SOAP Note II: Hypertension in an African American Male

SOAP Note II: Hypertension in an African American Male

Initials of patient: B.M.

Patient age: 51 years-old

Patient ethnicity: African American

Initials of provider:

Clinical setting: Primary Care Facility

Practice status: Established

CC: The patient is on a follow up visit for blood pressure management.

History of Present Illness:

PHI

The patient is a 51 year-old African American male coming to the facility for a follow up visit for his blood pressure management. He had been seen for an unrelated problem two weeks ago after which he had been put on exercise (aerobic and resistive) as well as dietary measures. The blood pressure had been found to be a high of 150/95 mmHg. This follow up visit had therefore been planned to reassess him after the two weeks of lifestyle modification in terms of exercise and diet. During this visit, he reports that he has been exercising by walking every evening for 30 minutes three times a week and also going to the gym another three times a week. He says that he does this alternately and rests on Sundays. On diet, he has abided by the instructions from the dietician and is restricting the intake of fatty foods and salt as he increases his dietary intake of fresh fruits and vegetables. He reports syncope once the previous week after getting up from sleep abruptly but denies the presence of any associated symptoms. He states that the light-headedness is transient and aggravated by walking. However, it is relieved by sitting down or lying down supine. He denies suffering any trauma or injury during the fainting. He also denies any shortness of breath, chest pain, edema, or headache presently.

PMH: Type II diabetes mellitus.

PFH: The mother died at 75 years of age from myocardial infarction. She was obese and hypertensive. The father is still alive in long-term care and has hypertension and type II diabetes mellitus. He has three siblings 38, 45 and 48 years respectively with two of them already in pre-hypertensive states. His two children – a son (30 years old) and a daughter (27 years old) – are alive and with no known medical problems.

PSH: He denies ever having any surgeries.

Hospitalizations: He denies ever being hospitalized.

Medications:

1. Metformin 500 mg orally BD.
2. Sitagliptin (Januvia) 100 mg orally OD.

Allergies: He has no known allergies to drugs, food, and environmental irritants.

Dietary Hx: He admits to having been carefree with diet consuming a lot of red meat, processed and junk foods, and infrequently alcohol. However, beginning the diagnosis of the hypertension two weeks ago, he has started restricting salt intake and that of fatty foods. He has alternatively increased his consumption of fresh fruits and vegetables.

Functional status: He is married lives with his wife of 30 years. Both of his two children are independent and have left home.

Immunizations: Patient BM’s immunization status is up to date. He recently got two doses of a COVID-19 vaccine as well as a booster shot.

Family Hx: He stays with his wife in a residential apartment on the outskirts of town.

Cultural background: African American

Cultural assessment: When asked about his condition patient BM is ware that he has a familial risk factor for developing hypertension. Culturally and ethnically, he is also aware that the African American community (or Blacks to be specific) are at a higher risk of high blood pressure than Whites or Hispanics (Wajngarten & Silva, 2019).

Spiritual history/ Religious/ Affiliations and Practices: He is deeply religious and states that he believes in the healing power of God even as he seeks conventional medical interventions. He is an Evangelical Christian and goes to church every Sunday.

ADL/Hobbies/Interests: Spreading the gospel in the community, counseling young people, and reading the Bible.

Type of family: Nuclear family. He lives with his wife.

Marital status: Married

Parental status: He has two children – a son who is 30 years old and a daughter who is 27 years old.

Work Hx: He has been a social worker all his adult life and continues to work as the same.

Sexual Hx/Orientation: He is male and identifies as heterosexual in a monogamous relationship.

Psychiatric history: He denies smoking or the use of illicit substances. He however admits to taking alcohol only occasionally because he is slowly stopping the habit after getting saved in Church. He avers that he had been advised that he cannot just stop abruptly as he was previously a very heavy drinker. He denies ever getting a diagnosis of depression, insomnia, anxiety, or even having suicidal/ homicidal thoughts.

Review of systems (ROS)

Subjective Data

Constitutional: He denies having chills, weight loss, fatigue, or fever.

Head: Negative for pain, trauma, or headache. He reports light-headedness and fainting on one occasion in the last two weeks. This is transient and does not have any associated aggravating or relieving factors.

Eye: Negative for diplopia, photophobia, tearing, or any other changes in vision.

Ears: Negative for otorrhea, ear pain, or tinnitus.

Nose: Negative for rhinorrhea, epistaxis, or loss of smell.

Mouth/Throat: Denies any redness of the gums or swelling. He is also negative for dysphagia or sore throat.

Respiratory: He denies shortness of breath, wheezing, or coughing.

Cardiovascular: He is negative for chest tightness, chest pains, palpitations, or pedal edema. He reports transient loss of consciousness and syncope once in the last two weeks.

GI: He denies nausea, vomiting, or diarrhea. He is negative for melena or fresh blood in stool. There are no changes in his appetite or bowel movements.

GU: He is negative for difficult urination, hesitancy, hematuria, frequency of micturition, or urethral discharge. There are no lesions reported in the genitourinary region.

Musculoskeletal: He denies joint pains and myalgia. He has no stiffness of the joints o back pain.

Integumentary: He is negative for bruising, rash, urticaria, loss of hair, or itching.

Neuro: He denies having paraesthesia, lack of co-ordination, or a tingling sensation. He is however positive for syncope once in the past two weeks.

Psychiatric: He is negative for depression, anxiety, suicidal ideation, addictions, or changes in sleep patterns.

Endocrine: He is negative for heat and cold intolerance, excessive thirst, excessive drinking of water, excessive diaphoresis, excessive urination, or weight gain/ loss. He also denies any history of hormonal therapy/ replacement.

Hematologic/Lymphatic: He denies vomiting blood, passing blood in urine, or coughing up blood. He is negative for clotting and bleeding disorders as well as any past history of blood transfusion.

Allergic/Immunologic: He denies eczema, hives, or atopic dermatitis. He also denies having any allergies or a past history of immunotherapy.

Objective Data

Vitals Signs: BP: 145/90 mm/Hg, right arm, sitting; HR: 77 beats/minute; RR: 16 respirations/minute; oral temperature: 98.1° F; SpO₂ 98%, resting, at room air; pain 0/10 (0-10 scale). BP LLE: 150/953 mmHg, lying supine; BP RLE: 155/100 mmHg, lying supine.

Height: 5’5”, Weight: 180 lbs, BMI: 29.9 kg/m² (overweight).

Physical Exam

Constitutional: The patient appears healthy and in a state of good nutrition. He is well-groomed, alert, and oriented in all aspects. His speech is coherent and goal-directed.

Head/Face: Head is normocephalic with absent signs of trauma. All features appear symmetrical.

Eyes: PERRLA, sclerae not yellow in color, absent erythema and non-watery conjunctiva. Normal fundoscopy findings with absent nystagmus.

ENMT: Normal light reflex of the tympanic membranes that are intact and non-ruptured. Nasal septum is midline and the turbinates re symmetrical.

Neck: Complete range of motion with no nuchal rigidity. Absent cervical lymphadenopathy or pain. The trachea in the front is placed midline.

Cardiovascular: Heart sounds S1 and S2 audible with no murmurs, bruits, or gallops noted. There are no peripheral pulses or edema. There is no cyanosis or finger clubbing noted. Good capillary refill in less than three seconds.

Respiratory: His breathing is not distressed. Clear lung fields bilaterally on auscultation. No crepitations, wheezes, rales, or rhonchi.

GI: There are audible bowel sounds. No abdominal distension noted and no organomegally. There is no abdominal tenderness, guarding, or distension.

GU: No urethral discharge noted; no tenderness, and no lesions.

Musculoskeletal: No structural postural deformity such as lordosis or kyphosis noted. Full range of motion in joints with no stiffness noted. There is no tenderness and no lesions.

Integumentary: The skin is warm to the touch, dry (not clammy), and evenly pigmented corresponding to race and ethnicity. No lesions or open wounds noted. Normal skin turgor and elasticity with moist mucous membranes. There is no clubbing or cyanosis and no tattoos or scars noted.

Psychiatric: No hallucinations or delusions apparent from his speech. His mood and affect are congruent. Judgment and insight are unaffected with no homicidal or suicidal ideation.

Neuro: No notable motor deficits, normal reflexes, and negative Romberg test. Cranial nerves intact and muscle tone unaffected. No speech or language deficits noted.

Hematologic/Lymphatic: There is no lymphadenopathy or signs of bleeding or bruising.

ASSESSMENT

Main diagnosis/Problem: Stage 2 secondary hypertension

Additional Health problem/Dx: Type II diabetes mellitus, overweight.

Differential Diagnoses for top diagnosis: Hyperthyroidism or primary hypertension (Hammer & McPhee, 2018; Jameson et al., 2018; Singh et al., 2017).

Risk Factors: Ethnicity (he is Black), a family history of hypertension (both mother and father with hypertension), gender (being male predisposes more to hypertension), borderline obesity (he has a BMI of 29.9 kg/m²; meaning that he is on the highest side of overweight), dietary indiscretions (he used to take a lot of salt in foods and eat junk processed foods with little or no fresh fruits and vegetables), and lack of exercise (Singh et al., 2017).

PLAN

Laboratory Tests or Diagnostic Data Needed: Complete blood count (CBC), complete metabolic profile (CMP), HbA1c, CRP, ECG, echocardiogram, renal profile, thyroid function tests (TFTs), liver function tests (LFTs), renal ultrasonography, and a plain chest X-ray (Hammer & McPhee, 2018; Jameson et al., 2018; Singh et al., 2017).

Pharmacological management: Losartan 100 mg orally OD and hydrochlorothiazide (HCTZ) 25 mg orally OD (Katzung, 2018; Rosenthal & Burchum, 2018).

Non-pharmacologic management: Isotonic aerobic exercise and resistive exercises consistently every week with each session lasting for at least 30 minutes (Kaplan, 2016; MacDonald & Pescatello, 2018). The other one is dietary increase in fresh fruits and vegetables and cessation of consumption of fatty and processed foods or sugary sweetened beverages (Xu et al., 2017). Salt intake should also be restricted and health education should generally be given concerning the promotion of dietary approaches to stop hypertension or DASH.

Some Cultural Remedies of Hypertension

            Being African American, there is a cultural attachment to traditional Black medicine that could be used to treat hypertension. Most of these are herbal-based and originate from Africa. Indigenous tree barks are boiled and drank severally during the day and these contain some active ingredients that have been found to be effective in controlling hypertension. According to Tabassum and Ahmad (2011), some of these herbs are recognizable in terms of their scientific names. They include Allium sativum, Annona muricata, Agathosma betulina, Aristolochia manshuriensis, Avena sativa, Apium graveolens, Artocarpus altilis, Camellia sinensis, and Desmodium styracifolium amongst others.

            Apart from natural herbal medicine, the other cultural modalities African Americans have used for centuries to treat hypertension are home remedies. These include food and non-food remedies. According to Quandt et al. (2015), the food remedies include baking soda, lemon, salt, honey, and vinegar amongst others. The non-food remedies on the other hand include oils, Epsom salts, and alcohol amongst others.

Black magic involving the power of spirits has also been mentioned as effective in dispelling generational curses that may be responsible for the development of resistant hypertension in a Black person. It may involve rituals such as making marks on the body and taking various concoctions. Black people have been known to be particularly susceptible genetically to the development of hypertension.

Anticipatory Guidance: Even as patient B is treated this time round, he will be informed that there will be follow up tests that will be done to determine conclusively the etiology of his hypertension. At the same time, he may also be referred to other specialists in other disciplines if it is deemed appropriate. For instance, if the renal profile suggests that he may be developing renal failure, he will be referred to a nephrologist for renal care. Also, in the event that the ECG and echocardiogram show that there are changes that have occurred in the coronary arteries due to the hypertension; referral will be made to a cardiologist. The patient will be strongly encouraged to continue with the lifestyle measures and never to stop. These are the first line of management according to clinical practice guidelines (ACC, 2017).

Health Education: Patient BM will be given proper and comprehensive health education and health promotion concerning the management of hypertension. This is a chronic condition that has to be managed long-term. First and foremost, he will be educated on the importance of adhering to the lifestyle interventions of exercise and diet. These are the recommended non-pharmacotherapeutic modalities that are evidence-based and produce results cost-effectively. But as he continues with the lifestyle measures, he will also have to keep attending the clinic appointments so that his progress can be professionally monitored and any deviations from normal addressed.

Equally, patient BM will be advised to comply with the hypertension medications prescribed and to never alter the dose or the time of taking the drug, or even the frequency without the consent and direction of the clinician. He will be taught about the side effects of the medications that he will have to look out for and report immediately to the healthcare team if he notices the same. He will also be taught how to use a blood pressure machine at home and then he will have to monitor his own blood pressure while at home. This way, he will be able to call 911 whenever there is an astronomical rise in the blood pressure that puts his life at risk.

Referrals/Consultations: In the case of a patient such as BM, the management of his condition would be best handled by a multidisciplinary team instead of one person or specialty. In this case, he will be referred to a dietician and physical therapist who will give out specific regimens of diet and exercise tailored to the patient’s condition and age. Depending on the results of the tests on the heart and the kidneys, the presence of abnormalities in these organs will necessitate referral to a cardiologist or a nephrologist or both.

Follow-up appointment: This will be in four weeks time with his primary care physician so that he may assess and evaluate his progress on the lifestyle measures and the medications prescribed.

Final Level of Decision Making

 Moderate Complexity: The diagnosis of hypertension means that the patient has a chronic condition that requires long-term strategies for management. After taking subjective and objective history to place the condition in perspective, laboratory tests and imaging studies were done to determine the etiology of the hypertension. This was also to rule out other underlying conditions that may be the cause of the hypertension. The history revealed that there has been a previous occasion of elevated blood pressure. Moreover, a number of risk factors apply to the patient as determined from the subjective and objective information obtained. The patient is male, African American, has a family history of hypertension, leads a pretty much sedentary lifestyle, and shows dietary indiscretions when it comes to what he consumes.

A significant observation from the history is that he had suffered syncope once in the previous two weeks when he attempted to get up quickly. This points to orthostatic hypertension. However, the fact that it only happened once makes this prospect unlikely. At this juncture, o other specific findings were made with regard to possible secondary causes of the hypertension. However, the finding of borderline obesity (overweight) is significant. When all the tests come out, the picture of secondary causation is expected to be clearer. When the vital signs were taken after the patient arrived, the BP was still elevated. Focal neurological signs were however absent on physical examination. Prescription of the medications losartan and HCTZ followed current clinical practice guidelines and pharmacotherapeutic principles.

Billing Level: 99214 (level 4 office visit: evaluation and management of established patient). Comprehensive HPI, ROS and physical examination were performed to address patient’s medical problem.

Patient Status: Established

Level of history: Comprehensive (HPI extended; involved 4 or more elements, complete ROS, complete PFSH, 20 3 history areas).

Level of physical (exam): Comprehensive and involving eight or more systems.

Level of Medical Decision Making: Moderate. Indications are that this is the onset of hypertension that is a chronic illness but that does not pose an immediate danger to the patient’s life.

Analysis

Subjective data supporting main diagnosis: The diagnosis arrived at is stage 2 secondary hypertension. The patient stated that he has type II diabetes and this condition is also known to predispose to hypertension with which it usually co-exists. He had been found with a high blood pressure two weeks prior to the current follow up visit. Once within that time, he has suffered syncope as he tried to stand up abruptly from the bed. This light-headedness was however transient and he has not experienced it again, probably because he figured out that if he got out of bed slowly nothing would happen. This patient has a significant family history of hypertension too. This is significant when one considers the genetic predisposition of the disease especially in a Black person.

Objective Data Supporting Main Diagnosis: Patient BM is African American and male. These are very specific risk factors to the development of hypertension. Additionally, the calculation of his BMI revealed that he actually had borderline obesity. Being overweight or obese is another of the risk factors to the development of hypertension. Taking his BP readings when supine and sitting, it was also found that all those showed high blood pressure. This means that the high blood pressure is not postural but due to a real pathological process.

Assessment Analysis of Main Diagnosis: The diagnosis of this condition inpatient BM has been reached after careful consideration of the information from the subjective and objective assessments. These were interpreted in light of the laboratory and imaging findings. The patient clearly had a number of predisposing factors some of which are modifiable while others are not. According to the guidelines by the American College of Cardiologists (ACC, 2017), there should be at least two office readings of elevated blood pressure for the diagnosis of hypertension to be made. This was the case with patient BM. With the coming out of the remaining laboratory results, the diagnosis may be updated or left as it is.

Plan Analysis for Main Diagnosis Discussion: Treatment decisions are taken if the clinical diagnosis has been established or it is highly suspected based on clinical findings. The American Heart Association and the American College of Cardiology suggest that pharmacologic therapy be started in African American adults with hypertension who do not have heart failure or chronic kidney disease (Chrysant & Chrysant, 2019). Because a thiazide-type diuretic or CCB should be included in the initial treatment, the writer begins with HCTZ 25 mg orally, twice day (ACC, 2017). In addition, in African American adults with hypertension, the JNC-8 guidelines advocate utilizing thiazide diuretics such HCTZ as the first line of treatment (Crysant & Chrysant, 2019). The non-pharmacological management plan includes promoting lifestyle changes such as stress management, weight control, and salt consumption limitation (ACC, 2017).

 

References

American College of Cardiology [ACC] (2017). New ACC/AHA high blood pressure guidelines lower definition of hypertension. https://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017

Chrysant, S.G., & Chrysant, G.S. (2019). Unintended consequences of the new ACC/AHA blood pressure treatment guidelines. Drugs Today, 55(4), 277–285. https://doi.org/10.1358/dot.2019.55.4.2954407

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds) (2018). Harrison’s principles of internal medicine, 20^th ed. McGraw-Hill Education.

Kaplan, N.M. (2016). Hypertension highlights: The many benefits of exercise. Journal of the American Society of Hypertension, 10(4), 280-281. https://doi.org/10.1016/j.jash.2016.01.016

Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14^th ed. McGraw-Hill Education.

MacDonald, H.V. & Pescatello, L.S. (2018). Exercise prescription for hypertension: New advances for optimizing blood pressure benefits. Lifestyle in Heart Health and Disease, 115-136. https://doi.org/10.1016/B978-0-12-811279-3.00009-4

Quandt, S. A., Sandberg, J. C., Grzywacz, J. G., Altizer, K. P., & Arcury, T. A. (2015). Home remedy use among African American and White older adults. Journal of the National Medical Association, 107(2), 121–129. https://doi.org/10.1016/s0027-9684(15)30036-5

Rosenthal, L.D., & Burchum, J.R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. Elsevier.

Singh, S., Shankar, R., & Singh, G. (2017). Prevalence and associated risk factors of hypertension. International Journal of Hypertension, 2017(1), 54–57. https://doi.org/10.1155/2017/5491838

Tabassum, N., & Ahmad, F. (2011). Role of natural herbs in the treatment of hypertension. Pharmacognosy Reviews, 5(9), 30. https://doi.org/10.4103/0973-7847.79097 

Wajngarten, M., & Silva, G.S. (2019). Hypertension and stroke: Update on treatment. European Cardiology Review, 14(2), 111-115. https://doi.org/10.15420/ecr.2019.11.1