Hypertension Follow Up Evaluation
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Hypertension Evaluation
Patient Name
Date
Patient DOB
MRN
Chief complaint/Reason for consult
Start Time
Referring MD
Stop time
Data Reviewed
History of Present Illness
Comorbid conditions
Allergy list Medication list Past Medical History Past Surgical History Social History Family Medical History
Cardiac disease Diabetes Dyslipidemia Polycystic ovarian syndrome Renal artery stenosis Renal disease, chronic Sleep apnea Thyroid disease Physical activity limited BMI t30 Smoking
Premature Coronary Artery Disease Familial Hyperlipidemia
Patient’s Blood Pressure log Recent labs and diagnostic tests Review of Systems
Physical Exam
= Patient denies problems Constitutional
Vitals Ht Wt BMI Pulse Rhythm Reg Irreg Respiratory Rate BP L arm R arm Sitting Standing Supine General Alert Well nourished Obese Cachectic Hygiene Appropriate Unkempt
✔
Weight changes Fatigue Fever
Eyes
Eyes
Vision changes Pain
ENT
ENT/Mouth
Neck
Ulcers Tooth pain Nose bleeds
Respiratory
Resp
Cardiovascular
GI
Dyspnea Cough Sputum
CV
Chest pain Exercise intolerance Diaphoresis Paroxysmal nocturnal dyspnea
Lymph
Gastrointestinal
Musc Extrem
Nausea Vomiting Diarrhea Abdominal pain after eating
Skin Neuro
Genitourinary
Dysuria Polyuria Erectile dysfunction
Musculoskeletal
Psych
WNL = Within Normal Limits
Conjunctivae WNL Pupils WNL Discs WNL No visible retinal pathology Nasal mucosa WNL Dentition WNL Oropharynx WNL Normal to palpation Thyroid WNL No JVD Clear to auscultation Clear to percussion Effort WNL Normal to palpation Auscultation WNL Palpation WNL No edema Carotids Aorta Femoral pulses Pedal pulses No palpable masses Liver and spleen not palpable No hepatojugular reflux No lymphadenopathy Enlarged lymph nodes palpable Neck Axilla Groin Other Gait Digit Inspection ROM Stability Strength No clubbing No cyanosis No sores Inspection Palpation Oriented CN DTR Sensation intact Vibratory sense intact Affect Orientation Insight Memory
Additional Findings
Myalgias Bony pain Claudication
Skin/breasts
Impression & Plan
Sores, ulcers Dry, cracked skin
Neurologic
Numbness Paresthesias Focal weakness
Endocrinologic
Hypoglycemia Tremors
Hematologic/Lymphatic
Blood Pressure Class Normal Prehypertension Stage 1 Stage 2
SBP <120 120-139 140-159 t160
DBP <80 80-89 90-99 t100
Patient at goal < 140/90 or <130/80 for DM Not at Goal
Easy bruising Swollen lymph nodes
Allergy/Immunology
Sinus pain Nasal discharge
Psychiatric
Depression Anxiety Hallucinations
Follow up
This clinic Cardiology Endocrinology Nephrology Ophthalmology Other Labs
Signature cc Estimated Creatinine Clearance * Multiply by 0.85 for females Normal Creatinine Clearance in healthy young females ~100mL/min/1.73m2 Normal Creatinine Clearance in healthy young males ~120mL/min/1.73 m2
(140 – age) x weight ( kg) = Plasma Creatinine x 72
Urinalysis CBC PT, PTT, INR BMP LFTs Triglyceride level LDL and HDL BNP EKG ECHO TSH Aspirin ACE-I or ARB Beta blocker Calcium Channel Blocker Thiazide diuretic Loop diuretic Statin Other
Therapy
©MB and RR 2006-2010
Revised 26Dec2009
e-medtools.com
Patient Name
Date
Patient DOB
MRN
Chief complaint/Reason for consult
Start Time
Referring MD
Stop time
Data Reviewed
History of Present Illness
Comorbid conditions
Allergy list Medication list Past Medical History Past Surgical History Social History Family Medical History
Cardiac disease Diabetes Dyslipidemia Polycystic ovarian syndrome Renal artery stenosis Renal disease, chronic Sleep apnea Thyroid disease Physical activity limited BMI t30 Smoking
Premature Coronary Artery Disease Familial Hyperlipidemia
Patient’s Blood Pressure log Recent labs and diagnostic tests Review of Systems
Physical Exam
= Patient denies problems Constitutional
Vitals Ht Wt BMI Pulse Rhythm Reg Irreg Respiratory Rate BP L arm R arm Sitting Standing Supine General Alert Well nourished Obese Cachectic Hygiene Appropriate Unkempt
✔
Weight changes Fatigue Fever
Eyes
Eyes
Vision changes Pain
ENT
ENT/Mouth
Neck
Ulcers Tooth pain Nose bleeds
Respiratory
Resp
Cardiovascular
GI
Dyspnea Cough Sputum
CV
Chest pain Exercise intolerance Diaphoresis Paroxysmal nocturnal dyspnea
Lymph
Gastrointestinal
Musc Extrem
Nausea Vomiting Diarrhea Abdominal pain after eating
Skin Neuro
Genitourinary
Dysuria Polyuria Erectile dysfunction
Musculoskeletal
Psych
WNL = Within Normal Limits
Conjunctivae WNL Pupils WNL Discs WNL No visible retinal pathology Nasal mucosa WNL Dentition WNL Oropharynx WNL Normal to palpation Thyroid WNL No JVD Clear to auscultation Clear to percussion Effort WNL Normal to palpation Auscultation WNL Palpation WNL No edema Carotids Aorta Femoral pulses Pedal pulses No palpable masses Liver and spleen not palpable No hepatojugular reflux No lymphadenopathy Enlarged lymph nodes palpable Neck Axilla Groin Other Gait Digit Inspection ROM Stability Strength No clubbing No cyanosis No sores Inspection Palpation Oriented CN DTR Sensation intact Vibratory sense intact Affect Orientation Insight Memory
Additional Findings
Myalgias Bony pain Claudication
Skin/breasts
Impression & Plan
Sores, ulcers Dry, cracked skin
Neurologic
Numbness Paresthesias Focal weakness
Endocrinologic
Hypoglycemia Tremors
Hematologic/Lymphatic
Blood Pressure Class Normal Prehypertension Stage 1 Stage 2
SBP <120 120-139 140-159 t160
DBP <80 80-89 90-99 t100
Patient at goal < 140/90 or <130/80 for DM Not at Goal
Easy bruising Swollen lymph nodes
Allergy/Immunology
Sinus pain Nasal discharge
Psychiatric
Depression Anxiety Hallucinations
Follow up
This clinic Cardiology Endocrinology Nephrology Ophthalmology Other Labs
Signature cc Estimated Creatinine Clearance * Multiply by 0.85 for females Normal Creatinine Clearance in healthy young females ~100mL/min/1.73m2 Normal Creatinine Clearance in healthy young males ~120mL/min/1.73 m2
(140 – age) x weight ( kg) = Plasma Creatinine x 72
Urinalysis CBC PT, PTT, INR BMP LFTs Triglyceride level LDL and HDL BNP EKG ECHO TSH Aspirin ACE-I or ARB Beta blocker Calcium Channel Blocker Thiazide diuretic Loop diuretic Statin Other
Therapy
©MB and RR 2006-2010
Revised 26Dec2009
e-medtools.com
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