What is a sample SOAP note for a 55-year-old African American female with HTN (Hypertension), DM2 (Diabetes Mellitus Type 2), and HLD (Hyperlipidemia)?

SOAP Note for 55-Year-Old African American Female with HTN, DM2, and HLD

A comprehensive SOAP note for this patient should focus on managing her hypertension, diabetes, and hyperlipidemia with appropriate medications and lifestyle modifications to reduce cardiovascular risk.

Subjective

• 55-year-old African American female presenting for follow-up of hypertension, type 2 diabetes mellitus, and hyperlipidemia
• Reports adherence to medications but occasional missed doses (1-2 times/week)
• Complains of occasional headaches in the morning (2-3 times/week)
• Reports moderate stress related to work
• Diet: Consumes fast food 3-4 times/week, high sodium intake, 1-2 sugary beverages daily
• Exercise: Walks 10 minutes daily, mostly sedentary job
• Denies chest pain, shortness of breath, dizziness, vision changes, or numbness/tingling in extremities
• Family history: Mother with HTN and stroke at age 62, father with DM2 and MI at age 60
• Social history: Non-smoker, occasional alcohol (1-2 glasses of wine on weekends)

Objective

• Vital signs:

  • BP: 146/92 mmHg (seated, right arm)
  • BP: 144/90 mmHg (seated, left arm)
  • HR: 78 bpm, regular
  • RR: 16/min
  • Temp: 98.6°F
  • Weight: 192 lbs (87.3 kg)
  • Height: 5'5" (165 cm)
  • BMI: 32 kg/m²

• Physical examination:

  • General: Alert, oriented, no acute distress
  • HEENT: Normal, no retinopathy
  • Cardiovascular: Regular rate and rhythm, no murmurs/gallops/rubs, normal S1/S2
  • Pulmonary: Clear to auscultation bilaterally
  • Abdomen: Soft, non-tender, no organomegaly
  • Extremities: No edema, pulses 2+ throughout, no skin lesions
  • Neurological: Intact, no focal deficits

• Laboratory findings:

  • Fasting blood glucose: 162 mg/dL (elevated)
  • HbA1c: 7.8% (elevated)
  • Total cholesterol: 212 mg/dL (elevated)
  • LDL: 138 mg/dL (elevated)
  • HDL: 42 mg/dL (low)
  • Triglycerides: 160 mg/dL (elevated)
  • Serum creatinine: 1.1 mg/dL
  • eGFR: 68 mL/min/1.73m²
  • Urine albumin/creatinine ratio: 45 mg/g (microalbuminuria)
  • Serum potassium: 4.2 mEq/L
  • Serum sodium: 138 mEq/L
  • TSH: 2.4 μIU/mL (normal)

• Current medications:

  • Lisinopril 20 mg daily
  • Metformin 1000 mg twice daily
  • Atorvastatin 20 mg daily
  • Aspirin 81 mg daily

Assessment

1. Uncontrolled hypertension (Stage 2) in African American female with target BP <130/80 mmHg based on high cardiovascular risk 1
2. Type 2 diabetes mellitus with suboptimal glycemic control (HbA1c 7.8%)
3. Hyperlipidemia with LDL above goal for patient with diabetes
4. Obesity (BMI 32 kg/m²) contributing to metabolic syndrome
5. Microalbuminuria indicating early diabetic nephropathy
6. High cardiovascular risk based on multiple risk factors (HTN, DM2, HLD, obesity, family history)

Plan

1. Hypertension management:

   • Add amlodipine 5 mg daily to current regimen as calcium channel blockers are particularly effective in African American patients 1, 2
   • Continue lisinopril 20 mg daily for renoprotective effects with diabetes and microalbuminuria
   • Consider adding a thiazide diuretic (chlorthalidone 12.5 mg daily) if BP remains uncontrolled at next visit 1, 2
   • Home BP monitoring at least weekly with log 3
   • Target BP <130/80 mmHg given diabetes and high cardiovascular risk 2

2. Diabetes management:

   • Continue metformin 1000 mg twice daily
   • Add SGLT2 inhibitor (empagliflozin 10 mg daily) for additional glycemic control and cardiovascular/renal protection
   • Target HbA1c <7.0%
   • Blood glucose monitoring before breakfast and 2 hours after largest meal
   • Diabetes education referral for nutrition counseling

3. Hyperlipidemia management:

   • Increase atorvastatin to 40 mg daily given high cardiovascular risk 4
   • Target LDL <70 mg/dL for patient with diabetes
   • Recheck lipid panel in 3 months

4. Lifestyle modifications:

   • DASH diet with sodium restriction (<2300 mg/day) 2
   • Weight loss goal of 5-10% of body weight over 6 months
   • Increase physical activity to 150 minutes of moderate-intensity exercise per week
   • Limit alcohol to ≤1 drink per day
   • Complete elimination of sugar-sweetened beverages 2

5. Monitoring plan:

   • Follow-up visit in 4 weeks to assess BP response to added medication
   • Labs at next visit: Basic metabolic panel, urine albumin/creatinine ratio
   • Comprehensive follow-up in 3 months with HbA1c and lipid panel
   • Annual diabetic eye exam, foot exam, and ECG
   • Consider echocardiogram to assess for target organ damage

6. Patient education:

   • Culturally appropriate education on importance of medication adherence 5
   • Avoid home remedies for BP control that may be ineffective or harmful 5
   • Stress management techniques
   • Importance of consistent medication timing
   • Recognition of hypoglycemia symptoms and management

7. Referrals:

   • Nutritionist for DASH diet education and diabetes meal planning 6
   • Consider referral to cardiologist for comprehensive cardiovascular risk assessment

This management plan addresses the patient's multiple cardiovascular risk factors with appropriate medication adjustments and lifestyle interventions tailored for an African American female with HTN, DM2, and HLD.