Patient Information:
Initials A.S Age 50 Sex Female Race African American
S.
CC (chief complaint) “I am feeling light headed, clammy and have a bad headache”
HPI: 52 year old African American female presents to the clinic complaining of being light headed at work today. Patient also complains of bad headache which she rates as 3/10. She reported that her co-worker gave her medication for the headache, but she was unable to provide the name and dose of the medication used. Patient reports that she is hypertensive and has not taken her blood pressures medication because she ran out of them. Patient also unable to list dose of current blood pressure medications ordered by her PCP.
Current Medications:

• Lisinopril 5mg PO QD
• Hydrochlorothiazide 12.5mg PO QD
• Amlodipine 5mg PO QD
  Allergies: NKDA
  VS 98.2, 167/117, 87, 24, 95% RA
  No past surgical Hx

With this patient in mind, address the following in a SOAP Note:

• Subjective: What details did the patient provide regarding his or her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?
• Reflection notes: What would you do differently in a similar patient evaluation?

References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

References
Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.

Sample Solution