Term
| What details go in assessment? |
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Definition
- Needs a drug
- Not recieving optimal drug
- Dose not optimal
- Adverse reactions, drug interaction
- Goals of therapy per guidelines |
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Term
| What details go in Subjective? |
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Definition
- Chief complaint
- PMH, FH, SH
- Lifestyle - exercise, diet, alcohol, smoking
- Psychosocial
- Allergies |
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Term
| What details go in objective? |
|
Definition
- Vital signs
- Physical exam relating to condition
- Labs
- Calculated values such as CrCl |
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Term
| What details belong in education? |
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Definition
HTN is a silent disease that can lead to heart disease and stoke, medications reduce this risk.
Home BP monitoring and diaries
Lifestyle monitoring – DASH, exercise, salt, alcohol |
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Term
| What details are specific to thiazides in regards to SOAPE notes? |
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Definition
- note presence of lithium or gout meds, osteoporosis
- Measure SCr and K+
- P: HCTZ 25 mg po daily
- E: Take in the morning, wear sunscreen |
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Term
| What details are specific to Ace inhibitors in regards to SOAPE notes? |
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Definition
S: H/O angioedema, BRAS, diabetes, CKD, post-MI, stroke -- used in every compelling indication.
O - Pregnancy, BP, K+, Mg, Na+, SCr, Glucose
P - Monitor K, BP, Scr in 1 month
E - monitor for cough and angioedema, contraception in women of childbearing age |
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Term
| What details are specific to DHB CCBs in regards to SOAPE notes? |
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Definition
S: H/O edema, do not use in post-MI or CHF, DM2 is a compelling indication.
O: BP, HR, P: BP, HR in 1 month
E: use bulk forming laxatives to treat constipation, warn about peripheral edema
Not first choice. |
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Term
| What details are specific to non-DHB CCBs in regards to SOAPE notes? |
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Definition
S: – 2nd/3rd AV block, SSS, acute MI, pulmonary congestion, beta blocker, Cyp3A4 inducters/inhibitors/substrates
O: BP, HR, P: BP, HR in 1 month
E: use bulk forming laxatives to treat constipation, do not crush or chew |
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Term
| What details are specific to Beta blockers in regards to SOAPE notes? |
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Definition
Subjective: do not use in bradycardia, diabetes, asthma/COPD. AV block, SSS, cardiogenic shock, decompensated HF, Stroke or CKD.
Compelling indications: CHF, post-MI, DM2
O: BP, HR P: BP, HR in 4 weeks
E: mask signs of hypoglycemia in diabetes, don’t stop abruptly, causes fatigue that will decrease with time |
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Term
| What details are specific to alpha blockers in regards to SOAPE notes? |
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Definition
- S: used in BPH, watch age or PDE-5 inhibitors
- O: take sitting and standing BP. P: Recheck BP, HR in 1 month
- E: rise slowing, first dose in the evening, postural hypotension, take at HS |
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