Hypertension
Age: years old
Gender:
HISTORY:
Returns for a hypertension follow-up
Last visit was ago
Blood pressure monitoring: (target )
Current symptoms:
, , , ,
, , , ,
Medications:
, , , , , ,
,
Adherence: ,
Over-the-counter supplements:
Social history:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
Caffeine: daily
Diet: , , , ,
Physical activity:
Weight: ,
Labs:
Creatinine:
Na: , K:
Hb:
HbA1c: %
Lipids: , Cholesterol: , LDL: , HDL: , Triglycerides:
TSH:
Urinalysis:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Metrics: weight: , height: cm, waist: cm, BMI:
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Extremities: , , cap refill sec, pulses , ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
ASSESSMENT:
,
DDx: essential hypertension, secondary hypertension, white coat hypertension, renal artery stenosis, chronic kidney disease, primary aldosteronism, Cushing's syndrome, pheochromocytoma, coarctation of the aorta, thyroid/parathyroid disease, sleep apnea, medication-induced hypertension, pregnancy-induced hypertension, preeclampsia, drug abuse (e.g., cocaine, amphetamines), alcohol-induced hypertension
PLAN:
Investigations:
- Blood work: , , , , , ,
- Urinalysis
- ECG if new onset
- Home blood pressure monitoring
Treatments:
- Lifestyle counseling: , , ,
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Further care:
- Referral to dietitian
- Follow-up in months
- Return if blood pressure is above target
HISTORY: EXAM: ASSESSMENT: PLAN: