What is a SOAP note example for a patient with hypertension?

SOAP Note Example for Hypertension Patient

A comprehensive SOAP note for a hypertensive patient should include detailed assessment of cardiovascular risk factors and a clear treatment plan targeting blood pressure <130/80 mmHg using guideline-recommended medications and lifestyle modifications.

Subjective

• Chief complaint: "My blood pressure has been running high lately" or "I'm here for my blood pressure check"
• History of present illness:
  • Duration of hypertension
  • Current symptoms (headache, dizziness, visual changes, chest pain, shortness of breath)
  • Home blood pressure readings and monitoring frequency
  • Current antihypertensive medications and adherence
  • Recent medication changes
  • Lifestyle factors (diet, exercise, salt intake, alcohol consumption)
• Past medical history:
  • Cardiovascular disease (coronary artery disease, heart failure, stroke, peripheral artery disease)
  • Diabetes mellitus
  • Chronic kidney disease
  • Hyperlipidemia
  • Sleep apnea
• Family history:
  • Hypertension, cardiovascular disease, sudden cardiac death
• Social history:
  • Smoking status
  • Alcohol intake
  • Physical activity level
  • Dietary habits (salt intake, DASH or Mediterranean diet adherence)
  • Stress levels
  • Occupation
• Review of systems:
  • Cardiovascular: chest pain, palpitations, edema
  • Neurological: headache, dizziness, vision changes
  • Renal: polyuria, nocturia, hematuria

Objective

• Vital signs:
  • Blood pressure (both arms, seated position after 5 minutes rest)
  • Heart rate
  • Respiratory rate
  • Temperature
  • Height, weight, BMI
• Physical examination:
  • General appearance
  • Cardiovascular: heart sounds, murmurs, jugular venous distention
  • Pulmonary: breath sounds, crackles
  • Extremities: peripheral pulses, edema
  • Neurological: mental status, focal deficits
  • Fundoscopic examination (if BP >180/110 mmHg) 1
• Laboratory data:
  • Comprehensive metabolic panel (electrolytes, renal function)
  • Lipid panel
  • Urinalysis (protein, blood)
  • Urine albumin-to-creatinine ratio 1
  • Hemoglobin A1c (if diabetic or at risk)
• Diagnostic studies:
  • 12-lead ECG 1
  • Echocardiogram (if indicated by ECG abnormalities) 1
  • Home or ambulatory blood pressure monitoring results (if available) 1

Assessment

• Hypertension classification (based on 2024 ESC Guidelines) 1:
  • Normal BP: <120/80 mmHg
  • Elevated BP: 120-139/70-89 mmHg
  • Hypertension: ≥140/90 mmHg
• Hypertension severity:
  • Stage 1: 140-159/90-99 mmHg
  • Stage 2: ≥160/100 mmHg
  • Hypertensive emergency if BP ≥180/110 mmHg with evidence of acute target organ damage 1
• Cardiovascular risk assessment:
  • SCORE2 or SCORE2-OP risk calculation for patients 40-69 years or ≥70 years respectively 1
  • Target organ damage evaluation (heart, kidneys, eyes, brain)
  • 10-year cardiovascular disease risk assessment
• Secondary causes of hypertension (if suspected)
• Medication adherence assessment
• Lifestyle factors contributing to hypertension

Plan

• Blood pressure goal: <130/80 mmHg (for most patients, especially those with diabetes, CKD, or established cardiovascular disease) 1, 2
• Pharmacological therapy:
  • First-line medications: thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, or calcium channel blockers 2
  • For non-Black patients: start with ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB (e.g., losartan 50 mg daily) 2, 3, 4
  • For Black patients: start with calcium channel blocker (e.g., amlodipine 5 mg daily) or thiazide diuretic 2, 5
  • Combination therapy if BP >20/10 mmHg above goal 2
  • Avoid combination of ACE inhibitors and ARBs due to increased risk of hyperkalemia 2
• Laboratory monitoring:
  • Check electrolytes, renal function within 4-12 weeks of starting therapy 2
  • Annual monitoring of renal function and electrolytes 2
• Lifestyle modifications:
  • Sodium restriction (<2 g/day) 1, 2
  • DASH or Mediterranean diet 2
  • Regular physical activity (≥150 minutes/week of moderate-intensity aerobic exercise plus resistance training 2-3 times/week) 1, 2
  • Weight management (target BMI 20-25 kg/m²) 1, 2
  • Alcohol limitation (<100 g/week) 1
  • Smoking cessation 2
• Follow-up:
  • Return visit in 2-4 weeks for medication adjustment if starting new therapy
  • Home blood pressure monitoring with log
  • Once controlled, follow-up every 3-6 months 2
• Patient education:
  • Explanation of hypertension risks and complications
  • Medication instructions and potential side effects
  • Home blood pressure monitoring technique
  • Lifestyle modification strategies
  • Warning signs of hypertensive emergency

Special Considerations

• For hypertensive emergencies (BP ≥180/110 mmHg with acute organ damage):
  • Immediate hospitalization and IV antihypertensive therapy 1
  • Target BP reduction of 20-25% within first hours 1
  • Specific BP targets based on clinical presentation (see Table 12 in guidelines) 1
• For resistant hypertension (BP ≥130/80 mmHg despite 3+ medications including a diuretic):
  • Rule out white coat effect with home or ambulatory monitoring 1
  • Assess medication adherence
  • Consider secondary causes
  • Consider adding spironolactone or other agents 1
  • Consider referral to hypertension specialist 1