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.