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

SOAP Note Example for Hypertension

A comprehensive SOAP note for a hypertensive patient should document blood pressure measurements, cardiovascular risk assessment, target organ damage evaluation, and a specific treatment plan with defined BP targets and follow-up intervals.

Subjective Section

The subjective component must capture specific hypertension-related information 1:

• Duration and severity: Document when hypertension was first diagnosed, previous BP readings, and current symptoms (headaches, visual disturbances, chest pain, dyspnea, dizziness) 1
• Medication history: List all current and previous antihypertensive medications, adherence patterns, side effects experienced, and any over-the-counter medications that may elevate BP (NSAIDs, steroids, sympathomimetics) 1
• Cardiovascular risk factors: Personal history of myocardial infarction, heart failure, stroke, TIA, diabetes, dyslipidemia, chronic kidney disease, smoking status, diet, alcohol intake (quantify in grams/week), physical activity level 1
• Family history: Hypertension, premature CVD, familial hypercholesterolemia, diabetes 1
• Secondary hypertension symptoms: Muscle weakness, tetany, cramps (suggesting hypokalemia/primary aldosteronism), flash pulmonary edema (renal artery stenosis), sweating with palpitations and headaches (pheochromocytoma), snoring with daytime sleepiness (obstructive sleep apnea) 1

Objective Section

Physical examination and diagnostic findings should include 1:

• Blood pressure measurements: Document office BP with proper technique, specify arm used, patient position, and multiple readings 1. Note if out-of-office measurements (home BP monitoring or ambulatory BP monitoring) were obtained to exclude white coat or masked hypertension 1
• Cardiovascular examination: Pulse rate/rhythm/character, jugular venous pressure, apex beat location, presence of extra heart sounds (S3, S4), basal crackles, peripheral edema, vascular bruits (carotid, abdominal, femoral), radio-femoral delay 1
• Body measurements: BMI, waist circumference (>40 cm suggests obstructive sleep apnea risk), neck circumference 1
• Fundoscopy findings: If BP >180/110 mmHg, document presence of hemorrhages, cotton wool spots, papilledema (indicating malignant hypertension) 1
• Laboratory results: Serum creatinine, eGFR, urine albumin-to-creatinine ratio (ACR), electrolytes (particularly potassium), hemoglobin, glucose, lipid panel 1
• ECG findings: Evidence of left ventricular hypertrophy, myocardial ischemia, or arrhythmias 1

Assessment Section

The assessment synthesizes findings and stratifies risk 1:

• BP classification: Specify stage (e.g., Stage 2 hypertension: 160/100 mmHg) and whether confirmed by out-of-office measurements 1
• Cardiovascular risk stratification: Use SCORE2 (ages 40-69) or SCORE2-OP (≥70 years) to calculate 10-year CVD risk; patients with ≥10% risk are considered high-risk 1. Alternatively, document ASCVD risk score per ACC/AHA guidelines 1
• Target organ damage: Document presence of hypertension-mediated organ damage (HMOD) including left ventricular hypertrophy on ECG/echocardiography, retinopathy, chronic kidney disease (eGFR <60 mL/min/1.73m² or ACR >30 mg/g), or vascular disease 1
• Secondary hypertension evaluation: Note if screening indicated based on clinical features (young age <40, resistant hypertension, hypokalemia, abdominal bruit) 1
• Comorbidities: List diabetes, CKD, coronary artery disease, heart failure, stroke history 1

Plan Section

The plan must specify treatment targets, medications, lifestyle modifications, and follow-up 1:

Blood Pressure Target

• General target: <130/80 mmHg for most patients 1
• Specific populations: Document individualized targets based on age, comorbidities, and tolerability 1

Pharmacological Treatment

• First-line agents: Initiate with ACE inhibitor, ARB, thiazide/thiazide-like diuretic, or dihydropyridine calcium channel blocker at lowest recommended dose 1, 2
• Combination therapy: If BP ≥20/10 mmHg above target, start with two-drug combination 1
• Specific example: "Start lisinopril 10 mg daily" or "Add hydrochlorothiazide 12.5 mg daily to current ramipril" 3, 2
• Monitoring: Check BP within 1 month after medication initiation or dose change; achieve target within 3 months 1, 4
• Renal function monitoring: Recheck creatinine, eGFR, and potassium 2-4 weeks after starting ACE inhibitor or ARB 1, 4, 3

Lifestyle Modifications

• Sodium restriction: Reduce to approximately 2 g sodium/day (equivalent to 5 g salt/day) 1
• Exercise: Moderate-intensity aerobic exercise ≥150 min/week (30 min, 5-7 days/week) plus resistance training 2-3 times/week 1
• Weight management: Target BMI 20-25 kg/m², waist circumference <94 cm (men) or <80 cm (women) 1
• Diet: Adopt Mediterranean or DASH diet 1
• Alcohol: Limit to <100 g/week of pure alcohol; preferably avoid completely 1
• Smoking cessation: Refer to cessation program if applicable 1

Follow-up Plan

• Initial phase: Recheck BP within 1 month after treatment initiation or medication change 1, 4
• Stable phase: Once BP controlled, follow-up every 3 months 1
• Laboratory monitoring: Annual creatinine, eGFR, and urine ACR if moderate-to-severe CKD present 1
• Referral criteria: Consider specialist referral if BP uncontrolled on 3+ medications, suspected secondary hypertension, or hypertensive emergency 1

Patient Education

• Self-monitoring: Instruct on proper home BP measurement technique if home monitoring recommended 1
• Medication adherence: Discuss importance of daily medication compliance 1
• Warning signs: Educate on symptoms requiring urgent evaluation (severe headache, chest pain, shortness of breath, neurological deficits) 1

Common Pitfalls to Avoid

• Inadequate BP measurement technique: Ensure patient rested 5 minutes, proper cuff size, arm supported at heart level 1
• Missing white coat or masked hypertension: Confirm diagnosis with out-of-office measurements when office BP 130-159/85-99 mmHg 1
• Overlooking secondary causes: Screen patients with resistant hypertension, age <40, or suggestive symptoms 1
• Excessive rapid BP lowering: In hypertensive emergencies, reduce mean arterial pressure by only 20-25% in first hour to avoid organ ischemia 1
• Inadequate follow-up: Failure to reassess within 1 month risks uncontrolled hypertension and progression to complications 1, 4