Nursing
Subjective: What details did the patient provide regarding his or her personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
PLEASE USE TEMPLATE
NEEDS PLAN SHOULD BE SPECIFIC
Subjective: What details did the patient provide regarding his or her personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
PLEASE USE TEMPLATE
NEEDS PLAN SHOULD BE SPECIFIC
ANSWER
Episodic/Focus Note Template
Patient Information:
T.W. 57 years, Male, Caucasian
S.
CC (chief complaint): Visits for his yearly physical examination and to follow up with his blood pressure
HPI: T.T a 57 year old Caucasian male visits the clinical for his annual physical examination and follow up on his blood pressure. He claims that his blood pressure has been shooting high for the last few weeks. The patient has been keeping records of his blood pressure readings every day, in the morning and evening which has allowed him to notice that BP is running higher than normal.
Location: Arterioles
Onset: Few Weeks
Character: High Pressure
Associated signs and symptoms: Unknown
Timing: All day
Exacerbating/ relieving factors: Amlodipine and Losartan that are used in treating high blood pressure.
Severity: 7/10 pain scale
Current Medications: Amlodipine 10mg PO daily and Losartan 50mg PO daily.
Allergies: No known allergies
PMHx: History of hypertension
Soc & Substance Hx: Unknown social and substance history
Fam Hx: No family history of any similar episodes.
Surgical Hx: No prior surgical procedures.
Mental Hx: Unknown mental health history
Violence Hx: No violence history
Reproductive Hx: Unknown reproductive history
ROS:
GENERAL: Complains of high blood pressure
HEENT: Denies any headache
Eyes: Denies any visual loss
Ears: Denies any ear pain or hearing impairment
Nose: No nasal obstruction, running or nose bleeds
Throat: Denies any sore throat
SKIN: No rashes, itching or open wounds.
CARDIOVASCULAR: No chest discomfort but denies edema.
RESPIRATORY: No coughing or shortness of breath
GASTROINTESTINAL: Denies nausea, vomiting, diarrhea or abdominal pains.
GENITOURINARY: No urinary leakage or inconsistencies.
NEUROLOGICAL: No headache, numbness, paralysis, ataxia, syncope or dizziness.
MUSCULOSKELETAL: No muscle pains
HEMATOLOGIC: No anemia, bruising or bleeding.
LYMPHATICS: No history of enlarged nodes or splenectomy
PSYCHIATRIC: No depression or anxiety
O.
Physical exam: The primary examination of a patient with a history of blood pressure requires a systemic evaluation of the probable causes. The physical examination will begin with general examination of the vital signs such as the BP, BMI, respiratory rate, pulse and temperature. The patient’s medical history and personal history will be examined characterize different symptoms. Since the patient has high blood pressure some tests were recommended to check the underlying conditions of high blood pressure and confirm the diagnosis. These tests include blood tests, cholesterol tests, urinalysis, ambulatory monitoring, and electrocardiogram (ECG).
Diagnostic results: When the pressure is about 180/120 mm Hg, then it’s a hypertensive crisis. The results of the diagnosis indicated that everything was normal but the patient was experiencing high blood pressure.
A.
Differential Diagnoses
Hypertension: Hypertension is a state that occurs after an extended period pressure of the blood in the artery walls extreme enough to cause problems (Charles, Triscott and Dobbs, 2017). An individual can have high blood pressure without symptoms. The symptoms fail to show until the high blood pressure becomes severe and life threatening and can lead to issues such as heart attack and stroke.
Hyperthyroidism: Overactive thyroids tend to produce more thyroid hormone (Boelaert et al., 2020). When more thyroid hormones are generated they pressure the heart to work more which raises the heart rate and increases the blood pressure. Ideally, the forces of the heart contractions tend to increase the systolic pressure which leads to high blood pressure.
Atherosclerosis: This entails the hardening and thickening of the arteries caused by building up of plaque in the artery’s inner lining. Plaque entails building up cholesterol, calcium or fat on the inner walls of the arteries that affect the blood flow which can lead to high blood pressure (Erbel et al., 2019). Some of the risk factors include high cholesterol, high blood pressure, and deposits of fatty substances, diabetes, smoking, and obesity.
Treatment plan for high blood pressure requires understanding of the patient condition as well as the associated signs and symptoms that help in diagnosis. Understanding the various factors that can influence the health condition of the patient is also effective in treatment and diagnosis. These include the personal factors, health history, socio-economic factors, family history which help in treatment and diagnosis. The treatment will be on the basis of diagnosis and condition in the assessment. The treatment plan will be detailed approach follows simple format typically include diagnosis of the health issue, measurable objectives, patient’s personal information, tracking progress and treatment progress timeline (Judge and Mellen, 2019). I have learnt that the treatment and diagnosis should be customized based on medical history, patient history, age and related complication of the condition. I will focus on conservative treatment options that will reduce the risks of high blood pressure that will promote health promotion. Parental and oral therapies would be effective in the treatment of high blood pressure. Lifestyle changes should also be an option the treatment and management of high blood pressure through dietary interventions.
References
Boelaert, K., Visser, W. E., Taylor, P. N., Moran, C., Léger, J., & Persani, L. (2020). Management of hyperthyroidism and hypothyroidism. Endocrinology, 183, G33-G9.
Charles, L., Triscott, J., & Dobbs, B. (2017). Secondary hypertension: discovering the underlying cause. American family physician, 96(7), 453-461.
Erbel, R., Lehmann, N., Stang, A., Churzidse, S., Moebus, S., & Jöckel, K. H. (2019). Blood Pressure and Atherosclerosis: Subclinical Arteriosclerosis as an Early Sign of Organ Damage. In Prehypertension and Cardiometabolic Syndrome (pp. 363-381). Springer, Cham.
Judge, D., & Mellen, L. (2019). Pharmacological interventions. In Substance Misuse and Young People (pp. 415-440). CRC Press.
