Subjective
CC: “I take my blood pressure at my local pharmacy and when I went it was high”
HPI: 29 y.o AA female G5P2111presents at 31 5/7 weeks’ gestation (third trimester) having
missed visits after being seen at 24 weeks gestation presenting with high blood pressure. At the
drug store ...
SOAP NOTE TEMPLATE
Demographics
Date: 11/4/2020
Name: Tina Sandler
Age: 29 years old
Occupation: Teacher
Name of Agency: Ihuman
Subjective
CC: “I take my blood pressure at my local pharmacy and when I went it was high”
HPI: 29 y.o AA female G5P2111presents at 31 5/7 weeks’ gestation (third trimester) having
missed visits after being seen at 24 weeks gestation presenting with high blood pressure. At the
drug store her systolic blood pressure was 140’s. Pt unaware how long BP has been elevated
given she does not check her blood pressure regularly at home, in office BP 146/90. Patient also
expressed a 4-pound weight gain this week. 2) Patient also complained of acid reflux while
laying supine. 3) patient complains of headaches are a 3/10 pain non-pulsitile. Headaches
increase when tension is high between patient and husband and last a few hours a few times a
week. Patient has been taking Tylenol to relive headaches.
ROS:
Cons: elevated blood pressure, acid reflux,
HEENT: Patient denies, dizziness, syncope, difficulty hearing, difficulty tasting, blurred vision,
ringing of the ears
Patient companies of headache
CV: Patient denies: chest pain, SOB, chest pressure
Patient companies of: increased edema of extremities and face
Lungs: Patient denies: SOB, cough, phlem, difficulty breathing
Breast: patient denies: Dipple discharge, masses, lesions, ulcerations, or skin variation
patient complains of tenderness
GI: patient denies: dysuria, incontinence, urgency frequency, painful intercourse
GU: Patient denies: nausea, vomiting, weight loss
Patient complains of: acid reflux when laying supine, weight gain r/t pregnancy
Psych: patient denies depression, anxiety, suicidal ideation
complains of: previous domestic violence w/o trauma
PMH: ectopic pregnancy, preeclampsia, 3rd trimester pregnancy loss
Allergies: Shell-fish
Medications: prenatal vitamins
SH: patient verbalized no smoking, ETOH use, or recreational drug use during pregnancy
Objective
VS: 5’5, 190lds, BP 146/90, pulse 82, RR18, temp 97.4, sp02 94%
Cons: 4 pound weight gain over the past 1 week
HEENT: no papilledema, no facial edema, PERRLA, EOMI, sclera is non-icteric, Fundi appear
normal including optic discs and vessels, no signs of nystagmus.
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