ANSWER
Subjective (S) of the SOAP Note for Consultation on Hypertension:
Chief Complaint (CC): “I have been experiencing headaches lately, and my blood pressure is not under control.”
Present Illness History (HPI):
A 59-year-old man with a history of hypertension (HTN) reported having headaches and high blood pressure (BP) readings in the last few days.
The patient regularly checks their blood pressure at home, and recent readings have been constantly around 150/95 mmHg, as opposed to their typical readings of 130/80 mmHg.
Due to a greater workload, attributes raised blood pressure in response to work-related stress.
denies experiencing changes in eyesight, shortness of breath, or chest pain.
Current prescriptions include hydrochlorothiazide 25 mg once daily and lisinopril 20 mg once daily.
denies dietary adjustments or missing dosages.
Hypertension is a past medical history (PMH).
Family History (FH): There are no known cardiovascular incidents in the immediate family, but the father had hypertension.
Social History (SH): Sedentary lifestyle, occasional alcohol consumption, nonsmoker. reports feeling more stressed out at work.
Review of Systems (ROS): Negative for dizziness, chest pain, shortness of breath, or changes in vision; positive for recent headaches.
Goal (O):
Vital Signs:
Blood pressure: 152/96 mmHg (at work).
HR: 78 beats per minute.
RR: 16 breaths per minute.
98.6°F is the temperature.
Physical Assessment:
In general: Looks ok, no severe discomfort.
Cardiovascular: No gallops, rubs, or murmurs; regular heartbeat and rhythm.
Respiratory: No crackles or wheezes, both lung fields are clear.
Neurological: x3 alert and focused. intact cranial nerves. No deficiencies in focus.
Ophthalmic: No retinal abnormalities or papilledema were found.
Extremities: Both sides have regular pulses and no edoema.
Evaluation (A):
Unmanaged hypertension:
Blood pressure was constantly high at home (150/95 mmHg) and increased to 152/96 mmHg at work.
The current dosage of 25 mg of hydrochlorothiazide and 20 mg of lisinopril seems inadequate.
Stress and possible food or lifestyle factors are likely to make it worse.
Headaches:
probably as a result of high blood pressure.
no symptoms or indicators that point to intracranial disease.
Plan (P):
Diagnostic Procedure:
Labs: Basic metabolic panel (BMP) to track electrolytes and renal function.
lipid panel to assess the risk of cardiovascular disease.
Proteinuria is evaluated by urinalysis.
ECG: Initial evaluation for any heart anomalies that may be present.
Modification of Medication:
Increase the daily dosage of lisinopril from 20 mg to 40 mg (the highest amount advised by guidelines).
Continue taking 25 mg of hydrochlorothiazide once daily.
Changes in Lifestyle:
Stress management: Talk about methods to reduce stress at work, like yoga, mindfulness, and relaxation techniques.
The DASH (Dietary Approaches to Stop Hypertension) diet should be prioritised.
Less than 2,300 mg of salt per day, preferably less than 1,500 mg.
Eat more lean protein, healthy grains, fruits, and veggies.
Exercise: Promote at least 150 minutes per week of moderate aerobic activity, such as brisk walking.
Don’t have more than one or two drinks a day.
Patient Instruction:
Talk about the significance of following a doctor’s prescription and lifestyle advice.
Teach people how to recognise the warning indications of hypertensive emergencies, such as a sharp headache, chest pain, or changes in eyesight, and when to get help right away.
Give them easily readable materials on stress and hypertension management.
Follow-up:
Arrange for a follow-up in two to four weeks to review blood pressure control and see how well medication changes are working.
Keep an eye out for any negative effects, like as coughing or dizziness, from taking more Lisinopril.
Citations:
Carey, R. M., Aronow, W. S., Whelton, P. K., et al. (2018). 2017 ACC, AHA, AAPA, ABC, ACPM, AGS, APHA, ASH, ASPC, NMA, and PCNA guidelines for the prevention, identification, assessment, and treatment of adult hypertension. e127–e248 in Journal of the American College of Cardiology, 71(19).
Mancia, G., Spiering, W., Williams, B., et al. (2018). ESC/ESH 2018 Recommendations for treating arterial hypertension. Journal of European Heart, 39(33), 3021–3104.
This method promotes long-term cardiovascular health while attending to the patient’s urgent problems.
QUESTION
CC: My blood pressure is not controlled and I have been having headaches lately
Patient is a 59y/o male with H/o /HTN who presents for consultation reporting increase on his BP and headache since a few days ago, he states has been feeling more stressed at work recently due to a increase of workload. He monitors his blood pressure at home and has recorded readings consistently around 150/95 mmHg, whereas his usual readings are around 130/80 mmHg. Today he states measured at home and it was high, so he decided to come for evaluation. He denies any chest pain, shortness of breath, or changes in vision. Patient has been taking Lisinopril 20 mg once daily, Hydrochlorothiazide 25 mg once daily. on the physical examination Blood Pressure: 152/96 mmHg