Case Study: Analysis of SOAP Note for Hypertension Management

This case study presents a SOAP note for a 43-year-old female, Ms. X, managing hypertension. The subjective section details her symptoms (headaches, weakness) and medication history (atenolol and hydrochlorothiazide). The objective section reveals high blood pressure readings and lab results, including elevated cholesterol and triglycerides. The assessment identifies moderate obesity. The plan involves transitioning her pharmacologic regimen, first to enalapril and then to losartan, along with lifestyle recommendations (exercise, diet). After the initial treatment plan failed, the ARB was started with positive results. The critique highlights adherence to clinical practice guidelines, emphasizing the importance of considering alternative treatment options to improve patient outcomes. References to supporting research on hypertension management are also provided.

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

SOAP NOTE 3
angiotensin-converting enzyme (ACE) inhibitor enalapril, 5 mg/day; and her HCTZ was
withdrawn (Kim et al., 2019). Moreover, she was advised to engage in a little regular exercise
and modify her diet to enable her to reduce her weight and cholesterol levels in line with the
recommendations of the Sixth Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC VI).
After three months of a trial of the underlying treatment plan, the patient’s condition
remained uncontrolled despite the escalation of enalapril dose to 20 mg/day. Nonetheless, a
review of her medical status, without many changes except for modification of the
antihypertensive therapy was done. Notably, the ACE inhibitor was stopped, and she started
using 50 mg/day 50 mg/day of the angiotensin-II receptor blocker (ARB) losartan (Kim et al.,
2019). After 2 months into the new technique with the ARB, she experienced a modest yet
impressive improvement in her blood pressure attaining a level of 133/100 mm Hg. The serum
electrolyte values from the laboratory were within the recommended limits while her physical
assessment slightly improved.
A month later, a reevaluation of the treatment approach was conducted with the intention of
reducing the dosage level of HCTZ to 12.5 mg/day if it were to be added to the routine.
Critique
The clinical practice guidelines dictate that physicians must always recommend all the
intended care alternatives with the primary aim of optimizing benefits (Lackland, Voeks, &
Boan, 2016). The plan complies with the spirit and letter of clinical practice as it provides
alternative courses of action for the patient just in case one fails to yield the desired or expected
outcomes. However, it practices guidelines despite the emphasis on an evidence-based approach,
it should give room right to trial of different approaches to treatment provided that the ultimate

SOAP NOTE 4
goal is to enhance the wellbeing of the patients.

SOAP NOTE 5
References
Bollampally, M., Chandershekhar, P., Kumar, K., Surakasula, A., Srikanth, S., & Reddy, T.
(2016). Assessment of patient’s knowledge, attitude, and practice regarding
hypertension. Int J Res Med Sci, 4(6), 3299-304.
Galiè, N., Humbert, M., Vachiery, J. L., Gibbs, S., Lang, I., Torbicki, A., ... & Ghofrani, A.
(2015). 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary
hypertension: the joint task force for the diagnosis and treatment of pulmonary
hypertension of the European Society of Cardiology (ESC) and the European Respiratory
Society (ERS): endorsed by: Association for European Paediatric and Congenital
Cardiology (AEPC), International Society for Heart and Lung Transplantation
(ISHLT). European heart journal, 37(1), 67-119.
Kim, H., Baik, S. Y., Yang, S. J., Kim, T. M., Lee, S. H., Cho, J. H., ... & Kim, H. S. (2019).
Clinical experiences and case review of angiotensin II receptor blocker‐related
angioedema in Korea. Basic & clinical pharmacology & toxicology, 124(1), 115-122.
Lackland, D. T., Voeks, J. H., & Boan, A. D. (2016). Hypertension and stroke: an appraisal of
the evidence and implications for clinical management. Expert review of cardiovascular
therapy, 14(5), 609-616.