Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement. Example: PATIENT INFORMATION Name: Mr. W.S. Age: 65-year-old Sex: Male Source: Patient Allergies: None Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime PMH: Hypercholesterolemia Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago. Surgical History: Appendectomy 47 years ago. Family History: Father- died 81 does not report information   Mother-alive, 88 years old, Diabetes Mellitus, HTN  Daughter-alive, 34 years old, healthy Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone. SUBJECTIVE: Chief complain : “headaches” that started two weeks ago Symptom analysis/HPI: The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness.He states that he has been under stress in his workplace for the last month. Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting. ROS: CONSTITUTIONAL : Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC : Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.  HEENT : HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing. Respiratory :Patient denies shortness of breath, cough or hemoptysis. Cardiovascular : No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea. Gastrointestinal :Denies abdominal pain or discomfort.Denies flatulence, nausea, vomiting or diarrhea. Genitourinary : Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence. MUSCULOSKELETAL : Denies falls or pain. Denies hearing a clicking or snapping sound. Skin : No change of coloration such as cyanosis or jaundice, no rashes or pruritus. Objective Data CONSTITUTIONAL : Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10. General appearance: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intac ...

1. Soap notes will be uploaded to Moodle and put through TURN-
It-In (anti-Plagiarism program)
Turn it in Score must be less than 50% or will not be accepted
for credit, must be your own work and in your own words. You
can resubmit, Final submission will be accepted if less than
50%. Copy paste from websites or textbooks will not be
accepted or tolerated. Please see College Handbook with
reference to Academic Misconduct Statement.
Example:
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at
bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza last 2018-year, tetanus, and hepatitis
A and B 4 years ago.

2. Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not report information
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional
alcoholic beverage consumption on social celebrations. Retired,
widow, he lives alone.
SUBJECTIVE:
Chief complain
: “headaches” that started two weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of
headaches and on 3 different occasions blood pressure was
measured, which was high (159/100, 158/98 and 160/100
respectively). Patient noticed the problem started two weeks ago
and sometimes it is accompanied by dizziness.He states that he
has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath,
nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizzeness as describe above. Denies changes in

3. LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes:
Denies any changes in vision, diplopia or blurred vision. Ear:
Denies pain in the ears. Denies loss of hearing or drainage.
Nose: Denies nasal drainage, congestion. THROAT: Denies
throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
:Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal
nocturnal
dyspnea.
Gastrointestinal
:Denies abdominal pain or discomfort.Denies flatulence, nausea,
vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency.
Denies difficulty starting/stopping stream of urine or
incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping
sound.
Skin
: No change of coloration such as cyanosis or jaundice, no
rashes or pruritus.

4. Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92
mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI
25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No
acute distress noted.
NEUROLOGIC:
Alert, CNII-XII grossly intact, oriented to person, place, and
time
.
Sensation intact to bilateral upper and lower extremities.
Bilateral UE/LE strength 5/5.
HEENT:
Head: Normocephalic, atraumatic, symmetric, non-tender.
Maxillary sinuses no tenderness. Eyes: No conjunctival
injection, no icterus, visual acuity and extraocular eye
movements intact. No nystagmus noted. Ears: Bilateral canals
patent without erythema, edema, or exudate. Bilateral tympanic
membranes intact, pearly gray with sharp cone of light.
Maxillary sinuses no tenderness. Nasal mucosa moist without
bleeding. Oral mucosa moist without lesions,.Lids non-
remarkable and appropriate for race.
Neck: supple without cervical lymphadenopathy, no jugular vein
distention, no thyroid swelling or masses.
Cardiovascular:
S1S2, regular rate and rhythm, no murmur or gallop noted.
Capillary refill < 2 sec.
Respiratory:

5. No dyspnea or use of accessory muscles observed. No
egophony, whispered pectoriloquy or tactile fremitus on
palpation. Breath sounds presents and clear bilaterally on
auscultation.
Gastrointestinal:
No mass or hernia observed. Upon auscultation, bowel sounds
present in all four quadrants, no bruits over renal and aorta
arteries. Abdomen soft non-tender, no guarding, no reboundno
distention or organomegaly noted on palpation
Musculoskeletal:
No pain to palpation. Active and passive ROM within normal
limits, no stiffness.
Integumentary:
intact, no lesions or rashes, no cyanosis or jaundice.
Assessment
Essential (Primary) Hypertension (ICD10 I10): Given the
symptoms and high blood pressure (156/92 mmhg), classified as
stage 2. Once the organic cause of hypertension has been ruled
out, such as renal, adrenal or thyroid, this diagnosis is
confirmed.
Differential diagnosis:
Ø Renal artery stenosis(ICD10 I70.1)
Ø Chronic kidney disease(ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
Plan

6. Diagnosis is based on the clinical evaluation through history,
physical examination, and routine laboratory tests to assess risk
factors, reveal identifiable causes and detect target-organ
damage, including evidence of cardiovascular disease.
These basic laboratory tests are:
· CMP
· Complete blood count
· Lipid profile
· Thyroid-stimulating hormone
· Urinalysis
· Electrocardiogram
Ø
Pharmacological treatment:
The treatment of choice in this case would be:
Thiazide-like diuretic and/or a CCB
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally
once daily.
Ø
Non-Pharmacologic treatment
:

7. · 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 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

8. · Evaluation with PCP in 1 weeks for managing blood pressure
and to evaluate current hypotensive therapy. Urgent Care visit
prn.
· No referrals needed at this time.
References
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The
5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute
Consult Series).
Codina Leik, M. T. (2014). Family Nurse Practitioner
Certification Intensive Review (2nd ed.). ISBN 978-0-8261-
3424-0