(ICD10 I70.1)
· Chronic kidney disease (ICD10 I12.9)
· Hyperthyroidism (ICD10 E05.90)
PLAN:
Labs and Diagnostic Test to be ordered:
· CMP
· Complete blood count (CBC)
· Lipid profile
· Thyroid-stimulating hormone (TSH)
· Urinalysis with Micro
· Electrocardiogram (EKG 12 lead)
Pharmacological treatment:
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.
· Lisinopril 10mg PO Daily
Non-Pharmacologic treatment:
· Weight loss
· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat
· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults
· Enhanced intake of dietary potassium
· Regular physical activity (Aerobic): 90–150 min/wk
· Tobacco cessation
· Measures to release stress and effective coping mechanisms.
Education
· Provide with nutrition/dietary information.
· Daily blood pressure monitoring log at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP
· Instruction about medication intake compliance.
· Education of possible complications such as stroke, heart attack, and other problems.
· Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all
Follow-ups/Referrals
· Follow up appointment 1 weeks for managing blood pressure and to evaluate current hypotensive therapy.
· No referrals needed at this time.
References
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
ISBN 978-0-8261-3424-0
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
(25th ed.). Print (The 5-Minute Consult Series).