13 May Patient is a 46 year old male with a PMH of depression, anxiety, HTN, HLD who presents today for his increased blood pressure despite medications.
ASSESSMENT: Primary diagnosis provided ICD-10 code. The plan was supported with 1-2 reference(s) and provided at least 2-3 differential diagnosis with rationales with ICD-10 codes in APA format. A reflection note provided.
PLAN: A pertinent plan of care, follow-up instructions, and patient education was developed and supported with at least one to two references in APA format.
SOURCES( please provide pertinent sources.) No Limit.
USE the Soap Template attached for reference
SOAP
CC
FOLLOW UP
Subjective
Patient iss a 46 year old male with a PMH of depression, anxiety, HTN, HLD who presents today for his increased blood pressure despite medications. Patient stated he adherres to his medication regemin and monitors his blood pressures at home with elevated readings. The patient reports it may be due to stress and anxiety as he is grieving the loss of his dog and recently lost his job. That patient has a psych appointment 04/05/26 to follow-up about increased anxiety and depression and possible changes in medication. The patient stated he has no SI/HI plans prior or at this time. Screening: Cologuard completed 3 months ago.
Pt denies SOB, chest, palpitations, N/V/D, fever/chills, or any acute changes to health status, recent illness & injuries other than CC/HPI
Medications
atenoloL 25 mg tablet, 1 tab by mouth daily (Edited by Anil Date on 01 Dec, 2025 at 01:04 PM )
Xanax 0.5 mg tablet, TAKE 1 TAB PO BID (Edited by Anil Date on 01 Dec, 2025 at 01:03 PM )
Lexapro 10 mg tablet, 1 tab by mouth daily (Edited by Anil Date on 01 Dec, 2025 at 01:03 PM )
losartan 50 mg tablet, TAKE 1 TAB PO BID (Edited by Anil Date on 01 Dec, 2025 at 01:02 PM )
Vitamin D3 50 mcg (2,000 unit) capsule, TAKE 1 CAP PO QD (Edited by Anil Date on 03 Jan, 2024 at 11:30 AM )
Allergies
No known allergies
Mental/Functional
PHQ-9 total score: 21 GAD-7 total score: 19
The patient’s speech was normal, sharing conversation with normal laryngeal efforts. Appropriate mood and affect.
Thought processes were logical, relevant, and thoughts were completed normally. Thought content was normal.
Thought content was normal with no psychotic or suicidal thoughts. The patient’s judgment was realistic with normal
insight into their present condition. Mental status included: correct time, place, person orientation, normal recent and
remote memory, normal attention span and concentration ability. Language skills included the ability to correctly name
objects. Fund of knowledge included normal awareness of current and past events.
Vitals
BP:
152.0 / 89.0
HR:
78.0 bpm
RR:
13.0 rpm
Temp:
98.2 °F
Ht/Lt:
5′ 6″
Wt:
164 lbs 4 oz
BMI:
26.51
SpO2:
98.0%
Comments: PT IS HERE TO FOLLOW UP.
Objective
GEN: NAD
NECK: supple, NT, FROM
RESP: lungs clear to auscultation bilaterally, no rales, wheezes or rhonchi, nonlabored breathing, no use of accessory of muscles of respiration
CV: RRR, no m/r/g
GI: +BS, nontender to palpation, no masses, no HSM
DERM: skin warm and dry
EXT: no cyanosis/clubbing/edema
NEURO: AO x 3
PSYCH: judgment/insight intact, NL mood/affect
Assessment
Moderate recurrent major depression (F33.1/296.32) Major depressive disorder, recurrent, moderate
Anxiety (finding) (F41.9/300.00) Anxiety disorder, unspecified
Benign essential hypertension (I10) Essential (primary) hypertension
Mixed hyperlipidemia (E78.2/272.2) Mixed hyperlipidemia
Plan
RX: Atenelol 50mg po qd, Refill of losartan 50mg, xanax 0.5mg, Lexapro 10mg.
-Advised to keep BP log and bring to follow up appt
-Advised to take medication only as ordered
Diagnostics/Labs: Annual labs
Referral: N/A
Follow-up: In 2 weeks for annual physical exam and lab review.
Moderate recurrent major depression
-Continue with medication
-Stay in touch. Don’t withdraw from life
-Be more active, utilize some form of exercise as able
-Avoid triggers
-Avoid alcohol
-Incorporate a healthy diet such as the DASH/Mediterranean diet
-Incorporate a daily routine.
Anxiety (finding)
-Practice relaxation techniques like deep breathing or mindfulness daily.
-Take anxiety medications only as prescribed; do not stop suddenly without guidance.
-Limit caffeine, alcohol, and recreational drugs, as they can worsen anxiety.
-Maintain a regular sleep schedule and engage in regular physical activity.
-Seek help if symptoms worsen or interfere with daily life.
Benign essential hypertension
-Monitor your blood pressure regularly to track progress and catch any changes early.
-Take medications exactly as prescribed, even if you feel fine.
-Limit salt (sodium) intake to help lower blood pressure—aim for under 2,300 mg/day.
-Exercise regularly, such as walking 30 minutes most days of the week.
-Avoid smoking and limit alcohol, both of which can raise blood pressure.
Mixed hyperlipidemia
-Encourage 30 minutes of exercise 3-4x per week, as tolerated
-Take statin medication as prescribed
-Avoid smoking tobacco; limit intake of alcoholic beverages
-Encourage Mediterranean diet – whole grains, beans, nuts, seeds and healthy fats
-Eat a low fat, low cholesterol diet; includes cutting back on fatty meats and avoiding saturated & trans fats
-Keep your stress level down
-reinforced the importance of maintaining a healthy weight, normal lipid profile, and consistent daily activity
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