Hypertension Evaluation Patient Name Patient DOB MRN

Date Chief complaint/Reason for consult Referring MD

Start Time Stop time

Data Reviewed History of Present Illness Comorbid conditions

‰Allergy list ‰Cardiac disease 
‰Medication list ‰Diabetes
‰Dyslipidemia
‰Past Medical History ‰Polycystic ovarian syndrome
‰Past Surgical History ‰Renal artery stenosis
‰Social History ‰Renal disease, chronic
‰Family Medical History ‰Sleep apnea 
‰Premature Coronary Artery Disease ‰Thyroid disease
‰Familial Hyperlipidemia ‰Physical activity limited
‰BMI t30
‰Patient’s Blood Pressure log ‰Smoking
‰Recent labs and diagnostic tests
Review of Systems Physical Exam WNL = Within Normal Limits

‰ = Patient denies problems

✔
Vitals Ht Wt BMI Pulse Rhythm ‰Reg ‰Irreg Respiratory Rate
‰Constitutional BP ‰L arm ‰R arm Sitting Standing Supine
‰Weight changes ‰Fatigue ‰Fever General ‰Alert ‰Well nourished ‰Obese ‰Cachectic Hygiene ‰Appropriate ‰Unkempt
‰Eyes Eyes ‰Conjunctivae WNL ‰Pupils WNL ‰Discs WNL ‰No visible retinal pathology
‰Vision changes ‰Pain ENT ‰Nasal mucosa WNL ‰Dentition WNL ‰Oropharynx WNL
‰ENT/Mouth Neck ‰Normal to palpation ‰Thyroid WNL ‰No JVD
‰Ulcers ‰Tooth pain ‰Nose bleeds Resp ‰Clear to auscultation ‰Clear to percussion ‰Effort WNL ‰Normal to palpation
‰Respiratory CV ‰Auscultation WNL ‰Palpation WNL ‰No edema ‰Carotids ‰Aorta ‰Femoral pulses ‰Pedal pulses
‰Dyspnea ‰Cough ‰Sputum
GI ‰No palpable masses ‰Liver and spleen not palpable ‰No hepatojugular reflux
‰Cardiovascular
‰Chest pain ‰Exercise intolerance Lymph ‰No lymphadenopathy ‰Enlarged lymph nodes palpable ‰Neck ‰Axilla ‰Groin ‰Other
‰Diaphoresis ‰Paroxysmal nocturnal dyspnea Musc ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength
‰Gastrointestinal Extrem ‰No clubbing ‰No cyanosis ‰No sores
‰Nausea ‰Vomiting ‰Diarrhea Skin ‰Inspection ‰Palpation
‰ Abdominal pain after eating Neuro ‰Oriented ‰CN ‰DTR ‰Sensation intact ‰Vibratory sense intact
‰Genitourinary Psych ‰Affect ‰Orientation ‰Insight ‰Memory
‰Dysuria ‰Polyuria ‰Erectile dysfunction Additional Findings
‰Musculoskeletal
‰Myalgias ‰Bony pain ‰Claudication
‰Skin/breasts Impression & Plan
‰Sores, ulcers ‰Dry, cracked skin
Blood Pressure Class SBP DBP
‰Neurologic ‰Normal <120 <80
‰Numbness ‰Paresthesias ‰Focal weakness ‰Prehypertension 120-139  80-89 ‰Patient at goal < 140/90 or <130/80 for DM
‰Endocrinologic ‰Stage 1 140-159  90-99 ‰Not at Goal
‰Hypoglycemia ‰Tremors ‰Stage 2 t160 t100
‰Hematologic/Lymphatic
‰Easy bruising ‰Swollen lymph nodes
‰Allergy/Immunology
‰Sinus pain ‰Nasal discharge
‰Psychiatric
‰Depression ‰Anxiety ‰Hallucinations
Follow up
‰This clinic
‰Cardiology
‰Endocrinology
‰Nephrology Signature
‰Ophthalmology cc
‰Other Estimated Creatinine Clearance * Multiply by 0.85 for females (140 – age) x weight ( kg) =
Normal Creatinine Clearance in healthy young females ~100mL/min/1.73m2 Plasma Creatinine x 72
Normal Creatinine Clearance in healthy young males ~120mL/min/1.73 m2
Labs ‰Urinalysis ‰CBC ‰PT, PTT, INR ‰BMP ‰LFTs ‰Triglyceride level ‰LDL and HDL ‰BNP ‰EKG ‰ECHO ‰TSH
Therapy ‰Aspirin ‰ACE-I or ARB ‰Beta blocker ‰Calcium Channel Blocker ‰Thiazide diuretic ‰Loop diuretic ‰Statin ‰Other

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