SOAP: Sick Visit
**
William Paterson University
NUR 6041-816: Advanced Nursing Practicum I
**
September 26th, 2025
, 2
SUBJECTIVE
CC: “I’ve noticed my blood pressure has been on the high side at home.”
HPI: M.R. is a 61-year-old female with a past medical history of hypertension,
hyperlipidemia, and hypothyroidism, who presents today with complaints of hypertension
at home. The patient reports checking BP (blood pressure) at home and noting elevated
blood pressures for the past month. BP logs at home show systolic pressure ranging from
128-148 and diastolic pressure ranging from 83-103. The patient is asymptomatic and
denies chest pain, palpitations, lower extremity edema, severe headache, shortness of
breath, blurred vision, or weakness. The patient reports being compliant with BP
medications: losartan 50 mg daily and metoprolol 50 mg daily. Reports no side effects
from the medications. States her BP tends to be higher at the end of the day. BP slightly
improves after taking her BP medications. Reports being compliant with a low-salt diet
but admits to not exercising. Denies stress, changes in weight, fatigue, and heat or cold
intolerance.
PMH: Hypertension, hyperlipidemia, and hypothyroidism. No recent hospitalizations
and no blood transfusions.
PSH: None
Family History:
Mother: age 85, living, hx of DM2 and HTN (onset age 60)
Father: age 84, living, hx of HTN, onset age 50
Sister: age 55, living, hx of HTN and neoplasm of the thyroid gland, onset age 53.
**
William Paterson University
NUR 6041-816: Advanced Nursing Practicum I
**
September 26th, 2025
, 2
SUBJECTIVE
CC: “I’ve noticed my blood pressure has been on the high side at home.”
HPI: M.R. is a 61-year-old female with a past medical history of hypertension,
hyperlipidemia, and hypothyroidism, who presents today with complaints of hypertension
at home. The patient reports checking BP (blood pressure) at home and noting elevated
blood pressures for the past month. BP logs at home show systolic pressure ranging from
128-148 and diastolic pressure ranging from 83-103. The patient is asymptomatic and
denies chest pain, palpitations, lower extremity edema, severe headache, shortness of
breath, blurred vision, or weakness. The patient reports being compliant with BP
medications: losartan 50 mg daily and metoprolol 50 mg daily. Reports no side effects
from the medications. States her BP tends to be higher at the end of the day. BP slightly
improves after taking her BP medications. Reports being compliant with a low-salt diet
but admits to not exercising. Denies stress, changes in weight, fatigue, and heat or cold
intolerance.
PMH: Hypertension, hyperlipidemia, and hypothyroidism. No recent hospitalizations
and no blood transfusions.
PSH: None
Family History:
Mother: age 85, living, hx of DM2 and HTN (onset age 60)
Father: age 84, living, hx of HTN, onset age 50
Sister: age 55, living, hx of HTN and neoplasm of the thyroid gland, onset age 53.
