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.