Assignment Prompt

Select a client from clinical experience with an acute health problem or complaint requiring at least two visits.  Submit a complete H & P from the initial visit with this client and a focused SOAP note for the follow-up visit. Based on this client’s condition, conduct a literature search for two research articles that discuss various approaches to the treatment of this condition. Peer reviewed articles must address the standardized procedure or guidelines for this diagnosis. Incorporate the research findings into the decision-making for this client’s treatment. In the paper, compare and contrast or address how treatment or the plan may have been different based on the research findings. The discussion on relating research to practice should be 3-4 pages and the total paper should be no longer than 10 pages including references. The research articles must be an original research contributions (no review articles or meta-analysis) and must have been published within the last five years. Cover the criteria listed below.  The paper should be APA formatted and no longer than 10 pages.  

  • Reviews topic and explains rationale for its selection in the context of client care. (2 pts)
  • Evaluates key concepts related to the topic. 2 pts)
  • Describes multiple viewpoints if this is a controversial issue or one for which there are no clear guidelines. (2 pts)
  • Assesses the merit of evidence found on this topic i.e. soundness of research (5pts)
  • Evaluates current EBM guidelines, if available. Or, recommends what these guidelines should be based on available research. Discuss the Standardized Procedure for this diagnosis. (5 pts)
  • Discusses how the evidence did impact/would impact practice.  What should be done differently based on the knowledge gained? (3 pts)
  • Consider cultural, spiritual, and socioeconomic issues as applicable. (2pts).
  • Utilizes APA guidelines, cite references (2 pts)
  • Writing style at the graduate level (2pts)

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Patient Name: SP

Chief complaint: none

HPI: SP is a 70-year-old woman who comes in for a follow-up on hypertension. She said that she feels well and she does not feel any fatigue, headache, or dizziness.

PMH 

Current Illnesses: hypertension 

Past Illness: kidney stones, renal insufficiency

Surgeries: C-section

            Allergies: IVP dye

 Medications: Hydrochlorothiazide 25 milligrams per day

            Hospitalizations: pregnancies

Trauma Injuries: none known

Social History

            Education: High school completed

 Military: None

            Work and Finances: retired

            Relationships and Family: Lives with sons family

            Habits or Risk Factors: drinks frequently for the last 40 years

 Reproductive History: menopause in the mid-50s

Family History

Father: Died of old age.

            Mother: Died of old age.

 Review of Systems 

General: has no fever.

 Head: denies any headache.

Eyes: reports good eyesight

            Cardiac denies any palpitations.

 Respiratory: denies shortness of breath

            GI: denies feeling any abdominal pain

            Musculoskeletal: denies feeling any muscle weakness

            GU: denies having any challenges urinating

 Neurologic: denies feeling dizzy, any unusual sensation, unusual smells, loss of balance, gait or walking, and changes in hearing.

            Psychiatric: denies having any mood changes.

SOAP Note

Subjective

Mrs. SP is a 70-year-old woman who reports to the clinic to follow up on her hypertension. She reports that she feels well generally and does not have any fatigue, headache, or dizziness.

 Mrs. SP has no history of other medical conditions other than hypertension. Her current medication is hydrochlorothiazide which she takes 25 milligrams per day. Mrs. SP’s weight has remained the same for the past two months.  She reports that she has been taking a low-fat diet and walking for 30 minutes every day. She also highlights that she takes two glasses of wine every evening. She states that she does not use any over-the-counter medications at the moment, such as herbal remedies or cold remedies.

 Objective

 In general, Mrs. SP appears healthy.  Her current weight is 160 pounds, her height 63 inches, and her BMI is 27.  BP 150/ 70. Mrs. SP has no signs of lower extremity edema.

Assessment

 Mrs. SP came to the clinic to follow up on hypertension.  Her hypertension is not yet well-controlled since her current blood pressure of 150/ 70 is well above the goal of 140/ 90. The possible causes of Mrs. SP’s poor blood pressure control maybe her over weightiness and frequent alcohol use.

 Plan

  • Continue exercising and taking a low-fat diet. Consider increasing working time to 45 minutes to assist in weight loss.
  • Discuss alcohol consumption and the relationship to hypertension. Patient to limit taking wine to at least only weekends.
  • Check the patient’s potassium levels, and she’s taking a diuretic.
  • Patient to monitor blood pressure at home.
  • Clients to come for a follow-up clinic after one month. Patient to bring a blood pressure diary on the next visit.
  • The administration of ACE inhibitors such as Lisinopril 5 mg daily should be considered during the patient’s next visit if the blood pressure is still elevated.