Sample SOAP Note: Chronic Problem
Daniel Radosevich
SUBJECTIVE
A.S. is a 68-year-old electrician who presents for ongoing management of essential hypertension. He was diagnosed with hypertension when he was 35 years old. An appropriate evaluation for secondary causes of hypertension at that time was unrevealing.
He reports feeling well today. He has had no interval chest pain, dyspnea, orthopnea, swelling of his extremities or change in exercise tolerance. He continues to take HCTZ 25mg/day and lisinopril 10mg/day as instructed. He states he “never misses a dose”. He continues to try to limit his intake of sodium and walks 2-3 miles/day.
He reports no history of CAD, Type II DM, dyslipidemia, or OSA. He drinks one 12oz can of beer per week. He takes no NSAIDs. He does not use tobacco products. Of note, he received influenza and SARS-CoV-2 vaccinations on the same day in late October. Past medical history is significant for perennial allergies for which he takes loratadine 10mg/day. NKDA.
OBJECTIVE
37C 128/84 BMI 30 16 respirations/minute 78 beats/minute 98% on room air
In general, he appears well. Affect bright. Breathing unlabored. No cough.
Lungs: CTA in the posterior and anterior fields. No rales/crackles/wheeze.
CV: RRR with normal S1/S2. No ectopy. No murmurs/rubs/gallops.
PMI is quarter-sized and is located in the left 5th ICS 2cm lateral to the mid-clavicular line.
No carotid bruits. Radial, dorsal pedal, and posterior pulses are normal and symmetrical.
No pedal edema.
No diagnostic tests performed today.
ASSESSMENT
- Hypertension; long-standing. Today’s blood pressure measurement in the elevated range.
- PMI displaced laterally. Not previously documented.
- Elevated BMI.
PLAN
- Continue HCTZ and Lisinopril as instructed. Prescriptions renewed for one year.
- Continue low sodium diet.
- We discussed his using an ambulatory blood pressure device to collect twice-daily measurements.
- We discussed his trying to walk a little farther each day and to eat fewer sweets in order to reduce his BMI over time.
- I commended him on his good habits and his recent vaccinations.
- After discussion with patient, will forego echocardiogram to assess possible cardiac hypertrophy given the minor, subtle displacement of his PMI.
- Follow up in one year; sooner PRN any concern.