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    (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).

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