HPI
_ y/o _ w/ _ PMH/PSH _, presents with asymptomatic hypertension.
_Denies any recent chest pain, denies SOB.
_Denies acute headache/slurred speech, ataxia, limb weakness, facial droop, changes in vision.
_Denies blood in urine.
Diagnosis: Asymptomatic Hypertension.
MDM:
Pt does not have any symptoms on history nor signs on physical exam concerning for end organ damage secondary to hypertension. Per ACEP Clinical Policies, routine screening for end organ damage in the ED is not required. Specifically, based up the patient’s presentation, the patient is at sufficiently low risk for:
_ (cardiac) ACS given no CP, no SOB, normal cardio-pulmonary exam
_ (neurologic) – SAH/stroke given no hx of acute headache/slurred speech, ataxia, limb weakness, facial droop, changes in vision and normal neurologic exam.
_ (renal) – end organ renal disease given no hematuria
The patient was counseled regarding the deleterious effects of hypertension and the necessity of follow up with the patient’s primary physician to establish a care plan.
Therapeutically:
_Outpatient anti-hypertensive medications were deferred at this time given risks of adverse events/benefits of initiating anti-hypertensive medication without continued monitoring (not feasible in Emergency Department setting). This is in accordance with ACEP clinical guidelines.
Counseling:
The patient was counseled regarding the deleterious long term effects of hypertension and the necessity of follow up with primary care to establish a care plan. The patient was provided with information for primary care providers in the event the patient is not able to obtain prompt follow up. The patient understands that at this time there is no evidence for a more malignant underlying process, but the patient also understands that early in the process of an illness, an initial workup can be falsely reassuring. Routine discharge counseling was given to the patient and the patient understands that worsening, changing or persistent symptoms should prompt an immediate return for reevaluation. The importance of appropriate follow up was also discussed with the patient. More extensive discharge instructions were given in the patient’s discharge paperwork. Patient expressed understanding of plan, was amenable to plan. All questions answered.
Disposition:
Discharged with primary care follow up.
*This information is intended for educational purposes only and not intended for use in patient care (which requires a trained credentialed attending physician and individualization of the medical care plan to the specific patient).