NR 509 Advanced Physical Assessment
Case Study 2026 – Hypertension (High
Blood Pressure) | Complete SOAP Note,
ROS, Physical Exam & Treatment Plan
High Blood Pressure (Hypertension)
,Introduction
Hypertension is a major public health concern affecting approximately one in
three adults globally. Persistent elevation of blood pressure contributes
significantly to cardiovascular diseases such as stroke, myocardial infarction,
heart failure, and kidney disease. Early detection and proper management are
essential in reducing long-term complications.
Advanced practice nurses play a critical role in identifying hypertension through
comprehensive health assessments and implementing appropriate treatment
strategies. This case study examines a patient presenting with symptoms
suggestive of hypertension and explores diagnostic reasoning, treatment
planning, and patient education.
Abstract
Hypertension is one of the most prevalent cardiovascular conditions globally and
a major risk factor for stroke, myocardial infarction, renal disease, and heart
failure. This case study evaluates a middle-aged patient presenting with elevated
blood pressure readings and associated symptoms. A comprehensive assessment
including patient history, physical examination, diagnostic evaluation, and
evidence-based treatment planning was conducted. The case emphasizes the
importance of early identification, lifestyle modification, pharmacological
management, and long-term monitoring to reduce cardiovascular risk. The study
demonstrates advanced nursing clinical reasoning in diagnosing and managing
primary hypertension.
Patient Biodata
Name: John D. Miller
Age: 52 years
Gender: Male
Ethnicity: African American
Marital Status: Married
Occupation: Accountant
, Height: 5 ft 10 in (178 cm)
Weight: 210 lbs (95 kg)
BMI: 30.1 (Obese Class I)
Date of Visit: March 2026
Chief Complaint: “I have been having frequent headaches and dizziness for the
past few weeks.”
Chief Complaint (CC)
Frequent headaches and occasional dizziness for approximately 3 weeks.
History of Present Illness (HPI)
John Miller is a 52-year-old male who presents to the clinic complaining of
intermittent headaches and dizziness that started approximately three weeks ago.
The headaches are described as dull, pressure-like pain localized in the occipital
region. They occur mostly in the morning and occasionally worsen during stressful
workdays.
The patient reports occasional episodes of blurred vision and mild fatigue. He
denies chest pain, palpitations, syncope, or shortness of breath. He states that he
checked his blood pressure at a pharmacy last week and the reading was 168/96
mmHg.
He reports increased work stress and admits to consuming fast foods frequently
due to a busy schedule. He exercises rarely and has gained approximately 15
pounds in the past two years.
The patient denies recent infections, trauma, or changes in medication.
Past Medical History (PMH)
• Hyperlipidemia diagnosed 4 years ago
• Prehypertension noted during annual exam 2 years ago
• No history of diabetes
Case Study 2026 – Hypertension (High
Blood Pressure) | Complete SOAP Note,
ROS, Physical Exam & Treatment Plan
High Blood Pressure (Hypertension)
,Introduction
Hypertension is a major public health concern affecting approximately one in
three adults globally. Persistent elevation of blood pressure contributes
significantly to cardiovascular diseases such as stroke, myocardial infarction,
heart failure, and kidney disease. Early detection and proper management are
essential in reducing long-term complications.
Advanced practice nurses play a critical role in identifying hypertension through
comprehensive health assessments and implementing appropriate treatment
strategies. This case study examines a patient presenting with symptoms
suggestive of hypertension and explores diagnostic reasoning, treatment
planning, and patient education.
Abstract
Hypertension is one of the most prevalent cardiovascular conditions globally and
a major risk factor for stroke, myocardial infarction, renal disease, and heart
failure. This case study evaluates a middle-aged patient presenting with elevated
blood pressure readings and associated symptoms. A comprehensive assessment
including patient history, physical examination, diagnostic evaluation, and
evidence-based treatment planning was conducted. The case emphasizes the
importance of early identification, lifestyle modification, pharmacological
management, and long-term monitoring to reduce cardiovascular risk. The study
demonstrates advanced nursing clinical reasoning in diagnosing and managing
primary hypertension.
Patient Biodata
Name: John D. Miller
Age: 52 years
Gender: Male
Ethnicity: African American
Marital Status: Married
Occupation: Accountant
, Height: 5 ft 10 in (178 cm)
Weight: 210 lbs (95 kg)
BMI: 30.1 (Obese Class I)
Date of Visit: March 2026
Chief Complaint: “I have been having frequent headaches and dizziness for the
past few weeks.”
Chief Complaint (CC)
Frequent headaches and occasional dizziness for approximately 3 weeks.
History of Present Illness (HPI)
John Miller is a 52-year-old male who presents to the clinic complaining of
intermittent headaches and dizziness that started approximately three weeks ago.
The headaches are described as dull, pressure-like pain localized in the occipital
region. They occur mostly in the morning and occasionally worsen during stressful
workdays.
The patient reports occasional episodes of blurred vision and mild fatigue. He
denies chest pain, palpitations, syncope, or shortness of breath. He states that he
checked his blood pressure at a pharmacy last week and the reading was 168/96
mmHg.
He reports increased work stress and admits to consuming fast foods frequently
due to a busy schedule. He exercises rarely and has gained approximately 15
pounds in the past two years.
The patient denies recent infections, trauma, or changes in medication.
Past Medical History (PMH)
• Hyperlipidemia diagnosed 4 years ago
• Prehypertension noted during annual exam 2 years ago
• No history of diabetes
