What is an example of a SOAP note for managing a patient with hypertension, considering their past medical history and current treatment?

Hypertension SOAP Note Example

Subjective

Chief Complaint: Follow-up for hypertension management 1

History of Present Illness:

• Patient reports adherence to current antihypertensive regimen (e.g., amlodipine 5 mg daily, lisinopril 10 mg daily) 2, 3
• Denies chest pain, shortness of breath, palpitations, or headaches 1
• Reports occasional dizziness when standing quickly (assess for orthostatic hypotension) 1
• Home blood pressure readings averaging 145/92 mmHg over past 2 weeks 1
• Dietary sodium intake approximately 3-4 g/day; limited physical activity 1
• Alcohol consumption: 2-3 drinks per week 1

Past Medical History:

• Hypertension diagnosed 3 years ago 4
• Type 2 diabetes mellitus (increases cardiovascular risk) 1
• No history of stroke, myocardial infarction, or heart failure 1

Medications:

• Amlodipine 5 mg daily 3
• Lisinopril 10 mg daily 2
• Metformin 1000 mg twice daily 1

Social History:

• Non-smoker 1
• Sedentary lifestyle, exercises <30 minutes per week 1
• High sodium diet with frequent processed foods 1

Family History:

• Father with myocardial infarction at age 58 1
• Mother with stroke at age 65 1

Objective

Vital Signs:

• Blood pressure (properly measured): 148/94 mmHg (seated, after 5 minutes rest, appropriate cuff size, arm supported at heart level, average of 2 readings) 1
• Heart rate: 78 bpm 1
• BMI: 32 kg/m² (obesity increases cardiovascular risk) 1
• Waist circumference: 102 cm (>94 cm in men indicates increased risk) 1

Physical Examination:

• General: Alert, no acute distress 1
• Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops; no jugular venous distention 1
• Pulmonary: Clear to auscultation bilaterally, no rales 1
• Extremities: No peripheral edema, pulses 2+ bilaterally and symmetric (assess for coarctation and peripheral vascular disease) 1
• Neurological: No focal deficits 1

Laboratory/Diagnostic Results:

• Serum creatinine: 1.1 mg/dL, eGFR: 72 mL/min/1.73m² (mild CKD) 1
• Urine albumin-to-creatinine ratio (ACR): 45 mg/g (microalbuminuria indicates target organ damage) 1
• Serum potassium: 4.2 mmol/L 1
• Fasting glucose: 142 mg/dL 1
• Lipid panel: Total cholesterol 220 mg/dL, LDL 145 mg/dL, HDL 38 mg/dL 1
• 12-lead ECG: Normal sinus rhythm, no left ventricular hypertrophy 1
• SCORE2 cardiovascular risk: 12% (10-year risk of fatal and non-fatal CVD) 1

Assessment

Primary Diagnosis: Uncontrolled Stage 2 hypertension (BP ≥140/90 mmHg) with high cardiovascular risk 1

Contributing Factors:

• Type 2 diabetes mellitus (qualifies as high-risk, target BP <130/80 mmHg) 1
• Obesity (BMI 32 kg/m²) 1
• Microalbuminuria indicating target organ damage 1
• Suboptimal medication dosing 4
• Poor lifestyle adherence (high sodium intake, sedentary lifestyle) 1
• 10-year cardiovascular disease risk ≥10% (considered increased risk) 1

Cardiovascular Risk Assessment:

• High-risk patient due to diabetes and target organ damage (microalbuminuria) 1
• Requires aggressive BP target of <130/80 mmHg 1

Plan

1. Pharmacologic Management

Immediate medication adjustment (patient requires intensification to reach target <130/80 mmHg): 1

• Increase lisinopril from 10 mg to 20 mg daily (ACE inhibitor indicated for diabetic nephropathy) 2, 4
• Increase amlodipine from 5 mg to 10 mg daily (calcium channel blocker for additional BP reduction) 3, 4
• Add chlorthalidone 12.5 mg daily (thiazide-like diuretic preferred over hydrochlorothiazide for superior cardiovascular outcomes; three-drug regimen needed as BP >20/10 mmHg above goal) 1, 4

Rationale for triple therapy: Current BP 148/94 mmHg is 18/14 mmHg above target of <130/80 mmHg for diabetic patient; most patients require 2-3 medications to achieve control 1, 4

2. Lifestyle Modifications (partially additive to pharmacologic therapy)

Dietary interventions: 1

• Sodium restriction to <2 g/day (approximately 5 g salt/day) 1
• Adopt Mediterranean or DASH diet pattern 1
• Restrict free sugar consumption to <10% of energy intake; eliminate sugar-sweetened beverages 1
• Increase potassium intake through fruits and vegetables 4

Physical activity: 1

• Moderate-intensity aerobic exercise ≥150 minutes/week (30 minutes, 5-7 days/week) 1
• Add low- to moderate-intensity resistance training 2-3 times/week 1

Weight management: 1

• Target BMI 20-25 kg/m² and waist circumference <94 cm 1
• Initial goal: 5-10% weight reduction 4

Alcohol moderation: 1

• Limit to <100 g/week of pure alcohol (approximately 7-12 standard drinks depending on portion size) 1

3. Monitoring and Follow-up

Blood pressure monitoring: 1

• Home blood pressure monitoring twice daily (morning and evening) for 1 week, then 2-3 times weekly 1
• Consider ambulatory blood pressure monitoring (ABPM) if white coat effect suspected 1
• Ensure proper technique: seated, back supported, 5 minutes rest, appropriate cuff size, arm at heart level 1

Laboratory monitoring: 1

• Recheck serum creatinine, eGFR, and urine ACR in 3-4 weeks after medication adjustment 1
• Monitor serum potassium in 2-3 weeks (risk of hyperkalemia with ACE inhibitor and potential addition of aldosterone antagonist) 1
• Annual monitoring of renal function and albuminuria given CKD 1

Follow-up visit: 5

• Schedule follow-up in 2-4 weeks to assess response to medication adjustment 5
• If BP remains >130/80 mmHg after 4 weeks on triple therapy, consider adding spironolactone 25 mg daily (if potassium <4.5 mmol/L and eGFR >45 mL/min/1.73m²) 1

4. Cardiovascular Risk Reduction

Additional interventions for high-risk patient: 1

• Initiate statin therapy (LDL 145 mg/dL with diabetes and 10-year CVD risk >10%) 1
• Consider low-dose aspirin 75-81 mg daily for primary prevention (age >50, diabetes, BP controlled <150/90 mmHg) 1
• Optimize diabetes management (current fasting glucose 142 mg/dL) 1

5. Patient Education

Key counseling points: 4

• Explain target BP <130/80 mmHg due to diabetes 1
• Emphasize medication adherence and proper home BP monitoring technique 1
• Discuss warning signs requiring immediate attention: severe headache, chest pain, shortness of breath, neurological symptoms 5, 6
• Reinforce importance of lifestyle modifications as adjunct to medications 1
• Address orthostatic symptoms: rise slowly from sitting/lying, adequate hydration 1

6. Screening for Secondary Hypertension

Not indicated at this time (patient does not meet criteria: age >30, no resistant hypertension, no sudden deterioration) 1

Reassess if: 1

• BP remains >140/90 mmHg on optimal doses of 3+ medications including diuretic (resistant hypertension) 1
• Sudden deterioration in BP control 1
• Serum potassium <3.5 mmol/L (screen for primary aldosteronism) 1