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Soap note on hypertensive patient
HPI:
E.W. is a 40-year old African American male, who has had difficulty controlling his HTN lately. He is visiting his primary care provider for a thorough physical examination and to renew a prescription to continue his blood pressure medication.
PMH:
- Chronic sinus infections
- Hypertension for approximately 11 years
- Pneumonia 6 years ago that resolved with antibiotic therapy
- One major episode of major depressive illness caused by the suicide of his wife of 15 years, 5 years ago.
- No surgeries
- Allergies to Penicillin (Rash)
FH:
- Father died at age 49 from AMI; had HTN
- Mother has DM and HTN
- Brother died at age 20 from complication of CF
- Two younger sisters are A & W
SH:
Soap note on hypertensive patient
The patient is a widower and lives alone. He has a 15-year-old son who lives with a maternal aunt. He has not spoken with his son for four years. The patient is an air traffic controller at the local airport. He smoked cigarettes for approximately 10 years but stopped smoking when he was diagnosed with HTN. He drinks “several beers every evening to relax” and does not pay particular attention to the sodium, fat or carbohydrate content of the foods that he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted. He takes an occasional walk but has no regular daily exercise program.
Meds:
- Hydrochlorothiazide 50 mg PO QD
- Pseudoephedrine hydrochloride 60 mg PO Q6hr prn
- Beclomethasone dipropionate 1 spray into each nostril Q6 hr prn
- States that his overall health has been fair to good during the past 12 months
- Weight has increased by approximately 20 pounds during the last year
- Denies chest pain, shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis
- Reports some shortness of breath with activity, especially when climbing stairs, and that breathing difficulties are getting worse
- Denies any nausea, vomiting, diarrhea, or blood in the stool
- Self-treats occasional right knee pain with OTC extra-strength acetaminophen
- Denies any genitourinary symptoms
Physical Exam and Lab tests
General:
The patient is an obese black man in no apparent distress. He appears to be his stated age.
Vital Signs:
BP: 155/96 sitting
HR: 73, regular
RR: 15, unlabored
Temp: 98.8 degrees F
Height: 5’11”
Weight: 221 lb
BMI: 31.
HEENT:
- Tympanic membrane intact and clear throughout
- No nasal drainage
- No exudates or erythema in oropharynx
- PERRLA, pupil diameter 3. mm bilaterally
- Sclera without icterus
- EOMI
- Fundoscopy reveals mild arteriolar narrowing with no nicking, hemorrhages, exudates, or papilledema.
Supple without masses or bruits
Thyroid normal
Negative lymphadenopathy
Lungs:
Mild basilar crackles bilaterally
No wheezes
Heart:
RRR
Prominent S3 sound
No murmurs or rubs
ABD:
Soft and nondistended
Non tender with no guarding or rebound
No masses, bruits, or organomegaly
Normal bowel sounds
Rectal/GU
Normal size prostate without nodules or asymmetry
Heme negative stool
Normal penis and testes
Ext:
No CCE
Limited ROM right knee
Neuro
No sensory or motor abnormalities
CNs II-XII intact
Negative Babinski
DTRs=2+
Muscle tone = 5/5 throughout
Laboratory tests
| Na 139meq/L | RBC 5.9mil/mm33 | Mg 2.4mg/dL |
| K 3.9meq/L | WBC 7,100/mm3 | P04 3.9mg/dL |
| Cl 102meq/L | AST 29 IU/L | Uric acid 7.3mg/dL |
| HCO3 27 meq/L | ALT 43 IU/L | Glu, fasting 110mg/dL |
| BUN 17mg/dL | ALK phos 123 IU/L | T. Chol 275mg/dL |
| Cr 1.0mg/dL | GGT 119 IU/L | HDL 31mg/dL |
| HgB 16.9g/dL | T. Bilirubin 0.9mg/dL | LDL 179mg/dL |
| Hct 48% | T. protein 6.0g/dL | Trig 290mg/dL |
| Plt 235,000/mm3 | Ca 9.3mg/dL | PSA 1.3ng/mL |
Urinalysis results:
Appearance- clear, amber in color
Specific gravity- 1.017
Ph- 5.3
Protein- negative
RBC- 0
WBC- 0
Bacteria- negative
ECG:
Increased QRS voltage suggestive of LVH
ECHO:
Moderate LVH with EF = 46%