i-Human Case Week #4 Full SOAP Note and Follow-Up Plan for a 56-Year-Old Female Presenting for a Blood Pressure Recheck

I-Human Case Week #4 Full Soap Note And Follow-Up Plan
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For 56-Year-Old Female Presenting For A Blood Pressure
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Recheck In An Outpatient Clinic i i i i i




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SOAP Note i i




Patient Information
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Name:i i-Humani Casei Weeki #4i
Age:i 56i yearsi
Sex:i Femalei
Height:i 5’5”i (165i cm)i
Weight:i 188i lbi (85.5i kg)i BMI:i
31.3i (Obesei Classi I)i

Chiefi Complaint:i
“I'mi herei toi havei myi bloodi pressurei rechecked.”i

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,S – Subjective
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History of Present Illness (HPI)
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56-year-oldi femalei presentsi fori ai follow-upi bloodi pressurei evaluationi afteri previousi elevatedi
readings.i Shei reportsi thati duringi heri lasti visiti heri bloodi pressurei wasi highi andi thei provideri askedi heri
toi returni fori reassessment.i

Shei statesi shei occasionallyi experiences:i

• Mildi headachesi
• Occasionali fatiguei
• Noi chesti paini
• Noi shortnessi ofi breathi
• Noi dizzinessi ori syncopei
• Noi palpitationsi
• Noi visioni changesi

Shei reportsi inconsistenti homei bloodi pressurei monitoring.i Wheni shei checks,i readingsi arei usuallyi
aroundi 145–155i systolici andi 90–95i diastolic.i

Shei denies:i

• Nauseai
• Vomitingi
• Edemai
• Orthopneai
• Neurologicali symptomsi

Symptomsi begani severali monthsi agoi andi havei remainedi stable.i

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Past Medical History
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• Hypertensioni (suspectedi /i previouslyi elevatedi BP)i
• Hyperlipidemiai (possiblei riski factor)i
• Obesityi

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Past Surgical History
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i Nonei reportedi
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, Medications i




• Hydrochlorothiazidei 12.5i mgi dailyi (possiblei currenti therapy)i
• Occasionali OTCi paini relieversi (acetaminophen)i

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Allergies i




i Noi knowni drugi allergiesi (NKDA)i

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Family History i i




• Fatheri –i Hypertensioni
• Motheri –i Typei 2i Diabetesi
• Noi familyi historyi ofi strokei ori earlyi cardiaci deathi reportedi

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Social History
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• Non-smokeri
• Occasionali alcoholi
• Sedentaryi lifestylei
• Dieti highi ini salti andi processedi foodsi
• Livesi withi familyi
• Worksi sedentaryi jobi

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Review of Systems (ROS)
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General:i Deniesi fever,i chills,i weighti lossi
Cardiovascular:i Noi chesti pain,i noi palpitationsi
Respiratory:i Noi coughi ori dyspneai
Neurological:i Occasionali headachesi
GI:i Noi nauseai ori vomitingi
GU:i Noi urinaryi complaintsi
Musculoskeletal:i Noi jointi paini
Psych:i Noi anxietyi ori depressioni symptomsi

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