(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).