S: CC: “I’m here for my annual wellness visit and to discuss my high blood pressure.”
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HPI: 57-year-old female with a past medical history of hypertension presents for an annual exam. Reports being adherent to her medication regimen of lisinopril 20mg daily and hydrochlorothiazide 12.5mg daily.
ROS:
Constitutional: Negative for fatigue, weakness, fever.
HEENT: Negative
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Respiratory: Negative, no shortness of breath, cough, wheezing.
Cardiovascular: Reports well-controlled blood pressure at home around 130/80.
GI: Negative, regular bowel movements.
GU: Post-menopausal, no complaints.
Musculoskeletal: Negative for joint pain, swelling.
Neurological: Negative, no headaches.
O: Vitals: BP 138/88, Pulse 80, RR 18, T 98.6F, Ht 5’4″, Wt 160lbs, BMI 28.9. General appearance healthy. HEENT WNL. Heart with regular rate and rhythm. Lungs clear to auscultation. Abdomen soft NTND. Extremities without edema. Neuro exam WNL.
A: Essential hypertension, controlled.
P: Hypertension remains well-controlled on current medication regimen. Recommend continued adherence and follow up in 6 months or sooner if symptoms change. Diet and exercise counseling provided to maintain healthy lifestyle changes. 10-year ASCVD risk of 15% discussed.