Soap Note: High Blood Pressure Plan Assessment 2022

Running head: SOAP NOTE 1
Name
Institution

SOAP NOTE 2
SOAP Note
Subjective
Ms. X, 43 years of age is following on her high blood pressure plan. “More often I suffer
from headache and experience a general feeling of weakness, I need your help”
Objective
Ms. X reported that she had been taking her medication for the condition for the last 3
years and later stopped because of the side effects of the drugs. She could not remember the
names of the drugs but she is currently taking 100 mg/day atenolol plus 12.5 mg/day
hydrochlorothiazide (HCTZ). “I take them irregularly, sometimes I forget,” she adds (Galiè et
al., 2015. Despite these efforts, her blood pressure remains high, ranging from 149 to 153/110 to
112 mm Hg. Additionally, she admits that changing her eating habits and that she rarely does
exercise, though she does not smoke.
Assessment
A physical examination reveals the presence of moderate obesity; (5 ft 2 in., 148 lbs).
The original laboratory data exposed blood urea nitrogen (BUN) 17 mg/dL (9 to 17 mg/dL);
serum sodium 135 mEq/L (133 to 142 mEq/L); potassium 3.3 mEq/L (3.3 to 4.8 mEq/L);
calcium 9.6 mg/dL (8.6 to 9.8 mg/dL); total cholesterol 264 mg/dL (< 243 mg/dL); triglycerides
227 mg/dL (< 157 mg/dL); and fasting glucose 103 mg/dL (65 to 106 mg/dL), creatinine 0.75
mg/dL (0.32 to 0.91 mg/dL).
Plan
Taking into the account of her historical challenges of adhering to the medication plan,
physical exercise as well as taking an appropriate diet, the physician took some radical measures
to help lower her blood pressure. Her pharmacologic regimen was transformed into a trial of the