Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension) Student Name Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. Rafael Camejo Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name : Mr. DT Age : 68-year-old Gender at Birth: Male Gender Identity : Male Source : Patient Allergies : PCN, Iodine Current Medications:  · Atorvastatin tab 20 mg, 1-tab PO at bedtime · ASA 81mg po daily · Multi-Vitamin Centrum Silver PMH: Hypercholesterolemia Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago. Preventive Care : Coloscopy 5 years ago (Negative)  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 History : No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone. Sexual Orientation : Straight Nutrition History : Diets off and on, Does not each seafood  Subjective Data: Chief Complaint : “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. Review of Systems (ROS) CONSTITUTIONAL : Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC : Headache and dizziness 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: 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 2/10. GENERAL APPREARANCE : The patient is aler.

1. Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX:
Hypertension)
Student Name
Miami Regional University
Date of Encounter:
Preceptor/Clinical Site:
Clinical Instructor: Dr. Rafael Camejo
Soap Note #
Main Diagnosis
( Exp: Soap Note #3 DX: Hypertension)
PATIENT INFORMATION
Name
: Mr. DT
Age
: 68-year-old
Gender at Birth:
Male
Gender Identity

2. : Male
Source
: Patient
Allergies
: PCN, Iodine
Current Medications:
· Atorvastatin tab 20 mg, 1-tab PO at bedtime
· ASA 81mg po daily
· Multi-Vitamin Centrum Silver
PMH:
Hypercholesterolemia
Immunizations:
Influenza last 2018-year, tetanus, and hepatitis A and B 4 years
ago.
Preventive Care
: Coloscopy 5 years ago (Negative)
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

3. Social History
: No smoking history or illicit drug use, occasional alcoholic
beverage consumption on social celebrations. Retired, widow,
he lives alone.
Sexual Orientation
: Straight
Nutrition History
: Diets off and on, Does not each seafood
Subjective Data:
Chief Complaint
: “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.
Review of Systems (ROS)
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in
LOC. Denies history of tremors or seizures.
HEENT

4. : 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:

5. 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 2/10.
GENERAL APPREARANCE
: 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:
No dyspnea or use of accessory muscles observed. No
egophony, whispered pectoriloquy or tactile fremitus on
palpation. Breath sounds presents and clear bilaterally on

6. 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 rebound no
distention or organomegaly noted on palpation
MUSKULOSKELETAL:
No pain to palpation. Active and passive ROM within normal
limits, no stiffness.
INTEGUMENTARY:
intact, no lesions or rashes, no cyanosis or jaundice.
ASSESSMENT:
Main Diagnosis
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 (Codina Leik, 2015). 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 (Domino et al,. 2017).
Differential diagnosis:
Ø Renal artery stenosis (ICD10 I70.1)
Ø Chronic kidney disease (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)

7. 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

8. · 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
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The

9. 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
NOTE:
PLEASE ADJUST TO THIS SAME TEMPLATE FORMAT