\u00a0\u00a0
\nPart I :\u00a0
\na. Soap Note Ankylosing Spondylitis
\nb. add questions from your case study\u00a0
\nPart II: Ankylosing Spondylitis
\na. Pathophysiology
\nb. Clinical Presentation
\nc. Physical Examination
\nd. Diagnostic Testing\u00a0
\ne. Differential Diagnosis
\nf. Management
\ng. Education and Health Promotion\u00a0
\nPower point
\n< 20 % plagiarism
\n5 References
\nSample Regular Soap Note Template
\nPATIENT INFORMATION
\nName: Mr. W.S.
\nAge: 65-year-old
\nSex: Male
\nSource: Patient
\nAllergies: None
\nCurrent Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
\nPMH: Hypercholesterolemia
\nImmunizations: Influenza last 2018: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online-year, tetanus, and hepatitis A and B 4 years ago.
\nSurgical History: Appendectomy 47 years ago.
\nFamily History: Father- died 81 does not report information
\nMother-alive, 88 years old, Diabetes Mellitus, HTN
\nDaughter-alive, 34 years old, healthy
\nSocial Hx:No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
\nSUBJECTIVE:
\nChief complain: \u201cheadaches\u201d that started two weeks ago
\nSymptom analysis\/HPI:
\nThe patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159\/100, 158\/98 and 160\/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness.He states that he has been under stress in his workplace for the last month.
\nPatient denies chest pain, palpitation, shortness of breath, nausea or vomiting.
\nROS:
\nCONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.\u00a0
\nHEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.
\nRespiratory: Patient denies shortness of breath, cough or hemoptysis.
\nCardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
\ndyspnea.
\nGastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
\ndiarrhea.
\nGenitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting\/stopping stream of urine or incontinence.
\nMUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
\nSkin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
\nObjective Data
\nCONSTITUTIONAL: Vital signs: Temperature: 98.5 \u00b0F, Pulse: 87, BP: 159\/92 mmhg, RR 20, PO2-98% on room air, Ht- 6\u20194\u201d, Wt 200lb, BMI 25. Report pain 0\/10.
\nGeneral appearance: The patient is alert and oriented x 3. No acute distress noted.NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE\/LE strength 5\/5.
\nHEENT:Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding.Oral mucosa moist without lesions,.Lids non-remarkable and appropriate for race.
\nNeck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.
\nCardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.
\nRespiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
\nGastrointestinal:No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation
\nMusculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness.
\nIntegumentary: intact, no lesions or rashes, no cyanosis or jaundice.
\nAssessment
\nEssential (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.
\nDifferential diagnosis:
\n\u00d8 Renal artery stenosis (ICD10 I70.1)
\n\u00d8 Chronic kidney disease (ICD10 I12.9)
\n\u00d8 Hyperthyroidism(ICD10E05.90)
\nPlan
\nDiagnosis 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.
\nThese basic laboratory tests are:
\n\u00b7 CMP
\n\u00b7 Complete blood count
\n\u00b7 Lipid profile
\n\u00b7 Thyroid-stimulating hormone
\n\u00b7 Urinalysis
\n\u00b7 Electrocardiogram
\n\u00d8 Pharmacological treatment:\u00a0
\nThe treatment of choice in this case would be:
\nThiazide-like diuretic and\/or a CCB
\n\u00b7 Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.\u00a0
\n\u00d8 Non-Pharmacologic treatment:\u00a0
\n\u00b7 Weight loss
\n\u00b7 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
\n\u00b7 Reduced intake of dietary sodium: <1,500 mg\/d is optimal goal but at least 1,000 mg\/d reduction in most adults
\n\u00b7 Enhanced intake of dietary potassium
\n\u00b7 Regular physical activity (Aerobic): 90\u2013150 min\/wk
\n\u00b7 Tobacco cessation
\n\u00b7 Measures to release stress and effective coping mechanisms.
\nEducation
\n\u00b7 Provide with nutrition\/dietary information.
\n\u00b7 Daily blood pressure monitoringat home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP
\n\u00b7 Instruction about medication intake compliance.\u00a0
\n\u00b7 Education of possible complications such as stroke, heart attack, and other problems.
\n\u00b7 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
\nFollow-ups\/Referrals
\n\u00b7 Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.
\n\u00b7 No referrals needed at this time.
\nReferences
\nDomino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).
\nCodinaLeik, M. T. (2014: 2024 – Essay Writing Service | Write My Essay For Me Without Delay). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0
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