HTN Clinic

Sinai-Grace Internal Medicine Residency Ambulatory Clinic Documentation Guides

Hypertension

  • HISTORY

    • Headaches, Dizziness, Blurry vision?

    • Chest pain, shortness of breath?

    • PND, Orthopnea, Pedal Edema?

    • Numbness, tingling, extremity weakness?

    • Hematuria

    • Current Anti-HTN therapy

    • Goal BP

      • H/O MI, CVA, DM, Smoking, Dyslipidemia

      • FH of MI, CVA

  • PHYSICAL EXAM

    • Vitals –BP, HR

    • General – BMI

    • Eyes – Fundus

    • Neck - JVD

    • Heart – Rate, Rhythm, murmurs, gallops, S3, S4

    • Lungs – crackles

    • Pulses including femoral bruits

  • INVESTIGATIONS

      • Urine Analysis - baseline

      • CBC - baseline

      • Chem – 12- baseline

      • Fasting Lipid Profile – yearly if at goal. If not, q6weeks.

      • Fasting Glucose - yearly

      • EKG - baseline

      • TSH – once or if symptoms present

      • CXR + ECHO – if signs of heart failure

Items in BOLD should be addressed every visit.