Nursing HTN SOAP Note for Hypertension Example [Solved]

Nursing HTN SOAP Note for Hypertension Example [Solved]

Assignment Brief: HTN SOAP Note for Hypertension

Overview:

This assignment focuses on creating a comprehensive SOAP (Subjective, Objective, Assessment, Plan) note for a hypothetical patient with hypertension. The objective is to improve your skills in documenting and communicating vital information related to hypertension care. By engaging in this assignment, you will strengthen your abilities in considering both subjective and objective elements, conducting assessments, and formulating appropriate plans for managing hypertension.

Understanding Assignment Objectives:

SOAP Note Structure:

• Understand the SOAP note structure.
• Identify and define each section’s purpose, including Subjective, Objective, Assessment, and Plan.

Patient Encounter Documentation:

• Learn to document a patient encounter systematically.
• Understand the importance of including subjective information, objective measurements, professional assessments, and tailored plans.

Hypertension Management:

• Explore the details of documenting hypertension-related information.
• Develop skills in assessing blood pressure readings, interpreting lab results, and creating effective plans for hypertension management.

The Student’s Role:

Your role as a student is to assume the position of a healthcare professional responsible for documenting a patient encounter related to hypertension. Imagine yourself as a nurse, nurse practitioner, or physician’s assistant in a clinical setting. Your task is to create a SOAP note that encapsulates crucial details regarding the patient’s hypertension, incorporating both the patient’s self-reported information and objectively measurable data.

Assignment Guidelines:

SOAP Note Creation:

• Create a detailed SOAP note for a hypothetical patient with hypertension.
• Ensure each section (Subjective, Objective, Assessment, Plan) is clearly defined and filled with relevant information.

Subjective Section:

• Include the patient’s self-reported information such as symptoms, concerns, lifestyle habits, medication adherence, and relevant medical history related to hypertension.

Objective Section:

• Document measurable and observable data, including blood pressure readings, physical examinations, and any relevant lab or diagnostic test results.

Assessment Section:

• Offer your professional assessment and interpretation of the patient’s hypertension status based on both subjective and objective information.

Plan Section:

Outline a comprehensive treatment plan, interventions, and recommendations for managing the patient’s hypertension. This should include lifestyle modifications, medication recommendations, follow-up plans, and educational aspects.

 HTN SOAP Note for Hypertension Example

Patient Information:

• Name: Mr. W.S.
• Age: 65-year-old
• Sex: Male
• Source: Patient
• Allergies: None
• Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
• PMH: Hypercholesterolemia
• Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.
• Surgical History: Appendectomy 47 years ago.
• Family History:
  • Father-died at 81; no reported information
  • Mother-alive, 88 years old, Diabetes Mellitus, HTN
  • Daughter-alive, 34 years old, healthy
• Social History: No smoking or illicit drug use, occasional alcoholic beverage consumption, retired, widow, lives alone.

SUBJECTIVE:

Chief Complaint: Headaches that started two weeks ago.

Symptom Analysis/HPI:

Mr. W.S., a 65-year-old male, complains of recurring headaches over the past two weeks. Blood pressure readings on three occasions were elevated (159/100, 158/98, and 160/100). He occasionally experiences dizziness. Stress in the workplace has been reported for the last month.

Denies chest pain, palpitation, shortness of breath, nausea, or vomiting.

Review of Systems (ROS):

• CONSTITUTIONAL: Denies fever or chills, weakness, or weight loss.
• NEUROLOGIC: Reports headaches and dizziness, denies changes in LOC, tremors, or seizures.
• HEENT: Denies head injury, changes in vision, diplopia, blurred vision, ear pain, hearing loss, or nasal issues.
• RESPIRATORY: Denies shortness of breath, cough, or hemoptysis.
• CARDIOVASCULAR: No chest pain, tachycardia, orthopnea, or paroxysmal nocturnal dyspnea.
• GASTROINTESTINAL: Denies abdominal pain, flatulence, nausea, vomiting, or diarrhea.
• GENITOURINARY: Denies hematuria, dysuria, or changes in urinary frequency.
• MUSCULOSKELETAL: Denies falls, pain, or abnormal sounds.
• SKIN: No changes in coloration, rashes, or pruritus.

Objective Data:

• CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmHg, RR: 20, PO2: 98% on room air, Ht: 6’4”, Wt: 200 lb, BMI: 25. Reports pain 0/10.
• General Appearance: Alert and oriented x 3, no acute distress.
• NEUROLOGIC: Alert, CN II-XII grossly intact, oriented, sensation intact, bilateral UE/LE strength 5/5.
• HEENT: Normocephalic, atraumatic, symmetric, non-tender. No abnormalities in eyes, ears, nose, or throat.
• CARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.
• RESPIRATORY: No dyspnea, use of accessory muscles. Clear breath sounds bilaterally.
• GASTROINTESTINAL: No mass or hernia. Bowel sounds present, no bruits. Abdomen soft, non-tender.
• MUSCULOSKELETAL: No pain, normal ROM.
• INTEGUMENTARY: Intact, no lesions, rashes, cyanosis, or jaundice.

Assessment:

Essential (Primary) Hypertension (ICD10 I10): Given symptoms and high blood pressure (156/92 mmHg), classified as stage 2. Once organic causes ruled out (renal, adrenal, thyroid), this diagnosis is confirmed.

Differential Diagnosis:

• Renal artery stenosis (ICD10 I70.1)
• Chronic kidney disease (ICD10 I12.9)
• Hyperthyroidism (ICD10 E05.90)

Plan:

Diagnosis: Clinical evaluation, history, physical examination, and routine laboratory tests. Basic tests include CMP, CBC, Lipid profile, TSH, Urinalysis, and ECG.

Pharmacological Treatment:

• Thiazide-like diuretic and/or CCB.
• Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

Non-Pharmacologic Treatment:

• Weight loss
• Healthy diet (DASH)
• Reduced sodium intake
• Increased potassium intake
• Regular physical activity
• Tobacco cessation
• Stress management

Education:

• Provide nutrition/dietary information.
• Daily blood pressure monitoring at home for 7 days, record, and bring to next visit.
• Medication intake compliance.
• Education on possible complications: stroke, heart attack, etc.

Follow-ups/Referrals:

• Evaluation with PCP in 1 week for managing blood pressure.
• Urgent Care visit prn.
• No referrals needed currently.

References:

Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0

HTN SOAP Note for Hypertension Example Two

Patient Information:

• Name: Mr. U
• Age: 48 years old
• Blood Pressure (BP): 165/90 mm Hg

Background:

Mr. U’s BP is elevated, and he is reluctant to take medication. He has been trying to manage it through diet and weight loss. His family history is significant for hypertension, with both parents and several siblings affected. Mr. U has a history of smoking one pack per day for 30 years, and he does not consume alcohol. He currently takes no medications.

Review of Symptoms:

Denies chest pain, shortness of breath, claudication, headache, dizziness, palpitations, weight change, constipation, daytime sleepiness, and snoring.

Physical Examination:

• BP: 165/90 mm Hg in both arms
• Pulse: 84 bpm
• Respiratory Rate: 16 breaths per minute
• Weight: 220 pounds
• BMI: 30 kg/m²

Additional Findings:

• Fundoscopic exam: Arteriolar narrowing with no hemorrhages or exudates
• Cardiovascular exam: S4 present, no S3 or murmurs
• No abdominal bruits, normal pulses, and no peripheral edema
• Neurologic exam: Normal

Initial Test Results:

• ECG: Left ventricular hypertrophy by voltage, otherwise normal
• TSH: 1.0 microunit/mL
• Urine albumin–creatinine ratio: Normal
• Electrolytes: Na 145 mEq/L, K 4.2 mEq/L, Cl 100 mEq/L, BUN 11 mg/dL, creatinine 0.5 mg/dL
• Fasting glucose: 90 mg/dL
• Fasting lipid panel: Total cholesterol 240 mg/dL, HDL 40 mg/dL, triglycerides 100 mg/dL, LDL 180 mg/dL

Assessment:

• Hypertension
• Early Retinopathy
• Hypercholesterolemia
• Left ventricular hypertrophy
• Obesity

Rule out secondary hypertension.

Plan:

• Smoking cessation counseling
• Referral to a nutritionist for diet and exercise guidance
• Medications:
  • Hydrochlorothiazide 12.5 mg daily for hypertension
  • Atorvastatin 40 mg daily for hypercholesterolemia

Follow-up:

One month later, BP is 145/85 mm Hg. Despite no initiation of exercise and continued smoking, counseling on lifestyle modifications is reinforced. Six months later, with diet changes and regular exercise, Mr. U has lost 5 pounds, and his BP is 135/82 mm Hg. He continues to smoke.

SOAP NOTE:

S:

A 48-year-old man presents with a BP of 165/90 mmHg. He has been attempting lifestyle modifications, including diet and weight management, to avoid medication. No alcohol use, and a significant family history of hypertension is noted. Past medical history includes smoking 1 pack/day for 30 years. Denies several symptoms, including chest pain, shortness of breath, headache, and more.

O:

BP: 165/90 mmHg in both arms, Pulse: 84 bpm, RR: 16 breaths per minute, Weight: 220 lbs, BMI: 30. Lungs clear, cardiac exam shows S4, no S3 or murmurs. Fundoscopic exam reveals arteriolar narrowing. Abdominal bruits, pulses, and peripheral edema are normal. Neurologic exam is unremarkable.

Initial test results include ECG findings of left ventricular hypertrophy, normal TSH, and urine albumin–creatinine ratio. Electrolytes, glucose, and lipid panel values are within normal limits.

A:

Hypertension, Early Retinopathy, Hypercholesterolemia, Left ventricular hypertrophy, Obesity. Rule out secondary hypertension.

P:

Counseling for smoking cessation, referral to a nutritionist. Medications initiated: Hydrochlorothiazide 12.5 mg and Atorvastatin 40 mg daily.

Summary:

Hypertension can be either primary or secondary. Mr. U, with a family history of hypertension, is managing his elevated BP through lifestyle changes and medications. Regular follow-ups and reinforcement of lifestyle modifications are essential in controlling hypertension and preventing complications.

HTN SOAP Note for Hypertension Example Three

SUBJECTIVE:

Chief Complaint (C/C): “I’ve had a couple high blood pressure readings at home and bloody nose x 3 days”

History of Present Illness (HPI):

A 35-year-old male landscape worker reports elevated home blood pressure readings, reaching over 200 and 235 mm Hg on two occasions this month. Additionally, he experienced three episodes of nosebleeds during the past week, unrelated to any specific triggers, which were self-managed by applying pressure and leaning forward. The patient works outdoors and is exposed to environmental factors and heat. He denies nasal congestion, vigorous nose blowing, but reports itchy eyes, alleviated by washing his face multiple times daily. No other health complaints. Reports a recent decrease in alcohol consumption, a shift to healthier meals, and stable weight. Review of systems is negative for other symptoms.

Objective:

Vital Signs:

• T: 98.0°F
• P: 54 bpm
• RR: 16 breaths per minute
• 1st BP: 150/84 mm Hg
• 2nd BP: 131/86 mm Hg
• Ht: 61 in
• Wt: 199.3 lbs
• BMI: 37.62

Laboratory Results:

• 1/2019: A1c: 5.5, LDL: 99, HDL: 49, Triglycerides: 180, Cholesterol: 189, GFR: 113, TSH: 3.65
• Labs drawn today (9/10/2020): CBC, CMP, lipid panel, TSH, HbA1c, microalbumin

Physical Examination:

• General: Well-appearing, groomed, cooperative
• Skin: Normal, no rashes or lesions
• HEENT: Normocephalic, atraumatic, normal bilateral tympanic membranes, clear nasal passages
• Neck: Supple, no lymphadenopathy
• Respiratory: Clear lung sounds, non-labored respirations
• Cardiovascular: Regular rate and rhythm, no murmurs or edema
• Musculoskeletal: No joint deformities or abnormalities
• Neurologic: Alert and oriented, normal speech, no motor or sensory deficits

Assessment:

Epistaxis (R04.0):

• Treatment: Saline nasal irrigation to reduce irritation.
• Diagnostics: None today.
• Education: Nasal precautions, use of saline nasal irrigation.
• Follow-up: In 4 weeks or as needed if symptoms worsen.

Essential Hypertension (I10):

• Treatment: Edarbi 40mg PO, lifestyle modifications.
• Diagnostics: Blood pressure re-check at end of visit (131/86 mm Hg).
• Education: BP control, lifestyle changes, medication adherence.
• Follow-up: In 4 weeks with home blood pressure logs for review.

Clinical Decision Making:

• Labs drawn today: To assess for possible chronic kidney disease, anemia, or hypothyroidism, potential causes of elevated blood pressure.
• Home blood pressure log: Monitors baseline and aids in effective medication titration.
• Language barrier: Addressed by involving a Spanish-speaking nurse and providing printed education materials in Spanish.
• Learning Experience: Utilized an otoscope for the first time, gaining valuable hands-on experience.
• Future Improvement: Consider taking a medical Spanish course to enhance communication skills.
• Insightful Takeaway: Effective communication and patient education are crucial, and language-appropriate materials enhance understanding.

References:

American Diabetes Association. (2019). Standards of Medical Care in Diabetes.

James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., … & Smith Jr, S. C. (2014). Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 311(5), 507-520.

National Heart, Lung, and Blood Institute. (2014). The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure.

HTN SOAP Note for Hypertension Example Four

Medical Specialty:

SOAP / Chart / Progress Notes

Sample Name: Hypertension – Progress Note

Description: Patient with hypertension, syncope, and spinal stenosis – for recheck.

SUBJECTIVE:

The patient, a 78-year-old female, presents for a recheck. She reports having hypertension but denies chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.

PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:

Reviewed and unchanged from the dictation on 12/03/2023.

MEDICATIONS:

• Atenolol 50 mg daily
• Premarin 0.625 mg daily
• Calcium with vitamin D (two to three pills daily)
• Multivitamin daily
• Aspirin as needed
• TriViFlor 25 mg (two pills daily)
• Elocon cream 0.1% and Synalar cream 0.01% used as needed for rash.

ALLERGIES:

• Benadryl, phenobarbitone, morphine, Lasix, and latex.

FAMILY HISTORY / PERSONAL HISTORY:

Reviewed. Positive family history of congestive heart failure, myocardial infarction, and ischemic cardiac disease. Brother deceased from lymphoma, and one living brother has had angioplasties x 2. Another brother has asthma. Mother died from congestive heart failure, and father died from myocardial infarction at 56. Personal history negative for alcohol or tobacco use.

REVIEW OF SYSTEMS:

• Bones and Joints: Lower back pain radiating down the right leg. Under evaluation by Dr. XYZ for spinal stenosis.
• Genitourinary: Occasional nocturia.

PHYSICAL EXAMINATION:

• Vital Signs: Weight: 227.2 pounds, Blood pressure: 144/72, Pulse: 80, Temperature: 97.5 degrees.
• General Appearance: Elderly female not in acute distress.
• Mouth: Posterior pharynx clear.
• Neck: Without adenopathy or thyromegaly.
• Chest: Lungs resonant to percussion. Normal breath sounds.
• Heart: Normal S1 and S2 without gallops or rubs.
• Abdomen: Without masses or tenderness.
• Extremities: Without edema.

IMPRESSION/PLAN:

Hypertension: Continue with current medication.

Syncope: No recurrence since the episode around Thanksgiving. No arrhythmias found in prior cardiac studies.

Spinal Stenosis: Under evaluation. Potential surgery in the near future.

References:

James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., … & Smith Jr, S. C. (2014). Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 311(5), 507-520.

American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. (2017). ACC/AHA hypertension guideline 2017. Journal of the American College of Cardiology, 71(19), e127-e248.

HTN SOAP Note for Hypertension Example Five

Patient Information:

• Name: Sanjay War
• Age: 64 Years
• Height: 6 Feet 2 Inches
• Weight: 95 Kg

S: Subjective:

Sanjay reports living alone and being an occasional drinker, but he does not smoke. Family history reveals both parents had hypertension. Current medications include Hydrochlorothiazide 25mg, Doxazosin 2mg, Carvedilol 12.5mg, Mucinex D 2 tablets, Naproxen 220 mg, and Metformin 500mg.

O: Objective Findings:

• Blood Pressure: 160/85 mm Hg (3 months ago)
• Heart Rate: 76 bpm
• Weight: 95 kg
• Height: 6’2
• BMI: 26.8 (overweight)
• Total Cholesterol: 171mg/dl, LDL: 99mg/dl, HDL: 40mg/dl
• Triglycerides: 158mg/dl
• Serum creatinine: 2.2 mg/dl
• Blood Glucose: 110mg/dl
• Uric Acid: 6.7 mg/dl

A: Assessment:

Sanjay’s blood pressure is above the goal, considering his diabetes. Factors contributing to suboptimal blood pressure control include medication side effects (Mucinex D, Naproxen), and non-compliance with a low sodium diet. ACEIs or ARBs are recommended for diabetes. Carvedilol, a non-selective beta-blocker, may not be the best choice for COPD.

P: Plan:

1. Discontinue guaifenesin/pseudoephedrine preparation.
2. Discontinue Naproxen. Replace with an alternative (e.g., acetaminophen) for headaches and gout.
3. Gradually discontinue Carvedilol.
4. Add Lisinopril 5mg once daily, considering dry cough or angioedema.
5. Monitor B.P, K, renal function, glucose, and lipid profile.
6. Continue HCLTZ 25mg po qam.
7. Continue Doxazosin 2mg. Change dosing schedule to reduce possible Doxazosin-induced dizziness.
8. Continue Metformin 500mg.

References:

James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., … & Smith Jr, S. C. (2014). Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 311(5), 507-520.

American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. (2017). ACC/AHA hypertension guideline 2017. Journal of the American College of Cardiology, 71(19), e127-e248.

Frequently Asked Questions (FAQs) on HTN SOAP Notes for Hypertension

What is a SOAP note for hypertension?

A SOAP note for hypertension is a structured method of documenting a patient’s encounter related to high blood pressure. It consists of four sections: Subjective, Objective, Assessment, and Plan, and is commonly used by healthcare professionals to record and communicate information about a patient’s hypertension.

What does the “S” in the SOAP note for hypertension stand for?

The “S” stands for “Subjective.” This section includes the patient’s self-reported information, such as their symptoms, concerns, lifestyle habits, medication adherence, and any relevant medical history related to hypertension.

What does the “O” in the SOAP note for hypertension stand for?

The “O” stands for “Objective.” Here, the healthcare provider documents measurable and observable data, including vital signs (such as blood pressure readings), physical examinations, and any relevant lab or diagnostic test results.

What does the “A” in the SOAP note for hypertension stand for?

The “A” stands for “Assessment.” In this section, the healthcare provider offers their professional assessment and interpretation of the patient’s hypertension status based on both subjective and objective information.

What does the “P” in the SOAP note for hypertension stand for?

The “P” stands for “Plan.” In this section, the healthcare provider outlines the treatment plan, interventions, and recommendations for managing the patient’s hypertension.

What information is included in the “Subjective” section for hypertension?

The “Subjective” section may include the patient’s reported symptoms (such as headaches, dizziness), medication history, lifestyle factors (diet, exercise), family history of hypertension, and any concerns or questions the patient may have.

What information is included in the “Objective” section for hypertension?

The “Objective” section includes the patient’s blood pressure readings (systolic and diastolic), heart rate, physical examination findings (like the presence of edema), and any relevant laboratory results (such as renal function tests).

What does the “Assessment” section involve for hypertension?

The “Assessment” section involves the healthcare provider’s clinical judgment of the patient’s hypertension condition. It may include the classification of the hypertension stage, risk assessment for complications, and evaluation of any related health issues.

What does the “Plan” section entail for hypertension?

The “Plan” section outlines the proposed management and treatment strategies for the patient’s hypertension. This can include lifestyle modifications, medication recommendations, follow-up appointments, and education on hypertension management.

How often should SOAP notes for hypertension be updated?

The frequency of updating SOAP notes for hypertension depends on the patient’s condition and treatment plan. They can be updated after each visit or as significant changes occur in the patient’s blood pressure or overall health.

Can patients access their own SOAP notes for hypertension?

In some cases, patients may have access to their medical records, including SOAP notes, as part of their right to access their health information. However, this can vary based on healthcare facility policies and regulations.

Are SOAP notes only used by doctors for hypertension?

No, SOAP notes are used by a variety of healthcare professionals, including doctors, nurses, nurse practitioners, and physician assistants, to document and communicate information about a patient’s hypertension care and management.

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