Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: This section may be blank or contain nonspecific complaints depending on the severity of hypertension.
Headache (especially frontal)
Dizziness
Fatigue
Palpitations (fluttering sensation in the chest) – less common
现病史 (xiàn bìng shǐ) History of Present Illness:
Duration of hypertension diagnosis
Highest recorded blood pressure readings
Presence of symptoms (see Chief Complaint) and their association with blood pressure readings
Recent changes in lifestyle (diet, exercise, stress)
Medication adherence (prescription and over-the-counter)
既往史 (jì wàng shǐ) Past Medical History:
Underlying medical conditions that can contribute to hypertension (diabetes, chronic kidney disease, sleep apnea)
Prior surgeries or procedures
History of other cardiovascular diseases (e.g., heart failure, stroke)
Family history of hypertension or cardiovascular disease
社会史 (shè huì shǐ) Social History:
Smoking history (significant risk factor)
Alcohol intake (excessive intake can worsen hypertension)
Diet (high sodium intake can worsen hypertension)
Exercise habits
Stress levels
家族史 (jiā zú shǐ) Family History:
Family history of hypertension or cardiovascular disease (important risk factor)
查体 (chá tǐ) Physical Examination:
Vital signs (blood pressure in both arms, heart rate)
General appearance (signs of acute illness)
Cardiovascular exam (presence of murmurs, bruits)
Fundoscopic exam (examination of the eye for signs of hypertensive retinopathy)
Neurological exam (gross assessment for abnormalities)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Electrolytes (potassium, sodium) – to assess electrolyte balance
Creatinine and BUN – to assess kidney function
Urinalysis – to rule out urinary tract infection or kidney disease
Fasting blood sugar – to screen for diabetes
Lipid panel – to assess cholesterol levels
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Imaging studies are not routinely done for uncomplicated hypertension. An ECG (electrocardiogram) may be indicated if there are concerning symptoms or findings on exam.
诊断 (zhěn duàn) Diagnosis:
Stage of hypertension (based on blood pressure readings)
Underlying cause of hypertension (if identified)
Presence of hypertensive end-organ damage (e.g., retinopathy, nephropathy)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Lifestyle modifications (smoking cessation, weight loss if overweight, dietary changes to reduce sodium intake, regular exercise)
Medications (consideration of different medication classes based on individual needs and comorbidities)
Target blood pressure goals (individualized based on age, comorbidities, and risk factors)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of hypertension, adherence to treatment, and presence of other risk factors.
Early diagnosis, lifestyle changes, and medication adherence are crucial to prevent complications like heart attack, stroke, and kidney disease.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of lifestyle modifications (healthy diet, exercise, weight management, stress management)
Importance of medication adherence and understanding potential side effects
Importance of regular blood pressure monitoring
Warning signs of worsening hypertension (severe headache, vision changes, chest pain)
Importance of follow-up appointments to monitor blood pressure and adjust treatment as needed
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the severity of hypertension and blood pressure control.
Regular follow-up is essential to monitor blood pressure and adjust treatment as needed.