HYPERTENSION SOAP Note
Patient Information
Name: Jessica Adams
Pt. Encounter Number: 1139
Date: 12/27/2022
Age: 19
Sex: Female
SUBJECTIVE
Chief Complaint (CC):
"I am experiencing an irregular heartbeat, increased chest pain, blurred vision, and increased headache,
especially after any slight activity."
History of Present Illness (HPI):
Ms. Adams, a 19-year-old Black American female, presents with complaints of increased irregular
heartbeat, chest pain, blurred vision, and increased headache, especially after any slight activity.
Symptoms began approximately a month ago and have worsened recently. She admits to using over-the-
counter Tylenol (400mg three times a day) to control the headaches, which she rates as 8/10 in severity.
Medications:
Tylenol: 400mg three times a day
Past Medical History (PMH):
Allergies: None
Medication Intolerances: None
Chronic Illnesses/Major Traumas: None
Hospitalizations/Surgeries: None
Obstetric/Gynecological (OB/GYN) History: Menarche at 12, regular menstrual cycles, no
dysmenorrhea or amenorrhea
Family History:
Hypertension and diabetes in both parents and two siblings
Paternal grandfather passed away due to colon cancer
Socio-occupational History:
University student studying law
Part-time work at a local restaurant
Occasional alcohol consumption, denies tobacco use
Review of Systems (ROS):
General: Denies fever, chills, fatigue, and lymphadenopathy
Cardiovascular: Reports irregular heartbeat, tachycardia, and chest pains
Eyes: Reports blurred vision, denies eye pain or redness
Respiratory: Denies coughing, wheezing, dyspnea
Gastrointestinal: Denies abdominal pain, nausea, vomiting
Ears/Nose/Throat: Denies hearing problems, nasal congestion
Genitourinary: Denies urinary symptoms
Neurological/Psychiatric: Denies attention deficit, numbness, convulsions
OBJECTIVE
Temp: 36.8°C
WT: 80 kilograms
BMI: 30.11
Height: 163cm
Pulse: 100 bpm
BP: 133/91 mmHg
Respiratory Rate: 22 breaths/minute
General Appearance:
Ms. Adams is well-kempt, nourished, interactive, and coherent.
HEENT:
Eyes: No visual abnormalities
Ears/Nose/Throat: No abnormalities
Cardiovascular:
S1 and S2 heart sounds clear, no murmurs
Capillary refill <2 seconds
Increased irregular heartbeat
Respiratory:
Lungs clear bilaterally, no distress
Gastrointestinal:
Soft abdomen, no organ enlargement, bowel sounds present
Neurological:
Alert and oriented, no deficits
Assessment:
1. Hypertension (likely primary hypertension) :
Hypertension, also known as high blood pressure, is a common medical condition characterized
by elevated blood pressure levels in the arteries. It is often referred to as primary hypertension
when the underlying cause of high blood pressure is unknown or not specifically attributable to
another medical condition. In the case of Jessica Adams, a 19-year-old black American female
presenting with symptoms such as irregular heartbeat, increased chest pain, blurred vision, and
headaches, especially after physical activity, primary hypertension is a likely diagnosis. Primary
hypertension accounts for the majority of hypertension cases and is typically related to a
combination of genetic, lifestyle, and environmental factors.
Genetic predisposition plays a significant role in primary hypertension, as individuals with a
family history of hypertension are more likely to develop the condition themselves. Jessica's
family history includes a notable presence of hypertension, with both parents and two siblings
already diagnosed with the condition. This genetic predisposition suggests a potential hereditary
component contributing to her elevated blood pressure levels.
Lifestyle factors also contribute significantly to primary hypertension. Obesity, sedentary
lifestyle, unhealthy dietary habits (such as high sodium intake and low potassium intake),
excessive alcohol consumption, and smoking are all known risk factors for developing high blood
pressure. Jessica's body mass index (BMI) of 30.11 indicates overweight status, which is a
common risk factor for hypertension. Her socio-occupational history, including university studies
and part-time work at a local restaurant, may also contribute to stress levels and lifestyle factors
that can impact blood pressure.
Additionally, although Jessica denies any chronic illnesses, major traumas, or medication
intolerances, certain medical conditions and hormonal disorders can contribute to secondary
hypertension, which is high blood pressure resulting from an identifiable underlying cause.
However, based on the absence of specific symptoms or indications in Jessica's history and
physical examination, primary hypertension is the most likely diagnosis.
Primary hypertension is a chronic condition that requires comprehensive management, including
lifestyle modifications, pharmacological interventions, regular monitoring, and patient
education. The goal of treatment is to lower blood pressure to within the target range to reduce
the risk of cardiovascular complications, such as stroke, heart attack, and kidney damage.
Collaborative care between healthcare providers and patients is essential in effectively managing
primary hypertension and promoting overall cardiovascular health.
2. Differential Diagnosis: Hyperaldosteronism, aortic valve disease (less likely)
Hyperaldosteronism is a medical condition characterized by excessive production of aldosterone
hormone by the adrenal glands. Aldosterone plays a key role in regulating sodium and potassium
balance in the body, and its overproduction can lead to salt and water retention, resulting in
elevated blood pressure. Symptoms of hyperaldosteronism may include hypertension, fatigue,
muscle weakness, and low potassium levels. In Jessica's case, hyperaldosteronism is a potential
differential diagnosis due to her elevated blood pressure levels and symptoms such as irregular
heartbeat, blurred vision, and headaches. However, further diagnostic tests would be necessary
to confirm or rule out hyperaldosteronism, such as aldosterone-to-renin ratio (ARR) testing,
plasma aldosterone concentration (PAC) measurements, and adrenal imaging studies.
Aortic valve disease involves abnormalities or dysfunction of the aortic valve, which regulates
blood flow from the left ventricle of the heart to the aorta. Types of aortic valve disease include
aortic stenosis and aortic regurgitation which is the leakage of blood back into the left ventricle.
Symptoms of aortic valve disease may include chest pain, shortness of breath, palpitations, and
fatigue. While aortic valve disease is less likely given Jessica's age and absence of specific cardiac
symptoms such as chest pain or shortness of breath, it remains a differential diagnosis to
consider, albeit a less probable one. A thorough cardiovascular examination, including
auscultation for heart murmurs and further cardiac imaging studies such as echocardiography
would be needed to evaluate the structure and function of the aortic valve and assess for any
abnormalities.
Plan of Care:
ARBs form a classification of anti-hypertensive medicines acting by blocking the actions of
angiotensin II, a hormone that contracts the blood vessels therefore lowering BP. The drugs are
preferred for the regimen for the control of elevated BP and to decrease the complications from
the conditions that include complications with stroke and damage of the myocardial infarction
and kidney. Close monitoring also makes it feasible to titrate antihypertensive therapy promptly
or institute appropriate measures in case the BP mandates further optimization of control. New
ARB patients should be educated on adherence to treatment and follow-up provided for the
assessment of the response to treatment, as well as for the detection and management of
adverse effects.
In addition to pharmacological therapy, health education plays a crucial role in managing
hypertension. On this case, Jessica should be educated on the need for routine measurement
and documentation of BP, using a good monitor that she can have at home and the technique of
doing that. Monitoring of BP is useful in the management of hypertension because it recognize
early any change in BP or abnormalities that may need medical attention. The advise is promptly
needed in case of drastic changes on BP's or the appearance of symptoms.
Furthermore, lifestyle modifications are integral to the overall management of hypertension.
Inform Jessica about a change in the transition to having a healthy heart, such as a low salt diet
and one low in saturated fat or cholesterol. She will be encouraged to eat more fresh fruit and
vegetables, whole grains, and lean proteins in order for her own body to maintain the weight
and keep the heart healthy. That makes the helps the taking of the daily regime in part of the
body exercise. This would also help an individual to learn stress control methods, for example,
mindfulness meditation, deep breathing, yoga exercises, which tend to lessen stress and
therefore had a positive contribution to better BP control. Smoking cessation and minimization
of alcohol intake also form major components of lifestyle change in reduction BP and therefore
risk for cardiovascular complications. Alternatively, one can inform hypertensive patients about
the adverse effects of smoking and excessive alcohol intake on BP and overall health.
Routine follow-up care for a patient diagnosed with hypertension should include keeping
appointments for the monitoring of blood pressure (BP) and for titration of meds to effective
doses. This holds true in the case of Jessica Adams, where her blood pressure is controlled in the
defined target range through prescription with an antihypertensive of 20mg angiotensin-
receptor blocker (ARB) once a day. The care plan will program regular monitoring of BP as a
follow-up visit to check on how well Jessica has progressed and what impact the
antihypertensive treatment has shown. In the next visits, calibrated doctor's
sphygmomanometer will continue to measure her BP with every visit, and the readings are to be
put down in further monitoring of the effectiveness on ARB therapy. Consistency in monitoring
the BP makes it periodically early for detecting any alterations in BP or change in target ranges,
well in time for making the adjustments in medicine dosage or treatment plans.
Besides blood pressure, the cornerstone of follow-up for hypertension is to check the efficacy of
medication taken by the individual. During office follow-up visits, Jessica will be assessed for
medication response to the ARB and for lifestyle modifications, so as to satisfactorily achieve and
maintain the control of an optimal BP. This may include looking over her BP readings over time
or the changes in the symptoms or side effects she is experiencing from her medication, or any
laboratory or diagnostic evaluations that are necessary. Thus, the follow-up schedule is tailor-
made to Jessica's needs and individual response to treatment whereby, in general, it can be at
least scheduled every 2-4 weeks for the beginning of follow up weaknesses in BP control and
modification of the plan of care subsequently if necessary.
Follow-up Instructions:
Return if symptoms worsen or experience medication side effects.
