1. This SOAP note is for a 65-year-old male patient who presented with headaches and high blood pressure readings over the past two weeks. 2. On examination, the patient's blood pressure was 159/92 mmHg. No other abnormalities were found. 3. The patient was diagnosed with essential (primary) hypertension. The treatment plan includes lifestyle modifications and starting hydrochlorothiazide 25 mg daily. Follow-up with his primary care provider in one week is recommended to monitor his blood pressure.

1. Soap Note Hypertension Draft
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INFORMATIONName: Mr. W.S.Age: 65-year-oldSex: MaleSource: PatientAllergies:
NoneCurrent Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtimePMH:
HypercholesterolemiaImmunizations: 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, HTNDaughter-
alive, 34 years old, healthySocial 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 agoSymptom
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 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 nocturnaldyspnea.Gastrointestinal: Denies abdominal pain or
discomfort. Denies flatulence, nausea, vomiting ordiarrhea.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 DataCONSTITUTIONAL: Vital signs: Temperature: 98.5 F, Pulse:
87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 64, Wt 200 lb, BMI 25. Report pain
0/10.General appearance: The patient is alert and oriented x 3. No acute distress noted.

2. 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 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
palpationMusculoskeletal:No pain to palpation. Active and passive ROM within normal
limits, no stiffness.Integumentary:intact, no lesions or rashes, no cyanosis or
jaundice.AssessmentEssential (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:Renal artery stenosis(ICD10 I70.1)Chronic kidney
disease(ICD10 I12.9)Hyperthyroidism (ICD10 E05.90)PlanDiagnosis 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:CMPComplete blood countLipid
profileThyroid-stimulating hormoneUrinalysisElectrocardiogramPharmacological
treatment: The treatment of choice in this case would be:Thiazide-like diuretic and/or a
CCBHydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. Non-
Pharmacologic treatment: Weight lossHealthy diet (DASH dietary pattern): Diet rich in
fruits, vegetables, whole grains, and low-fat dairy products with reduced content of
saturated and trans l fatReduced intake of dietary sodium: <1,500 mg/d is optimal goal but
at least 1,000 mg/d reduction in most adultsEnhanced intake of dietary potassiumRegular
physical activity (Aerobic): 90150 min/wkTobacco cessationMeasures to release stress and
effective coping mechanisms.EducationProvide 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 PCPInstruction 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 allFollow-ups/ReferralsEvaluation with PCP in 1 weeks for managing
blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.No
needed at this time.ReferencesDomino, 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.

3. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-
8261-3424-0