To/Do Need to Write 2 pages about 3 life style modifications for a person with elevated blood pressure, smoker, no physical activities, overweight . APA7 Format Read the SOAP note, the person also is a smoker and has a family history of heart disease, all the information is in the SOAP note./n Ohio University Advanced Pharmacology Case Study Module 1 SOAP Bob Cat Module 1 New patient HTN Demographics: • Patient Name: Bob Cat • Age: 50 • Gender: Male Subjective: • Past Medical History: None • Current Medications: None • Surgical History: None • Allergies: Penicillin, tree nuts Social History: • Smoking Status: Current smoker, averaging 1 pack per day for the past 20 years • Alcohol: Occasionally consumes 1-2 beers with dinner • Diet: Strives to eat healthy with no specific diet • Exercise: Rarely engages in physical activity • Family History: Father passed away at 65 due to heart failure, mother currently 80 and well, no family history of cancer, only child Chief Complaint: "I haven't seen a provider in about 20 years, so I'm here to see you as my new PCP." Review of Systems (ROS): • Constitutional: Denies fevers, chills, sweats, and weight changes. • Eyes: Denies any visual symptoms, eye pain, crusting, or drainage. • Ears, Nose, and Throat: No difficulties with hearing. No symptoms of rhinitis or sore throat. Cardiovascular: Denies chest pains, palpitations, orthopnea, paroxysmal nocturnal dyspnea, or extremity edema. • Respiratory: No dyspnea on exertion, no wheezing or cough. Gl: No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia, or melena. Ohio University Advanced Pharmacology Case Study Module 1 GU: No urinary hesitancy or dribbling. No nocturia or urinary frequency. No abnormal urethral discharge. Musculoskeletal: No myalgias or arthralgias. Neurologic: No chronic headaches, no seizures. Patient denies numbness, tingling, or weakness. • Psychiatric: Denies problems with mood disturbance. No problems with anxiety. • Endocrine: No excessive urination or excessive thirst. • Dermatologic: Denies any rashes or skin changes. Objective: • Vitals: • Height: 5' 10" • Weight: 190 lbs • BMI: 26 • Temperature: 97.8°F • Blood pressure: 148/94 (recheck 150/88) Heart rate: 70 SPO2: 98% Pain: 0 Physical Exam: • General: Well-appearing, well-nourished, in no distress. Oriented x 3, normal mood, and affect. Ambulating without difficulty. Skin: Good turgor, no rash, unusual bruising, or prominent lesions. Normal hair texture and distribution. Nails exhibit normal color with no deformities. • HEENT: Normocephalic, atraumatic head. Eyes show intact visual acuity, clear conjunctiva, non-icteric sclera, and normal fundi. Ears have clear ear canals, translucent • and mobile tympanic membranes. Nose and mouth exhibit no abnormalities. Neck: Supple, without lesions, bruits, or adenopathy. Non-enlarged and non-tender thyroid. Cardiovascular: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop. Ohio University Advanced Pharmacology Case Study Module 1 • • • • Respiratory: Clear to auscultation and percussion, no wheezes, rhonchi, or crackles. Abdomen: Normal bowel sounds, no tenderness, organomegaly, masses, or hernia. Back: Normal spine without deformity or tenderness, no CVA tenderness. Extremities: No amputations or deformities, cyanosis, edema, or varicosities. Peripheral pulses intact. Neurological: CN 2-12 normal, normal sensation to pain, touch, and proprioception. Normal deep tendon reflexes, no pathologic reflexes. Psychiatry: Oriented X3, intact recent and remote memory, judgment, insight, normal mood, and affect. G/U: Circumcised penis without lesions, normal urethral meatus without discharge, normal-sized testes and epididymides. Assessment: 1. Z00.00 Well Adult Exam 2. R03.0 - Elevated blood-pressure reading, without diagnosis of hypertension 3. F17.200- Smoker 20-year pack history Plan: 1. Z00.00 Well Adult Exam - • Labs ordered include CBC, CMP, TSH, A1C, Lipid panel. • Counseled on age-related screenings; colonoscopy ordered. • Administered PCV15 pneumonia vaccine. 2. R03.0 - Elevated blood-pressure reading, without diagnosis of hypertension Initial elevated blood pressure reading. Follow-up scheduled in one week. ***STUDENT TO PRESCRIBE LIFESTYLE MODIFICATIONS*** 3. F17.200-Smoker 20-year pack history • Counseled on smoking cessation; patient not currently ready to quit.