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

Example of a SOAP Note for a Patient with Hypertension

Subjective

• Chief complaint: "My doctor told me I have high blood pressure and need to follow up."
• History of present illness: 58-year-old male diagnosed with hypertension 3 months ago. Reports occasional headaches and dizziness. No chest pain, shortness of breath, or visual disturbances.
• Medications: Currently taking hydrochlorothiazide 25mg daily, started 3 months ago
• Relevant past medical history: Family history of hypertension (father and mother)
• Social history: Works as an accountant, sedentary lifestyle, reports high stress levels
• Diet: High sodium intake, 2-3 alcoholic drinks per day
• Exercise: Minimal physical activity, walks occasionally on weekends
• Smoking: 1 pack per day for 30 years (30 pack-years)

Objective

• Vital signs: BP 152/94 mmHg (average of two readings), HR 82, RR 16, Temp 98.6°F, O2 sat 98% on room air
• Weight: 92 kg, Height: 175 cm, BMI: 30.1 kg/m²
• Physical examination:
  • General: Alert, oriented, no acute distress
  • HEENT: No retinopathy on fundoscopic exam
  • Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops
  • Respiratory: Clear to auscultation bilaterally
  • Abdomen: Soft, non-tender, no organomegaly, no bruits
  • Extremities: No edema, pulses 2+ throughout
• Laboratory findings:
  • Serum creatinine: 1.1 mg/dL, eGFR: 75 mL/min
  • Electrolytes: Na 138, K 3.9, Cl 102, CO2 24
  • Fasting glucose: 102 mg/dL
  • Lipid panel: Total cholesterol 220 mg/dL, LDL 142 mg/dL, HDL 38 mg/dL, Triglycerides 200 mg/dL
  • Urinalysis: No protein, no blood
• ECG: Normal sinus rhythm, no LVH or ischemic changes

Assessment

1. Uncontrolled Stage 2 Hypertension (BP 152/94 mmHg) despite monotherapy with hydrochlorothiazide 1
2. Multiple cardiovascular risk factors:
   • Obesity (BMI 30.1)
   • Current smoker (30 pack-years)
   • Dyslipidemia
   • Sedentary lifestyle
   • Family history of hypertension
3. 10-year cardiovascular disease risk >15% based on risk factors

Plan

1. Blood pressure management:

   • Add amlodipine 5mg daily to current hydrochlorothiazide regimen as blood pressure remains above target of ≤140/85 mmHg despite monotherapy 1
   • Target BP goal: <140/85 mmHg based on current guidelines 1
   • Home BP monitoring twice daily and maintain log
   • Follow-up in 4 weeks to reassess BP control 2

2. Lifestyle modifications:

   • Sodium restriction to approximately 2g per day 1
   • DASH diet education provided
   • Moderate-intensity aerobic exercise ≥150 min/week plus resistance training 2-3 times/week 1
   • Weight loss goal of 5kg over next 3 months to achieve healthier BMI 1
   • Alcohol reduction to <100g/week (≤1 drink/day) 1
   • Smoking cessation - referral to smoking cessation program and nicotine replacement therapy options discussed 1

3. Additional cardiovascular risk management:

   • Start atorvastatin 20mg daily for dyslipidemia and cardiovascular risk reduction 2
   • Consider aspirin 75mg daily as patient has hypertension with 10-year CHD risk >15% 1

4. Laboratory monitoring:

   • Repeat serum creatinine, eGFR, and electrolytes in 2 weeks after medication change 2
   • HbA1c check to rule out diabetes

5. Patient education:

   • Explained relationship between hypertension and cardiovascular disease risk
   • Reviewed warning signs of hypertensive emergency requiring immediate attention
   • Provided written educational materials on hypertension management

6. Follow-up appointment scheduled in 4 weeks to assess response to therapy