Based on the case below, using the template uploaded create a SOAP note using APA 7 format and scholarly references no older than 5 years

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CC: My blood pressure is not controlled and I have been having headaches lately

Patient is a 59y/o male with H/o /HTN who presents for consultation reporting increase on his BP and headache since a few days ago, he states has been feeling more stressed at work recently due to a increase of workload. He monitors his blood pressure at home and has recorded readings consistently around 150/95 mmHg, whereas his usual readings are around 130/80 mmHg. Today he states measured at home and it was high, so he decided to come for evaluation. He denies any chest pain, shortness of breath, or changes in vision. Patient has been taking Lisinopril 20 mg once daily, Hydrochlorothiazide 25 mg once daily. on the physical examination Blood Pressure: 152/96 mmHg

ICD 10: I16.0: Hypertensive urgency

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2 years ago
25.11.2024
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