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SOAP Note for Primary Hypertension – JRC, 43-Year-Old Female

Maureen

SOAP Note for Primary Hypertension – JRC, 43-Year-Old Female

ID: JRC, DOB 1/1/1980, age 43 Gender: Female Race:  Hispanic

She is married. She came to the clinic alone and appears to be a reliable historian.

Subjective:

CC: “My heart pounds a lot, and I easily get tired”

HPI: A 43-year-old Hispanic female presented to the clinic with complaints of easily getting fatigued and palpitations. The symptoms began close to six months ago and have been present since.  The palpitations last a few minutes whenever they occur but may be present for even hours. They are usually accompanied by a bilateral throbbing headache, nausea, fatigue, and sometimes vision loss. These manifestations are made worse by activity, especially strenuous exercises, and alleviated by rest. They are intermittent as they come and go during most of the day. The symptoms subside at night and get worse during the day. The symptoms have been increasing in intensity and severity since their onset.

Past Medical History:

Medical problem list 

No reports of any chronic illness, past accidents, head injuries, or hospitalization.

Surgical:

No reports of any past surgeries.

Allergies:

No known drug or food allergies.

Medications:

No reports of any current or past medication use.

Vaccinations:

The patient is up to date with all her vaccinations. She received the annual flu vaccine in February. She has also taken all her COVID-19 vaccines, including the booster doses.

Social History:

Chemical history: The patient has no history of alcohol use or cigarette smoking. She also denied having ever taken any substance of abuse.

Other: The patient consumes a balanced diet. However, she expressed a liking for high salt. She takes two cups of coffee daily.

Family History:

Her father is alive. He is 72 years old and has a history of hypertension, diabetes, and hypercholesterolemia. Her mother died at the age of 31 due to complications in pregnancy. Her eldest sister is 45 years old and has a history of hypertension. Her grandmother died at 80 years old due to myocardial infarction, while her grandfather died at 75 due to a stroke.

Reproductive: The patient’s LMP was 4/30/2024. There are no reports of amenorrhea, oligomenorrhoea, or any other menstrual abnormalities. She also denies experiencing a reduction in her libido or sexual patterns.

ROS: 

Constitutional: The patient reports occasional fatigue and weakness. She denies any changes in weight, fever, or chills.

Eyes: The patient reports occasional blurred vision. However, there were no reports of visual aids, unusual tearing, double vision, or discharge.

ENT: There were no reports of hearing loss, use of hearing aids, ear discharge, earaches, or ear infections. There were also no reports of nasal discharge, rhinorrhea, or sore throat. The patient also denied having ever used any dental applications or dentures.

Cardiovascular: The patient reported experiencing palpitations for the last six months. The palpitations often proceed with an activity. She, however, denied experiencing chest pain or swelling in her extremities.         

Pulmonary: No reports of wheezing, shortness of breath, or unusual coughing.

Genitourinary: no reports of changes in the urinary volume. The patient also denies hematuria or unusual changes in the appearance of the urine.

Endocrine: No reports of excessive sweating, skin dryness, diabetes, or cold intolerance.

Neurological: The patient reported occasional headaches. The headaches usually accompany the palpitations and are more apparent in the morning hours. She may also experience some dizziness in the process. She also experiences occasional nausea. She, however, denied experiencing any seizures, fainting, weakness, or numbness in her extremities and personality changes.

Hematologic: No reports of anemia, easy bruising, or excessive bleeding.

Lymph: There are no reports of splenectomy or lymphatic swelling in her neck and joint areas.

Objective

VS: T – 98 P – 80 R – 16 BP – 138/87 mm Hg, 137/86 mm Hg on repeat. O2 sat – 99% – Wt.: 175 lbs. Height: 5’1 BMI; 33.1

Labs, radiology, or other pertinent studies: A third BP reading of alternate hands confirmed high blood pressure, with values of 137/88mm Hg on the left arm and 136/88 mm Hg on the right arm. A 12-lead ECG was also negative for left ventricular hypertrophy or angina. The thyroid function test revealed a total T3 of 1.3 ng/mL, a total T4 of 8 ug/dl, and a TSH of 2.0. The blood chemistry panel revealed no electrolyte abnormalities. A chest x-ray was also negative for cardiomegaly or pulmonary congestion.

CBC was also ordered to rule out a possible underlying inflammatory response and an infection, which may also cause high blood pressure. CBC for JRC, a female aged 43 on 5/11/2024

Hematology Result Normal range
Red cell count 5.5 x 1012/L 4.5–5.7
White cell count 8 x 109/L 4.0–10.0
Hemoglobin 156 g/L 133–167
Hematocrit 0.49 0.35–0.53
MCV 93 FL 77–98
MCH 31.9 pg. 26–33
MCHC 351 g/L 330–370
RDW 13.5% 10.3–15.3

Physical Examination

General survey: The patient is alert. There are no signs of significant weight loss or fever, and there were no signs of cyanosis, pallor, or edema on the extremities.

Eyes: The eyes are symmetrical. Her vision is intact, with a visual acuity of 20/20. The pupillary reactivity to light is intact. There were no signs of eye discharge, ptosis, or corneal lesions. There were also no signs of emboli or infarct, Roth spots, or optical disc edema on the retina. There was also no sign of conjunctival pallor or corneal arcus.

ENT:  No signs of hearing loss, ear discharge, ear swelling, or tenderness. There were also no signs of nasal discharge or tenderness, dental application, or pain during swallowing. There were no signs of bluish discoloration on the lips, angular stomatitis, and high arched palate.

Neck: The neck was symmetrical and consistent in color. The trachea was midline. There was no sign of swelling on the neck. There was also no sign of pain on palpation of the lower portion of the neck. No sign of jugular venous distension.

Chest and Thorax:  Visual inspection of the chest and the thorax revealed that the chest is symmetrical. There were no signs of scars or visible pulsations. There was no sign of labored breathing or use of accessory muscles for respiration. No wheezing or pericardial friction rub sounds were heard on auscultations.  The heart rate is rhythmic. No heart murmurs were heard on auscultation of all the four valves of the heart there were also no bruit sounds heard. There was no sign of heaves or thrills on palpation of the chest, at the apex, ruling out right ventricular hypertrophy.  The carotid artery, internal jugular, and radial pulse were all felt on palpation.

Abdomen: The abdomen is symmetrical. There are no signs of scars, striae, or skin color inconsistencies on inspection of the abdomen. There were also no signs of abdominal pain or tenderness on light and deep palpation of the abdomen. Abdominal sounds were heard in all of the four abdominal quadrants on auscultation.

Lymph: There were no signs of splenomegaly on palpation.

Neurological: The patient is alert and responsive. She verbalizes what brought her to the hospital and can remember all the events of the day. She is also oriented to place time, and event.

Integumentary: The skin is warm to the touch. There was no sign of skin color inconsistencies, unusual skin thickening or thinning, unusual skill dryness or sweating, irregular distribution of hair on the skin, or cyanosis. There was also no sign of finger clubbing. The capillary refill time for her upper and lower fingernails was approximately 2 seconds.

Assessment

Differential Diagnosis

  1. Primary Hypertension ICD-10 I10:Primary hypertension is a medical condition characterized by sustained high blood pressure. According to the ESH guidelines, a blood pressure value above 130 mm Hg systolic and a diastolic pressure above 80 mm Hg is considered high (Unger et al., 2020). A diagnosis of hypertension is made after obtaining at least two repeat readings in an office setup and when the average eclipses the threshold of 130/80 mm Hg (Jones et al., 2020). Notwithstanding, a comprehensive assessment of the patient is necessary to rule out other potential causes of BP and secondary hypertension. In the case presented, the patient had sustained high blood pressure. This warranted the inclusion of this differential.
  2. Hyperthyroidism ICD-10 E05:Hyperthyroidism is a medical condition characterized by marked production of the thyroid hormone. This results in thyroid hormone excess and subsequent increases in system-level thyroid effects (Wiersinga et al., 2023). In the cardiovascular system, hyperthyroidism causes a hyperadrenergic state, with palpitations, tachycardia, and sustained elevation of blood pressure being apparent. Patients with hyperthyroidism also develop a hypermetabolic state with weight loss, anxiety, muscle weakness, oligomenorrhoea, and loss of libido being apparent (Raguthu et al., 2022). The patient in the case presented reported complaints of palpitations and fatigue. Additionally, her vital signs were positive for high blood pressure. This warranted the inclusion of this differential in the differentials list. A thyroid function test was necessitated to rule out this diagnosis.
  3. Chronic Kidney Disease ICD-10 N18: Chronic kidney disease is the presence of kidney damage with a consequent reduction in the glomerulus filtration rate, persisting for more than three months. CKD has a multi-factorial etiology, with diabetes Mellitus being the leading cause (Wilson et al., 2021). Patients with CKD will commonly manifest symptoms such as fatigue, muscle weakness, swelling of the extremities, elevated high blood pressure, sleep disturbances, and hypertension that is difficult to control (Kalantar-Zadeh et al., 2021). The patient in the case presented had hypertension, as revealed by her BP measurements, and fatigue. These manifestations warranted the inclusion of this differential in the differentials list. This differential was ruled out because of the absence of other supportive features of the disease.

Diagnosis: The presumptive diagnosis for the patient in the case presented in primary hypertension ICD-10 code I10. The patient in the case presented with symptoms like those of hypertension. These include palpitations, headache, and ease of fatigue. This warranted a clinical suspicion of hypertension. Assessment findings revealed a family history of hypertension and marked elevation of blood pressure, confirmed by two separate readings, further affirming the clinical diagnosis. The thyroid function tests were normal ruling out hyperthyroidism as a causal factor for the elevation in Blood pressure. The CBC also ruled out the presence of an infection or inflammatory processes that also have the potential to cause high blood pressure. The kidney function tests were also normal ruling out kidney diseases as a causal factor for high blood pressure. The presumptive diagnosis, in this case, is thus primary hypertension.

Plan

1.) Primary Hypertension ICD-10 I10:

Blood Pressure Measurements: BP measurements are confirmatory of the disease. According to the JNC-8 reports, a BP reading of more than 130/80 mm Hg meets the criteria for diagnosing hypertension. The ESH recommends two or more office measurements on two separate occasions to diagnose the disease (Unger et al., 2020).

Diagnostics: 

Labwork: 

Treatment:

Education: 

Follow-Up: The patient is expected to return to the clinic after two months. However, she should keep monitoring her BP reading and convey the results to the caregivers. An early revisit may be necessary when the readings go unusually high.

References

Chen, T. K., Knicely, D. H., & Grams, M. E. (2019). Chronic kidney disease diagnosis and management. JAMA, 322(13), 1294. https://doi.org/10.1001/jama.2019.14745

D’Souza, A. C., Lau, K. J., & Phillips, S. M. (2021). Exercise in the maintenance of weight loss: Health benefits beyond lost weight on the scale. British Journal of Sports Medicine, 56(13), 771–772. https://doi.org/10.1136/bjsports-2021-104754

Jones, N. R., McCormack, T., Constanti, M., & McManus, R. J. (2020). Diagnosis and management of hypertension in adults: Nice guideline update 2019. British Journal of General Practice, 70(691), 90–91. https://doi.org/10.3399/bjgp20x708053

Kahaly, G. J. (2020). Management of graves thyroidal and extrathyroidal disease: An update. The Journal of Clinical Endocrinology & Metabolism, 105(12), 3704–3720. https://doi.org/10.1210/clinem/dgaa646

Kalantar-Zadeh, K., Jafar, T. H., Nitsch, D., Neuen, B. L., & Perkovic, V. (2021). Chronic kidney disease. The Lancet, 398(10302), 786–802. https://doi.org/10.1016/s0140-6736(21)00519-5

Raguthu, C. C., Gajjela, H., Kela, I., Kakarala, C. L., Hassan, M., Belavadi, R., Gudigopuram, S. V., & Sange, I. (2022). Cardiovascular involvement in thyrotoxicosis resulting in heart failure: The risk factors and hemodynamic implications. Cureus. https://doi.org/10.7759/cureus.21213

Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N. R., Prabhakaran, D., Ramirez, A., Schlaich, M., Stergiou, G. S., Tomaszewski, M., Wainford, R. D., Williams, B., & Schutte, A. E. (2020). 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension, 75(6), 1334–1357. https://doi.org/10.1161/hypertensionaha.120.15026

Wiersinga, W. M., Poppe, K. G., & Effraimidis, G. (2023). Hyperthyroidism: Aetiology, pathogenesis, diagnosis, management, complications, and prognosis. The Lancet Diabetes & Endocrinology, 11(4), 282–298. https://doi.org/10.1016/s2213-8587(23)00005-0

Wilson, S., Mone, P., Jankauskas, S. S., Gambardella, J., & Santulli, G. (2021). Chronic kidney disease: Definition, updated epidemiology, staging, and mechanisms of increased cardiovascular risk. The Journal of Clinical Hypertension, 23(4), 831–834. https://doi.org/10.1111/jch.14186

Zhang, Z.-Y., Yu, Y.-L., Asayama, K., Hansen, T. W., Maestre, G. E., & Staessen, J. A. (2021). Starting antihypertensive drug treatment with combination therapy. Hypertension, 77(3), 788–798. https://doi.org/10.1161/hypertensionaha.120.12858

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Question 

Create a pretend SOAP NOTE for Primary Hypertension
2.) Here are some pretend details, JRC, is a 43-year-old female, DOB Jan 1, 1980, married, came to the clinic alone, and is a reliable historian. She has no past medical history and just beginning to experience some symptoms of hypertension.

SOAP Note for Primary Hypertension – JRC, 43-Year-Old Female

3.) Family History: Dad Alive, 72 has a history of hypertension, diabetes, and high cholesterol.
Mom died at 31 years old due to complications in pregnancy
Eldest sister at 45, is alive and has a history of hypertension
Grandmother died at 80 years old due to myocardial infarction.
Grandfather died at 75 due to stroke

4.) Please check out the templates attached, use a title page
5.) Please make sure that the treatment and diagnostics will be pertaining to the chief complaints on how to make the patient well.
6.) Please use a Clinical Guidelines reference.
7.) The more specific the treatment the better. Always look at why the patient came to the clinic, what is the chief complaint and how she will be better. Please follow the instructions on the template. Thanks so much
8.) Please double-check the spelling, grammar, and APA format, no blue highlights on the link.
9.) Please put the ICD-10 Code for differentials and main diagnosis

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