March 11, 2008

New Hypertension Management MedicalTemplate

A new hypertension evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected hypertension (high blood pressure) was released today.

The Hypertension management MedicalTemplate includes reminders for the JNC7 hypertension management goals.

Read this document on Scribd: Hypertension Follow up Evaluation

Hypertension Evaluation Date Start Time Stop time Patient Name Patient DOB MRN Chief complaint/Reason for consult History of Present Illness Referring MD Data Reviewed ‰Allergy list ‰Medication list ‰Past Medical History ‰Past Surgical History ‰Social History ‰Family Medical History ‰Patient’s Blood Pressure log ‰Recent labs and diagnostic tests Review of Systems ‰Premature Coronary Artery Disease ‰Hyperlipidemia ‰Cardiac disease ‰Congenital Adrenal Hyperplasia ‰Diabetes ‰Dyslipidemia ‰Renal disease ‰Polycystic Ovarian Syndrome ‰Sleep Apnea ‰Renal artery stenosis Pulse Sitting RR Standing ‰Thyroid disease ‰BMI t  ‰Smoking ‰Physical inactivity Physical Exam Vitals Ht Wt BMI BP L arm R arm General ‰ Alert Eyes ENT Neck Resp CV GI Lymph Musc Extrem Skin Neuro Psych Supine ‰ = Patient denies problems ‰Constitutional ‰Eyes ‰Vision changes ‰Pain ‰Weight changes ‰Fatigue ‰Fever ‰ENT/mouth ‰Resp ‰CV ‰GI ‰Ulcers ‰Tooth pain ‰Nose bleeds ‰Dyspnea ‰Cough ‰Sputum ‰Chest pain ‰Exercise intolerance ‰Diaphoresis ‰Paroxysmal nocturnal dyspnea ‰Nausea ‰Vomiting ‰Diarrhea ‰ Abdominal pain after eating ‰Dysuria ‰Polyuria ‰Erectile dysfunction ‰Myalgias ‰Bony pain ‰Claudication ‰Sores, ulcers ‰Dry, cracked skin ‰Numbness ‰Paresthesias ‰Focal weakness ‰Hypoglycemia ‰Tremors ‰GU Additional Findings ‰Conjunctivae ‰Pupils ‰Discs ‰No visible retinal pathology ‰Nasal mucosa ‰Dentition ‰Oropharynx ‰Normal to palpation ‰Thyroid ‰No JVD ‰Clear to auscultation ‰Clear to percussion ‰Effort ‰Normal to palpation ‰Auscultation ‰Palpation ‰Edema ‰Carotids ‰Aorta ‰Femoral pulses ‰Pedal pulses ‰No palpable masses ‰Liver and spleen not palpable ‰No hepatojugular reflux ‰No lymphadenopathy ‰Enlarged lymph nodes palpable ‰Neck ‰Axilla ‰Groin ‰Other ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength ‰No clubbing ‰No cyanosis ‰No sores ‰Inspection ‰Palpation ‰Oriented ‰CN ‰DTR ‰Sensation intact ‰Vibratory sense intact ‰Affect ‰Orientation ‰Insight ‰Memory ‰Musc ‰Skin/breasts ‰Neuro ‰Endo Impression & Plan Blood Pressure Class ‰Normal ‰Prehypertension ‰Stage 1 ‰Stage 2 SBP <120 120-139 140-159 t160 DBP <80 80-89 90-99 t100 ‰Patient at goal < 140/90 or <130/80 for DM ‰Not at Goal ‰Heme/lymph ‰Allergy/Immun ‰Psych ‰Easy bruising ‰Swollen lymph nodes ‰Sinus pain ‰Nasal discharge ‰Depression ‰Anxiety ‰Hallucinations Follow up ‰This clinic ‰Endocrinology ‰Nephrology ‰Ophthalmology ‰Other Signature cc Estimated Creatinine Clearance * Multiply by 0.85 for females Normal Creatinine Clearance in healthy young females ~100mL/min/1.73m2 Normal Creatinine Clearance in healthy young males ~120mL/min/1.73 m2 (140 – age) x weight (in kg) = Plasma Creatinine x 72 Labs Therapy ‰Urinalysis ‰CBC ‰PT, PTT, INR ‰BMP ‰LFTs ‰Triglyceride level ‰LDL and HDL ‰BNP ‰EKG ‰ECHO ‰TSH ‰Aspirin ‰ACE-I or ARB ‰Beta blocker ‰Calcium Channel Blocker ‰Thiazide diuretic ‰Loop diuretic ‰Statin ‰Other ©MB and RR 2006-2008 Revised 10March08

JNC 7 Guidelines

The hypertension evaluation MedicalTemplate includes the hypertension staging system and reminders for the suggested laboratory workup outlined in the JNC 7 report. The JNC 7 is the The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure of the National Heart, Lung, and Blood institute.

JNC 7 Full Guidelines
JNC 7 Pocket Reference

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