Posted: May 1st, 2025

Pharmacy SOAP note on Hypertension case

SOAP Note Template Guide
Current
Medicatio
ns
S
&
O
Subjective & Objective Evidence
Chief
Complaint(s
)
Assessment
A
List the chief complaint(s) that is presented by the patient
A one-sentence summary of why you are seeing the patient. E.g. “55 y/o female patient presents
to the ER with severe headache”. Include age and gender.
DO NOT COPY AND PASTE! USE YOUR OWN WORDS
S: List pertinent subjective information:
O: List pertinent objective information:
• History of Present Illness (HPI):
• Vital signs
patient’s complaint/symptoms (see
• Physical assessment
attachment for guide to symptom
• Laboratory results
analysis)
• Results of procedures or diagnostic tests
• Past Medical History (PMH), Past
• Immunizations, if applicable to disease
Surgical History
state
• Social History (SH)
Indirect Info:
• Family History (FH)
May choose to include information useful in
• Information in Review of Systems
evaluating and selecting therapy (e.g. wt., IBW,
(ROS)
calculated BMI, CrCl, BSA) although it does not
• Allergies (drug, food, etc.), and type directly support the diagnosis.
of reaction if patient has allergies
• State variables used and equations used
o Or NKDA if applicable
for these
• List pertinent medications that the patient is currently taking
• Do not list medication(s) that will be started (This will be in the Plan.)
Evaluate the Disease State (Prioritize your assessment in the order of urgency/importance,
including condition pertinent to patient’s chief complaint, considering patient-specific risk
factors and etiology):
• Prioritize the list of problems; use the same numbering through Assessment/Plan
• Determine patient’s risk factors for the disease
• Evaluate patient-specific known/potential causes of the disease or exacerbation of the
disease
• Evaluate the disease(s) for the following (if applicable) and provide rationale:
• Type (e.g., Type 1 vs. Type 2 DM or community vs. hospital acquired pneumonia)
• Severity (mild, moderate, or severe)
• Acuity (acute vs. chronic)
• Status (stable, unstable, or progressive)
• Stage (e.g., Stage I-IV Cancer)
• Classification (e.g., NYHA Class I-IV, or Child-Pugh Classification)
• Risk score (e.g., TIMI Risk Score, APACHE II Score, or Glasgow Coma Score)
• Grade (e.g., ulcer grade 1-4)
• Therapeutic target (e.g., target BP or A1C)
Were the sign/symptoms drug-induced, related to a disease process, or a combination of both?
• To determine if drug-induced, ask yourself:
• What types of drugs can cause these signs/symptoms?
•
•
•
Is the time frame consistent with a drug-induced cause?
Are the signs/symptoms caused by a high dose of a drug or drug interaction?
Are the signs/symptoms related to an ADR?
Evaluate the appropriateness of current medications
Are the current medication(s) appropriate in terms of the following?
• Indication and contraindications
• Drug class
• Drug
• Dose
• Route
• Frequency
• Duration
• When making your decision, consider:
• Patient-specific factors
• Evidence Based Medicine (EBM): clinical practice guidelines and primary
literature
• Efficacy/response
• Toxicity/ADR
• Convenience/adherence issues
• Drug interactions
• Pharmacokinetic parameters
• Cost
Examples of stating drug-therapy problems
1. Safety-dosage too high: Patient is experiencing signs and symptoms of digoxin toxicity
(“funny” heartbeat, weakness, nausea, vomiting, anorexia, bradycardia (HR 54),
hyperkalemia (K+ 5.5), occasional PVCs and first-degree heart block [PR 0.22] on EKG,
and has an elevated serum digoxin level of 2.8), and needs modification in digoxin
therapy.
2. Indication- need additional drug therapy: Patient is at risk of death and recurrent MI
secondary to not receiving aspirin for secondary prevention post‐MI.
Evaluate the Need for Treatment:
• Does the patient need additional treatment based on urgency of disease state(s)?
• If yes:
• What is the appropriate level of aggressiveness?
• Are self-care products appropriate?
• Does the patient need a referral?
• What are the applicable pharmacological and non-pharmacological (e.g., surgery)
treatment options?
• What are the indications and contraindications?
• For pharmacological treatment options
• What are the pharmacological treatments in terms of drug class?
• What are the pros and cons for each drug class?
•
•
•
If no:
•
What are the pros and cons for medications within each drug
class?
When comparing pros and cons, consider:
• Patient-specific factors
• Apply principles of evidence‐based medicine (e.g. current
clinical practice guidelines, standards of care, and/or
primary literature) in comparing efficacy/response and
toxicity/ADR
• Convenience/adherence issues
• Drug interactions
• Pharmacokinetic parameters
• Cost
Discuss consequences of no treatment versus treatment
Continue using the problem list created above in the Assessment Section, prioritized during
your initial assessment
•
Rationale for recommendation should be included in the assessment section.
•
Provide recommendations to current therapy as well as new pharmacological and nonpharmacological for each problem stated in the Assessment Section
o Prioritize recommendations, considering urgency/importance
o Consider patient-specific factors (labs, co-morbid conditions, other medications,
etc.)
o Provide recommendations on further tests needed to assess problem or establish
a baseline before treatment is started
• For pharmacologic recommendations
• Include name of drug, dose, frequency, route, and duration
• Do not use unapproved abbreviations, acronyms, short-hand language, or trailing
zeros (The Joint Commission guidelines)
• Be patient-specific
• Do not write 6 mg/kg
• Calculate the specific dose
• Be practical
• Consider available dosage forms
• Round to the nearest reasonable dose if necessary
Recommendations
P
•
Provide recommendations on the management of drug interaction(s)
•
•
Examples
•
Separate ciprofloxacin and ferrous sulfate by 4 hours
•
Hold tube feeding 1 hour before phenytoin
Recommend relevant pharmacologic and/or non-pharmacologic preventive treatments
•
Examples
• Start ASA 81 mg orally daily as primary prevention
• Give pneumococcal vaccine IM X 1 dose now
Patient Education
Monitoring &
Follow-up
Goals
•
•
Identify long-term and short-term goals for each recommendation
What are the goal therapeutic outcomes?
• Is the goal to cure the disease?
• Is the goal to slow the disease progression?
• Is the goal to reduce or eliminate signs and/or symptoms?
• Is the goal to prevent reoccurrence signs and/or symptoms?
• Is the goal to normalize physiological parameters (e.g., decrease blood pressure or heart
rate)?
Proper follow-up should be stated (what, when, how often, who) for both efficacy and toxicity
Efficacy
• Include monitoring and follow up (by whom) and what to do if condition changes or
symptoms worsen with each recommendation.
• List specific monitoring parameters to assess efficacy
• May need to establish baseline prior to starting therapy
• Parameters may be based on subjective (e.g., improvement in severity of pain) and/or
objective information
• Include specific frequency
• Provide time frame that changes are expected to occur
• Determine endpoint which will indicate that the therapy is effective/complete/ineffective and
alternative therapy may be warranted
• If applicable, determine if patient needs to follow-up with a provider (or specialist) and when
Toxicity
• Monitoring parameters that will indicate whether the patient is experiencing ADR for each
recommended drug
• May be based on subjective and/or objective information
• Include specific monitoring frequency
• Provide time frame when expected changes to occur
• Recommend actions to manage the ADRs
• Example
• Discontinue simvastatin if LFTs increase by >3X baseline
Relevant drug interactions with other drugs, food, labs for each recommended drug
Provide relevant education on the following areas:
• Disease state(s)
• Pharmacologic and non-pharmacologic treatments
• Pharmacologic and non-pharmacologic preventive measures
• Self-monitoring of the disease
• USE PATIENT FRIENDLY LANGUAGE
Necessary patient education may include the following:
• General disease state information
• Preventive measures (diet/exercise counseling)
• Self‐monitoring of the disease
• Medication information (SE, storage, missed dose, etc.)
• Drug-drug, drug-food, and drug-lab interactions relevant to plan
• Goals of therapy
•
Follow-up date and what to do if condition changes or symptoms worsen
General Expectations: The above SOAP Note is a general guide and provides suggestions that may be
considered when completing your SOAP Note. Some suggestions may not necessarily apply to a given
patient case. When completing your own SOAP Note, consider patient-specific factors and relevant
information. Simply copying and pasting information will not help develop your clinical and critical
thinking skills. Do not use unapproved abbreviations or short-hand language (The Joint Commission
guidelines). Further, writing exhaustive summaries on broad topics such as disease states without
taking into consideration patient-specific factors will not be conducive since every patient is different.
Accordingly, clinical decisions must always be tailored and individualized to meet the needs of each
unique patient.
The next provider should be able understand the problem(s) based on the information provided in the
SOAP note and make clinical decisions accordingly. Since the SOAP note is contained the medical chart,
it is considered a legal document. It may be reviewed in legal cases (e.g., malpractice lawsuits) as well as
other cases where a chart review may be required (e.g., incident reports, medication error).
CS 858 Integrated Pharmacotherapy II: Cardiology
SOAP Note: Hypertension Case
Chief Complaint
“I’m here to see my new doctor for a checkup. I’m just getting over a cold. Overall, I’m feeling fine,
except for occasional headaches. I know that my blood pressure runs high. My other doctor prescribed a
low-salt diet for me, so I got rid of my salt shaker!”
History of Present Illness:
A 64-year-old black man presents for establishment of care with a new provider and for evaluation and
follow-up of his medical problems. He generally has no complaints, except for occasional mild
headaches. He states that he is aware that his blood pressure is uncontrolled and has attempted to reduce
his salt intake by not adding extra salt to his food.
Past Medical History:
HTN × 14 years
Type 2 diabetes mellitus (DM) × 16 years
BPH
CKD
Family History:
Father died of acute MI at age 73. Mother died of multiple myeloma at age 69. Father had HTN and
dyslipidemia. Mother had HTN and DM.
Social History:
Has never smoked; reports moderate amount of alcohol intake (one to two drinks per day). He watches his
intake of carbohydrates and has attempted to reduce his sodium intake. He does not exercise regularly. He
works at Wal-Mart and has healthcare insurance through his employer. Lives alone.
Home Medications:
Hydrochlorothiazide/triamterene 25 mg/37.5 mg PO Q AM
Insulin glargine 36 units subcutaneously daily
Insulin lispro 12 units subcutaneously TID with meals
Doxazosin 2 mg PO Q HS
Mucinex D® two tablets Q 12 H PRN cough/congestion
Naproxen 220 mg PO Q 8 H PRN HA
Allergy
PCN—rash
Review of Systems:
Patient states that overall he is doing well and recovering from a cold with symptoms of nasal congestion,
sore throat, and cough that have nearly resolved. He has noticed no major weight changes over the past
few years. He complains of occasional headaches, which are usually relieved by naproxen, and he denies
blurred vision and chest pain. He denies shortness of breath, although he admits to being “out of shape.”
He denies experiencing any hemoptysis or epistaxis; he also denies nausea, vomiting, abdominal pain,
cramping, diarrhea, constipation, or blood in stool. He denies urinary frequency but states that he used to
have more difficulty urinating until his physician started him on doxazosin a few months ago. He has no
history of arthritic symptoms and denies joint or musculoskeletal pain.
Physical Examination:
General: WDWN, black man; moderately overweight; in no acute distress
Vitals: BP 162/90 mm Hg (sitting; repeat 164/92 mm Hg), HR 76 bpm (regular), RR 16/min, T 37°C; Wt
95 kg, Ht 6′2″
HEENT: TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages, exudates, or papilledema
Neck: Supple without masses or bruits, no thyroid enlargement or lymphadenopathy
Lungs: Lung fields CTA bilaterally. No wheezes or crackles.
Heart: RRR; normal S1 and S2. No S3 or S4.
Abd: Soft, NTND; no masses, bruits, or organomegaly. Normal BS.
Genit/Rect: Enlarged prostate
Ext: No CCE; no apparent joint swelling or signs of tophi
Neuro: No gross motor-sensory deficits present. A & O × 3.
Labs:
Na
K
Cl
CO2
BUN
SCr
Glucose
Ca
Mg
A1C
Albumin
Hgb
Hct
WBC
Plts
Today
138 mEq/L
4.7 mEq/L
99 mEq/L
27 mEq/L
22 mg/dL
2.2 mg/dL
110 mg/dL
9.7 mg/dL
2.3 mEq/L
6.1%
3.4 g/dL
13 g/dL
40%
9 x 103/mm3
189 x 103/mm3
Fasting lipid panel
Total Cholesterol 161 mg/dL
LDL
79 mg/dL
HDL
53 mg/dL
TG
144 mg/dL
Reference
135-146 mEq/L
3.5-5.0 mEq/L
95-106 mEq/L
23–29 mEq/L
7-20 mg/dL
0.6-1.3 mg/dL
65-99 mg/dL
8.5-10.5 mg/dL
1.3-2.1 mEq/L
≤6.5%
3.5-5 g/dL
13-18 g/dL
38-50%
4-11 x 103 cells/mm3
150-450 x 103
cells/mm3
50 mg/dL
< 100 mg/dL
90%)
• Secondary hypertension
◦ < 10% of HTN patients
◦ Disease states
▪ Chronic kidney disease
▪ Obstructive sleep apnea
◦ Medications
Drugs That can Increase Blood Pressure
Medications
Others
•
•
•
•
•
•
• Alcohol (excessive)*
• Cocaine & cocaine
withdrawal
• Methamphetamine
• Nicotine*
• Caffeine*
• Herbal (licorice,
ephedra/ma huang, St.
John's wort)*
Amphetamines (eg, amphetamine, methylphenidate, etc.)
Antidepressants (bupropion, desvenlafaxine, and venlafaxine)
Immunosuppressants (cyclosporine and tacrolimus)
Systemic corticosteroids
Decongestants (eg, phenylephrine, pseudoephedrine)*
Erythropoiesis-stimulating agents (darbepoetin &
erythropoietin)
• Oral contraceptives (estrogen containing- ethinyl estradiol)
• NSAIDS*
*Life-style modification
*OTC (Patient education) for patient’s with HTN
Pathophysiology
• Blood pressure = CO x PVR
• Cardiac output (CO) – major determinant of systolic blood pressure (SBP)
◦ CO = Heart rate (HR) X stroke volume (SV)
• Peripheral vascular resistance (PVR) – major determinant of diastolic blood
pressure (DBP)
• ↑ Cardiac output (CO) + ↑ Peripheral vascular resistance (PVR) = ↑ Blood
Pressure
• Drugs for hypertension work by decreasing CO, PVR, or both
Pathophysiology
• Factors influence/regulate blood pressure:
◦ Adrenergic nervous system (norepinephrine)
◦ Renin-angiotensin-aldosterone system (RAAS): regulates systemic and renal blood
flow
◦ Fluid/electrolyte balance: renal functions and renal blood flow
◦ Hormonal factors (vasopressin, thyroid hormone)
◦ Vascular endothelium (nitric oxide, bradykinin, prostacyclin, endothelin)
Renin-angiotensin-aldosterone system
(RAAS)
Effects of Angiotensin II
1) Binds to angiotensin II receptors on blood vessels
leading to smooth muscle contraction, resulting in
vasoconstriction
• ↑ PVR → ↑ BP
2) Stimulates aldosterone release (from adrenal cortex)
• ↑ sodium and water reabsorption in the distal tubule of
the nephron, as well as ↑ potassium (K) excretion in the
urine
3) Stimulates sodium and water reabsorption in the
proximal tubule of the nephron
• ↑ blood volume (BV), stroke volume (SV), cardiac output
(CO), and blood pressure (BP)
Katzung , Figure 21-2
Effects of Angiotensin II
4) Stimulates antidiuretic hormone (ADH)/vasopressin
release
• ↑ water reabsorption in the collecting duct of the
nephron, and it also binds to vasopressin receptors on
blood vessels causing smooth muscle contraction and
vasoconstriction
5)
Increase Sympathetic Outflow (epinephrine and
norepinephrine)
• Stimulate α-receptors (α1) on arterioles and venules →
vasoconstriction
• Stimulate β1-receptors in the heart → ↑ heart rate &
force of contraction
• Stimulate β2-receptors in the lungs → vasodilation in
arteries and veins
Katzung , Figure 21-2
Risk Factors for Hypertension
• Family history
• Obesity/overweight*
• Race (increased in African Americans) • lifestyle habits:*
• Sex (increased risk in males)
• Age (≥55 years for men, ≥65 years for
women)
• Chronic kidney disease (CKD)
• Obstructive sleep apnea
• Diabetes*
• Dyslipidemia*
* Modifiable risk factors
◦ High sodium (salt) intake
◦ Cigarette smoking/secondhand smoking
◦ Alcohol abuse
◦ Physical inactivity
• Low socioeconomic/educational
status
Presentation and
Diagnosis
Clinical Presentation
• Usually asymptomatic- “silent killer”
• Symptoms often due to complications of the disease: cardiovascular,
cerebrovascular, and renal
• Elevated blood pressure is often the only sign
• Other signs may develop due to complications of the disease:
◦ Heart disease – angina, Myocardial Infarction (MI), heart failure
◦ Cerebrovascular disease – stroke, Transient ischemic attack (TIA)
◦ Kidney disease-CKD
◦ Retinopathy
◦ Peripheral arterial disease
Classification of Hypertension
• Should be based on the average of 2 or more BP readings on at least 2 separate occasions
• Individuals with SBP and DBP in 2 categories should be designated to the higher BP category
Classification
Systolic BP (mmHg)
and/or
Diastolic BP (mmHg)
Normal