SOAP: hypertension, visual floaters, elevated glucose
LM is a 71-year-old Caucasian woman, retired manager, married with two children. She has a history of hypertension. Family history parents both died from complications due to strokes, both parents were in their 80s when they deceased. LM.’s mother had a stroke earlier at the age of 48; she also had a history of HTN.
LM. comes in today because she recently started having floaters in her vision. She made appointments to see both the ophthalmologist and her primary doctor.
S: H.L. has only one concern and that is her elevated BP. She was at the dentist in October and the dentist said her blood pressure was high. She doesn’t remember what the BP reading was, she thought she had better come in to have it evaluated. She has had high blood pressure for approximately 7 years. She has been well controlled in the past with her medications and low salt diet. In the past her BPs ranged from 130-160/70-80s. She denies headaches, being lightheaded, blurred vision, numbness, loss of sensation or any symptoms of TIAs. She has recently developed floaters in her vision and went to her ophthalmologist for a visual check and subsequently had her prescription to get her glasses changed. She stated she needed stronger prescriptions. She has no other complaints; she said she has been healthy as a horse. On ROS everything normal. Her last visit her glucose was 116. She denies any symptoms polyuria, polydipsia, polyphagia, lethargy, change in weight, or neuropathy.
O: BP 186/102 half hour later BP essentially unchanged 186/104. P 68, R 18, weight 159.
Cardiac rate 68, regular rhythm without murmur or gallop. No carotid bruits.
Chest clear.
Breasts soft without masses, dimpling or nipple discharge.
Abdomen soft without masses or tenderness. No organomegaly.
Peripheral vascular small varicosities on both extremities without ulcerations, feet warm, good CMS bilaterally, dorsalis pulses +2, post tibials +1.
Neruo. DTR elicited symmetrical, negative Homan’s, negative Bibinski. Alert, oriented pleasant woman engages easily in conversation, has quick wit and sense of humor.
Pelvic/Rectum no lesions on labia or vulva. Vaginal canal smooth, pink also without lesions. Cervix intact and normal. Adnexa without masses or tenderness. Uterus barely palpable without masses. Rectum also without masses. Small hemorrhoids on external anus without bleeding. Stool hemmocult negative.
Medications:
Tenormin 50 mg QD
Calcium 500 mg QD
Vit. D 400 u QD
Previous abnormal labs 9/93:
Glucose 116
Hgb A1C 6.2