SOap Note Blue Print
Course: NURS5102R50 Student: Emily Young Faculty: Dr. Tracy Collins
Pt Initials: HH Age: 57 Race: Hispanic Sex: M New Pt: Y Established Pt:
Info Source: Patient Reliability: Reliable E&M Code(s) I.10
S CC: Elevated blood pressure
HPI: A 57-year-old Hispanic male presents to the clinic “I had my blood pressure checked at a health fair earlier
and it was high, my wife convinced me to come in.” Patient describes a sedentary lifestyle and poor eating
choices such as fast food multiple times per week that have resulted in recent weight gain. Patient
describes “dull” headaches that “occur 2-3 times a week, usually beginning in the morning,” in which he
takes Ibuprofen “about 4-5 pills per day,” as well as “not being able to sleep well, and feeling tired all day.”
Wife is present this visit and states that at night, “he has periods of not breathing, and when she wakes him
up he resumes sleep.” Pt. currently “works 5 days/week in construction.”
Histories: PMH: Reports past medical history of “similar symptoms” and a “Dr. warning him of the importance of his
high blood pressure and lifestyle choices a few years ago.” Pt. describes seeing no primary care since this
occurrence, admits to not altering diet/exercise as he was advised to. Reports he is not up to date on
current immunizations, no childhood illnesses.
FH: Brother and uncle both diagnosed with HTN in mid and late 40’s, both “alive and well,” Paternal
Grandfather deceased d/t MI at age 52., Father deceased d/t stroke at age 62. Mother alive with Diabetes.
Med Hx: Ibuprofen taken when headaches occur, up to 4-5 pills per day.
SH: Pt. reports smoking a pack per day “since his 20’s.” Denies use of drugs. Reports drinking beer “only on
weekends.” Pt is married, lives with spouse and children, and works in construction.
ROS: HEENT: Afebrile. Skin dry, warm, and intact. Pupils equal, round, reactive to light. Thyroid palpable,
no enlargement noted.
Cardiovascular: Elevated BP readings x2, laterally displaced PMI, denies chest pain.
Respiratory: Respirations are even, unlabored.
GI: Pt. is of overweight status. Describes high fat and high sodium diet of frequent fast food and TexMex
style meals at home, daily coffee intake. Reports weight gain of more than 10 pounds within the last year.
Neuro: Reports dull headaches that begin in the morning occurring 2-3 times per week.
O Vital Signs: T: 98.5, HR: 70, RR: 14, BP: 172/94 (sitting), 154/94 (standing), O2: 96% on RA
Px Exam: Pt. appears well groomed, fatigued.
Ht: 5’9, Wt. 195 lbs., BMI: 28.8.
HEENT: Assessment of the eyes and thyroid in this case d/t potential retinopathy r/t HTN. Thyroid function
can be reasoning for recent weight gain.
Cardiovascular: These findings further support HTN diagnosis. PMI is displaced probably d/t
cardiomegaly.
Respiratory: Shortness of breath can indicate cardiomegaly, which is common with HTN, Mr. Hoya’s
results showed mild cardiomegaly.
GI: HTN is commonly associated with high sodium diets (Mexican foods, processed/fast foods),
obesity, and with the recent weight gain and diet, further supports HTN diagnosis.
Neuro: Headaches r/t HTN commonly appear in early mornings and are a dull, back of the head type of pain.
Diagnostics: 12-lead EKG: this can show any heart and/or rhythm abnormality. Heart attacks and heart
abnormalities are common with hypertension. In HH’s case, his result was a NSR with
Left Ventricular hypertrophy.
Echo: Illustrates the size/structure of the heart. Cardiomegaly commonly presents with HTN.
Chest X-ray: can illustrate any infiltrates, lung/chest abnormalities. HTN can be associated with
being SOB, which can show as the heart being larger than usual. Cardiomegaly common in HTN
diagnosis.
Course: NURS5102R50 Student: Emily Young Faculty: Dr. Tracy Collins
Pt Initials: HH Age: 57 Race: Hispanic Sex: M New Pt: Y Established Pt:
Info Source: Patient Reliability: Reliable E&M Code(s) I.10
S CC: Elevated blood pressure
HPI: A 57-year-old Hispanic male presents to the clinic “I had my blood pressure checked at a health fair earlier
and it was high, my wife convinced me to come in.” Patient describes a sedentary lifestyle and poor eating
choices such as fast food multiple times per week that have resulted in recent weight gain. Patient
describes “dull” headaches that “occur 2-3 times a week, usually beginning in the morning,” in which he
takes Ibuprofen “about 4-5 pills per day,” as well as “not being able to sleep well, and feeling tired all day.”
Wife is present this visit and states that at night, “he has periods of not breathing, and when she wakes him
up he resumes sleep.” Pt. currently “works 5 days/week in construction.”
Histories: PMH: Reports past medical history of “similar symptoms” and a “Dr. warning him of the importance of his
high blood pressure and lifestyle choices a few years ago.” Pt. describes seeing no primary care since this
occurrence, admits to not altering diet/exercise as he was advised to. Reports he is not up to date on
current immunizations, no childhood illnesses.
FH: Brother and uncle both diagnosed with HTN in mid and late 40’s, both “alive and well,” Paternal
Grandfather deceased d/t MI at age 52., Father deceased d/t stroke at age 62. Mother alive with Diabetes.
Med Hx: Ibuprofen taken when headaches occur, up to 4-5 pills per day.
SH: Pt. reports smoking a pack per day “since his 20’s.” Denies use of drugs. Reports drinking beer “only on
weekends.” Pt is married, lives with spouse and children, and works in construction.
ROS: HEENT: Afebrile. Skin dry, warm, and intact. Pupils equal, round, reactive to light. Thyroid palpable,
no enlargement noted.
Cardiovascular: Elevated BP readings x2, laterally displaced PMI, denies chest pain.
Respiratory: Respirations are even, unlabored.
GI: Pt. is of overweight status. Describes high fat and high sodium diet of frequent fast food and TexMex
style meals at home, daily coffee intake. Reports weight gain of more than 10 pounds within the last year.
Neuro: Reports dull headaches that begin in the morning occurring 2-3 times per week.
O Vital Signs: T: 98.5, HR: 70, RR: 14, BP: 172/94 (sitting), 154/94 (standing), O2: 96% on RA
Px Exam: Pt. appears well groomed, fatigued.
Ht: 5’9, Wt. 195 lbs., BMI: 28.8.
HEENT: Assessment of the eyes and thyroid in this case d/t potential retinopathy r/t HTN. Thyroid function
can be reasoning for recent weight gain.
Cardiovascular: These findings further support HTN diagnosis. PMI is displaced probably d/t
cardiomegaly.
Respiratory: Shortness of breath can indicate cardiomegaly, which is common with HTN, Mr. Hoya’s
results showed mild cardiomegaly.
GI: HTN is commonly associated with high sodium diets (Mexican foods, processed/fast foods),
obesity, and with the recent weight gain and diet, further supports HTN diagnosis.
Neuro: Headaches r/t HTN commonly appear in early mornings and are a dull, back of the head type of pain.
Diagnostics: 12-lead EKG: this can show any heart and/or rhythm abnormality. Heart attacks and heart
abnormalities are common with hypertension. In HH’s case, his result was a NSR with
Left Ventricular hypertrophy.
Echo: Illustrates the size/structure of the heart. Cardiomegaly commonly presents with HTN.
Chest X-ray: can illustrate any infiltrates, lung/chest abnormalities. HTN can be associated with
being SOB, which can show as the heart being larger than usual. Cardiomegaly common in HTN
diagnosis.
