SOAP Note

Soap Note

Florida International University

NGR 6002 – Advanced Health Assessment

Dr. Rosa Roche & Dr. Dana Sherman

February 1, 2025

Patient Age: 47 years old

Patient Ethnicity: African-American

Clinical Setting: Office visit

Patient Status: Established (since the patient was

seen 3 weeks ago for a follow-up visit)

Subjective Data

Chief Complaint:

"I’m here for a follow-up visit. I was told a few weeks ago that my blood pressure was high, but I feel fine and don’t have any symptoms."

History of Present Illness

The patient is a 47-year-old African-American male who presents for follow-up after an

upper respiratory infection visit three weeks ago, where he was incidentally found to have

elevated blood pressure (164/98 mm Hg). He recalls being told in the past that his blood pressure

was ‘borderline’ but has never been formally diagnosed with hypertension. Today, repeat blood

pressure readings are 156/96 mm Hg (left arm) and 152/98 mm Hg (right arm). He denies

headache, dizziness, chest pain, shortness of breath, or other symptoms. His lifestyle includes no

regular exercise and occasional alcohol consumption (“a couple of beers on the weekends”). He

reports no known aggravating or relieving factors. Family history is significant for his father

passing away from a stroke at age 69, increasing his cardiovascular risk.

Past Medical History

Chronic Illness: Hypertension (Date of onset not specified; likely chronic, as patient recalls blood pressure being "borderline" in the past).

Medications None.

Past Surgical History

Denies any past surgical history.

Allergies

NKDA

Past Psychiatric History

Denies any past psychiatric history.

Health Promotion and Maintenance

BP check: Elevated blood pressure noted at recent office visits.

Annual Physical: Follow-up visit for blood pressure.

Immunizations: Up to date on routine immunizations, including annual influenza vaccine. Denies receiving pneumococcal or shingles vaccine.

• Eye exams: Last eye exam was 2 years ago, no corrective lenses needed. Reports occasional eye strain after prolonged screen time.

• Dental exams: Last visit 9 months ago, no major dental issues, advised to continue routine care.

• Lipid screening: Last lipid profile performed 18 months ago (results recalled by patient):

• Total Cholesterol: 198

• LDL Cholesterol: 112

• HDL: 49

• Triglycerides: 153

• CBC and BMP: Last completed during a wellness check 1 year ago, within normal limits (WNL).

• Colonoscopies: Not yet completed. Advised to begin screening at age 50, earlier if family history changes.

• Annual physical: Last full physical was 15 months ago, noted elevated blood pressure at that time but no follow-up was done. No prior diabetes screening.

Functional Status:

The patient is fully independent with ADLs.

Family History: Parents: • Father: Deceased at age 69 due to stroke. • Mother: Alive at age 72, in good health. Siblings: • Brother (45): No significant health conditions reported. • Sister (50): Hypertension, obesity (BMI 32).

Social History

Marital status- Divorced

Parental status- Father deceased (stroke at age 69), mother alive (age 72, in good health).

Work history- Works a sedentary job.

Financial history- Stable income, employed full-time in a sedentary job, no major financial concerns.

Diet- occasional alcohol consumption noted ("a couple of beers on the weekends").

Exercise- Does not exercise regularly.

Stress management- Reports modest job stress but does not handle it. Lack of formal stressreduction methods.

Sleep- Reports sleeping 6-7 hours per night, no difficulty falling asleep or staying asleep.

Sexual history/orientation- Heterosexual.

Living arrangement-lives alone in an apartment.

Social support- Limited social support, occasional contact with family, no close friends

mentioned.

Spiritual History/Religious Affiliation and Practices: Identifies as Christian but does not attend church regularly. Believes in the power of prayer and occasionally engages in personal reflection for stress relief. Open to discussions about faith in relation to health.

Complementary/Alternative Care Practices: Occasionally takes herbal supplements, including garlic for heart health. Interested in meditation for stress management but has not yet implemented it into his routine.

Type of Family: Lives alone but maintains contact with his mother and siblings. Reports having an extended family network that he reaches out to occasionally for support but is mostly independent in daily activities.

Travel history- No recent travel history.

Cultural Background

Black and African Americans make up 12.5% of the U.S. population, rising to 15% when

combined with other racial identities (Lang et al., 2022). It is important to acknowledge how

marginalization, discrimination, systemic racism, and access to healthcare disproportionately

affect Black patients compared to White individuals. Implicit bias in clinical decision-making

has been shown to negatively impact patient outcomes, communication, treatment options, and

overall quality of care (Lang et al., 2022).

The current patient, a 47-year-old African American male with newly diagnosed

hypertension, faces several modifiable and non-modifiable risk factors. His family history of

stroke, sedentary lifestyle, and alcohol consumption increase his cardiovascular risk.

Additionally, systemic racism and implicit bias in healthcare settings may contribute to

underdiagnosis and undertreatment of hypertension in Black patients (Lang et al., 2022).

This patient should receive early counseling on lifestyle modifications, including dietary

changes, increased physical activity, and stress management techniques. Providing culturally

competent care that aligns with the patient’s background and traditions is essential for

improving health outcomes. Addressing potential barriers to medication adherence and ensuring

patient education on long-term hypertension management will help improve engagement and

reduce complications (Lang et al., 2022). Encouraging community-based support programs and

fostering trust in healthcare providers can further enhance hypertension control in African

American patients (Lang et al., 2022).

Review of Systems (Patient as Historian)

Constitutional: Denies fever, chills, fatigue, night sweats, or weight changes.

Head/Face: Denies headaches, facial pain, trauma, or swelling.

Eyes: Denies vision changes, redness, dryness, irritation, discharge, or eye pain.

Ears: Denies hearing loss, tinnitus, vertigo, ear pain, or discharge.

Nose: Denies nasal congestion, rhinorrhea, epistaxis, or sinus pain.

Mouth/Throat/Neck: Denies sore throat, dysphagia, hoarseness, oral ulcers, neck swelling, or pain.

Respiratory: Denies cough, dyspnea, wheezing, or hemoptysis.

Cardiac: Denies chest pain, palpitations, orthopnea, or edema.

Gastrointestinal (GI): Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or blood in stool.

Genitourinary (GU): Denies dysuria, frequency, urgency, hematuria, or flank pain.

Reproductive (Male): Denies penile discharge, erectile dysfunction, or testicular pain/swelling.

Musculoskeletal: Denies joint pain, stiffness, swelling, or muscle weakness.

Skin/Integumentary: Denies rashes, itching, lesions, or changes in skin color/texture.

Psychiatric: Denies anxiety, depression, mood changes, or insomnia.

Neurological: Denies headaches, dizziness, seizures, numbness, or weakness. No Kernig’s or Brudzinski’s signs.

Endocrine: Denies polyuria, polydipsia, heat/cold intolerance, or hair/skin changes.

Hematologic/Lymphatic: Denies easy bruising, bleeding, or lymph node enlargement.

Allergic/Immunologic: Denies allergies, recurrent infections, or autoimmune symptoms

Level of History:

Comprehensive

• HPI: 4 or more findings documented.

• ROS: Covers 10-14 systems (meeting “Comprehensive” level).

• PFSH: Includes 2-3 areas (Past Medical, Family, and Social History).

Objective Data

Vital Signs:

• Blood Pressure: 156/96 mm Hg (left arm), 152/98 mm Hg (right arm)

• Heart Rate: 78 bpm

• Respiratory Rate: 14 breaths/min

• Oxygen Saturation: 98% on room air

• Temperature: Afebrile (assumed normal)

• Height: 70 inches (5’10”)

• Weight: 210 lbs

• BMI: 30.1 (obese per CDC guidelines)

Constitutional: Well-groomed, appears stated age, no distress. No jaundice, cyanosis, or pallor.

General: No acute distress, well-nourished, well-developed.

Physical Examination

Head/Face: Normocephalic, atraumatic, symmetrical facial movements. No swelling or tenderness.

Eyes: PERRLA, EOMI. Conjunctiva clear, sclera white, no discharge.

Ears: Normal external ears, no lesions or discharge. TM intact bilaterally.

Nose: Midline, no septal deviation. Nasal mucosa pink, no discharge or polyps.

Mouth/Throat/Neck: Moist oral mucosa, no ulcers. Tonsils not enlarged. No thyromegaly or lymphadenopathy.

Respiratory: Symmetric chest expansion, clear bilateral breath sounds. No wheezes, rhonchi, or rales.

Cardiac: Regular rate and rhythm (RRR). S1, S2 present, no murmurs, rubs, or gallops. No heaves or thrills. Capillary refill <2 sec.

GI: Soft, non-tender, non-distended. Normal bowel sounds, no hepatosplenomegaly.

GU: No lesions, normal external genitalia. No inguinal hernias.

Reproductive (male): No penile lesions, discharge, or testicular masses. No tenderness or swelling of the testes or epididymis. No inguinal or femoral hernias noted.

Musculoskeletal: Full range of motion in all extremities, no joint tenderness or swelling. Normal gait.

Skin: Warm, dry, intact, no lesions or ulcers. Normal turgor.

Neurological: CN II-XII grossly intact. 5/5 strength bilaterally. Normal coordination, sensation intact to light touch. No Kernig’s or Brudzinski’s signs.

Psychiatric: Calm, cooperative, appropriate mood and affect. No signs of acute distress.

Hematologic/Lymphatic/Immunologic: No lymphadenopathy, bruising, or signs of immunologic dysfunction.

Billing Level of Physical Objective Exam:

• Comprehensive • 8 or more organ systems examined (meeting the highest level of physical exam

documentation).

Laboratory Data Already Ordered and Available for Review:

• No labs reviewed during this visit; labs will be ordered in the plan section.

Diagnostic Procedures/Data Already Ordered and Available for Review:

• No imaging or diagnostic tests reviewed during this visit; necessary tests will be included in the plan section.

Assessment

Main Diagnosis/Problem: Primary Diagnosis: Hypertension (Essential, Primary) ICD-10 Code: I10 - Essential (Primary) Hypertension (WHO, 2022) Differential Diagnosis: Secondary Hypertension (due to kidney disease, endocrine disorders) (Hegde & Aeddula, 2023) White Coat Hypertension (office readings elevated, but normal at home) (Townsend & Cohen, 2024) Obstructive Sleep Apnea (due to weight, sedentary lifestyle) (Slowik & Collen, 2024) Rationale for Main Diagnosis: The patient has consistently elevated blood pressure readings (164/98 mm Hg and 156/96 mm Hg). He has no symptoms but is at increased risk due to family history (stroke in father) and lack of regular exercise. His blood pressure has been borderline in the past, suggesting a possible history of untreated or poorly managed hypertension (WHO, 2022). Risk Factors: Family history of stroke (father at age 69) Age (47 years old) Obesity (BMI of 32.3) Sedentary lifestyle Alcohol use (occasional beer consumption).

This visit involves the evaluation and management of an established patient with a chronic condition (hypertension). The comprehensive history, detailed physical exam, and moderate complexity decision-making support the use of E/M code 99214, per standard billing guidelines.

Plan

Hypertension (Primary)

Additional Laboratory Tests or Diagnostic Data Needed:

• Basic metabolic panel (BMP) to assess kidney function

• Lipid profile to evaluate cardiovascular risk

• Urinalysis to rule out secondary causes (e.g., kidney disease)

• EKG to assess for signs of cardiac strain

Pharmacologic Management:

• Drug: Lisinopril 10 mg, oral, once daily

• SIG: Take 1 tablet by mouth once a day

• Dispense amount: 30 tablets (1 month supply)

Non-Pharmacologic Management:

• Encourage weight loss (aim for 5-10% reduction in body weight)

• Increase physical activity (at least 150 minutes of moderate-intensity exercise per week)

• Limit alcohol consumption to 1-2 drinks per day

Complementary Therapies:

Consider adding relaxation techniques (e.g., yoga, meditation) to manage stress

Health Education:

• Educate patient on the importance of controlling blood pressure to prevent complications

such as stroke and heart disease

• Discuss the role of lifestyle modifications (diet, exercise, alcohol intake) in managing

hypertension

Referrals:

Referral to dietitian for weight management and nutritional counseling

Follow-up Appointment:

Recheck blood pressure in 2 weeks to assess initial response to medication. Follow-up in 1

month to evaluate medication adherence, potential side effects, and treatment effectiveness. The

patient will be instructed on how to properly measure and record home blood pressure readings,

which will be reviewed at each follow-up to guide therapy adjustments as needed.

Patient Status: Established

Level of History: Comprehensive (HPI includes 4+ elements, ROS covers 10+ systems, PFSH includes 2+ areas)

Level of Physical Exam: Detailed (5-7 organ systems) or Comprehensive (8+ organ systems)

Level of Medical Decision-Making: Moderate Complexity (chronic condition requiring medication and diagnostic testing)

Billing Code: 99214 (Established patient, moderate complexity, detailed exam)

Justification: The patient presents for follow-up on persistently elevated blood pressure readings with a history of “borderline” hypertension. This visit includes a comprehensive history, a detailed physical examination covering multiple systems, and moderate medical decisionmaking, including initiation of pharmacologic therapy and lifestyle modifications.

Analysis

Hypertension is a major risk factor for cardiovascular morbidity and mortality,

particularly among African American men, who are disproportionately affected by the condition

(WHO, 2022). This patient’s persistently elevated blood pressure readings (164/98 mm Hg at the

previous visit and 152/98 mm Hg currently) place him at high risk for complications such as

stroke, myocardial infarction, and kidney disease. Despite a slight reduction in his blood

pressure, his levels remain above the hypertension threshold (≥140/90 mm Hg), necessitating

immediate intervention. His father’s history of stroke at age 69 further increases his

cardiovascular risk. Given the patient’s lack of symptoms, sedentary lifestyle, and occasional

alcohol consumption, pharmacologic and lifestyle modifications are essential for effective

hypertension management (WHO, 2022).

Pharmacologic and Non-Pharmacologic Management

The first-line pharmacologic treatment for this patient is Lisinopril 10 mg, oral, once

daily, an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors have shown efficacy in

reducing blood pressure and providing renal protection, particularly in patients with

cardiovascular risk factors (Hegde & Aeddula, 2023). However, studies indicate that African

American patients may respond better to calcium channel blockers (CCBs) or thiazide diuretics

than ACE inhibitors (WHO, 2022). If Lisinopril alone does not provide adequate control,

Amlodipine (a CCB) or Hydrochlorothiazide (a thiazide diuretic) may be considered as

alternative or adjunctive therapy (Townsend & Cohen, 2024).

Non-pharmacologic interventions are equally essential for blood pressure control. The

DASH diet (Dietary Approaches to Stop Hypertension), which emphasizes reducing sodium

intake (<2,300 mg/day) and increasing potassium-rich foods, has been shown to lower blood

pressure significantly (WHO, 2022). Weight loss of 5-10% of total body weight, at least 150

minutes of moderate-intensity exercise per week, and limiting alcohol intake to ≤2 drinks per day

are strongly recommended. The patient should also be encouraged to self-monitor his blood

pressure at home and maintain a blood pressure log for review at follow-up visits (Hegde &

Aeddula, 2023).

Monitoring and Follow-Up

Close monitoring is crucial to ensure effective hypertension management and prevent

complications. The patient should have blood pressure checks every two weeks initially to assess

medication response and adherence. Additional laboratory tests, including a basic metabolic

panel (BMP), lipid panel, HbA1c, and urinalysis, should be conducted to evaluate kidney

function, lipid abnormalities, and potential secondary causes of hypertension (Hegde & Aeddula,

2023). If his blood pressure remains uncontrolled at the next follow-up visit, treatment

intensification with dose adjustments or additional antihypertensive agents will be considered

(Townsend & Cohen, 2024).

Patient Education

Since hypertension is often asymptomatic, patient education is critical to improving

adherence. The patient should be informed about the long-term consequences of uncontrolled

hypertension, including stroke, heart failure, and kidney damage (WHO, 2022). He should

receive guidance on reading nutrition labels, reducing processed foods, and incorporating

healthier meal options to improve his dietary habits. Additionally, stress management techniques,

such as yoga, deep breathing exercises, or mindfulness practices, may be beneficial in lowering

blood pressure (Slowik & Collen, 2024). Encouraging the patient to participate in community

health programs or hypertension support groups may enhance motivation and adherence to

treatment.

Referrals and Cultural Considerations

The patient should be referred to a dietitian for weight management and nutritional

counseling and a primary care physician for continued hypertension management. Given his

African American background, it is essential to address cultural barriers to healthcare access and

medication adherence (Townsend & Cohen, 2024). Research indicates that African Americans

have higher rates of treatment-resistant hypertension due to genetic predisposition,

socioeconomic disparities, and healthcare access challenges (Slowik & Collen, 2024).

Establishing trust, providing culturally tailored education, and ensuring accessible care options

will significantly improve adherence and health outcomes.

Conclusion

A comprehensive approach combining pharmacologic therapy, lifestyle modifications,

frequent monitoring, and culturally competent patient education will help optimize this patient’s

blood pressure control and reduce his risk of future cardiovascular events. A four-week followup

visit is scheduled to reassess blood pressure trends, medication adherence, and laboratory results.

If necessary, medication adjustments will be made to ensure long-term hypertension

management.

References

Hegde, S., & Aeddula, N. R. (2023). Secondary Hypertension. Nih.gov; StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK544305/

Lang, Q., Roberson-Moore, T., Rogers, K. M., & Wilson, W. E. (2022). Cultural considerations

in working with Black and African American youth. Child and Adolescent Psychiatric

Clinics of North America, 31(4), 733–744. https://doi.org/10.1016/j.chc.2022.05.003

Slowik, J. M., & Collen, J. F. (2024). Obstructive sleep apnea. PubMed; StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK459252/

Townsend, R. R., & Cohen, J. B. (2024). White coat hypertension & cardiovascular outcomes.

Current Hypertension Reports. https://doi.org/10.1007/s11906-024-01309-0

WHO. (2022). Hypertension. Www.who.int. https://www.who.int/health-topics/hypertension