Please sse this case study to make

Please sse this case study to make a SOAP note. Use the OLD CARTS when interviewing the patient. Provide 1 diagnosis and 3 differential diagnoses. All diagnoses must be ICD 10 coded. Case Study You are working in the office of Dr. Rodriguez, a general internist. He asks you to see a patient named Mr. Bradford Hicks, a 45-year-old male who is coming in for a follow-up visit. Before seeing the patient, you review his chart. Mr. Hicks was last in the office about three months ago, and that had been his first visit. He had come for an employment physical. He was noted then to have a blood pressure of 176/104. Because of limited time at the last visit, Dr. Rodriguez had asked him to return in a week to recheck his blood pressure and do a more thorough exam. Mr. Hicks had missed that appointment but then had rescheduled one for today. Today, his blood pressure is 172/98. Dr. Rodriguez comments, “His blood pressure has been high now on two occasions.” You walk into the room and introduce yourself to Mr. Hicks. You explain that you are a student working with Dr. Rodriguez and that you will be interviewing and examining him first, and then Dr. Rodriguez will join you. SUBJECTIVE Reason for visit “What brings you to the office today?” “Frankly, I am worried about my blood pressure. When I was in the office three months ago and heard my blood pressure, I thought it was because I was nervous. I hate going to see doctors. But since then, I read a little bit online about high blood pressure and I got pretty scared. I read that it can cause strokes, and that really freaked me out. My father had a stroke when he was 55, and it was a bad one. They said it was his blood pressure, and I just don’t want that to happen to me. I mean, is this thing hereditary?” Patient History “Mr. Hicks, have you had any chest pains?” “Yes, sometimes I get sharp chest pain when I am not doing anything. It lasts for a few seconds and goes away on its own.” “Do you feel anything else with the chest pains?” “No, I don’t feel dizziness or my heart beating fast at all—just the sharp pain.” “Have you had any headaches?” “No, I haven’t had any headaches lately.” When you ask him about other specific symptoms, you learn he has had no changes in vision, shortness of breath, leg swelling, pain with walking, or changes in his urinary habits. He takes no medications on a routine basis and takes no herbal or complementary remedies. “Aside from your last visit with Dr. Rodriguez, has a doctor or other health professional told you in the past that you have high blood pressure?” “You know, I haven’t been to the doctor much, but I think a doctor told me a few years ago that I had high blood pressure then.” You also learn that he doesn’t take any medications on a daily basis and has never been treated for hypertension. He does not take any decongestants or non-steroidal anti-inflammatories (NSAIDs) on a regular basis, and he has no history of heart disease or kidney disease, though he again states that he rarely sees doctors. “Many substances such as tobacco, alcohol, and recreational drugs like cocaine or speed can affect blood pressure. Are you currently using or have you in the past used any of these substances?” “I’ve been smoking about a half a pack a day since I was 18 but I’ve never used any street drugs.” He also relates that he drinks one to two alcoholic beverages per month. He does not follow any diet but often eats at diners and fast-food restaurants. He works as a computer systems analyst for a large corporation and travels quite often. In addition to his father having high blood pressure, his family history is significant for his mother having type 2 DM and one of his two brothers is being treated for hypertension. You ask Mr. Hicks to change into a gown. As you walk out of the examining room you bump into Dr. Rodriguez. “So, how’s it going with Mr. Hicks?” he asks. You brief Dr. Rodriguez on what you have learned so far. You wonder if this is just a case of white-coat hypertension because Mr. Hicks seems a little nervous. Dr. Rodriguez states, “That’s a good point. But given the degree of Mr. Hicks’ blood pressure elevation and his risk factors, I suspect that his blood pressure is consistently in the hypertensive range. OBJECTIVE You re-enter the room and do a complete exam, finding the following: Physical Exam General appearance: Middle-aged male, sitting comfortably. Vital signs: Temperature is 37 C (98.2 F) Pulse is 86 beats/minute Respiratory rate is 10 breaths/minute Blood pressure is 182/102 mmHg right arm, 178/100 mmHg left arm Weight is 109 kg (240 lbs) Height is 188 cm (74 in) Body Mass Index is 31 kg/m2 ASSESSMENT Head, eyes, ears, nose, and throat (HEENT): Retinas are difficult to visualize because pupils are not dilated. Neck: Carotid pulses 2+, thyroid not enlarged or tender, no jugular venous distention. Lungs: Clear to auscultation, no crackles, or wheezes. Heart: Regular rate and rhythm with a normal S1 and S2, no murmurs or gallops. PMI was difficult to assess given the patient’s body habitus. Abdomen: Obese, normal bowel sounds, soft, non-tender, no organomegaly, no masses, no bruits, aortic pulse not palpable. Extremities: No edema. Pulses: 2+ radial, brachial, femoral, dorsal pedal, and posterior tibial pulses. Popliteal pulses are difficult to appreciate. Neurologic: Pupils are equal and reactive, extraocular movements are intact, the face is symmetric in movement and sensation is normal to light touch, hearing intact to finger rub, palate elevation is symmetric, tongue midline; sensation intact to light touch and strength 5/5 in all four extremities. No pronator drifts. DTRs 2/4 at patellar tendons. Babinski absent. After you complete the exam, you tell Mr. Hicks that you will be going to discuss the exam with Dr. Rodriguez and will return afterward. You find Dr. Rodriguez in the hallway and tell him about your findings on history and exam. Dr. Rodriguez says, “Mr. Hicks’ pressure has been high now on multiple readings, and he may have long-standing hypertension based on his history.” Labs and Diagnostics You say, “Dr. Rodriguez, I was thinking that we should get electrolytes, BUN and creatinine, and an ECG, Diabetes screening, Fasting lipid panel, and Hematocrit Urine analysis. Pending when results return What is the diagnosis, what is the pathophysiology of the diagnosis? Mention 3 other differential diagnoses with ICD10 codes, their pathophysiology, and why they should be ruled out. The ECG shows a normal sinus rhythm at a rate of 90. The QRS axis is at approximately -30 degrees (lead II is nearly isoelectric, with lead I having a positive deflection). The deep S wave in V2 and the large R wave in V6 meet the voltage criteria for LVH (depth of S wave in V1 or V2 plus the height of V5 or V6 is > 35 mm). There are also ST depression and T wave inversions in V5 and V6. The large terminal downward deflection of the P wave in V1 is consistent with left atrial enlargement. ECG Interpretation The large QRS voltages are a finding that is very specific (but less sensitive) for left ventricular hypertrophy. The ST segment depressions and T wave inversions in left precordial leads can occur in left ventricular hypertrophy and is known as a strain pattern. The urinalysis is significant for 1+ protein. The remainder of the dipstick is normal. The random finger-stick glucose is 87. PLAN Pharmacological therapy Renin-angiotensin system blockers: Lisinopril, Provide additional benefits for the following conditions Heart failure, h/o MI, chronic kidney disease, and recurrent stroke prevention. Thiazide diuretics: HCTZ, Provide additional benefits for the following conditions CV disease prevention, and recurrent stroke prevention. Nonpharmacological treatment Smoking cessation Lifestyle modification- DASH diet, exercising, stress management Follow-up instructions for the patient? Reflections?

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