Focused SOAP Note
M, 66, M, Hispanic
CC (chief complaint): History of uncontrolled hypertension.
HPI (history of present illness): Mario is a 66-year-old Hispanic male who presents to the emergency room at his local hospital with acute aphasia, right facial droop, and right-sided weakness. The sudden onset of symptoms occurred at the post office where he works part time. One of his co-workers called 911. On the way to the hospital, the advanced squad team evaluated Mario’s neurologic deficits and glucose levels. The squad team then notified the receiving hospital of a possible stroke patient. Lucinda, his wife, tells the nurse practitioner that Mario has a history of uncontrolled hypertension (and he was often non-compliant with his anti-hypertensive medications). His recent diagnosis of diabetes also was noted, as well as the oral hypoglycemic agents he was taking.
Tenormin (atenolol) 25-50 mg/day PO to treat hypertension
Sulfonylureas 2.5/250 mg twice daily with meals to treat diabetes
Allergies: No known food and drug allergies.
PMHx: Hypertension and diabetes.
Soc and Substance Hx: Mario leads a sedentary lifestyle that had contributed to his excess weight. Mario is a smoker, usually smoking about a pack and a half each day. He takes alcohol occasionally.
Fam Hx: Mario’s parents passed away from myocardial infarctions when they were in their late 60s. His children are healthy without significant medical history. His two sisters suffer from hypertension while his only brother is diabetic.
Surgical Hx: Splenectomy at 38 years.
Mental Hx: Mario has a history of depression after his retirement one year ago. He was treated successfully. He has no history of suicidal ideation or self-harm tendencies.
Violence Hx: Mario lives peacefully with the neighbors with no incidences of sexual or physical violence.
Reproductive Hx: Mario has two daughters. He is sexually active with his wife. No history of sexual dysfunction. He practices vaginal sex without history of oral sex.
ROS (review of symptoms):
GENERAL: No unintentional fever, chills, fatigue, or body weight changes.
• Eyes: Difficulty in seeing. He uses eye glasses due to a history of shortsightedness.
• Ears, Nose, Throat: No hearing difficulty, runny nose, or sore throat.
SKIN: No skin lesions or rashes.
CARDIOVASCULAR: The patient has a history of chest pains and pressure.
RESPIRATORY: Contracted Covid-19 last year June. Since his discharged he has no incidence of shortness of breath or cough.
GASTROINTESTINAL: No history of diarrhea, vomiting, or nausea. Has normal bowel movement and no pain.
GENITOURINARY: No history of burning on urination.
NEUROLOGICAL: The patient feels dizzy, loss of balance, and experiences numbness and mild headache. No change in bowel movement. He has a drooping face and slurred speech.
MUSCULOSKELETAL: No pain or malfunction of the muscles or joint.
HEMATOLOGIC: No history of bleeding or anemia.
LYMPHATICS: Splenectomy at 38 years.
PSYCHIATRIC: The patient has a history of depression after retirement.
ENDOCRINOLOGIC: No history of sweating since recovering from Covid-19.
REPRODUCTIVE: He is sexually active but past the child-bearing age.
ALLERGIES: No known food or cold allergies.
Vital signs: 97.8 F, 124/89 mmHg, 18, 72/100, 5’5” inches, 255 pounds, BMI 42.43
CT scan to check for brain damage or bleeding.
MRI to diagnose stroke and check for damages in the brain or tissues.
ECG to determine heart disease triggering stroke such as Atrial Fibrillation or MI.
CBC and coagulation profile to assess for thrombocytopenia before recommending antithrombotic therapy.
CT scan shows a diagnosis of stroke. No bleeding or ischemia.
Stroke or cerebrovascular accident or CVA involves a loss of blood supply in one part of the brain causing massive damage (Campbell et al., 2019). It is a medical emergency that is characterized by difficulty in walking, slurred speech, numbness, and dizziness (Campbell et al., 2019). Treatment such as clot buster is effective in reducing brain damage.
Brain tumor involves the growth of abnormal cells in the brain. Some of the risk factors include genetic mutations or exposure to radiation (Seetha & Raja, 2018). A brain tumor can cut short the supply of blood in the brain. Individuals may slowly develop symptoms related to speech over months such as slurred speech.
The condition occurs due to brain dysfunction due to relatively high blood pressure (Miller et al., 2018). Some of the symptoms may include headache, vomiting, confusion, and trouble balancing.
Traumatic Brain Injury (Epidural/Subdural Hemorrhage)
The condition involves a sudden injury that causes damage to the brain (Campbell et al., 2019). It occurs when the skull is under impact from a blunt object or due to a fall.
The patient and the wife should be educated about stroke, the risk factors, diagnostic tests, and appropriate treatment. The discussion with the wife should include the symptom and the risk factors (Morin et al., 2021). For instance, brain tumor or impact on the skull. Other risk factors include hypertension, diabetes, smoking, and a sedentary lifestyle.
The patient will require medication to reduce the extent of brain damage. A clot buster is essential to reduce the damage. A referral to a physical therapist, occupational therapist, and speech therapist is essential to restore the functioning of the body parts (Morin et al., 2021). Failure of therapeutic interventions can undermine the mobility of a patient.
The case study shows that non-adherence to hypertension medication can increase the risk of stroke. Educating patients about adherence is essential for recovery. Practitioners should follow up to ensure appropriate adherence. Immediate response is essential to reduce the extent of the damage.
The patient is at risk of stroke due to contributing factors such as hypertension, diabetes, smoking, and a sedentary lifestyle. The patient should review the lifestyle to promote recovery and reduce reoccurrence.
Campbell, B. C., De Silva, D. A., Macleod, M. R., Coutts, S. B., Schwamm, L. H., Davis, S. M., & Donnan, G. A. (2019). Ischaemic stroke. Nature Reviews Disease Primers, 5(1), 1-22.
Miller, J. B., Suchdev, K., Jayaprakash, N., Hrabec, D., Sood, A., Sharma, S., & Levy, P. D. (2018). New developments in hypertensive encephalopathy. Current hypertension reports, 20(2), 1-7.
Morin, D., Rémillard, S., Salerno, A., & Michel, P. (2021). Stroke patient education: scientific evidence, practical application. Therapeutische Umschau. Revue Therapeutique, 78(6), 249-258.
Seetha, J., & Raja, S. S. (2018). Brain tumor classification using convolutional neural networks. Biomedical & Pharmacology Journal, 11(3), 1457.