Subjective: Pt. reports history of neck pain. Reports knowledge of elevated BP over past decade.
Objective: 57-year-old mixed race male. Diagnosis of spinal stenosis at C5-C6 level. BP is 217/109
Assessment: Pt. is is a 57-year-old mixed race male coming to the office to be assess for a cervical traction research study. Pt. does not currently see a healthcare provider. Upon assessment, pt. blood pressure is 217/109. Pt. reports he knows that his BP has been at this level for the past decade and has taken no measures to address it. Based off of assessment, pt. does not meet current requirements to move forward with his intended research study.
Therapeutics: pharmacologic interventions, if any â€“ new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]
Pt. will be started on Thiazide 25mg tablet daily. Will monitor for improvement and increase dose as necessary. Thiazide works to enhance sodium excretion, which lowers extracellular volume, which ultimately lowers cardiac output (Rysz et. al., 2020). Pt. will also be started on a cardiac diet which will significantly decrease the pts. Daily salt intake, otherwise known as the DASH diet which is the most effective diet for those with hypertension (Valenzuela et. al., 2021).
Educational: health information clients need in order to address their presenting problem(s); health information in support of any of the â€˜therapeuticsâ€™ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
Pt. received education on monitoring BP at home and the importance of a healthy diet and exercise. Pt. educated on not smoking and to limit drinking. Pt. educated on seeing provider at least twice a a year until BP is properly under control with medication management. Pt. educated on importance of seeing healthcare provider on a regular basis for all health concerns given his older age and risk for further cimplications related to untreated hypertension for multiple years. Itâ€™s important that the pt. be aware f his condition but it is not unexpected that he does not monitor his blood pressure as roughly â€œ46 percent of U.S. adults are estimated to have hypertension, among whom only 80 percent are aware of their condition, and even fewer follow pharmacological treatmentâ€ (Rysz et. al., 2020). Pt. educated on importance of diet and medication compliance.
Consultation/Collaboration: if appropriate – collaborative â€˜Advanced Care Planningâ€™ with the patient/patientâ€™s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate â€“ consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making