SOAP Note _______ Name:_________________________

Typhon Encounter #: _____________________

NU___:_________ Comprehensive:____Focused:____
Herzing University

S: SUBJECTIVE DATA
CC:
Routine physical examination.

HPI: The patient is a 50 years old man that comes to the office for a routine
physical examination. The patient is hypertensive that is managed with
chlorthalidone 25 mg PO daily. The patient reports visual changes when
reading and increased urination and thirst. The patient takes Tylenol
medication for the management of pain. The father is deceased with a
history of heart attack that presents a hereditary risk factor for
hypertension and obesity, indicated in a BMI of 31. The patient reports no
history of treated or managed heart attacks. The patient denies fever,
shortness of breath, headaches, vomiting, or coughing.
PMH: Hypertension.
Visual changes
Increased urination and thirst
ALLERGIES No seasonal, food, or medication allergies reported

MEDICATIONS The patient has been using chlorthalidone 25 mg PO daily for

hypertension management.
The patient is also using Tylenol for pain management.
SH The patient is married in a monogamous relationship and has no children.
The patient has two siblings and a mother. His father is deceased. The
patient has a high school diploma and works full-time for a local
landscaping business. He denies drinking alcohol, smoking, and using
recreational drugs. Additionally, the patient does not exercise.
FH
Mother is alive at age 80 and healthy with no known history of chronic
and hereditary conditions. The patient has two siblings with no known
history of adverse medical conditions. Father is deceased. He died of a
heart attack at 73 years. Cardiac arrest is a potential hereditary risk factor
SOAP Note _______ Name:_________________________
Typhon Encounter #: _____________________
NU___:_________ Comprehensive:____Focused:____
Herzing University

for the patient.

HEALTH
PROMOTION &
Counseling and health education on the importance of regular exercise
MAINTENANC
and adherence to medication. Additionally, the patient should be
E
counseled on the importance of regular dental checkups and eye exams.
Additional education on risk factors for heart attack and hereditary factors
should be emphasized to make him aware of potential hereditary risk
factors that affect his health. Proper nutrition and weight management
should also be emphasized for managing the overweight condition. Health
promotion should emphasize the importance of regulating sodium intake
and its role in the development of hypertension.
ROS Constitutional Negative for chills, fever, weakness,
malaise, weight gain, or loss.

(put N/A in sections Head Denies headaches or dizziness

not completed on the
day of the exam) Eyes Negative for pain, discharge, vision loss,
double vision, photophobia, and redness.
Reports visual changes when reading.
Ears, Nose, Mouth, Throat Denies hearing changes
Negative for: hearing loss, headaches, ear
pain, and sore throat.
Neck No pain or discomfort
Cardiovascular/Peripheral Negative for: chest discomfort, orthopnea,
Vascular palpitations, leg swelling, and near-
syncope.
Respiratory Denies shortness of breath
Symmetrical chest. No accessory muscle
for ventilation. Breath sounds in both
lungs are clear to auscultation. No chest
tenderness.
Breast N/A
SOAP Note _______ Name:_________________________
Typhon Encounter #: _____________________
NU___:_________ Comprehensive:____Focused:____
Herzing University

Gastrointestinal Denies abdominal pain and reports

increased thirst.
Denies nausea, vomiting, or change in
appetite.
Genitourinary Reports increased urination
Musculoskeletal N/A
Integumentary Warm, dry, and intact skin. Denies rushes
or bug bites.
Neurological The patient is alert and oriented to person,
place, occasion, and time.
Psychiatric (screening tools: Ex: Denies anxiety and depression.
PHQ-9, MMSE, GAD-7)

Endocrine N/A
Hematologic/Lymphatic N/A
Allergic/Immunologic No allergies
Other N/A

O: OBJECTIVE DATA
VITALS: HR: 80beats/min RR: 18 BP: 126/82 Temp: N/A

SpO2%: N/A Ht: 67 inches Wt: 190lbs BMI: 31

Age: 50 LMP: N/A PAIN: N/A

PHYSICAL General Appearance The patient is oriented to person, place,

EXAM situation, and time. Does not appear to
be in acute distress, and responses are
SOAP Note _______ Name:_________________________
Typhon Encounter #: _____________________
NU___:_________ Comprehensive:____Focused:____
Herzing University

appropriate. The patient appears well-

nourished.
(Pertinent data
related to Head Normocephalic
presenting
problem or Eyes Pupils are reactive to light, normal
visit type. Put
equal, and round. No discharge and
N/A in sections
not completed scleral icterus in the eyes. Extraocular
on the day of movements are intact in six directions.
the exam)
ENT, Mouth
Neck
Cardiovascular/Peripheral Vascular Heart rate 80 beats per minute. Regular
rhythm, no murmurs, symmetrical.
Respiratory Symmetrical chest. No accessory
muscle for ventilation. Breath sounds
in both lungs are clear to auscultation.
No chest tenderness.
Breast N/A
Gastrointestinal N/A
Genitourinary Male
● External Exam N/A
● Internal Exam N/A
Genitourinary Female
● External Exam N/A
● Internal Exam N/A
Musculoskeletal N/A

Integumentary Warm, dry, and intact skin. Denies

rushes or bug bites.
Neurological The patient is alert and oriented to
person, place, occasion, and time.
SOAP Note _______ Name:_________________________
Typhon Encounter #: _____________________
NU___:_________ Comprehensive:____Focused:____
Herzing University

Psychiatric The patient is alert with intact

cognition and memory.
Endocrine No metabolic anomalies
Hematologic/Lymphatic No inguinal adenopathy found
Allergic/Immunologic No allergies found
Other N/A

A: ASSESSMENT AND DIAGNOSIS

DIAGNOSIS ICD-10 CODES

PRIORITIZE 1. Hypertension I10.9

DIAGNOSIS
2. Obesity E66.3

3.

VISIT CODES CPT BILLING CODES 99473

DIAGNOSTICS POC TESTING Z13.9

TESTS REVIEWED N/A

P: PLAN
ACTIONS 1. Diagnosis: hypertension and overweight

Diagnostics Order: The two most important diagnostic tests that

were carried out for hypertension and overweight were blood
pressure and weight and height tests. These tests are essential for the
diagnosis of hypertension and overweight. Body Mass Index (BMI)
SOAP Note _______ Name:_________________________
Typhon Encounter #: _____________________
NU___:_________ Comprehensive:____Focused:____
Herzing University

was essential for the diagnosis of overweight condition.

Therapeutic: Medication is essential for the management of

hypertension and obesity. The patient is currently on chlorthalidone
25 mg PO daily. However, no changes in medication are
recommended because the medication is not showing any adverse
effects. According to Burnia et al. (2020), drug adherence should be
emphasized to improve care outcomes among older adult patients.
Burnia et al. (2020) study shows that drug adherence for
hypertension in older adult patients > 65- 80 years is more effective
at leading to better health outcomes than in younger hypertensive
patients.

Additionally, Tylenol will be continued for pain management, and

refills for the two medications were facilitated. Additionally,
Phentermine 37.5 mg orally daily is recommended for weight
management.

Education:
Patient education is essential for improving care outcomes (Bhattad
& Pacifico, 2022). The patient should be educated on the importance
of regular visits and checkups for dental and eyes. Patient education
should focus on the importance of medication adherence for
managing hypertension. Additionally, education should stress the
importance of regular exercise to manage weight and blood
pressure. Weekly and monthly follow-up is recommended for blood
monitoring and weight management.

Consultation/Collaboration: Consultation with a physical

therapist and nutritionist is essential for blood pressure and weight
management. Consultation and follow-up ensure the patient stays
physically active and has good cardiac health. Interprofessional
SOAP Note _______ Name:_________________________
Typhon Encounter #: _____________________
NU___:_________ Comprehensive:____Focused:____
Herzing University

collaboration and coordinated care could ensure better outcomes.

Follow-up on cardiac health would prevent the risk of cardiac arrest.
Weekly and monthly blood pressure and weight monitoring would
determine the patient's progress.

PREVENTATIVE Due to the hypertensive condition and overweight, the patient is at

high risk of cardiovascular disorders. Exercise, diet, and nutrition
were preventive measures against overweight and hypertension.
(Used for Exercise, diet, and nutrition are essential for managing hypertension
comprehensive exams)
and overweight.

FOLLOW UP Follow-up with a nutritionist for diet planning to manage

overweight and obesity conditions. Diet planning should focus on
the regulation of the intake of sodium chloride, as it is a potential
risk factor for hypertension (Tinawi, 2022). Weekly and monthly
blood pressure monitoring and BMI measurements to monitor the
progress of the proposed care plan. Patients with high BMI and
hypertension have a high risk for cardiovascular disorders. Given
the family history of cardiac arrest, the patient should be on a
follow-up with a cardiologist for management of the heart
condition.

References
SOAP Note _______ Name:_________________________
Typhon Encounter #: _____________________
NU___:_________ Comprehensive:____Focused:____
Herzing University

Burnia M, Polychronopolou, E., & Wuerzner G., (2020). Hypertension and drug adherence in

the Elderly. Frontiers in Cardiovascular Medicine, 7, 49.

https://doi.org/10.3389/fcvm.2020.00049

Bhattad, P., B., & Pacifico L., (2022). Empowering Patients: Promoting patient education and

Health Literacy. Cureus. 14(7), e27336. https://doi.org/10.7759/cureus.27336

Tinawi M., (2022). New trends in the diagnosis and management of hypertension. Cureus 14(2).

E22393. https://doi.org/10.7759/cureus.22393