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

  1. Continue current medication regimen (Lisinopril 10 mg daily).

  2. Advise regular monitoring of blood pressure at home.

  3. Encourage weight loss, continued exercise, and a low-sodium diet.

  4. Follow-up appointment in 6 months for blood pressure recheck.

  5. Discuss lifestyle modifications to further reduce cardiovascular risk.

  6. Educate the patient about symptoms of hypertension complications (e.g., chest pain, dizziness).

Signature


Dr. [Your Name], MD



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