SOAP Note on Hypertension: Pharmacotherapeutics Practical
Name: Sanjay War
Age: 64 Years
Height: 6 Feet 2 Inches
Weight: 95 Kg
I live alone and I am an occasional drinker but I do not smoke
My father as well as mother both had Hypertension
Currently, I am on the following medication for hypertension as well as pain
Mucinex D 2 tablet
Naproxen 220 mg and
O: Objective Findings
Past Medication History (PMH) about 3 months ago,
Blood Pressure: 160/85 mm Hg
Heart Rate- 76 bpm
Total Cholesterol- 171mg/dl, LDL- 99mg/dl, HDL- 40mg/dl
Serum creatinine- 2.2 mg/dl
Blood Glucose- 110mg/dl
Uric Acid- 6.7 mg/dl
Sanjay’s BP is not at goal, because he is diabetic his goal should be <130/80mmHG.
Despite triple antihypertensive therapy, B.P is not optimal because of many factors including the use of Mucinex D(which contains pseudoephedrine), Naproxen(NSAID) & non-compliance with a low sodium diet
ACEIs or ARB as drugs of choice for Diabetes.
The use of a non-selective beta blocker is not the best selection for COPD
Sanjay has BPH & is on Doxazosin, an alpha-blocker that seems to control his BPH symptoms as well.
However, dizziness & headaches like side effects of Doxazosin can be minimize by take the dose at night
Discontinue guaifenesin/pseudoephedrine preparation(especially if no longer needed for cold symptoms) or give a product containing only guaifenesin next time.
Go for an alternative(eg. acetaminophen) for headache and gout
Discontinue Carvedilol gradually
Add Lisinopril 5mg once daily, increase if not enough. It can cause dry cough or angioedema.
Monitor B.P, K, renal function, glucose, Lipid profile
Continue HCLTZ 25mg po qam
Continue Doxazosin 2mg
Change dosing schedule to reduce possible Doxazosin-induced dizziness
Continue metformin 500mg
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