2 soaps notes Use Chronic Hypertensive Disease soap note 1 Diabetes mellitus decompensate soap note 2 Follow the MRU Soap Note template as a guide Use APA format and must include a minimum of 2 Scholarly Citations. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program).  Copy-paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

SOAP Note 1: Chronic Hypertensive Disease

Subjective:
The patient, a 55-year-old male, presents with complaints of frequent headaches, dizziness, and blurry vision over the past month. He reports a family history of hypertension and is concerned about his blood pressure levels. The patient admits to not consistently taking his antihypertensive medication as prescribed.

Objective:
Vital signs:
– Blood pressure: 160/100 mmHg
– Heart rate: 80 bpm
– Temperature: 98.6°F
– Respiratory rate: 16 breaths per minute

Physical examination:
– General appearance: The patient appears well-nourished but slightly overweight.
– HEENT: No papilledema or abnormalities noted. Pupils equal and reactive to light.
– Neck: No jugular venous distention. No carotid bruits.
– Lungs: Clear breath sounds bilaterally.
– Heart: Regular rhythm without murmurs or extra heart sounds.
– Abdomen: No tenderness or masses. Bowel sounds present.
– Extremities: No edema. Pulses intact bilaterally.

Assessment:
Based on the patient’s symptoms, family history, and elevated blood pressure, the diagnosis of chronic hypertensive disease is likely. The patient’s non-compliance with antihypertensive therapy may be contributing to his symptoms.

Plan:
1. Education: The patient will be counseled about the importance of adherence to antihypertensive medication and the potential risks associated with uncontrolled hypertension. The importance of lifestyle modifications, such as a low-sodium diet, regular exercise, and weight loss, will also be emphasized.
2. Medication adjustment: The patient’s current antihypertensive regimen will be reviewed and modified, if necessary, to optimize blood pressure control.
3. Follow-up: The patient will be scheduled for a follow-up appointment in two weeks to monitor his blood pressure and assess any improvement in symptoms.
4. Laboratory testing: Blood tests, including a comprehensive metabolic panel, lipid panel, and hemoglobin A1c, will be ordered to assess the patient’s overall cardiovascular health and screen for any comorbidities.
5. Referral: A referral to a registered dietitian will be made to provide further guidance on dietary modifications and weight management.
6. Lifestyle modifications: The patient will be encouraged to engage in regular aerobic exercise for at least 30 minutes per day, five days a week, and to adhere to a low-sodium diet (<2,300 mg/day). He will also be advised to limit alcohol consumption and quit smoking. SOAP Note 2: Diabetes Mellitus Decompensate Subjective: The patient, a 65-year-old female with a known history of type 2 diabetes mellitus (DM), presents with complaints of increased thirst, frequent urination, and unintentional weight loss over the past month. She states that she has been feeling fatigued and weak, noting that her appetite has decreased. The patient has been experiencing severe headaches and occasional blurred vision. Objective: Vital signs: - Blood pressure: 150/90 mmHg - Heart rate: 90 bpm - Temperature: 98.4°F - Respiratory rate: 18 breaths per minute Physical examination: - General appearance: The patient appears pale and fatigued. - HEENT: No signs of retinopathy. Pupils equal and reactive to light. - Neck: No jugular venous distention. No enlarged lymph nodes. - Lungs: Clear breath sounds bilaterally. - Heart: Regular rhythm without murmurs or extra heart sounds. - Abdomen: No tenderness or masses. Bowel sounds present. - Extremities: No edema. Pulses intact bilaterally. Assessment: Based on the patient's symptoms, previous history of type 2 DM, and physical examination findings, she presents with decompensated diabetes mellitus. The elevated blood pressure indicates possible hypertensive complications. Plan: 1. Glycemic control: The patient's blood glucose levels will be closely monitored. Insulin therapy will be initiated to achieve glycemic control. 2. Fluid and electrolyte management: The patient will be assessed for signs of dehydration and electrolyte imbalances. Her fluid intake and output will be closely monitored. 3. Blood pressure management: Antihypertensive medication will be initiated or adjusted to target a blood pressure goal of <130/80 mmHg. 4. Dietary counseling: The patient will receive education on diabetic meal planning, focusing on carbohydrate counting and portion control. 5. Foot care: Proper foot care and daily inspection will be emphasized to prevent complications such as diabetic foot ulcers. 6. Ophthalmic referral: The patient will be referred to an ophthalmologist for further evaluation of her headaches and blurred vision. 7. Education: The patient will be counseled on the symptoms and self-management of diabetes, as well as the importance of medication adherence and regular follow-up appointments. 8. Follow-up: The patient will be scheduled for a follow-up appointment in one week to assess her response to treatment and adjust the therapeutic plan accordingly. In conclusion, both SOAP notes outline the subjective and objective findings, assessment, and plan for patients with chronic hypertensive disease and decompensated diabetes mellitus. These cases illustrate the importance of individualized management plans, including medication adjustment, lifestyle modifications, and patient education. Early intervention and diligent monitoring are crucial in preventing complications and improving patient outcomes.