Hypertension

HISTORY:

Hypertension follow-up

Blood pressure monitoring: ‍ ‍not monitored (target ‍135/85)

Current symptoms: ‍none

‍headache

‍chest pain

‍shortness of breath

‍palpitations

‍dizziness

‍blurred vision

‍fatigue

‍confusion



Medications:

‍ACEI, ‍ARBs, ‍Beta blockers, ‍Calcium channel blockers, ‍Diuretics, ‍Others, ‍combinations

‍NSAIDs, ‍oral steroids

Adherence: ‍goodaveragepoor, ‍adverse effects

Over-the-counter supplements: ‍ ‍none



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU

Caffeine: ‍ daily

Diet: ‍goodaveragepoor, ‍high in salt, ‍high in carbs, ‍high in fat, ‍vegan

Physical activity: ‍adequateaveragesedentary

Weight: ‍ ‍lbskg, ‍gainunchangedloss



Labs:

Creatinine: ‍ ‍normal

Na: ‍ ‍normal, K: ‍ ‍normal

Hb: ‍ ‍normal

HbA1c: ‍% ‍normal

Lipids: ‍normal, Cholesterol: ‍, LDL: ‍, HDL: ‍, Triglycerides: ‍

TSH: ‍ ‍normal

Urinalysis: ‍ ‍normalproteins



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Measurements: weight: ‍ kg, height: ‍ cm, waist: ‍ cm, BMI: ‍

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable



ASSESSMENT:

‍Hypertension ‍likelysuspectedpossible, ‍well-controlled

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍glucose, ‍HbA1c, ‍lipid profil, ‍TSH

- Urinalysis

- ECG if new onset

- Home blood pressure monitoring

- Lifestyle counseling: ‍sodium restriction, ‍DASH diet, ‍increase exercise, ‍weight loss

- ‍ACEs

- ‍ARBs

- ‍Beta-blockers

- ‍Calcium-channel blockers

- ‍Diuretics

- ‍Others anti-hypertensives

- Referral to dietitian

- Follow-up in ‍ months

- Return if blood pressure is above target