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 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 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 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 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: 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 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.