Pneumonia Of Left Lung
Must use the sample template for your soap note,
Use APA format and must include minimum of 2 Scholarly Citations.
Turn it in Score must be less than 15% or will not be accepted for credit, must be your own work and in your own words. Pneumonia Of Left Lung
The use of tempates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.
Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed (Codina Leik, 2015). Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease (Domino et al,. 2017).
Renal artery stenosis (ICD10 I70.1)
Chronic kidney disease (ICD10 I12.9)
Hyperthyroidism (ICD10 E05.90) Pneumonia Of Left Lung
Labs and Diagnostic Test to be ordered:
• Complete blood count (CBC)
• Lipid profile
• Thyroid-stimulating hormone (TSH)
• Urinalysis with Micro
• Electrocardiogram (EKG 12 lead)
• Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.
• Lisinopril 10mg PO Daily
• Weight loss
• Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat
• Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults
• Enhanced intake of dietary potassium
• Regular physical activity (Aerobic): 90–150 min/wk
• Tobacco cessation
• Measures to release stress and effective coping mechanisms.
• Provide with nutrition/dietary information.
• Daily blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP
• Instruction about medication intake compliance. Pneumonia Of Left Lung
• Education of possible complications such as stroke, heart attack, and other problems.
• Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all
• Follow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Pneumonia Of Left Lung