Note templates: hypertension outpatient evaluation

Review of systems

Paragraph format

Focused review of systems for hypertension evaluation

No fatigue, hyperactivity, anxiety, headaches, seizures, visual disturbances, hearing loss, recent pharyngitis, snoring, palpitations, irregular heartbeat, chest pain, exertional dyspnea, edema, vomiting, bloody stools, hematuria, cola-colored urine, flank/abdominal pain, dysuria, urinary urgency, urinary frequency, joint swelling, rashes, unexplained sweating, pallor, impetigo, or paroxysms of pallor/flushing/diaphoresis

Systems-based format

Focused review of systems for hypertension evaluation

General: no fatigue, hyperactivity, anxiety
Pregnancy: not pregnant (or not applicable)
Head: no headaches or seizures
Eyes: no visual disturbances
Ears: no hearing loss
Throat: no recent pharyngitis
Respiratory: no snoring
Cardiovascular: no palpitations, irregular heartbeat, chest pain, exertional dyspnea, or edema
Gastrointestinal: no vomiting or bloody stools
Genitourinary: no hematuria, cola-colored urine, flank pain, flank/abdominal pain, dysuria, increased urinary urgency, or increased urinary frequency
Musculoskeletal: no joint swelling

Patient history

Medications

• not currently taking stimulants (e.g., amphetamines, methylphenidate), oral contraceptives, corticosteroids, calcineurin inhibitors (cyclosporine, tacrolimus), or tricyclic antidepressants
• denies regular NSAID use

Medical history

• no recurrent UTI or episodes of unexplained fever
• no prior diagnosis of hydronephrosis or vesicoureteral reflux [VUR]
• no recent head trauma or seizures
• no anxiety disorder
• no perinatal complications: prematurity, anoxia, oligohydramnios, need for umbilical artery catheter

Social history

• dietary intake: mostly eats {home-cooked meals vs processed foods}, favorite snacks include ***, {uses salt shaker at dinner table}, estimates salt intake to be {low/average/high}
• denies recreational drug use, anabolic steroids, weight loss supplements, smoking/vaping
• no tobacco smoke exposure in the home
• exercise: PE at school***, {playing with siblings}, {walking around the neighborhood}, {jogging/running}, {bicycling}, {dance classes}, {weightlifting}, {regular exercise}, {organized sports}
• denies significant stressors at home/school; does not report significant anxiety with doctor’s office visits

Family history

No family history of hypertension (primary or secondary), hypercholesterolemia, early myocardial infarction [MI], stroke, diabetes, OSA, hearing loss (Alport syndrome), kidney disease, need for dialysis/kidney transplant

Objective

Vitals

• Four point BPs: Right upper: /. Left upper: /. Left lower: /. Right lower: /. {upper >> lower is concerning for coarctation, especially if >20 mmHg}
• Heart rate *** {note if tachycardic}

Physical exam

General: well appearing, normal stature for age
Head/face: atraumatic, no elfin or Cushingoid facies
Eyes: no proptosis, {non-dilated ophthalmoscopic exam: optic disc margins sharp; no arteriovenous nicking, retinal hemorrhages, or cotton wool patches}
Throat: no tonsillar hypertrophy
Neck: supple, thyroid not enlarged, no excess skin folds
Chest: symmetric, without deformity
Cardiovascular: normal heart sounds, no murmur or friction rub, PMI nondisplaced, no visible heave, radial and femoral pulses 2+ without radiofemoral delay, no peripheral edema
Respiratory: good air movement throughout, no accessory muscle use
Abdomen: soft, {non}obese, no palpable masses, no bruit over the epigastrium or flanks
Extremities: normal muscle strength, no joint swelling, no peripheral edema
Skin: normal color, no rashes, cafe au lait spots, ash leaf spots, adenoma sebaceum, acne, petechiae/purpura, acanthosis, hirsutism, or striae

Historical data reviewed

• BPs from {other encounters, PCP, home BP chart if available}
• No known prior episodes of UTI or unexplained fever suspicious for UTI/pyelonephritis {- No prior kidney/bladder ultrasounds, VCUG or echocardiograms available for review} {- Kidney/bladder ultrasound {date} showed normal sized kidneys with no structural abnormalities, scarring, or evidence of nephrocalcinosis} {- Prior VCUG {date} showed no evidence of vesicoureteral reflux} {- Prior echocardiogram {date} showed no evidence of left ventricular hypertrophy}