Soap note: hashimoto tyroiditis | Nursing homework help

Assessment:

The patient is a 68-year-old male presenting with a chief complaint of headaches that started two weeks ago. On examination, the patient’s blood pressure was elevated on three different occasions, with a current reading of 159/92 mmHg. The patient has a history of hypercholesterolemia and a family history of diabetes mellitus and hypertension. The patient denies chest pain, palpitations, shortness of breath, nausea, or vomiting. The patient’s neurological, respiratory, gastrointestinal, genitourinary, and musculoskeletal systems are all within normal limits. The patient’s skin appears normal.

Based on the patient’s history and examination, the primary diagnosis is hypertension. The patient is also at risk for cardiovascular disease due to his history of hypercholesterolemia and family history of hypertension and diabetes mellitus.

Plan:

The patient will be prescribed an antihypertensive medication to manage his blood pressure. Lifestyle modifications will also be recommended, including a heart-healthy diet and regular exercise. The patient will be advised to monitor his blood pressure regularly and return for follow-up in two weeks to assess the effectiveness of treatment. Additionally, the patient will be advised to continue taking his current medications, including atorvastatin and ASA.