E Young Cardiovascular SOAP Note Harvey Hoya

E Young Cardiovascular SOAP Note Harvey Hoya

Elevated blood pressure
HPI: A 57-year-old Hispanic male presents to the clinic “I had my blood pressure checked at a health fair earlier
and it was high, my wife convinced me to come in.” Patient describes a sedentary lifestyle and poor eating
choices such as fast food multiple times per week that have resulted in recent weight gain. Patient describes
“dull” headaches that “occur 2-3 times a week, usually beginning in the morning,” in which he takes
Ibuprofen “about 4-5 pills per day,” as well as “not being able to sleep well, and feeling tired all day.” Wife is
present this visit and states that at night, “he has periods of not breathing, and when she wakes him up he
resumes sleep.” Pt. currently “works 5 days/week in construction.”

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