SOAP notes for Hypertension: Pharmacotherapeutics Practical
1. SOAP notes for Hypertension 2. SOAP notes for Angina Pectoris 3. SOAP notes for Myocardial Infarction 4. SOAP notes for Hyperlipidaemia 5. SOAP notes for Rheumatoid arthritis 6. SOAP notes for Asthma 7. SOAP notes for COPD 8. SOAP notes for Diabetes 9. SOAP notes for Epilepsy 10. SOAP notes for Stroke 11. SOAP notes for Depression 12. SOAP notes for Tuberculosis 13. SOAP notes for Anaemia 14. SOAP notes for Viral infection 15. SOAP notes for Dermatological conditions
Patient Information
The patient is a 78-year-old female who returns for a recheck. She has hypertension. She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.
Name: Mrs. Bhavya Kale
Age: 78
Source: Patient
Allergies: Benadryl, phenobarbitone, morphine, Lasix, and latex.
Current Medications: Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily. She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.
Past Medical History: Nil
Surgical History: Nil
Family History: Mother died from congestive heart failure. Father died from myocardial infarction at the age of 56. Family history is positive for ischemic cardiac disease. Brother died from lymphoma. She has one brother living who has had angioplasties x 2. She has one brother with asthma.
Social History: Negative for use of alcohol or tobacco.
SUBJECTIVE
Chief complain: “headaches” that started two weeks ago.
HPI: The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month. Patient denies (feels) chest pain, palpitation, shortness of breath, nausea or vomiting.
ROS
Constitutional: Denies fever or chills. Denies weakness or weight loss NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC.
Respiratory: Patient denies shortness of breath, cough or haemoptysis.
Cardiovascular: No chest pain, tachycardia. No orthopnoea or paroxysmal nocturnal
dyspnoea.
Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or diarrhoea.
Genitourinary: Denies haematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.
Musculoskeletal: Denies falls or pain. Denies hearing a clicking or snapping sound.
Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus
OBJECTIVE
Constitutional: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mm/hg, RR 20, PO2-98% on room air, Ht- 6’4″, Wt 200 lb, BMI 25. Report pain 0/10.
General appearance: The patient is alert and oriented No acute distress noted.
Neurologic: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.
Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness.
Nasal mucosa moist without bleeding. Oral mucosa moist without lesions, Lids non-remarkable and appropriate for race.
Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.
Cardiovascular: regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.
Respiratory: No dyspnoea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on
auscultation.
Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound distention or organomegaly noted on palpation..
Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness.
Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.
ASSESSMENT
Essential (Primary) Hypertension: Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed.
Differential diagnosis
• Renal artery stenosis.
• Chronic kidney disease.
• Hyperthyroidism.
PLAN
Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease.
These basic laboratory tests are
CMP.
Complete blood count.
Lipid profile.
Thyroid-stimulating hormone.
Urinalysis.
Electrocardiogram.
Pharmacological treatment
The treatment of choice in this case would be
Thiazide-like diuretic and/or a CCB.
Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. Non-Pharmacologic treatment: Weight loss.
Healthy diet (Dash dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans I fat. Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults. Enhanced intake of dietary potassium.
Regular physical activity (Aerobic): 90-150 min/wk.
Tobacco cessation.
Measures to release stress and effective coping mechanisms.
Education Provide with nutrition/dietary information.
Daily blood pressure monitoring at home twice a day for 7 days, keep a record, and bring the record
on the next visit with her PCP.
Instruction about medication intake compliance. Education of possible complications such as stroke, heart attack, and other problems. The patient was educated on the course of hypertension, as well as warning signs and symptoms, Answered all pt. questions/concerns. Pt verbalizes understanding to all. Follow-ups/Referrals. Evaluation with PCP in 1 week for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn. No referrals needed at this time
When Writing a SOAP Note
Do’s
Be concise
Be specific
Write in the past tense
Don’t
Make general statements
Use words like “seem” and “appear”
