SOAP Note: A Hypertension Case Study
An Academic Guide for Nursing and Healthcare Students.
This guide provides a detailed, section-by-section breakdown of a SOAP note for a patient with hypertension, demonstrating how to apply clinical reasoning to documentation.
Order a Custom SOAP NoteThe SOAP Note Framework
The SOAP note (Subjective, Objective, Assessment, Plan) is a fundamental tool for clinical documentation in healthcare. It provides a standardized structure for organizing patient information, facilitating clear communication among providers and supporting sound clinical reasoning. This guide uses a case study of a 66-year-old Hispanic female with hypertension to illustrate how to construct each component of a thorough and compliant SOAP note. Mastering this format is a critical skill for all healthcare students.
S: Subjective Data
Demographics
Patient is a 66-year-old Hispanic female.
Chief Complaint (CC)
“I’m here for my follow-up appointment for my high blood pressure.”
History of Present Illness (HPI)
The patient is a 66-year-old Hispanic female with a 10-year history of essential hypertension, here for a scheduled follow-up. She was started on lisinopril 10 mg daily six months ago. She reports checking her blood pressure at home “a few times a week,” with recent readings ranging from 145-155/90-95 mmHg. She admits to sometimes forgetting to take her medication, estimating she misses 2-3 doses per week, especially on weekends when her routine is different. She denies chest pain, palpitations, shortness of breath, and visual changes. She reports occasional, mild headaches in the morning that resolve on their own, which she rates as 2/10 in severity. She follows a diet that she describes as “pretty good,” but notes it is often high in sodium due to frequent consumption of canned soups and processed foods for convenience. She does not engage in regular structured exercise.
Allergies
No Known Drug Allergies (NKDA).
Medications
- Lisinopril 10 mg, once daily (patient reports inconsistent adherence)
- Atorvastatin 20 mg, once daily
- Multivitamin, once daily
Past Medical History (PMH)
- Essential Hypertension (diagnosed 10 years ago)
- Hyperlipidemia (diagnosed 5 years ago)
- Postmenopausal
Past Surgical History (PSH)
Cholecystectomy (2010), Hysterectomy (2005)
Family History
Mother died at age 70 from a myocardial infarction, had a history of hypertension. Father died at age 75 from a stroke, also with a history of hypertension and Type 2 Diabetes. Sister (age 68) is alive and well with hypertension.
Social History
Patient is a retired school teacher, lives with her husband. She denies any history of smoking or illicit drug use. Reports drinking one glass of wine with dinner 2-3 times per week. She is her husband’s primary caregiver, which she describes as stressful. She is a high school graduate and follows the Catholic faith.
Review of Systems (ROS)
- General: Reports good overall health despite headaches. Denies fever, chills, or weight changes.
- HEENT: Reports occasional mild headaches. Denies vision changes, hearing loss, or sore throat.
- Cardiovascular: Denies chest pain, palpitations, or edema.
- Respiratory: Denies shortness of breath, cough, or wheezing.
- Gastrointestinal: Denies nausea, vomiting, or abdominal pain.
- Neurological: Denies dizziness, syncope, or focal weakness.
- Musculoskeletal: Denies myalgias or arthralgias.
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O: Objective Data
Vital Signs
- BP: 156/94 mmHg (right arm, seated)
- HR: 78 bpm, regular
- RR: 16 breaths/min
- Temp: 98.6°F (oral)
- O2 Sat: 99% on room air
- Weight: 165 lbs
- Height: 5’4″
- BMI: 28.3
Labs
Last lipid panel (6 months ago): Total Chol 210, LDL 130, HDL 45, Trig 150. Last BMP (6 months ago): WNL.
Physical Examination
- General: Alert and oriented x4, in no acute distress. Well-appearing and well-groomed.
- HEENT: Normocephalic, atraumatic. PERRLA. Funduscopic exam reveals mild arteriovenous (AV) nicking, no hemorrhages or exudates.
- Neck: Supple, no carotid bruits, no thyromegaly.
- Lungs: Clear to auscultation bilaterally, no wheezes or rales.
- Cardio: Regular rate and rhythm. Normal S1, S2. Presence of an S4 gallop. No murmurs or rubs.
- Abdomen: Soft, non-tender, non-distended. Bowel sounds are normoactive.
- Extremities: No cyanosis or edema. 2+ peripheral pulses bilaterally.
A/P: Assessment and Plan
Diagnosis
Uncontrolled Essential Hypertension
Differential Diagnosis
- Non-adherence to medication
- Dietary indiscretion (high sodium intake)
- Secondary Hypertension (less likely given long-standing history)
- White Coat Hypertension
ICD-10 Coding
I10 – Essential (primary) hypertension
Pharmacologic Treatment Plan
Increase Lisinopril from 10 mg to 20 mg once daily. Continue Atorvastatin 20 mg daily. The decision to increase medication is based on current guidelines for blood pressure management, which emphasize achieving target goals to reduce cardiovascular risk. A 2024 review highlights the latest updates in pharmacological treatment, underscoring the importance of timely medication titration.
Diagnostic/Lab Testing
- Basic Metabolic Panel (BMP) to monitor renal function and electrolytes in 2 weeks after lisinopril dose increase.
- Lipid panel today to re-assess cholesterol levels.
- Electrocardiogram (ECG) today to assess for left ventricular hypertrophy (LVH) given S4 finding.
Education
- Discussed the importance of medication adherence. Provided patient with a pill organizer and discussed strategies to remember medication, such as setting a daily phone alarm.
- Educated on a low-sodium (DASH) diet. Provided a handout with food examples and tips for reading food labels.
- Recommended initiating a walking program, starting with 15 minutes, 3 times a week, and gradually increasing as tolerated.
- Instructed on proper home blood pressure monitoring technique and to keep a log to bring to the next appointment.
Anticipatory Guidance
Advised patient on potential side effects of increased lisinopril dose, including dizziness or a dry cough, and instructed her to call the office if these occur. Emphasized that lifestyle changes are as important as medication for long-term blood pressure control. A 2024 article on lifestyle modification highlights its central role in hypertension care.
Follow-up Plan
Return to clinic in 4 weeks for blood pressure re-check and review of lab results. Call if home BP readings are consistently >160/100 mmHg or if symptoms worsen.
Prescription
Drug: Lisinopril
Dose: 20 mg
Route: PO (by mouth)
Frequency: Once daily
Dispense: #90 (ninety)
Refills: 3
Frequently Asked Questions
What is the most common mistake students make when writing SOAP notes?
The most common mistake is mixing subjective and objective information. The ‘S’ section should only contain what the patient reports, while the ‘O’ section is reserved for measurable findings from the physical exam and diagnostic tests. Keeping these sections distinct is crucial for clear clinical communication.
How do I formulate a good differential diagnosis for hypertension?
A good differential diagnosis considers other potential causes for the patient’s condition. For hypertension, while over 90% of cases are ‘essential’ (no known cause), you should consider secondary causes like renal artery stenosis, thyroid disorders, or obstructive sleep apnea, especially if the blood pressure is resistant to treatment or the patient is young.
What are the key patient education points for a newly diagnosed hypertension patient?
Key education points include the importance of medication adherence (taking it daily as prescribed), lifestyle modifications (such as the DASH diet and regular exercise), how to monitor blood pressure at home, and when to seek urgent medical attention (symptoms like severe headache, chest pain, or shortness of breath).
Our Nursing and Medical Experts
Our writers hold advanced degrees, including Doctor of Nursing Practice (DNP), and have extensive clinical experience, making them uniquely qualified to assist with SOAP notes, case studies, and other healthcare assignments.
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Dr. Zacchaeus Kiragu, DNP
Nursing Practice & Public Health
With a DNP and clinical background, Dr. Kiragu is an expert in clinical documentation, patient assessment, and evidence-based treatment plans for chronic conditions like hypertension.
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Julia Muthoni
Psychology & Mental Health
Julia’s expertise in psychology provides insight into the psychosocial aspects of chronic illness, including patient adherence, stress management, and health behaviors.
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