SOAP NOTE – Hypertensive Heart Disease Without Heart Failure

“Elevated blood pressure despite medications.”

Margaret Davis is a 59-year-old female presenting to the clinic for the management of persistent high blood pressure. She reports consistently elevated home readings averaging 162/94 mmHg over the past three weeks despite taking lisinopril 10 mg daily. She experiences mild morning headaches and occasional fatigue but denies chest pain, palpitations, orthopnea, or peripheral edema. She adheres to a low-sodium diet and walks 30 minutes five days a week. There are no recent changes in stress, diet, or routine. She is concerned about her cardiovascular health and seeks a medication review.

·         Lisinopril 10 mg daily – for Hypertension

·         Atorvastatin 20 mg nightly – for hyperlipidemia

·         Calcium + Vitamin D – for bone health

Allergies:

No known drug/food allergies

Medication Intolerances:

None reported

Chronic Illnesses/Major traumas

Hypertension

Hyperlipidemia

Hospitalizations/Surgeries

Total abdominal hysterectomy at age 46

She has hypertension and heart disease but no diabetes, HTN, peptic ulcer disease, asthma, lung disease, cancer, TB, thyroid problems, kidney disease, or psychiatric diagnosis.

Their father had hypertension and died of myocardial infarction at 66; her mother has type 2 diabetes and is still living; her brother has hypertension. There is no family history of TB, cancer, or psychiatric illness.

Retired high school librarian. College educated. Married, lives with a spouse. Denies smoking, recreational drugs, or alcohol use beyond occasional weekend wine. Engages in regular walking and follows a low-sodium diet. Feels safe at home and in the neighborhood.

Fatigue, no fever, chills, or weight change

Denies chest pain, palpitations, PND, orthopnea, or edema

No rashes, lesions, delayed healing, or bruising

Denies cough, wheezing, or dyspnea, pneumonia history, and TB

Wears reading glasses, no vision changes

Denies nausea, vomiting, constipation, or GI bleeding

No hearing loss, pain, or tinnitus

No urinary symptoms. Post-hysterectomy, sexually active, and uses contraception

Denies sore throat, congestion, or dental pain

Denies joint pain, stiffness, or back pain

No lumps, discharge, or changes

Denies dizziness, weakness, or numbness

No swollen glands, polyuria, or heat/cold intolerance

No depression, anxiety, or sleep issues and no suicidal ideation or attempts

Healthy, alert female in no acute distress. Oriented, cooperative.

Warm, dry, intact. No lesions or abnormalities.

Normocephalic, atraumatic. PERRLA. No scleral injection. The oral mucosa is moist. No pharyngeal erythema. Tympanic membrane intact.

S1, S2 regular. No murmurs, gallops, or edema. Pulses 3+ bilaterally.

Clear to auscultation bilaterally. No adventitious sounds.

Soft, non-tender. No hepatosplenomegaly. Normal bowel sounds.

No tenderness, discharge, or masses.

Bladder non-distended. No CVA tenderness. Well, estrogenized mucosa. No lesions or discharge.

Full ROM in all extremities. No joint deformities.

Gait is stable, speech is clear, and there are no focal deficits.

Calm, appropriate affect. Insight and judgment intact.

Pending:

Complete Metabolic Panel (CMP)

Lipid Panel

ECG

Urinalysis

Ambulatory BP monitoring if poor control continues

o    1- Hypertensive Heart Disease without Heart Failure (ICD-10: I11.9): This is quite likely due to her history of prolonged Hypertension, lack of signs of heart failure, and known end-organ risk. While she does not show acute cardiac symptoms, her blood pressures indicate that her cardiovascular system is under stress (Tackling & Borhade, 2023). This condition in her age and other comorbid risk factors should be managed to prevent the further development of structural heart disease and maintain long-term cardiac function.

o    2- Primary (Essential) Hypertension (ICD-10: I10): This is the case for individuals with no identifiable secondary causes of Hypertension, which brings us to the basic form of essential Hypertension. It remains the cause of hypertensive heart disease predisposing factor. A family history of cardiovascular disease and her age group also predispose her to this type of diagnosis (Iqbal & Jamal, 2023). However, the development of end-organ strain elevates hypertensive heart disease as the more precise clinical label at this stage of her chronic condition.

o    3- Secondary Hypertension (ICD-10: I15.9): Secondary Hypertension should always be considered in resistant cases. Even though rare, it may be caused by renal, endocrine, or drugs. This is because she does not smoke, does not drink alcohol, and does not use non-steroidal anti-inflammatory drugs. However, testing should be done (Hegde et al., 2023). More investigations in the laboratory and imaging, if necessary, will assist in ruling out this possibility since there has been an inadequate response to monotherapy for a long time.

Diagnosis

o    The patient is diagnosed with Hypertensive Heart Disease without Heart Failure (ICD-10: I11.9). This is due to her history of Hypertension, her blood pressure still being high even with compliance to her medication, and the symptoms that come with the same include headaches in the morning and fatigue (Tackling & Borhade, 2023). However, due to the chronicity of the complaints made, she may have early cardiac involvement despite her denial of dyspnea or edema. This diagnosis indicates that there is a therapeutic target to avoid the worsening of heart failure or other cardiovascular events.

§   Further testing

Lab orders also include the comprehensive metabolic panel, the lipid profile, the urinalysis, and the ECG. These tests will help evaluate the degree of renal impairment, electrolyte status, and the amount of stress on the cardiac muscles. The objective is to check for complications of end organs and exclude secondary causes of Hypertension. In regard to this, if the clinical suspicion remains high or blood pressure continues to be uncontrolled after dose modification, ambulatory blood pressure monitoring may be warranted during follow-up.

§   Medication

Patient antihypertensive management will be altered by stepping up the lisinopril dose from 10 mg to 20 mg once a day. The patient will continue to be managed for cardiovascular risk by taking Atorvastatin 20 mg at bedtime. The patient was advised to report to the hospital in case of any adverse effects of the treatment, including dizziness, persistent cough, or angioedema. These stepwise medication modifications are in order to assure blood pressure control and to prevent possible long-term cardiovascular consequences.

§   Education

The patient was counseled on hypertensive heart disease and its association with prolonged Hypertension. The need to take the medications as prescribed, regular check-ups, and changes in the diet was highlighted. She was, therefore, advised to take a low-sodium diet like the DASH diet, check her blood pressure twice daily, and record it (Challa et al., 2023). Some features, such as swelling of the face, chest pain, or dizziness, were explained in detail as warning signs.

§   Non-medication treatments

She was advised to undergo at least 30 minutes of vigorous workouts at least five days a week. The aim of weight loss, which included weight loss of 10-15 pounds to improve cardiovascular health, was suggested. Other bearings of stress management, such as breathing exercises and mindfulness, were also explained (Verma et al., 2021). Such non-pharmacological strategies help to decrease the variability of blood pressure and enhance the cardiovascular prognosis in addition to drug modification.

The patient was keen and compliant and showed an understanding of their health status. She accepted the changes to the medication, and other recommendations on lifestyle changes were made to her. Her responses demonstrated a good attitude regarding the management of her blood pressure. She requested some pertinent queries that were relevant and showed concern about aspects such as Hypertension if not well controlled. The patient was advised to have a recheck appointment within two weeks for review and management of the findings.