SOAP Note — AI Generated
JM
James R. Mitchell
BP
158/96
HR
78
TEMP
98.4°F
SPO2
96%
RR
18
WEIGHT
94 kg
● Subjective
Patient reports persistent headaches and occasional dizziness over the past 2 weeks. Denies chest pain, SOB, or visual changes. Compliant with all medications. Admits to higher sodium intake recently.
● Objective
Alert, oriented x3. BP 158/96 (sitting), 162/94 (standing). Fundoscopic: mild arteriolar narrowing. Cardiac: RRR, no murmurs. Lungs: CTA bilaterally. Extremities: trace bilateral pedal edema.
● Assessment
Resistant hypertension — on 3-drug regimen (ACEi + CCB + thiazide) at max/near-max doses with persistently elevated BP. Contributing factors: elevated aldosterone (22 ng/dL), CKD stage 3a (eGFR 52), suboptimal dietary sodium restriction, poorly controlled DM2 (HbA1c 7.8%).
● Plan
Consider adding Spironolactone 25mg daily as 4th-line agent given elevated aldosterone and resistant HTN. Monitor K+ closely given CKD (baseline 4.1). Repeat BMP in 1 week. Dietary counseling: strict sodium restriction < 2g/day. Follow-up BP check in 2 weeks.
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💊 Current Medications
- Lisinopril40mg daily
- Amlodipine10mg daily
- Hydrochlorothiazide25mg daily
- Metformin1000mg BID
- Atorvastatin40mg daily
🧪 Lab Results
Serum Creatinine
1.4 mg/dLHIGH
Potassium
4.1 mEq/LNORMAL
HbA1c
7.8%HIGH
Aldosterone
22 ng/dLHIGH
eGFR
52 mL/minHIGH
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