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Vasoconstriction from chronic hypertension and vessel resistance can result in decreased cardiac output This is the 3rd cpmc admission for this 83 year old woman with a long history of hypertension who presented with the chief complaint of substernal “toothache like” chest pain of 12 hours duration. Patient will manifest blood pressure and pulses within acceptable limits
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Patient will not develop complications from hypertension. These sample physician query documents are offered solely as examples of standardized physician queries to clarify clinical documentation within the medical record. Discussed with patient their elevated blood pressure and need for close outpatient management of their hypertension
Will provide a prescription for amlodipine 5mg po daily and arrange for the patient to follow up in a primary care clinic
I have discussed with the patient the possible reasons for why there is an elevation in blood pressure today Patient understands that this may be in part because of anxiety or discomfort related to today's visit. Patient’s description of headaches, swelling of the lower extremities, consecutive uncontrolled hypertensive blood pressures, combined with the potential for chronic hypertensive damage leading to organ dysfunction, provides rationale for this differential diagnosis. Explore our comprehensive collection of 10 common nurse practitioner soap note examples, designed to enhance your clinical documentation skills.
Patient states she was here 1 week ago for a general check up and her blood pressure was elevated Patients bp at that time was 170/96 Patient was told to monitor her bp for 1 week and to come back with her readings Patient brought in her bp readings for the week
Patient states her bp has been running around 160’s to 180’s at times.
High blood pressure emergency room transcribed medical transcription example report for reference by medical transcriptionists/allied health professionals.
