i-Human Case Week #4: Comprehensive SOAP Note and
Follow-Up Plan for 56-Year-Old Female Blood Pressure
Recheck by i-Human Patients Academic Team
,i-Human Case Week #4
Comprehensive SOAP Note and Follow-Up Plan
Patient: 56-Year-Old Female – Blood Pressure Recheck
S: Subjective
Chief Complaint (CC):
"I am here for my blood pressure check."
History of Present Illness (HPI):
The patient is a 56-year-old female with a known history of hypertension
presenting for a routine blood pressure recheck. She reports adherence to her
prescribed antihypertensive medications. She denies headaches, dizziness, chest
pain, palpitations, shortness of breath, blurred vision, or syncope. She reports
occasional mild fatigue but attributes it to daily activities. She has been
attempting to reduce salt intake and increase physical activity.
,Past Medical History (PMH):
Hypertension (diagnosed ~5 years ago)
Hyperlipidemia
Past Surgical History (PSH):
None reported
Medications:
Lisinopril 20 mg daily
Hydrochlorothiazide 25 mg daily
Atorvastatin 20 mg nightly
Allergies:
No known drug allergies (NKDA)
Family History:
, Father: Hypertension, died of myocardial infarction at 68
Mother: Type 2 diabetes
Social History:
Non-smoker
Occasional alcohol use
Lives with spouse
Diet: Working on low-sodium diet
Exercise: Walks 2–3 times per week
Review of Systems (ROS):
General: Denies fever, weight loss
Cardiovascular: Denies chest pain, palpitations
Respiratory: Denies dyspnea
Follow-Up Plan for 56-Year-Old Female Blood Pressure
Recheck by i-Human Patients Academic Team
,i-Human Case Week #4
Comprehensive SOAP Note and Follow-Up Plan
Patient: 56-Year-Old Female – Blood Pressure Recheck
S: Subjective
Chief Complaint (CC):
"I am here for my blood pressure check."
History of Present Illness (HPI):
The patient is a 56-year-old female with a known history of hypertension
presenting for a routine blood pressure recheck. She reports adherence to her
prescribed antihypertensive medications. She denies headaches, dizziness, chest
pain, palpitations, shortness of breath, blurred vision, or syncope. She reports
occasional mild fatigue but attributes it to daily activities. She has been
attempting to reduce salt intake and increase physical activity.
,Past Medical History (PMH):
Hypertension (diagnosed ~5 years ago)
Hyperlipidemia
Past Surgical History (PSH):
None reported
Medications:
Lisinopril 20 mg daily
Hydrochlorothiazide 25 mg daily
Atorvastatin 20 mg nightly
Allergies:
No known drug allergies (NKDA)
Family History:
, Father: Hypertension, died of myocardial infarction at 68
Mother: Type 2 diabetes
Social History:
Non-smoker
Occasional alcohol use
Lives with spouse
Diet: Working on low-sodium diet
Exercise: Walks 2–3 times per week
Review of Systems (ROS):
General: Denies fever, weight loss
Cardiovascular: Denies chest pain, palpitations
Respiratory: Denies dyspnea
