SOAP Model HTN Case

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Clinical Pharmacy Department
Pharmacy Practice Lab-3
PHCL 413
This is a sample of a Model SOAP Note for the case in Chapter 13 of Pharmacotherapy
Casebook: A Patient-Focused Approach, 8th edition
Uncontrolled Hypertension
Subjective
‘’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 and some dizziness in the morning. My other doctor
prescribed a low - salt diet for me, but I don't like it!’’. JF is a 64 years old African American with
a history of HTN x 14 years, Type 2 DM, Stage 2 (moderate) COPD, BPH, Stage 3 CKD and recent
recovery from cold. His father & mother had HTN. He is nonadherent to his low-sodium diet
(states, "I eat whatever I want "), he does not exercise regularly mainly because of the limited
functionally caused by his COPD. He is currently on: Triamterene/ hydrochlorot hiazide 37.5 mg
/ 25 mg po Q AM, Doxazosin 2 mg po Q AM, Carvedilol 12.5 mg po BID. Mucinex D two tablet s
Q 12 h PRN for cough/ congestion, Naproxen 220 mg po Q8h PRN for pain/HA
Objective
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BP 162/90 mm Hg (sitting; repeat 164/92 mm Hg) , HR 76 bpm ( regular) , Wt 95 kg, Ht
6'2, BMI 26.8 Overweight
AV nicking noted on eye examination
Na 138 mEq/L↔, Ca 9.7 mg/dL↔, K 4.7 m Eq/L↔, Mg 2.3 mEq/L↔, Cl 99 mEq/ L↔,
Total Chol 171 mg/ dL↔, LDL 99 mg/ dL↔, HDL 40 mg/ dL↓, TG 158 mg/ dL↑, BUN
22 mg/dL↔, SCr 2.2 mg/ dL ↑, Clcr 45.6 ml/min↓ , Glucose 110 mg/dL↔, Uric acid
6.7 mg/dL ↔
(+ ) protein on UA
Echo: Mild LVH
Assessment
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JF’s BP is not at goal, because he is diabetic and has multiple risk factors that put him at
high risk of CHD (HTN, estimated glomerular filtration rate <60 mL/min, proteinuria,
DM, age (male >55 years), physical inactivity), his goal should be <130/80 mmHg.
Despite triple antihypertensive therapy, BP is not optimal because of many factors
including: the use of MucinexD® (contains pseudoephedrine), naproxen (NSAID) and
noncompliance with low sodium diet.
Based on the above, JF blood pressure medication need to be further optimized to
include medications with strong evidence to reduce the likelihood of CHD morbidity and
mortality. ACEIs (e.g. lisinopril) or ARB are the drug of choice in patients with diabetes
with nephropathy. A long acting DHP CCB is also an option either as an added therapy
for further control of JF’s BP (he is African American) or if he is not tolerating ACEI/ARB.
Clinical Pharmacy Department
Pharmacy Practice Lab-3
PHCL 413
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Continue hydrochlorot hiazide which is considered an appropriate first-line
antihypertensive according to JNC 7 guideline, in addition it will help enhance the effect
of ACEI in African American.
The use of beta blocker for HTN in the absence of compelling indication (e.g. CAD, AF)
may not be optimal. In addition, a non-selective BB is not the best selection for a patient
with COPD.
JF has BPH and is on doxazosin, an alpha blocker that seems to control his BPH
symptoms as well as it has a blood pressure lowering effect. However because of the
dizziness and headache side effects (most probably because of doxazosin), the dose can
be taken at night to minimize such complaints. If after such change JF still continues to
have those symptoms an alternative for doxazosin maybe considered (e.g. Finasteride).
Plan
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Emphasize the importance of low-Na diet. Assist JF in recognizing healthy diet options
and consider referring him to a dietitian.
Encourage physical activity compatible with his COPD. Consider gradual and steady
aerobic exercise 3-4x/week. May refer to pulmonary rehab program if JF faced difficulty.
Discontinue the guaifenesin/pseudoephedrine preparation (especially if no longer
needed for cold symptoms) or switch the product to a preparation that contains only
guaifenesin.
Discontinue naproxen because of its ability to worsen BP control. Recommend an
alternative (e.g. acetaminophen) for management of headache and gout pain.
Discontinue Carvedilol gradually.
Add lisinopril 5-10 mg po once daily and titrate every week and as tolerated (maximum
40 mg/day). Monitor BP, K, renal function, SE: orthostasis, lightheadedness, dry cough,
angioedema
Continue Triamterene/ hydrochlorot hiazide 37.5 mg / 25 mg po Q AM, The dose of
hydrochlorothiazide should not be increased, due to the potential for higher doses to
cause elevations in blood glucose, uric acid, lipids and electrolyte abnormalities.
Monitor K closely to avoid the risk of hyperkalemia with the addition of lisinopril. If this
occur, then d/c triamterene component. Monitor: BP, electrolyte (K, Na), renal function,
SE: hypotension, signs of dehydration.
Continue Doxazosin 2 mg po because it helps with the control of both BPH and BP.
Change the dosing schedule to QHS to reduce possible doxazosin-induced
orthostasis/dizziness. Monitor BP and SE in the next follow up visit.
Educate JF on about hypertension, role of medications and low Na diet, exercise and
keeping clinic appointments.
Clinical Pharmacy Department
Pharmacy Practice Lab-3
PHCL 413
Follow up plan:
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Ask JF to return to clinic in 2-4 weeks to check BP control, titrate lisinopril dose, assess
presence of side effects, compliance with drug therapy and the progress if life style
modification (diet, exercise).
If the patient develops persistent dry cough after using lisinopril, it can be replaced with
ARB (e.g. losartan).
If the patient BP is still uncontrolled after reaching maximum recommended doses of
lisinopril, consider adding a CCB.
Items of Patient Education
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These medicines do not cure high blood pressure. You will probably need to continue
taking these medications on a long-term basis to keep your blood pressure controlled.
Because these drugs lower your blood pressure, you may feel dizzy or lightheaded when
going from lying down or sitting to a standing position. Use caution and rise slowly from
these positions until you know how your body reacts. These effects will diminish with
time.
Thiazide diuretics can make you sensitive to sunlight. Be sure to apply a sunscreen
before any extended exposure to sunlight. Thiazide diuretics may also cause you to lose
potassium. Your physician will monitor your potassium balance carefully. If you
experience cramping in your feet or lower extremities, this may be a sign that your
potassium has dropped. If this occurs, notify your physician.
Lisinopril can sometimes cause a chronic dry cough. If this occurs, please contact your
heath care provider. If you experience any swelling in your face, lips, or tongue, or have
breathing problems, immediately stop taking this medication and go to the emergency
room. If you experience a significant decrease in urinary frequency while taking this
medication, be sure to contact your provider.
Doxazosin treats the symptoms of BPH and may also treat your high blood pressure.
This medicine may make you dizzy or drowsy. Avoid driving, using machines, or doing
anything else that could be dangerous if you are not alert. Because you report
symptoms of dizziness currently after taking this medicine in the morning, begin taking
this medication at night, before you go to bed. If you continue to experience symptoms
of dizziness or lightheadedness, or if you experience fainting, notify your physician.
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