Vincent Frank Ihuman SOAP Note

Vincent Frank is a caucasian male that has been diagnosed with symptoms of hypertension. The Ihuman case study presents the tests, medications and recommendations on the patient. A SOAP note provides a compiled and detailed brief of an Ihuman case study.

Chief Complaint: Vincent Frank, 46 y/o

Diagnosis: Hypertension

Height & Weight: 5ft 11, 220lbs, 

BMI: 30.8

Risk factors: smoking, alcohol use, lack of physical activity, work-related and physiological stressors

About Frank

• On 5 medications for blood pressure control
• Lost 20 lbs in a year and a half
• Has a glass of wine on Friday and Saturdays, but otherwise doesn’t drink
• Extremely compliant with medications
• Doesn’t smoke
• Leg cramps (began one year ago)
• Hypokalemia
• Osteoarthritis- knee pain. Takes Tylenol
• Family history of hypertension
• Father had stroke at 35
• high cholesterol (good question)
• No history of DM/Dyslipidemia (not good questions)
• Not significant to ask about headaches, sleep apnea, eye problems/blurred vision,or cough/sob specific HPI questions

Physical Examination

• Funduscopic exam
• Inspect/Palpate head
• PMI
• Auscultation of the heart
• Abdominal assessment for bruits, enlargedkidneys
  • Include auscultation/palpation
• Carotid arteries for bruits/neck veins for distention
• Thyroid: enlargement or nodules
• Lungs- normal
• Peripheral pulses/edema
  • Weak pulse
• BP (150/92) (elevated/widen)
  • Hypertension
    • Stage 1: 130-139or diastolic over 80-89
    • Stage 2: >140or diastolic over 90

Diagnostics

• UA- proteinuria
• BUN/creatinine- increased
• CBC- may be anemia
• K- increased or decreased
• Blood glucose- may be increased
• Lipid panel (triglycerides, HDL, LDL)- increased
• 12 lead ECG- target organ damage (LVH or left atrial enlargement)
• BNP- hormone released to indicate increased myocardial demand

Differential diagnosis

Cushing’s Syndrome (Alt/MnM)

• Cortisol, urine
• Cortisol, PM
• Cortisol, AM Hypertension, primary(alt)
• No labs

Primary hyperaldosteronism (Lead/MnM)

• Renin to aldosterone ration-Restricted sodium
• Primary aldosterone concentration/Plasma renin concentration (?)
• Adrenal CT
• 24hr urine

Renal thrombosis/artery (Alt/MnM)

• Renal ultrasound

Chronic kidney disease (Alt/MnM)

• BMP
• CBC Pheochromocytoma (Alt/MnM)
• metanephrine

Management

Primary hyperaldosteronism

Recommended first line treatment would be to surgically remove the tumor that is present. Usually about 60-70%of patients may return to a normotensive state within 3-6months.

Secondary option would be to treat with a medication known as spironolactone, which is a mineralocorticoid antagonist, that helps to control normal blood pressure control and potassium concentrations by inhibiting ligands to the mineralocorticoid receptor.

Ongoing encouragement of physical activity, DASH diet, weight reduction, and continuing to limit alcohol.

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