COMPREHENSIVE I HUMAN CASE STUDY WEEK# 7
57 YEAR OLD REASON FOR ENCOUNTER HIGH
BLOOD PRESSURE {SOAP NOTE} NEWEST
VERSION
2026!!!!!!
History of Present Illness (HPI)
A 57-year-old patient presents for evaluation of elevated blood pressure, first noted [e.g., 2–3
weeks ago / during routine checkup]. The patient reports [persistent/intermittent] high
readings, with recent measurements around [e.g., 150–160/90–100 mmHg].
The patient [denies/reports] symptoms such as headache, dizziness, blurred vision, chest pain,
shortness of breath, or palpitations. There are [no/occasional] episodes of fatigue.
The patient has a history of [known hypertension/newly diagnosed] and is currently [on
medication/not on medication]. If on medication, adherence is [good/poor] and medications
include [e.g., amlodipine, lisinopril].
Risk factors include [family history of hypertension, high salt intake, obesity, smoking, alcohol
use, sedentary lifestyle]. The patient denies recent stressors or changes in health.
, There is [no/history of] complications such as stroke, heart disease, or kidney disease.
Key Questions to Ask (to complete history)
• When was high BP first noticed?
• Any symptoms (headache, vision changes, chest pain)?
• Current medications + adherence?
• Diet (salt intake)?
• Smoking/alcohol use?
• Exercise habits?
• Family history of hypertension or heart disease?
Physical Examination
General Appearance:
Patient is alert, oriented ×3, and in no acute distress. Appears well/overweight/obese.
Vital Signs:
• Blood Pressure: Elevated (e.g., 150–160/90–100 mmHg)
• Heart Rate: [e.g., 70–90 bpm]
• Respiratory Rate: Normal (12–20/min) • Temperature: Afebrile
• BMI: [overweight/obese if applicable]
Cardiovascular Examination:
• Normal S1 and S2, no murmurs, rubs, or gallops
• Regular rate and rhythm
• No peripheral edema
• Peripheral pulses intact and symmetrical
57 YEAR OLD REASON FOR ENCOUNTER HIGH
BLOOD PRESSURE {SOAP NOTE} NEWEST
VERSION
2026!!!!!!
History of Present Illness (HPI)
A 57-year-old patient presents for evaluation of elevated blood pressure, first noted [e.g., 2–3
weeks ago / during routine checkup]. The patient reports [persistent/intermittent] high
readings, with recent measurements around [e.g., 150–160/90–100 mmHg].
The patient [denies/reports] symptoms such as headache, dizziness, blurred vision, chest pain,
shortness of breath, or palpitations. There are [no/occasional] episodes of fatigue.
The patient has a history of [known hypertension/newly diagnosed] and is currently [on
medication/not on medication]. If on medication, adherence is [good/poor] and medications
include [e.g., amlodipine, lisinopril].
Risk factors include [family history of hypertension, high salt intake, obesity, smoking, alcohol
use, sedentary lifestyle]. The patient denies recent stressors or changes in health.
, There is [no/history of] complications such as stroke, heart disease, or kidney disease.
Key Questions to Ask (to complete history)
• When was high BP first noticed?
• Any symptoms (headache, vision changes, chest pain)?
• Current medications + adherence?
• Diet (salt intake)?
• Smoking/alcohol use?
• Exercise habits?
• Family history of hypertension or heart disease?
Physical Examination
General Appearance:
Patient is alert, oriented ×3, and in no acute distress. Appears well/overweight/obese.
Vital Signs:
• Blood Pressure: Elevated (e.g., 150–160/90–100 mmHg)
• Heart Rate: [e.g., 70–90 bpm]
• Respiratory Rate: Normal (12–20/min) • Temperature: Afebrile
• BMI: [overweight/obese if applicable]
Cardiovascular Examination:
• Normal S1 and S2, no murmurs, rubs, or gallops
• Regular rate and rhythm
• No peripheral edema
• Peripheral pulses intact and symmetrical
