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.