Free Primary Care Soap Note Template
Primary Care Soap Note
Patient Information
Name: Tom Walter
Age: 45
Gender: Male
Date: November 26, 2050
Reason for Visit: Annual check-up and evaluation of hypertension
I. Subjective
A. Chief Complaint
"I came in for my annual check-up and would like to make sure my blood pressure is under control."
B. History of Present Illness
Tom reports that he has a history of high blood pressure, which has been managed with medication for the past 2 years. He states that he feels well overall, with no chest pain or shortness of breath. He has been following a low-salt diet and exercising regularly. No recent changes in weight, diet, or lifestyle.
C. Review of Systems
System |
Findings |
---|---|
Cardiovascular |
No palpitations or chest pain. |
Respiratory |
No shortness of breath, cough, or wheezing. |
Gastrointestinal |
No nausea, vomiting, or abdominal pain. |
Musculoskeletal |
No joint pain or stiffness. |
Neurological |
No headaches, dizziness, or visual disturbances. |
D. Medications
Lisinopril 10 mg daily, aspirin 81 mg daily.
E. Allergies
No known drug allergies.
II. Objective
A. Vital Signs
Vital Sign |
Value |
---|---|
Blood Pressure |
138/85 mmHg (left arm, seated) |
Heart Rate |
72 bpm |
Respiratory Rate |
16 breaths/min |
Temperature |
98.4°F (oral) |
Weight |
210 lbs |
Height |
5'10" |
B. Physical Exam
System |
Findings |
---|---|
General |
Alert and oriented, in no acute distress. |
Cardiovascular |
Regular rate and rhythm, no murmurs or gallops. |
Respiratory |
Clear to auscultation bilaterally. |
Gastrointestinal |
Abdomen soft, non-tender, no hepatosplenomegaly. |
Musculoskeletal |
Full range of motion, no joint deformities. |
Neurological |
Cranial nerves intact, normal gait, no focal deficits. |
III. Assessment
-
Hypertension is well-controlled on current medication.
-
No evidence of acute illness or complications.
-
The patient is at risk for developing complications if blood pressure remains uncontrolled.
IV. Plan
-
Continue current medication regimen (Lisinopril 10 mg daily).
-
Advise regular monitoring of blood pressure at home.
-
Encourage weight loss, continued exercise, and a low-sodium diet.
-
Follow-up appointment in 6 months for blood pressure recheck.
-
Discuss lifestyle modifications to further reduce cardiovascular risk.
-
Educate the patient about symptoms of hypertension complications (e.g., chest pain, dizziness).
Signature
Dr. [Your Name], MD