Follow-up: Managing hypertension requires long-term treatment and follow-up. After starting treatment, it is important to have regular checkups with your doctor to ensure the treatment is working and to check for any side effects. If you have hypertension, you should check your blood pressure at least once a year. You may need frequent checkups if your blood pressure is not well controlled.

Anticipatory Guidance

Some tips on how to prevent hypertension include:

eating a healthy diet that is low in salt, fat, and cholesterol
getting regular exercise
maintaining a healthy weight
avoiding tobacco products
limiting alcohol intake
managing stress in a healthy way

Signature (with appropriate credentials): M.B.

Cite current evidenced-based guideline(s) used to guide care (Mandatory).

Al-Makki, A., DiPette, D., Whelton, P. K., Murad, M. H., Mustafa, R. A., Acharya, S., Beheiry, H. M., Champagne, B., Connell, K., Cooney, M. T., Ezeigwe, N., Gaziano, T. A., Gidio, A., Lopez-Jaramillo, P., Khan, U. I., Kumarapeli, V., Moran, A. E., Silwimba, M. M., Rayner, B., & Sukonthasan, A. (2021). Hypertension Pharmacological Treatment in Adults: A World Health Organization Guideline Executive Summary. Hypertension, 79(1).

Carey, R. M., Whelton, P. K., & 2017 ACC/AHA Hypertension Guideline Writing Committee. (2018). Prevention, detection, evaluation, and management of high blood pressure in adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Annals of internal medicine, 168(5), 351-358.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C. Jr., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., William, K. A.,& & Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71(19), e127-e248.

DEA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials) B.M. Age: 38

Date: 22 December 2020

RX ______________________________________

SIG:_________________________________________

Dispense: ___________ Refill: _________________

No Substitution

Signature: ____________________________________________________________

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