SOAP NOTE 6 HYPERTENSION
SOAP NOTE SIX HYPERTENSION
SOAP Note Six
Hypertension Spring Arbor
University Brett Locke
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https://www.coursehero.com/file/81720749/SOAP-Note-Six-Hypertension-Brett-Lockedocx/
, SOAP NOTE SIX HYPERTENSION
Name: F.K. Date : 6/19/2020 Time : 1400
DOB: 12/18/1975 Sex: Male
Subjective
CC: Wellness exam
HPI:
Patient is a pleasant 44-year-old male who presents to the office today for a wellness exam.
His last wellness exam was performed roughly one year ago. He was last seen in the office
three weeks ago for annual laboratories and was found to have elevated blood pressure at that
time at 148/91. He has kept a blood pressure log since that time which demonstrates elevated
readings with a systolic reading in the 150’s, diastolic in the mid 90’s. He complains of an
occasional low-grade headache and mild fatigue. He denies chest pain, vision changes, nose
bleeds, palpitations or shortness of breath. He is not experiencing fever, chills or night sweats.
Medications: Denies
Allergies: NKDA
PMI
Illnesses/Injuries
Childhood- Broken left arm at age 12; Varicella age
8. Adult- Back injury while in Iraq, 2007
Hospitalizations/Surgeries: L5-S1 laminectomy/discectomy
Vaccinations
Influenza- 11/2019 Pneumovax- no hx Tetanus- 2014 HPV- no hx Hep B- childhood
Health Maintenance:
Last mammogram- not indicated, no male or first-degree family history of breast cancer
Last colonoscopy- no history of colonoscopy, not indicated until age 45 based on new NCCN
guidelines
Last prostate exam- n/a, start screening at age 50 with exam and PSA
FH:
Stroke – no history
Diabetes – no history
Lung disease – no history
HTN – mother, father
Heart disease – paternal grandmother, paternal grandfather
Cancer – Leukemia, paternal cousin
SH: Married x 20 years. Has four children, 2 boys and 2 girls. Works as a surgical technician at
local hospital.
Tobacco: Denies ETOH: Socially; once per week Illicit drugs: Denies history of
illicit drug use
Caffeine: 1-2 diet coke’s daily
ROS
SOAP NOTE SIX HYPERTENSION
SOAP Note Six
Hypertension Spring Arbor
University Brett Locke
This study source was downloaded by 100000829907498 from CourseHero.com on 08-17-2021 15:54:38 GMT -05:00
https://www.coursehero.com/file/81720749/SOAP-Note-Six-Hypertension-Brett-Lockedocx/
, SOAP NOTE SIX HYPERTENSION
Name: F.K. Date : 6/19/2020 Time : 1400
DOB: 12/18/1975 Sex: Male
Subjective
CC: Wellness exam
HPI:
Patient is a pleasant 44-year-old male who presents to the office today for a wellness exam.
His last wellness exam was performed roughly one year ago. He was last seen in the office
three weeks ago for annual laboratories and was found to have elevated blood pressure at that
time at 148/91. He has kept a blood pressure log since that time which demonstrates elevated
readings with a systolic reading in the 150’s, diastolic in the mid 90’s. He complains of an
occasional low-grade headache and mild fatigue. He denies chest pain, vision changes, nose
bleeds, palpitations or shortness of breath. He is not experiencing fever, chills or night sweats.
Medications: Denies
Allergies: NKDA
PMI
Illnesses/Injuries
Childhood- Broken left arm at age 12; Varicella age
8. Adult- Back injury while in Iraq, 2007
Hospitalizations/Surgeries: L5-S1 laminectomy/discectomy
Vaccinations
Influenza- 11/2019 Pneumovax- no hx Tetanus- 2014 HPV- no hx Hep B- childhood
Health Maintenance:
Last mammogram- not indicated, no male or first-degree family history of breast cancer
Last colonoscopy- no history of colonoscopy, not indicated until age 45 based on new NCCN
guidelines
Last prostate exam- n/a, start screening at age 50 with exam and PSA
FH:
Stroke – no history
Diabetes – no history
Lung disease – no history
HTN – mother, father
Heart disease – paternal grandmother, paternal grandfather
Cancer – Leukemia, paternal cousin
SH: Married x 20 years. Has four children, 2 boys and 2 girls. Works as a surgical technician at
local hospital.
Tobacco: Denies ETOH: Socially; once per week Illicit drugs: Denies history of
illicit drug use
Caffeine: 1-2 diet coke’s daily
ROS
