CCS: Primary HTN
• Vital signs: B.P. 150/90 mm Hg. Pulse- 78/minute, Temperature- 98.6F, RR- 12/minute, weight- 180 lb.
• Cc: Routine Physical
• History of Present Illness: 50 year old white male came for routine physical examination. He has not
seen any physician for last 10 years. He recently had blood pressure checked at a local pharmacy where
blood pressure was 156/90mm Hg. Since he has very strong family history of hypertension, he decided
to have the physical exam done. He denied headache, dizziness, chest pain or shortness of breath. He
regularly goes to gym and exercise. He has been healthy throughout his life and never was admitted in the
hospital. Only medication he takes is multivitamin. He smokes 1/2 pack daily for last 20 years; drinks
alcohol socially, denied use of street drugs. He is sexually active with only one sexual partner for last 20
• Past Medical History: None
• Allergy: No known drug allergy
• Medication: Multivitamin
• Family History: Father had hypertension, died with stroke at the age of 50. Mother has Diabetes and
Hypertension, 2 brothers both have hypertension.
• Note: Patient is in the office, there is no acuteness, and our next step should be physical exam.
• Examination: Full exam as patient is in the clinic
• Only positive finding is mild obesity.
• Note: At this point we should order routine labs, advice life style modification and ask patient to return
to clinic with in 8weeks. Before we diagnose hypertension and start treatment we try to get 3 reading.
• Order: CBC with differential-routine, Chem8-routine, Liver function test-routine, Lipid profile, Urine
• Advice: Weight reduction, Exercise, Low salt diet, Decrease alcohol intake, Quit smoking
• Change location to home, schedule to come back in 6 week.
• Move the clock after 6 week; in between you will get the labs back.
• All the labs are normal
• Patient has arrived for his appointment:
• Vitals: B.P. 154/90 mm Hg. Pulse- 78/minute, Temperature- 98.600F, RR- 12/minute,, weight- 184 lb
• Do a focal exam: Results: No significant change
• Order: Hydrochlorothiazide-oral-continuous
• Change patient location to home, reschedule to come back in 2 months.
• Thank you for taking care of the patient.
• Diagnosis: Primary Hypertension
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