SOAP Note For Patient With Essential Hypertension ✓ Solved

SOAP Note for Patient with Essential Hypertension

Patient Information:

Name: Mr. K.V.

Age: 50 years

Gender: Male

Medical History: The patient has a history of elevated cholesterol levels and underwent tonsillectomy at age 14. His family history includes heart attack and hypertension on the maternal side, while the paternal side has a history of hypertension and arterial aneurysms.

Social and Lifestyle History:

Mr. K.V. works full-time in a high-stress job. He reports drinking up to three beers each evening, smoking cigarettes, and consuming tobacco thrice weekly. He has a self-reported history of stable physical activities and engages in four meals per day while managing his hypertension.

Subjective Data:

Chief Complaint: The patient reports regular medical check-ups for hypertension, along with persistent headaches and chest pain that has been recurring intermittently.

Symptom Analysis: K.V. visits urgent care bi-weekly for blood pressure checks, attributing his headaches and chest pains to elevated blood pressure readings he has noted over the past few months. The symptoms are described as mild to moderate.

Review of Systems (ROS):

The patient denies constitutional symptoms including fever or fatigue. Neurologically, he reports experiences of migraines but denies dizziness or loss of consciousness. Cardiovascularly, there are no sudden severe chest pains, while respiratory system assessments reveal no cough or shortness of breath. Gastrointestinal and genitourinary systems are unremarkable upon evaluation.

Objective Data:

Vital Signs:

• Height: 1.8 meters
• Weight: 241 lbs
• BMI: 34.6
• Heart Rate: 79 bpm
• Blood Pressure: 185/88 mmHg
• Respiratory Rate: 15 breaths/min
• Temperature: 97.7°F
• Oxygen Saturation: 100% on room air

The general appearance is appropriate for his age, with effective hygiene and cooperation during the examination.

Assessment:

Mr. K.V. has been diagnosed with Essential Hypertension (ICD-10: I10). Despite not reporting any acute symptoms associated with hypertension, his persistent high blood pressure readings necessitate further evaluation and management, particularly considering his family history of cardiovascular diseases.

Differential Diagnosis:

1. Obstructive Sleep Apnea: A known condition linked to hypertension and often exacerbated by obesity.
2. Renal Artery Stenosis: Narrowing of arteries supplying blood to the kidneys, which can elevate blood pressure.
3. Stress-Induced Hypertension: Increased sympathetic activity resulting from environmental stressors contributing to blood pressure elevation.

Plan:

Laboratory Tests:

• Complete Blood Count (CBC)
• Urinalysis
• Lipid Profile

Pharmacological Treatment:

• Continue Amlodipine 10 mg PO daily
• Increase Losartan to 100 mg PO daily
• Consider Clonidine 0.1 mg PO as needed for SBP >189 or DBP >98.

Non-Pharmacological Treatment:

Patient advised to follow a low-sodium, DASH diet and to incorporate regular physical activity, aiming for 30 minutes of moderate exercise four times a week.

Patient understands the importance of regular blood pressure monitoring and follow-ups scheduled for two weeks to reassess blood pressure management strategies.

Education:

Emphasized the importance of blood pressure monitoring and adhering to lifestyle changes to manage hypertension effectively, especially given his family's medical history.

Follow-ups/Referrals:

Referral to a cardiologist if blood pressure remains unmanaged; nutritionist consult recommended after initial follow-up.

References

• AACC. (2017). Hypertension. Retrieved from Lab Tests Online.
• ADAA. (2016). Physical activity reduces stress. Retrieved from Anxiety and Depression Association of America.
• American Heart Association. (2017). Managing stress to control high blood pressure. Retrieved from American Heart Association.
• CardioSmart. (2015). Sleep apnea and high blood pressure: A dangerous pair. Retrieved from CardioSmart.
• Heller, M. (2017). The DASH eating plan. Retrieved from The DASH Diet Eating Plan.
• Mayo Clinic. (2016). High blood pressure (Hypertension). Retrieved from Mayo Clinic.
• Mayo Clinic. (2017). Renal artery stenosis. Retrieved from Mayo Clinic.