SOAP Note – Patient with Hypertension and Lifestyle Complications

S – Subjective

• Chief Complaint: “I’ve been feeling tired lately and sometimes get headaches, especially after work.”
• History of Present Illness (HPI): Mr. K. complains of chronic fatigue in the past three weeks. He at times suffers from pounding headaches, especially during the late afternoon hours. He acknowledges that he is poor at taking his antihypertensive drugs (losartan 50 mg/1 daily) and that he forgets about evening doses. Eats high amounts of processed foods and sodium. Reports poor exercise, with an average of 1-2 brief walks in a week. Sleeps 5-6 hours a night because of a long working day. Denies aches in the chest, palpitations, dyspnea, or syncope.
• Past Medical History: Diagnosed with hypertension 5 years ago. Overweight (BMI 31.4). No diabetes. No known allergies.
• Family History: Father passed away from a myocardial infarction at 58 years old. Mother is alive, has hypertension, and type 2 diabetes.
• Social History: Job as an accountant (sedentary job). Smokes one pack of cigarettes/week, drinks socially (3-4 beers on weekends). Food consists of regular fast food and red meat.
• Review of Systems (ROS):
  • Constitutional: Fatigue, occasional headaches.
  • Cardiovascular: Denies chest pain or palpitations.
  • Respiratory: No dyspnea.
  • GI: No nausea or abdominal pain.
  • Neuro: No dizziness, weakness, or visual changes.

O – Objective

• Vital Signs:
  • BP: 158/96 mmHg (right arm, sitting)
  • HR: 86 bpm
  • RR: 18/min
  • Temp: 36.8°C
  • SpO₂: 98% RA
• General: Alert, overweight male, no acute distress.
• Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
• Respiratory: Lungs are clear bilaterally.
• Abdomen: Soft, non-tender, no hepatosplenomegaly.
• Extremities: No edema.
• Labs: Last lipid panel (3 months ago) – total cholesterol 230 mg/dL, LDL 160 mg/dL, HDL 38 mg/dL. Fasting blood glucose 104 mg/dL.

A – Assessment

1. Uncontrolled Hypertension (Stage 2): This is probably associated with low adherence to medications, a high-sodium diet, and a lack of exercise. BP 158/96 mmHg above normal (<130/80 according to the ACC/AHA standards).
2. Obesity (BMI 31.4): It is a risk factor of hypertension and cardiovascular risk (Krist et al., 2021).
3. Dyslipidemia: High LDL and low HDL, worsening long-term cardiovascular risk.
4. Lifestyle Risk Factors: Physical inactivity, poor nutrition, smoking, and alcohol consumption.

P – Plan

• Diagnostics: Repeat lipid panel and HbA1c to evaluate prediabetes. Take into consideration renal function tests (serum creatinine, eGFR) in case of long-term hypertension (Mayo Clinic, 2023).
• Drugs: Help to continue taking losartan 50mg daily. Titration or addition of a thiazide diuretic can be considered in case of uncontrolled BP despite 4-6 weeks.
• Lifestyle Modifications:
  • Diet: Start with DASH diet education (sodium reduction, intake of fruits/vegetables, lean protein increase). Refer to a dietitian.
  • Exercise: 150 minutes/week of moderate aerobic activity should be recommended (Johns Hopkins Medicine, 2023). Start with fast walking for 30 minutes, 5 days/week.
  • Weight Management: Aim to lose 5-10 percent of body weight in 6 months. o Smoking Cessation: Make a referral to the smoking cessation program; talk about nicotine replacement.
  • Alcohol: Drink no more than 2 a week.
• Patient Education: Educate on the dangers of non-adherence to medications and the dangers of untreated hypertension (stroke, heart disease, kidney damage). Provide written materials.
• Follow-up: Check back in 1 month after the BP check. When BP>140/90, then think about medication.
• Referral: Cardiology referral should be considered in the instance of resistant hypertension despite two medications.

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