Hypertension

Chief Complaint

Hypertension

Template

Thank you for referring [name], a [age] year old [gender], for assessment of hypertension. Consent: I obtained consent from the patient for use of an AI scribe software. I explained that Empathia saves a copy of our conversation on their website for the purpose of generating a note, and that this software is FDA approved. History of Presenting Illness: Age of hypertension onset: Prior hypertensive crisis: Prior heart failure: Prior strokes: Prior retinal hemorrhage or papilledema: Salt intake: Stimulant or amphetamine use: Symptoms of Cushing's syndrome: Symptoms of pheochromocytoma: Symptoms of hyperthyroidism: Symptoms of hypercalcemia: Symptoms of sleep apnea: Current antihypertensive medications: (List numerically with each having its own line) Medical history: [medical_history] (List numerically with each having its own line) Other Medications: [medications] (List numerically with each having its own line) Allergies: [allergies] (List numerically with each having its own line) Social history: Work: [work] Extended coverage: [coverage] Alcohol: [alcohol] Cigarettes: [cigarettes] Drugs: [drugs] Family history: [family_history] There [is/is no] family history of [hypertension, adrenal tumors, or premature heart disease or stroke]. Exam: [exam] Weight: [weight] Height: [height] Blood pressure: [blood_pressure] Heart rate: [heart_rate] Investigations: [investigations] Impression and Plan: [name] is a [age] [gender] with hypertension due to [diagnosis]. 1. Hypertension: (List detailed action plans using the correct person tone, e.g., 'I have started [medication] for diabetes control' or 'The family doctor has initiated...) - I have provided a requisition to rule out endocrinopathies associated with hypertension, including hyperaldosteronism, hypercalcemia, thyroid disease, pheochromocytoma, acromegly, and Cushing's syndrome Thank you for involving me in the care of this pleasant patient. Please do not hesitate to contact me with any questions or concerns. Dr. [name], MD, FRCPC [clinic]