1|Page
## SECTION 1: SUBJECTIVE DATA
### Chief Complaint (CC)
"Follow-up for high blood pressure. My readings have been running
150s-160s over 90s-100s at home. I feel fine otherwise, but my husband
worries."
,2|Page
### History of Present Illness (HPI)
**Patient:** 56-year-old African American female
**Source:** Self; reliable
**Onset:** Patient diagnosed with hypertension 8 years ago. Current
home BP readings (past 2 weeks) average **152/94** (morning) and
**148/90** (evening). Last office BP 3 months ago was **158/96**.
**Location:** Systemic – no headache, chest pain, or vision changes.
**Duration:** Poorly controlled for approximately 12-18 months per
patient report.
**Character:** Asymptomatic ("silent") – denies dizziness, palpitations,
dyspnea on exertion, or epistaxis.
**Aggravating factors:** None specifically. Salt intake remains high
(processed foods, canned soups, adding table salt).
**Relieving factors:** Rest, lying down – no significant change.
**Timing:** Morning BPs tend to be higher.
, 3|Page
**Severity:** Patient rates "control" as **fair** – has missed multiple
doses of lisinopril in the past month ("forgot to refill" or "took when I
remembered").
### Associated Symptoms (ROS positive findings)
- Occasional mild ankle swelling (worse after long shifts – patient works
as cashier, standing 8+ hours)
- Fatigue – wakes unrefreshed, possible sleep apnea (husband reports
loud snoring)
- No nocturia, no headaches, no chest pain, no SOB, no palpitations
### Past Medical History (PMH)
- **Hypertension** – diagnosed 2016
- **Hyperlipidemia** – diagnosed 2018
- **Osteopenia** – diagnosed 2022 (T-score -1.8)
- **Gastroesophageal reflux disease (GERD)** – intermittent
- **No diabetes, no CKD, no CAD, no stroke/TIA**
### Past Surgical History (PSH)
- Cholecystectomy (2005)
- Tubal ligation (1995)
## SECTION 1: SUBJECTIVE DATA
### Chief Complaint (CC)
"Follow-up for high blood pressure. My readings have been running
150s-160s over 90s-100s at home. I feel fine otherwise, but my husband
worries."
,2|Page
### History of Present Illness (HPI)
**Patient:** 56-year-old African American female
**Source:** Self; reliable
**Onset:** Patient diagnosed with hypertension 8 years ago. Current
home BP readings (past 2 weeks) average **152/94** (morning) and
**148/90** (evening). Last office BP 3 months ago was **158/96**.
**Location:** Systemic – no headache, chest pain, or vision changes.
**Duration:** Poorly controlled for approximately 12-18 months per
patient report.
**Character:** Asymptomatic ("silent") – denies dizziness, palpitations,
dyspnea on exertion, or epistaxis.
**Aggravating factors:** None specifically. Salt intake remains high
(processed foods, canned soups, adding table salt).
**Relieving factors:** Rest, lying down – no significant change.
**Timing:** Morning BPs tend to be higher.
, 3|Page
**Severity:** Patient rates "control" as **fair** – has missed multiple
doses of lisinopril in the past month ("forgot to refill" or "took when I
remembered").
### Associated Symptoms (ROS positive findings)
- Occasional mild ankle swelling (worse after long shifts – patient works
as cashier, standing 8+ hours)
- Fatigue – wakes unrefreshed, possible sleep apnea (husband reports
loud snoring)
- No nocturia, no headaches, no chest pain, no SOB, no palpitations
### Past Medical History (PMH)
- **Hypertension** – diagnosed 2016
- **Hyperlipidemia** – diagnosed 2018
- **Osteopenia** – diagnosed 2022 (T-score -1.8)
- **Gastroesophageal reflux disease (GERD)** – intermittent
- **No diabetes, no CKD, no CAD, no stroke/TIA**
### Past Surgical History (PSH)
- Cholecystectomy (2005)
- Tubal ligation (1995)
