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Soap note Hypertension | complete soap note

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SOAP NOTE HYPERTENSION 2 Subjective Data: Chief Complaint: “I’m here for my yearly physical and to follow up on my blood pressure.” S.M is a 60-year-old Caucasian male who comes in the facili ... ty for his annual physical checkup and to follow up on his blood pressure. For the past few weeks, his blood has been running high. He shows the records he has been keeping about his pressure rise twice per day, morning and evening, every time he feels the blood pressure is higher than normal. Objective data: Temperature: 36.9 C Heart Rate: 89 Respiratory Rate: 18 Blood Pressure: 161/90 Weight: 106.6 kg Height: 5’11’’ Neurological: AAOx3, GCS 15, PERRLA. Normal motor and coordination observed. Normal speech observed. Neck: Moist mucous membranes, no JVD, Carotid Pulses (+) BL. Pulmonary/Chest: Normal respiratory effort. Clear to auscultation BL. Symmetrical chest wall expansion. Cardiovascular: RRR, No M, R, G. S1, S2 present. Cap refill < 3 seconds. +2 pulses BL. No edema, clubbing, or cyanosis. Gastrointestinal: Abdomen non-distended soft, non-tender. No rebound, guarding. Genitourinary: Voids Musculoskeletal: no deformity, no swelling, no tenderness, normal strength, Normal ROM. Skin: Warm, dry, intact Assessment: Hypertension Differential Diagnoses: 1. Stress 2. Renal Artery Stenosis [Show More]

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