Hypertension Soap Note

Soap Note: Hypertension. Miami Regional University. HPI: BA is a 62 year old woman with a past medical history of multiple TIAs, subarachnoid hemorrhages, seizures, and type 2 diabetes mellitus presenting with new onset weakness and altered mental status in the last 24 hours. Hyponatremia: Case Description, SOAP Note and the Summary. High Blood Pressure: Medicines to Help You external icon: This guide from the U. SOAP NOTE 4 The patient has no history of other diseases connected to eyesight. Hypertension Soap Note Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program). The patient was seen by us last in October of last year, and at that time, we felt he was doing quite well from the cardiac standpoint. Two weeks ago she had her blood pressure taken during a health fair at the mall. The patient reports that he has been engaging in. HYPERTENSION SOAP NOTE 2. Hypertension SOAP note sample template. Description: Patient with hypertension, syncope, and spinal stenosis - for recheck. Hypertension, or abnormally high blood pressure, is a leading risk factor for cardiovascular disease. CHIEF COMPLAINT: Pulmonary hypertension with an estimated pulmonary artery systolic pressure of 50-60 on recent echocardiogram, hypertrophic nonischemic cardiomyopathy with normal systolic function, home oxygen therapy 3 liters at rest, 4 liters with activity starting today. Practicum Experience: SOAP Note and Journal. (Medical Transcription Sample Report) SUBJECTIVE: The patient is a 78-year-old female who returns for recheck. Her blood pressure measured 150/92 at that fair. h/o head ache x 3 days; Past h/o HTN; No c/o chest pain, palpitations, syncope; No neurological deficits, constitutional symptoms; Currently on ACEI, Coversyl at 4 mg; No h/o substance abuse, trauma, vision changes, sob, pedal edema; O. Description: Patient with hypertension, syncope, and spinal stenosis - for recheck. József Balla Language lector: Dr. Learning. Source: Patient. Subjective – The “history” section. · Lunch- “Large salad, peanut butter cookie, and sweet tea” Family History: Patient reports her mother is 59 years old and alive with history of hypertension, type 2 diabetes, and obesity. COMPLETE SOAP NOTE #3 3 · Breakfast- “Scrambled eggs, bacon, biscuit and 2 cups of coffee with cream and sugar”. In the United States, there are approximately 67 million adults who have hypertension, of whom over half do not have it under control. Her blood pressure measured 150/92 at that fair. Patient says he cannot remember to take two of the 30mg pills and would like the labels on the pill to properly reflect what he needs to take. Hypertension SOAP Note. In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. Hyponatremia: Case Description, SOAP Note and the Summary. He has a long history of mild tension-type headaches managed with acetaminophen. 2 HYPERTENSION SOAP NOTE Hypertension SOAP Note Patient Information Name: Mr. He stated to experience a persistent chest pain. Routine chemistries reveal a serum sodium of 128 mEq/L. Focused Soap Note Example For Hypertension 76541 case 01 10 final jones amp bartlett learning. Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. Make sure you include Psych History as well and also Genitourinary system. soap note “Hypertension” August 28, 2021 / in Uncategorized / by Admin. docx from NARE 446 at Egerton University. You can resubmit, Final submission will be accepted if less than 50%. SUBJECTIVE: The patient is a (XX)-year-old male known to us because of a history of coronary artery disease and a CABG back in October, who returns for a followup visit. History & Physical (admission note) CC: weakness x 1 day. Gender at Birth: Male. A CASE STUDY ON UNCONTROLLED HYPERTENSION PRESENTED BY Arunima Shrestha Harif Ghimire Mamata Panthi Romit Subba Trilochan Pandey [B. Pharmacy 2nd Year] 2. SUBJECTIVE: The patient is a (XX)-year-old Hispanic female with a past medical history significant for type 2 diabetes mellitus, hypertension, dyslipidemia, heart murmur, history of ruptured appendix as a child, history of a large scar hernia located in the right lower quadrant. COMPLETE SOAP NOTE #3 3 · Breakfast- “Scrambled eggs, bacon, biscuit and 2 cups of coffee with cream and sugar”. The patient reports that he has been engaging in. The patient was seen by us last in October of last year, and at that time, we felt he was doing quite well from the cardiac standpoint. SUBJECTIVE: The patient presents today for followup of poor blood pressure control. Description: Patient with hypertension, syncope, and spinal stenosis - for recheck. Problem List Subjective, Objective, Assessment, Plan (SOAP) note Acceptable Hypertension Diagnoses Accelerated HTN Arterial Hypertension /Arterial HTN Benign HTN / Borderline HTN/Malignant HTN Elevated Blood Pressure / Elevated BP / ↑BP Essential HTN Essential Hypertension (ICD 9 401. SUBJECTIVE. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. SOAP NOTE ON PATIENT WITH HYPERTENSION Subject: - Nursing. She has hypertension. PS paid a visit to the clinic for a follow up of his HTN. No previous history of eye infections is recorded. In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. Hypertension Soap Note. Subjective – The “history” section. Gender: Male. Poor Blood Pressure Control Followup SOAP Note Sample Report. Learning. Follow these guidelines for APA. Differential Diagnosis I: Primary Hypertension. The patient states that she got up in the morning to use the. Some of the causes of hypertension is smoking, obesity BMI over 30, “sedentary lifestyle,” diet high in salt, alcohol, stress, as well as age (webmd). soap note “Hypertension” August 28, 2021 / in Uncategorized / by Admin. PMH- HTN*14 yrs, DM II, Stage 2 COPD, BPH & recent recovery from. HYPERTENSION SOAP NOTE 2. Faith Based Nurse Practitioner. Food and Drug Administration can help you better understand blood pressure medicines and talk to a health care provider about what is right for you. Miami Regional University. Age: 68-year-old. Gender at Birth: Male. A CASE STUDY ON UNCONTROLLED HYPERTENSION PRESENTED BY Arunima Shrestha Harif Ghimire Mamata Panthi Romit Subba Trilochan Pandey [B. Hypertension SOAP note sample template. HPI: BA is a 62 year old woman with a past medical history of multiple TIAs, subarachnoid hemorrhages, seizures, and type 2 diabetes mellitus presenting with new onset weakness and altered mental status in the last 24 hours. The SOAP note template used for evaluation of elevated blood pressure includes reminders to ask questions regarding signs and symptoms of hypertensive emergency. Father deceased at age 67 with colon cancer. She has hypertension. Running head: HYPERTENSION Clinical Soap Note on Hypertension Students Name Institutional. · Lunch- “Large salad, peanut butter cookie, and sweet tea” Family History: Patient reports her mother is 59 years old and alive with history of hypertension, type 2 diabetes, and obesity. He states he is temporarily staying with his son and that has created some confusion in terms of taking pills and doing them on time. PMH- HTN*14 yrs, DM II, Stage 2 COPD, BPH & recent recovery from. (Medical Transcription Sample Report) SUBJECTIVE: The patient is a 78-year-old female who returns for recheck. Some of the causes of hypertension is smoking, obesity BMI over 30, “sedentary lifestyle,” diet high in salt, alcohol, stress, as well as age (webmd). Sample Soap Note: Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension) Student Name. He states he is temporarily staying with his son and that has created some confusion in terms of taking pills and doing them on time. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings. Follow these guidelines for APA. 'examples of soap notes for chronic problems may 7th, 2018 - subject image created date 5 15 2012 2 26 20 pm' 'soap note examples medical assistant net may 8th, 2018 - soap note examples for medical assistants a soap note is always written in a particular format a hypertension controlled'. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. L is a 60-year-old woman who comes to see you for a follow-up of her hypertension. She has hypertension. Hypertension Soap Note, is a note with data about the patient, which is composed or introduced in a particular request, which incorporates certain segments for patients. CC: High blood pressure plan is what the patient was undergoing. Soap Note "Hypertension" July 28, 2021 / by Mabel Keaton / 0. · Lunch- “Large salad, peanut butter cookie, and sweet tea” Family History: Patient reports her mother is 59 years old and alive with history of hypertension, type 2 diabetes, and obesity. Impact on lifestyle/Pt explanatory model: Pt feels his symptoms are a result of his cirrhosis, which he feels is getting worse. h/o head ache x 3 days; Past h/o HTN; No c/o chest pain, palpitations, syncope; No neurological deficits, constitutional symptoms; Currently on ACEI, Coversyl at 4 mg; No h/o substance abuse, trauma, vision changes, sob, pedal edema; O. He stated to experience a persistent chest pain. solved#2336347 - Soap Note: Hypertension. Please refer to […]. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. In the United States, there are approximately 67 million adults who have hypertension, of whom over half do not have it under control. Followup Evaluation Type 2 Diabetes SOAP Note Sample. You can resubmit, Final submission will be accepted if less than 50%. High Blood Pressure: Medicines to Help You external icon: This guide from the U. He states he is temporarily staying with his son and that has created some confusion in terms of taking pills and doing them on time. The father has a history of regulated hypertension. Father deceased at age 67 with colon cancer. This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings. In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. Comment: ASSIGNMENT. (Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. Follow these guidelines for APA. Rafael Camejo Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION. She only complains of mild fatigue. Copy paste from websites or textbooks will not be accepted or. Soap Note assignment #1 55-year-old male wellness visit Soap Note assignment #2 67-year-old female with shortness of breath and lower-leg swelling Soap Note assignment #3 45-year-old male with hypertension. Gender Identity: Male. Description: Patient with hypertension, syncope, and spinal stenosis - for recheck. Encounter Number: 234. All Docs; 77-year-old male, with past medical history of well-controlled hypertension & treated prostate cancer (5 years ago), presents with 3 day. Soap Note “Hypertension”. SOAP NOTE 4 The patient has no history of other diseases connected to eyesight. Impact on lifestyle/Pt explanatory model: Pt feels his symptoms are a result of his cirrhosis, which he feels is getting worse. Running head: HYPERTENSION Clinical Soap Note on Hypertension Students Name Institutional. 'examples of soap notes for chronic problems may 7th, 2018 - subject image created date 5 15 2012 2 26 20 pm' 'soap note examples medical assistant net may 8th, 2018 - soap note examples for medical assistants a soap note is always written in a particular format a hypertension controlled'. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. Pulmonary Hypertension SOAP Note Transcription Sample Report. COMPLETE SOAP NOTE #3 3 · Breakfast- “Scrambled eggs, bacon, biscuit and 2 cups of coffee with cream and sugar”. In the United States, there are approximately 67 million adults who have hypertension, of whom over half do not have it under control. View Notes - Clinical Soap Note on Hypertension. He states he is temporarily staying with his son and that has created some confusion in terms of taking pills and doing them on time. M Age: 56 Years Gender: Male Subjective Data CC: "I have come to make a follow-up on my hypertension plan. Focused Soap Note Example For Hypertension 76541 case 01 10 final jones amp bartlett learning. HYPERTENSION SOAP NOTE 2. No previous history of eye infections is recorded. Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. Rafael Camejo Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION. Grandfather deceased at age 50 auto accident. SOAPE NOTE Subjective - JF is a 64 y/o A. Patient says he cannot remember to take two of the 30mg pills and would like the labels on the pill to properly reflect what he needs to take. Gender: Male. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. In the United States, there are approximately 67 million adults who have hypertension, of whom over half do not have it under control. Grandmother deceased at 86 with hear disease. SUBJECTIVE: The patient is a 78-year-old female who returns for recheck. · Lunch- “Large salad, peanut butter cookie, and sweet tea” Family History: Patient reports her mother is 59 years old and alive with history of hypertension, type 2 diabetes, and obesity. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Practicum Experience: SOAP Note and Journal. Her blood pressure measured 150/92 at that fair. Family Medicine 02: 55-year-old male wellness visit User: Beatriz Duque Email: [email protected] Date: September 24, 2020 2:10PM. Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. Pt has no further […]. Patient says he cannot remember to take two of the 30mg pills and would like the labels on the pill to properly reflect what he needs to take. HYPERTENSION SOAP NOTE 2. Uncategorized. She has hypertension. Hypertension Soap Note. womens health soap note. M Age: 56 Years Gender: Male Subjective Data CC: "I have come to make a follow-up on my hypertension plan. Father deceased at age 67 with colon cancer. Discover Chartnote Medical Dictation and Smart Templates – We are passionate about preventing physician burnout by decreasing the burden of medical documentation. You can resubmit, Final dependence obtain be received if short. Pertinent past medical history. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. Medical Specialty:SOAP / Chart / Progress NotesSample Name: Hypertension - Progress Note. Patient says he cannot remember to take two of the 30mg pills and would like the labels on the pill to properly reflect what he needs to take. S: F/u HTN, pt has concerns about nifedipine medication since his dose was recently increased from 30mg to 60mg daily on 04 Oct. M seen today for f/u for his HTN. Two weeks ago she had her blood pressure taken during a health fair at the mall. (Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. medical documentation and ed charting cdem curriculum. L is a 60-year-old woman who comes to see you for a follow-up of her hypertension. CC: High blood pressure plan is what the patient was undergoing. Age: 68-year-old. HYPERTENSION SOAP NOTE 2. SOAP NOTE ON PATIENT WITH HYPERTENSION Subject: - Nursing. Fact Sheets About Hypertension and Related Conditions and Behaviors. Soap Note "Hypertension" July 28, 2021 / by Mabel Keaton / 0. · Lunch- “Large salad, peanut butter cookie, and sweet tea” Family History: Patient reports her mother is 59 years old and alive with history of hypertension, type 2 diabetes, and obesity. SUBJECTIVE: The patient is a (XX)-year-old male known to us because of a history of coronary artery disease and a CABG back in October, who returns for a followup visit. Soap Note “Hypertension”. Hypertension SOAP Note. He describes this headache as the "worst headache of his. István Wittmann Lector: Prof. Problem List Subjective, Objective, Assessment, Plan (SOAP) note Acceptable Hypertension Diagnoses Accelerated HTN Arterial Hypertension /Arterial HTN Benign HTN / Borderline HTN/Malignant HTN Elevated Blood Pressure / Elevated BP / ↑BP Essential HTN Essential Hypertension (ICD 9 401. National Heart Lung and Blood Institute. examples of soap notes in nursing video amp lesson. She has hypertension. Differential Diagnosis I: Primary Hypertension. solved#2336347 - Soap Note: Hypertension. CC: High blood pressure plan is what the patient was undergoing. Her blood pressure measured 150/92 at that fair. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. Poor Blood Pressure Control Followup SOAP Note Sample Report. Encounter Number: 234. Age: 68-year-old. High Blood Pressure: Medicines to Help You external icon: This guide from the U. History & Physical (admission note) CC: weakness x 1 day. POST your compiled case information and SOAP note. October 19, 2020. Date: 14/10/20. He states he is temporarily staying with his son and that has created some confusion in terms of taking pills and doing them on time. Hypertension Soap Note, is a note with data about the patient, which is composed or introduced in a particular request, which incorporates certain segments for patients. Description: Patient with hypertension, syncope, and spinal stenosis - for recheck. Subject: Image Created Date: 5/15/2012 2:26:20 PM. SOAP Note (by creating your soap notes, you have created a concrete concept on HTN management) S. SOAP Notes, such as the ones required in this course, are often. Some of the causes of hypertension is smoking, obesity BMI over 30, “sedentary lifestyle,” diet high in salt, alcohol, stress, as well as age (webmd). He takes medications and performs regularly check-ups at the hospital. National Heart Lung and Blood Institute. womens health soap note. The patient reports that he has been engaging in. HPI: BA is a 62 year old woman with a past medical history of multiple TIAs, subarachnoid hemorrhages, seizures, and type 2 diabetes mellitus presenting with new onset weakness and altered mental status in the last 24 hours. SOAP Note Exercise. 2 HYPERTENSION SOAP NOTE Hypertension SOAP Note Patient Information Name: Mr. Learning. History of present illness: Mr. SOAP NOTE ON PATIENT WITH HYPERTENSION Subject: - Nursing. History of Present Illness & Analysis of Symptom Pt reports that she had labwork drawn one week ago as part of her six-month follow-up appointment. This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings. Hypertension SOAP note sample template. Three days ago, a severe headache suddenly developed while he was weight lifting. Problem List Subjective, Objective, Assessment, Plan (SOAP) note Acceptable Hypertension Diagnoses Accelerated HTN Arterial Hypertension /Arterial HTN Benign HTN / Borderline HTN/Malignant HTN Elevated Blood Pressure / Elevated BP / ↑BP Essential HTN Essential Hypertension (ICD 9 401. Template for Clinical SOAP Note Format. You can resubmit, Final submission will be accepted if less than 50%. D is following up from a visit 3 months ago in which he was noted to have possible hypertension. Pt has no further […]. the focused interview soap notes and progress notes. Among the adults whose hypertension was not under control, 14 million were unaware they had hypertension. July 28, 2021 / by Mabel Keaton / 0. SOAP NOTE NUMBER THREE - Faith Based Nurse Practitioner. Hypertension SOAP note sample template. ASSIGNMENT. Practicum Experience: SOAP Note and Journal. SUBJECTIVE: The patient is a (XX)-year-old Hispanic female with a past medical history significant for type 2 diabetes mellitus, hypertension, dyslipidemia, heart murmur, history of ruptured appendix as a child, history of a large scar hernia located in the right lower quadrant. Impact on lifestyle/Pt explanatory model: Pt feels his symptoms are a result of his cirrhosis, which he feels is getting worse. Hypertension Soap Note. Subjective – The “history” section. SOAP / Chart / Progress Notes Sample Name: Hypertension - Progress Note Description: Patient with hypertension, syncope, and spinal stenosis - for recheck. M Age: 56 Years Gender: Male Subjective Data CC: "I have come to make a follow-up on my hypertension plan. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. He states he is temporarily staying with his son and that has created some confusion in terms of taking pills and doing them on time. Miami Regional University. David Trabanco DNP, APRN, AGNP-C, FNP-C Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name: Mr. " HPI: The patient indicates that he had visited the health facility to do a follow-up of her treatment plan after hypertension diagnosis three months ago. Hypertension SOAP note sample template. She has hypertension. 'examples of soap notes for chronic problems may 7th, 2018 - subject image created date 5 15 2012 2 26 20 pm' 'soap note examples medical assistant net may 8th, 2018 - soap note examples for medical assistants a soap note is always written in a particular format a hypertension controlled'. SOAP NOTE ON PATIENT WITH HYPERTENSION Subject: - Nursing. BP: 160/100mmhg. Soap Note: Hypertension. SOAP Note Case. Running head: HYPERTENSION Clinical Soap Note on Hypertension Students Name Institutional. Faith Based Nurse Practitioner. womens health soap note. Learning. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Father deceased at age 67 with colon cancer. Family Medicine 02: 55-year-old male wellness visit User: Beatriz Duque Email: [email protected] Date: September 24, 2020 2:10PM. Problem List Subjective, Objective, Assessment, Plan (SOAP) note Acceptable Hypertension Diagnoses Accelerated HTN Arterial Hypertension /Arterial HTN Benign HTN / Borderline HTN/Malignant HTN Elevated Blood Pressure / Elevated BP / ↑BP Essential HTN Essential Hypertension (ICD 9 401. SOAP NOTE NUMBER THREE - Faith Based Nurse Practitioner. (Medical Transcription Sample Report) SUBJECTIVE: The patient is a 78-year-old female who returns for recheck. You can resubmit, Final submission will be accepted if less than 50%. Learning. Soap Referablee "Hypertension". Gender at Birth: Male. " HPI: The patient indicates that he had visited the health facility to do a follow-up of her treatment plan after hypertension diagnosis three months ago. Gender: Male. Hypertension, or abnormally high blood pressure, is a leading risk factor for cardiovascular disease. XX is a 70 y/o man with hypertension, hyperlipidemia, obesity, 40 pack-years smoking history and a brother who died of MI at 60 y/o. COMPLETE SOAP NOTE #3 3 · Breakfast- “Scrambled eggs, bacon, biscuit and 2 cups of coffee with cream and sugar”. On physical exam, her BP is well controlled at 126/84 mm Hg. Subject: Image Created Date: 5/15/2012 2:26:20 PM. J is a 27-year-old man who arrives at his primary care physician's office complaining of a headache. July 28, 2021 / by Mabel Keaton / 0. HYPERTENSION SOAP NOTE 2. Paternal Grandparents: Grandfather deceased at age 65 with pancreatic cancer. Comment: ASSIGNMENT. Family History The patient denies having any family history relevant to his condition. Soap Note assignment #1 55-year-old male wellness visit Soap Note assignment #2 67-year-old female with shortness of breath and lower-leg swelling Soap Note assignment #3 45-year-old male with hypertension. This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings. A CASE STUDY ON UNCONTROLLED HYPERTENSION PRESENTED BY Arunima Shrestha Harif Ghimire Mamata Panthi Romit Subba Trilochan Pandey [B. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. soap note “Hypertension” August 28, 2021 / in Uncategorized / by Admin. Soap Note "Hypertension" July 28, 2021 / by Mabel Keaton / 0. Soap Note Hypertension Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. He stated to experience a persistent chest pain. Learning. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. High Blood Pressure: Medicines to Help You external icon: This guide from the U. You can resubmit, Final submission will be accepted if less than 50%. Follow these guidelines for APA. Two weeks ago she had her blood pressure taken during a health fair at the mall. Date: 14/10/20. Patient initials and age: MD,47. SUBJECTIVE: The patient presents today for followup of poor blood pressure control. Gender at Birth: Male. SOAP NOTE ON PATIENT WITH HYPERTENSION. Sample Soap Note: Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension) Student Name. Miami Regional University. Practicum Experience: SOAP Note and Journal. · Lunch- “Large salad, peanut butter cookie, and sweet tea” Family History: Patient reports her mother is 59 years old and alive with history of hypertension, type 2 diabetes, and obesity. Some of the causes of hypertension is smoking, obesity BMI over 30, “sedentary lifestyle,” diet high in salt, alcohol, stress, as well as age (webmd). Gender: Male. SOAP Notes, such as the ones required in this course, are often. Grandmother deceased at 86 with hear disease. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. A soape note on uncontrolled hypertension. Hypertension Soap Note Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program). (Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. SOAP Note (by creating your soap notes, you have created a concrete concept on HTN management) S. M seen today for f/u for his HTN. Make sure you include Psych History as well and also Genitourinary system. Soap Note “Hypertension”. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. Soap Note assignment #1 55-year-old male wellness visit Soap Note assignment #2 67-year-old female with shortness of breath and lower-leg swelling Soap Note assignment #3 45-year-old male with hypertension. Three days ago, a severe headache suddenly developed while he was weight lifting. He states he is temporarily staying with his son and that has created some confusion in terms of taking pills and doing them on time. Poor Blood Pressure Control Followup SOAP Note Sample Report. Hypertension, or abnormally high blood pressure, is a leading risk factor for cardiovascular disease. He describes this headache as the "worst headache of his. October 19, 2020. Hypertension SOAP Note. Hypertension Soap Note, is a note with data about the patient, which is composed or introduced in a particular request, which incorporates certain segments for patients. SOAP NOTE ON PATIENT WITH HYPERTENSION Subject: - Nursing. Rafael Camejo Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION. Miami Regional University. DT Age: 68-year-old Gender at Birth: Male Gender Identity: Male Source: Patient Allergies: PCN, Iodine Current Medications: · Atorvastatin tab […]. Soap Referablee "Hypertension". Unfortunately, he did not take his dose before coming here. This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings. The patient was seen by us last in October of last year, and at that time, we felt he was doing quite well from the cardiac standpoint. He has a long history of mild tension-type headaches managed with acetaminophen. PS paid a visit to the clinic for a follow up of his HTN. Hypertension SOAP note sample template. Fact Sheets About Hypertension and Related Conditions and Behaviors. Paternal Grandparents: Grandfather deceased at age 65 with pancreatic cancer. She denies difficulty with chest pain, palpations. Learning. The father has a history of regulated hypertension. Due to patient's age, BMI, lifestyle, consecutive hypertensive blood pressures, and description of headaches (bilateral temporal throbbing - occurring throughout day with decreased intensity as the day progresses), lower extremity edema, and knowledge that primary hypertension is the most. Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. No previous history of eye infections is recorded. This is maternity note ,please adapt to advance primary care References in APA have to be within a 5-year range. M seen today for f/u for his HTN. Two weeks ago she had her blood pressure taken during a health fair at the mall. Learning. HYPERTENSION SOAP NOTE 2. SUBJECTIVE: The patient is a (XX)-year-old male known to us because of a history of coronary artery disease and a CABG back in October, who returns for a followup visit. Faith Based Nurse Practitioner. Rouse Written by the staff of the 2nd Department of Medicine and Nephrological Center, Faculty of Medicine, University of Pécs „AZ ÉLETTUDOMÁNYI -KLINIKAI. A CASE STUDY ON UNCONTROLLED HYPERTENSION PRESENTED BY Arunima Shrestha Harif Ghimire Mamata Panthi Romit Subba Trilochan Pandey [B. Hyponatremia: Case Description, SOAP Note and the Summary. History & Physical (admission note) CC: weakness x 1 day. Soap referablees obtain be uploaded to Moodle and arrange through TURN-It-In (anti-Plagiarism program) Turn it in Score must be short than 50% or obtain referable be received control faith, must be your confess product and in your confess suffrage. Running head: HYPERTENSION Clinical Soap Note on Hypertension Students Name Institutional. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. (Medical Transcription Sample Report) SUBJECTIVE: The patient is a 78-year-old female who returns for recheck. · Lunch- “Large salad, peanut butter cookie, and sweet tea” Family History: Patient reports her mother is 59 years old and alive with history of hypertension, type 2 diabetes, and obesity. Fact Sheets About Hypertension and Related Conditions and Behaviors. You can resubmit, Final submission will be accepted if less than 50%. J is a 27-year-old man who arrives at his primary care physician's office complaining of a headache. Among the adults whose hypertension was not under control, 14 million were unaware they had hypertension. SUBJECTIVE: The patient presents today for followup of poor blood pressure control. October 19, 2020. " HPI: The patient indicates that he had visited the health facility to do a follow-up of her treatment plan after hypertension diagnosis three months ago. Family Medicine 02: 55-year-old male wellness visit User: Beatriz Duque Email: [email protected] Date: September 24, 2020 2:10PM. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. He describes this headache as the "worst headache of his. David Trabanco DNP, APRN, AGNP-C, FNP-C Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name: Mr. DT Age: 68-year-old Gender at Birth: Male Gender Identity: Male Source: Patient Allergies: PCN, Iodine Current Medications: · Atorvastatin tab […]. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. Practicum Experience: SOAP Note and Journal. National Heart Lung and Blood Institute. Soap note 1 on Hypertension Order Description In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. (Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. History of present illness: Mr. BP: 160/100mmhg. You can resubmit, Final submission will be accepted if less than 50%. Age: 68-year-old. Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. Patient says he cannot remember to take two of the 30mg pills and would like the labels on the pill to properly reflect what he needs to take. SOAP NOTE ON PATIENT WITH HYPERTENSION Subject: - Nursing. COMPLETE SOAP NOTE #3 3 · Breakfast- “Scrambled eggs, bacon, biscuit and 2 cups of coffee with cream and sugar”. Follow these guidelines for APA. COMPLETE SOAP NOTE #3 3 · Breakfast- “Scrambled eggs, bacon, biscuit and 2 cups of coffee with cream and sugar”. SUBJECTIVE. solved#2336347 - Soap Note: Hypertension. Fact Sheets About Hypertension and Related Conditions and Behaviors. Pharmacy 2nd Year] 2. Gender: Male. BP: 160/100mmhg. This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings. Please refer to […]. Two weeks ago she had her blood pressure taken during a health fair at the mall. SOAP Note Case. (Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. No previous history of eye infections is recorded. Problem List Subjective, Objective, Assessment, Plan (SOAP) note Acceptable Hypertension Diagnoses Accelerated HTN Arterial Hypertension /Arterial HTN Benign HTN / Borderline HTN/Malignant HTN Elevated Blood Pressure / Elevated BP / ↑BP Essential HTN Essential Hypertension (ICD 9 401. S: F/u HTN, pt has concerns about nifedipine medication since his dose was recently increased from 30mg to 60mg daily on 04 Oct. Hypertension Soap Note. You can resubmit, Final submission will be accepted if less than 50%. Sample Soap Note: Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension) Student Name. Chief complaint: Patient states he is, "following up on my high blood pressure. Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. The patient states that she got up in the morning to use the. Medical Specialty:SOAP / Chart / Progress NotesSample Name: Hypertension - Progress Note. In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. Hypertension, or abnormally high blood pressure, is a leading risk factor for cardiovascular disease. Soap Note "Hypertension" July 28, 2021 / by Mabel Keaton / 0. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. He states he is temporarily staying with his son and that has created some confusion in terms of taking pills and doing them on time. Learning. L is a 60-year-old woman who comes to see you for a follow-up of her hypertension. Miami Regional University. SOAPE NOTE Subjective - JF is a 64 y/o A. SOAP NOTE ON PATIENT WITH HYPERTENSION Subject: - Nursing. Gender at Birth: Male. Hypertension Soap Note, is a note with data about the patient, which is composed or introduced in a particular request, which incorporates certain segments for patients. Routine chemistries reveal a serum sodium of 128 mEq/L. This is maternity note ,please adapt to advance primary care References in APA have to be within a 5-year range. Soap Note assignment #1 55-year-old male wellness visit Soap Note assignment #2 67-year-old female with shortness of breath and lower-leg swelling Soap Note assignment #3 45-year-old male with hypertension. Chief complaint: Patient states he is, "following up on my high blood pressure. SOAP NOTE 4 The patient has no history of other diseases connected to eyesight. David Trabanco DNP, APRN, AGNP-C, FNP-C Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name: Mr. He stated to experience a persistent chest pain. On physical exam, her BP is well controlled at 126/84 mm Hg. National Heart Lung and Blood Institute. Comment: ASSIGNMENT. Age: 68-year-old. Miami Regional University. You can resubmit, Final submission will be accepted if less than 50%. Template for Clinical SOAP Note Format. Patient initials and age: MD,47. COMPLETE SOAP NOTE #3 3 · Breakfast- “Scrambled eggs, bacon, biscuit and 2 cups of coffee with cream and sugar”. Medical Specialty:SOAP / Chart / Progress NotesSample Name: Hypertension - Progress Note. Follow these guidelines for APA. SOAP / Chart / Progress Notes Sample Name: Hypertension - Progress Note Description: Patient with hypertension, syncope, and spinal stenosis - for recheck. He states he is temporarily staying with his son and that has created some confusion in terms of taking pills and doing them on time. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. Differential Diagnosis I: Primary Hypertension. CHIEF COMPLAINT: Pulmonary hypertension with an estimated pulmonary artery systolic pressure of 50-60 on recent echocardiogram, hypertrophic nonischemic cardiomyopathy with normal systolic function, home oxygen therapy 3 liters at rest, 4 liters with activity starting today. Due to patient's age, BMI, lifestyle, consecutive hypertensive blood pressures, and description of headaches (bilateral temporal throbbing - occurring throughout day with decreased intensity as the day progresses), lower extremity edema, and knowledge that primary hypertension is the most. In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. Soap Note assignment #1 55-year-old male wellness visit Soap Note assignment #2 67-year-old female with shortness of breath and lower-leg swelling Soap Note assignment #3 45-year-old male with hypertension. M seen today for f/u for his HTN. · Lunch- “Large salad, peanut butter cookie, and sweet tea” Family History: Patient reports her mother is 59 years old and alive with history of hypertension, type 2 diabetes, and obesity. Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime ASA 81mg po daily Multi-Vitamin Centrum Silver. Chief complaint: Patient states he is, "following up on my high blood pressure. Hypertension Soap Note, is a note with data about the patient, which is composed or introduced in a particular request, which incorporates certain segments for patients. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. Miami Regional University. COMPLETE SOAP NOTE #3 3 · Breakfast- “Scrambled eggs, bacon, biscuit and 2 cups of coffee with cream and sugar”. Gender Identity: Male. Rafael Camejo Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION. The patient reports that he has been engaging in. Uncategorized. He stated to experience a persistent chest pain. Some of the causes of hypertension is smoking, obesity BMI over 30, “sedentary lifestyle,” diet high in salt, alcohol, stress, as well as age (webmd). No previous history of eye infections is recorded. examples of soap notes in nursing video amp lesson. Among the adults whose hypertension was not under control, 14 million were unaware they had hypertension. Age: 68-year-old. J is a 27-year-old man who arrives at his primary care physician's office complaining of a headache. Hypertension SOAP note sample template. Three days ago, a severe headache suddenly developed while he was weight lifting. " HPI: The patient indicates that he had visited the health facility to do a follow-up of her treatment plan after hypertension diagnosis three months ago. SUBJECTIVE: The patient is a 78-year-old female who returns for recheck. SOAP / Chart / Progress Notes Sample Name: Hypertension - Progress Note Description: Patient with hypertension, syncope, and spinal stenosis - for recheck. Rafael Camejo Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION. Chief complaint: Patient states he is, "following up on my high blood pressure. Age: 68-year-old. This is to reduce the risk of missing this important diagnosis. XX is a 70 y/o man with hypertension, hyperlipidemia, obesity, 40 pack-years smoking history and a brother who died of MI at 60 y/o. He takes medications and performs regularly check-ups at the hospital. SUBJECTIVE: The patient is a (XX)-year-old male known to us because of a history of coronary artery disease and a CABG back in October, who returns for a followup visit. SUBJECTIVE: The patient is a 78-year-old female who returns for recheck. Learning. October 19, 2020. M Age: 56 Years Gender: Male Subjective Data CC: "I have come to make a follow-up on my hypertension plan. S: F/u HTN, pt has concerns about nifedipine medication since his dose was recently increased from 30mg to 60mg daily on 04 Oct. Age: 68-year-old. SOAP NOTE ONE SUBJECTIVE Ms. He stated to experience a persistent chest pain. Hypertension SOAP Note. Family History: Mother 82, in fair health diagnosed with hypertension 20 years ago and takes medication for. Source: Patient. FAMILY MEDICINE Focused H&P CC: Blood pressure check PMH: The patient is a 51 year old female who presents for a check of blood pressure. J is a 27-year-old man who arrives at his primary care physician's office complaining of a headache. In the United States, there are approximately 67 million adults who have hypertension, of whom over half do not have it under control. examples of soap notes in nursing video amp lesson. All Docs; 77-year-old male, with past medical history of well-controlled hypertension & treated prostate cancer (5 years ago), presents with 3 day. History of present illness: Mr. Date: 14/10/20. National Heart Lung and Blood Institute. (Medical Transcription Sample Report) SUBJECTIVE: The patient is a 78-year-old female who returns for recheck. Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. SUBJECTIVE: The patient presents today for followup of poor blood pressure control. This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings. The patient was seen by us last in October of last year, and at that time, we felt he was doing quite well from the cardiac standpoint. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. D is following up from a visit 3 months ago in which he was noted to have possible hypertension. Subject: Image Created Date: 5/15/2012 2:26:20 PM. COMPLETE SOAP NOTE #3 3 · Breakfast- “Scrambled eggs, bacon, biscuit and 2 cups of coffee with cream and sugar”. Sample Soap Note: Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension) Student Name. solved#2336347 - Soap Note: Hypertension. The patient states that she got up in the morning to use the. Follow these guidelines for APA. He describes this headache as the "worst headache of his. On physical exam, her BP is well controlled at 126/84 mm Hg. A CASE STUDY ON UNCONTROLLED HYPERTENSION PRESENTED BY Arunima Shrestha Harif Ghimire Mamata Panthi Romit Subba Trilochan Pandey [B. · Lunch- “Large salad, peanut butter cookie, and sweet tea” Family History: Patient reports her mother is 59 years old and alive with history of hypertension, type 2 diabetes, and obesity. ASSIGNMENT. HPI: BA is a 62 year old woman with a past medical history of multiple TIAs, subarachnoid hemorrhages, seizures, and type 2 diabetes mellitus presenting with new onset weakness and altered mental status in the last 24 hours. SOAP NOTE ONE SUBJECTIVE Ms. Chief complaint: Patient states he is, "following up on my high blood pressure. S: F/u HTN, pt has concerns about nifedipine medication since his dose was recently increased from 30mg to 60mg daily on 04 Oct. SUBJECTIVE: The patient is a (XX)-year-old Hispanic female with a past medical history significant for type 2 diabetes mellitus, hypertension, dyslipidemia, heart murmur, history of ruptured appendix as a child, history of a large scar hernia located in the right lower quadrant. Discover Chartnote Medical Dictation and Smart Templates – We are passionate about preventing physician burnout by decreasing the burden of medical documentation. Problem List Subjective, Objective, Assessment, Plan (SOAP) note Acceptable Hypertension Diagnoses Accelerated HTN Arterial Hypertension /Arterial HTN Benign HTN / Borderline HTN/Malignant HTN Elevated Blood Pressure / Elevated BP / ↑BP Essential HTN Essential Hypertension (ICD 9 401. SOAP / Chart / Progress Notes Sample Name: Hypertension - Progress Note Description: Patient with hypertension, syncope, and spinal stenosis - for recheck. You can resubmit, Final submission will be accepted if less than 50%. medical documentation and ed charting cdem curriculum. Rafael Camejo Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION. D is following up from a visit 3 months ago in which he was noted to have possible hypertension. Poor Blood Pressure Control Followup SOAP Note Sample Report. HPI: BA is a 62 year old woman with a past medical history of multiple TIAs, subarachnoid hemorrhages, seizures, and type 2 diabetes mellitus presenting with new onset weakness and altered mental status in the last 24 hours. SOAP NOTE 4 The patient has no history of other diseases connected to eyesight. Soap Note assignment #1 55-year-old male wellness visit Soap Note assignment #2 67-year-old female with shortness of breath and lower-leg swelling Soap Note assignment #3 45-year-old male with hypertension. Learning. Soap Note Hypertension Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. POST your compiled case information and SOAP note. CC: High blood pressure plan is what the patient was undergoing. Problem List Subjective, Objective, Assessment, Plan (SOAP) note Acceptable Hypertension Diagnoses Accelerated HTN Arterial Hypertension /Arterial HTN Benign HTN / Borderline HTN/Malignant HTN Elevated Blood Pressure / Elevated BP / ↑BP Essential HTN Essential Hypertension (ICD 9 401. Gender at Birth: Male. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. SOAP NOTE ON PATIENT WITH HYPERTENSION. Discover Chartnote Medical Dictation and Smart Templates - We are passionate about preventing physician burnout by decreasing the burden of medical documentation. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. Soap referablees obtain be uploaded to Moodle and arrange through TURN-It-In (anti-Plagiarism program) Turn it in Score must be short than 50% or obtain referable be received control faith, must be your confess product and in your confess suffrage. COMPLETE SOAP NOTE #3 3 · Breakfast- “Scrambled eggs, bacon, biscuit and 2 cups of coffee with cream and sugar”. Hypertension, or abnormally high blood pressure, is a leading risk factor for cardiovascular disease. Sample Soap Note: Soap Note # Main Diagnosis ( Exp: H&P Note #3 DX: Hypertension) Student Name. SOAP #1 - Abby Griffith Family History: Diabetes: Mother (deceased) Heart Disease: Mother and Father (deceased) Hypertension: Father Denies family history of GI cancer or liver disease. J is a 27-year-old man who arrives at his primary care physician's office complaining of a headache. SOAP / Chart / Progress Notes Sample Name: Hypertension - Progress Note Description: Patient with hypertension, syncope, and spinal stenosis - for recheck. National Heart Lung and Blood Institute. History of present illness: Mr. Learning. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. solved#2336347 - Soap Note: Hypertension. " HPI: The patient indicates that he had visited the health facility to do a follow-up of her treatment plan after hypertension diagnosis three months ago. No previous history of eye infections is recorded. HPI: BA is a 62 year old woman with a past medical history of multiple TIAs, subarachnoid hemorrhages, seizures, and type 2 diabetes mellitus presenting with new onset weakness and altered mental status in the last 24 hours. Cardiology SOAP Note Sample Report #2. Problem List Subjective, Objective, Assessment, Plan (SOAP) note Acceptable Hypertension Diagnoses Accelerated HTN Arterial Hypertension /Arterial HTN Benign HTN / Borderline HTN/Malignant HTN Elevated Blood Pressure / Elevated BP / ↑BP Essential HTN Essential Hypertension (ICD 9 401. Discover Chartnote Medical Dictation and Smart Templates – We are passionate about preventing physician burnout by decreasing the burden of medical documentation. HYPERTENSION SOAP NOTE 2. Hypertension Soap Note, is a note with data about the patient, which is composed or introduced in a particular request, which incorporates certain segments for patients. D is following up from a visit 3 months ago in which he was noted to have possible hypertension. National Heart Lung and Blood Institute. Gender at Birth: Male. J is a 27-year-old man who arrives at his primary care physician's office complaining of a headache. Running head: HYPERTENSION Clinical Soap Note on Hypertension Students Name Institutional. Father deceased at age 67 with colon cancer. A CASE STUDY ON UNCONTROLLED HYPERTENSION PRESENTED BY Arunima Shrestha Harif Ghimire Mamata Panthi Romit Subba Trilochan Pandey [B. Gender at Birth: Male. medical documentation and ed charting cdem curriculum. History of present illness: Mr. First SOAP note. Copy paste from websites or textbooks will not be accepted or. SOAP NOTE ON PATIENT WITH HYPERTENSION. Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. SOAP NOTE ON PATIENT WITH HYPERTENSION Subject: - Nursing. A soape note on uncontrolled hypertension. Soap Note "Hypertension" July 28, 2021 / by Mabel Keaton / 0. CC: High blood pressure plan is what the patient was undergoing. SUBJECTIVE. Learning. Miami Regional University. This article outlines the four parts of SOAP notes and examines the importance and effectiveness of SOAP notes in clinical settings. Age: 68-year-old. Medical Specialty:SOAP / Chart / Progress NotesSample Name: Hypertension - Progress Note. This is to reduce the risk of missing this important diagnosis. National Heart Lung and Blood Institute. KH is a 47-year-old Caucasian female who presented to the Magnolia Healthcare clinic October 11, 2013 alone to review abnormal lab work. In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. He stated to experience a persistent chest pain. (Student Name) Miami Regional University Date of Encounter: Preceptor/Clinical Site: Clinical Instructor: Dr. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. David Trabanco DNP, APRN, AGNP-C, FNP-C Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION Name: Mr. KH is a 47-year-old Caucasian female who presented to the Magnolia Healthcare clinic October 11, 2013 alone to review abnormal lab work. Rafael Camejo Soap Note # Main Diagnosis ( Exp: Soap Note #3 DX: Hypertension) PATIENT INFORMATION. The patient reports that he has been engaging in. Paternal Grandparents: Grandfather deceased at age 65 with pancreatic cancer. SOAP NOTE ONE SUBJECTIVE Ms. He describes this headache as the "worst headache of his. Miami Regional University. SOAP Note Exercise. Facts About Hypertension: Stay up to date on the latest facts about hypertension from the CDC. Her blood pressure measured 150/92 at that fair. Family History The patient denies having any family history relevant to his condition. A CASE STUDY ON UNCONTROLLED HYPERTENSION PRESENTED BY Arunima Shrestha Harif Ghimire Mamata Panthi Romit Subba Trilochan Pandey [B. Follow these guidelines for APA. Impact on lifestyle/Pt explanatory model: Pt feels his symptoms are a result of his cirrhosis, which he feels is getting worse. Comment: ASSIGNMENT. View Notes - Clinical Soap Note on Hypertension. Date: 14/10/20. Followup Evaluation Type 2 Diabetes SOAP Note Sample. M Age: 56 Years Gender: Male Subjective Data CC: "I have come to make a follow-up on my hypertension plan.