What is a SOAP note example for a hypertensive patient with symptoms like headaches and dizziness, including their past medical history and comorbid conditions like diabetes or impaired renal function?

SOAP Note Example for Hypertensive Patient with Headaches and Dizziness

A SOAP note for a hypertensive patient presenting with headaches and dizziness should systematically document the clinical encounter while screening for target organ damage, secondary causes, and cardiovascular risk factors that directly impact treatment decisions and prognosis. 1

Subjective (S)

Chief Complaint:

• "I've been having headaches and feeling dizzy for the past 2 weeks." 1

History of Present Illness:

• Document specific characteristics: occipital headaches (intermittent vs. constant), timing, severity (1-10 scale), associated symptoms (blurred vision, nausea, palpitations, diaphoresis) 1
• Characterize dizziness: lightheadedness vs. vertigo, positional changes, frequency of episodes 1
• Critical screening questions for hypertensive emergencies: chest pain, shortness of breath, focal neurological symptoms, visual changes beyond mild blurring 1
• Red flags for secondary hypertension: episodic symptoms with palpitations/sweating (pheochromocytoma), muscle weakness/cramps (hypokalemia from aldosteronism), snoring/daytime sleepiness (sleep apnea) 1, 2

Past Medical History:

• Hypertension: duration, previous BP readings, prior antihypertensive medications and side effects, medication adherence 1
• Diabetes mellitus: type, duration, current medications, most recent HbA1c, presence of microvascular complications 1
• Renal disease: history of proteinuria, elevated creatinine, known CKD stage 1
• Cardiovascular history: myocardial infarction, heart failure, stroke/TIA, peripheral artery disease 1
• Dyslipidemia status and treatment 1

Medications:

• List all current antihypertensives with doses and adherence patterns 1
• Screen for BP-elevating substances: NSAIDs, decongestants, oral contraceptives, steroids, cocaine, amphetamines 1, 2
• Diabetes medications (metformin, insulin, etc.) 1

Social History:

• Smoking status (pack-years) 1
• Alcohol consumption (drinks per day/week) 1
• Dietary sodium intake and patterns 1
• Physical activity level 1
• Occupational stress factors 1

Family History:

• Hypertension, premature cardiovascular disease (<55 years men, <65 years women), diabetes, familial hypercholesterolemia, sudden cardiac death 1

Review of Systems:

• Cardiovascular: chest pain, palpitations, orthopnea, paresthesias 1
• Renal: nocturia, hematuria, decreased urine output 1
• Neurological: focal weakness, speech changes, gait disturbances 1
• Endocrine: heat/cold intolerance, weight changes, easy bruising (Cushing's) 1, 2

Objective (O)

Vital Signs:

• Blood pressure: Document multiple readings (at least 2-3 measurements, 1-2 minutes apart), specify arm used, patient position (seated after 5 minutes rest) 1
  • Example: BP 168/102 mmHg (right arm, seated), 165/100 mmHg (repeat)
• Orthostatic vital signs: BP and pulse supine and after 1 minute standing (>20 mmHg SBP drop or >10 mmHg DBP drop is abnormal) 1, 2
• Heart rate, respiratory rate, temperature 1
• Weight, height, BMI, waist circumference 1

Physical Examination:

General: Alert, oriented, no acute distress 1

HEENT:

• Fundoscopic exam: arteriovenous nicking, copper/silver wiring, hemorrhages, exudates, papilledema (hypertensive retinopathy grade) 1
• Thyroid: enlargement, nodules 1
• Neck circumference (>40 cm suggests sleep apnea) 1

Cardiovascular:

• Jugular venous pressure 1
• Point of maximal impulse location and character (displaced/sustained suggests LVH) 1
• Heart sounds: S3 (heart failure), S4 (LVH), murmurs 1
• Peripheral pulses: radial-femoral delay (coarctation), diminished peripheral pulses (peripheral artery disease) 1
• Carotid, abdominal, femoral bruits (atherosclerosis, renal artery stenosis) 1

Pulmonary: Bibasilar crackles (heart failure, flash pulmonary edema) 1

Abdomen:

• Enlarged kidneys (polycystic kidney disease) 1
• Abdominal masses 1

Extremities:

• Peripheral edema (heart failure, renal disease) 1
• Skin: striae, central obesity, facial plethora (Cushing's) 1

Neurological:

• Mental status, cranial nerves, motor/sensory exam, reflexes, gait 1
• Focal deficits suggesting stroke/TIA 1

Laboratory Data:

Basic metabolic panel:

• Sodium, potassium (hypokalemia <3.5 mEq/L suggests aldosteronism) 1
• Serum creatinine and eGFR (renal function) 1
• Fasting glucose or HbA1c (diabetes screening/control) 1, 3

Lipid profile: Total cholesterol, LDL, HDL, triglycerides 1, 3

Urinalysis:

• Protein, blood, glucose 1
• Urine albumin-to-creatinine ratio (microalbuminuria indicates target organ damage) 1, 3

Complete blood count 1

Thyroid-stimulating hormone 1

Electrocardiogram:

• Left ventricular hypertrophy (Sokolow-Lyon or Cornell criteria) 1
• Atrial fibrillation, ischemic changes, prior MI 1

Additional Testing (if indicated):

• Echocardiogram: LVH, ejection fraction, diastolic dysfunction 1
• Plasma metanephrines or 24-hour urine metanephrines (if episodic symptoms suggest pheochromocytoma) 2
• Aldosterone-renin ratio (if hypokalemia or resistant hypertension) 1, 2
• Renal artery duplex ultrasound (if flash pulmonary edema or resistant hypertension with renal dysfunction) 1, 2

Assessment (A)

Primary Diagnosis:

1. Hypertension, Stage 2 (BP 168/102 mmHg) 1, 3
   • Requires confirmation with repeated office measurements or out-of-office BP monitoring within days to weeks 1, 3
   • Headaches and dizziness are nonspecific symptoms that do NOT constitute hypertensive emergency in absence of acute target organ damage 3

Comorbidities and Risk Factors: 2. Type 2 Diabetes Mellitus (or prediabetes if HbA1c 5.7-6.4%) 1, 3

• Document current glycemic control status 1, 3

1. Chronic Kidney Disease, Stage [specify based on eGFR] (if eGFR <60 mL/min/1.73m²) 1

   • Presence of albuminuria indicates hypertension-mediated organ damage 1, 3

2. Dyslipidemia (if LDL elevated) 1, 3

3. Obesity (if BMI ≥30 kg/m²) 1

4. Tobacco use disorder (if applicable) 1

Target Organ Damage Assessment:

• Hypertensive retinopathy (if arteriovenous nicking present) 1, 3
• Left ventricular hypertrophy (if present on ECG or echo) 1, 3
• Albuminuria/proteinuria (if present) 1, 3

Cardiovascular Risk Stratification:

• Calculate 10-year ASCVD risk using pooled cohort equations (age, sex, race, total cholesterol, HDL, SBP, diabetes, smoking) 1, 3
• High-risk features: diabetes, CKD, LVH, established CVD 1, 3

Differential Considerations for Secondary Hypertension:

• Low suspicion given gradual BP rise, family history, and absence of red flags 1, 3
• Would require further workup if: age <30 or >55 at onset, resistant hypertension (uncontrolled on 3 drugs including diuretic), episodic symptoms with palpitations/sweating, hypokalemia, or acute BP rise 1, 2

Plan (P)

Blood Pressure Management:

1. Confirm diagnosis:

   • Repeat office BP measurements on 2-3 separate visits over 1-2 weeks OR obtain home BP monitoring or 24-hour ambulatory BP monitoring to exclude white coat hypertension 1, 3

2. Initiate pharmacotherapy (for Stage 2 hypertension with diabetes/CKD):

   • Start ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB as first-line for patients with diabetes or CKD 1, 4
   • Common pitfall: Monitor serum potassium and creatinine within 2-4 weeks after initiation, as ACE inhibitors can cause hyperkalemia and acute kidney injury, especially in patients with renal artery stenosis or volume depletion 4
   • Contraindications: History of angioedema, pregnancy, bilateral renal artery stenosis 4
   • Expected adverse effects: dry cough (2.5% incidence), dizziness (3.5%), headache (3.8%) 4

3. Consider combination therapy:

   • Add thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) or calcium channel blocker (amlodipine 5-10 mg daily) if BP remains >140/90 mmHg after 2-4 weeks 1
   • Caution: Monitor for orthostatic hypotension, especially in elderly or those with autonomic dysfunction 4

4. BP target: <130/80 mmHg (for patients with diabetes, CKD, or high cardiovascular risk) 1

Lifestyle Modifications:

1. Dietary sodium restriction: <2 grams sodium per day (DASH diet) 1

2. Weight reduction: Target BMI <25 kg/m² (each 1 kg weight loss reduces SBP by ~1 mmHg) 1

3. Physical activity: 150 minutes/week moderate-intensity aerobic exercise 1

4. Alcohol reduction: Limit to ≤2 drinks/day for men, ≤1 drink/day for women (can reduce SBP by 5.5 mmHg in heavy drinkers) 1

5. Smoking cessation: Refer to cessation program, consider pharmacotherapy 1

Diabetes Management:

1. Optimize glycemic control: Target HbA1c <7% (individualize based on comorbidities) 1, 3

2. Continue current diabetes medications (specify regimen) 1

Renal Protection:

1. Monitor renal function: Repeat serum creatinine, eGFR, and urine albumin-to-creatinine ratio in 3 months 1

2. Nephrology referral if eGFR <30 mL/min/1.73m² or rapidly declining renal function 1

Cardiovascular Risk Reduction:

1. Statin therapy: Initiate moderate-to-high intensity statin (e.g., atorvastatin 40 mg daily) for ASCVD risk reduction 1, 3

2. Aspirin: Consider low-dose aspirin (81 mg daily) if 10-year ASCVD risk >10% and low bleeding risk 1

Monitoring and Follow-up:

1. Laboratory monitoring:

   • Recheck basic metabolic panel (potassium, creatinine) in 2-4 weeks after ACE inhibitor initiation 4
   • Repeat lipid panel and HbA1c in 3 months 1, 3

2. Follow-up visit:

   • Return in 2-4 weeks to assess BP response, medication tolerance, and review home BP log 1
   • Urgent evaluation needed if: BP >180/120 mmHg with symptoms (severe headache, chest pain, dyspnea, visual changes, focal neurological deficits) suggesting hypertensive emergency 1, 3

3. Patient education:

   • Teach proper home BP monitoring technique (validated device, seated position, 5 minutes rest) 1
   • Discuss medication adherence, adverse effects to report (angioedema, syncope, severe dizziness) 4
   • Provide written lifestyle modification goals 1

Screening for Secondary Hypertension (if indicated):

1. Defer extensive workup unless BP remains uncontrolled on 3-drug regimen or red flags develop 1, 3, 2

2. Future consideration: If resistant hypertension develops, screen for primary aldosteronism (aldosterone-renin ratio), obstructive sleep apnea (polysomnography), or renovascular disease (renal artery duplex) 1, 2