Answerand Explanation Solved by verified expert SOAP Notes:…
Question Answerand Explanation Solved by verified expert SOAP Notes:… Answer and ExplanationSolved by verified expertSOAP Notes:Subjective Findings:This is a case of a 62 y/o white female who presented in the clinic for annual visit. She has a medical history of hypertension, which was diagnosed when she was 27 years old, with maintenance medication of Lisinopril 5mg PO daily. Patient also reported to have elevated total cholesterol levels for the last 10 years, but had no maintenance medication. She also did not report any chest pains, palpitations, or lower extremity edema. Patient is divorced, employed full-time as a graduate nursing program professor. Patient is a non-smoker, but reported to have been occasionally drinking 2-3 ounces of wine. Her health maintenance activities include 1.5 – 2 hours of exercise and a low glycemic Pescatarian diet. Patient had not engaged with the recommended colonoscopy, did not undergo any screening mammograms. Patient also did not get flu shots, and had not had any other recommended adult immunizations since then.Objective Findings:On physical examination, the patient generally appears healthy. Her height is 64 inches, and weighs 127 pounds, with the BMI of 21.8, which is within normal limits. Her vital signs were unremarkable with a blood pressure of 112/60 mmHg, pulse rate of 68 beats per minute, temperature of 97.9 F (temporal), respiratory rate of 16 cycles per minute, and SpO2 of 99%.Her skin was pink, warm, and dry to touch. Patients eyes had no arcus senilis. Cardiovascular system was unremarkable with regular heart rate and rhythm, S1 and S2 distinct; no S3 or S4, murmur or gallop; no carotid bruits. Peripheral vascular system was also unremarkable with radial pulses palpable and pedal pulses 2+; no lower extremity edema; capillary refill <3 secs bilateral.On laboratory, patient's lipid panel showed a total cholesterol of 302 (HDL 117, Triglycerides 45).Assessment:Problem #1: Hyperlipidemia, high cholesterol levels not well-managed with pharmacologic treatments.Problem #2: Hypertension, well-controlled on Lisinopril 5mg PO daily.Plan:Therapeutic: Initiate hyperlipidemia treatment with high intensity statins (Lipitor 40-80mg or Crestor 20-40 mg). Continue low glycemic Pescatarian diet and exercise routine. Consider adding DASH diet and regular walking. Continue antihypertensive therapy(Bozkurt et al., 2016; Burnier & Egan, 2019).Educational: Discuss HTN and hyperlipidemia symptoms, the importance of medication adherence, medication side-effects and ways of alleviating them, and recommend reduction of wine intake. Follow up in 3 months to evaluate adherence and effectiveness of medication regimen (Arcangelo et al., 2017).Consultation/Collaboration: Collaborate with other providers to monitor BP, potassium levels, and lipid profile every 3-12 months. Consider non-statin therapy if response is not achieved or in case of statin intolerance (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).Step-by-step explanationReferences:Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017).Pharmacotherapeutics for advanced practice: A practice approach(4thed.).Philadelphia, PA: Wolters Kluwer.Bozkurt, B., Aguilar, D., Deswal, A., Dunbar, S. B., Francis, G. S., Horwich, T., ... Yancy, C.(2016).Contributory risk and management of comorbidities of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in chronic heart failure.Circulation,134, e535-e578. DOI: 10.1161/CIR. 0000000000000450. Health Science Science Nursing NU 636 Share QuestionEmailCopy link Comments (0)
