she has never been identified as being diabetic hypercholesterolemic and hypertensive not thus has a history of cancers bleeding disorder unexplained anemia gastrointestinal tract disturbanc
Convert the below dictated lines into History and Physical Report transcription with appropriate format of Hx/ Px Report including headings and all the rules of report transcription with proper closing
a pleasant middle aged woman who is seen for the evaluation of hypertension
she was recently seen for the first time and is found to be hypertensive
the blood pressure was not seriously elevated
never had a history of hypertension
she has never been identified as being diabetic hypercholesterolemic and hypertensive
not thus has a history of cancers bleeding disorder unexplained anemia gastrointestinal tract disturbance or endocrinology problem
review of the system (ROS) this patient is a very healthy woman
the rest of the review is negative not contributory
family history (FH) it is completely not contributory as she is adopted and has no information of her biological family
social history (SH) it indicates a woman who in her twenties smoked cigarettes for about ten years and consumed almost a pack a day but she has not done smoking for over thirty years
she is not a user of alcoholic beverages
she works forty eight hours a week at an auto part painting company and therefore exposes dust and paint fumes
she does not exercise at home
physical examination
general appearance a mildly overweight middle aged woman is encountered
vital sign the blood pressure i obtained in the exam is one fifty eight over one hundred and four pulse rate ninety per minute
eyes examination it does not reveal lipidosis
neck examination it feels radial jugular venous distention (JVD) or carotid bruit
chest examination it reveals a good movement of air about wheezes rales or rhonchi
cardiac examination it demonstrates a normal sinus rhythm without murmur gallop or palpable cardiac enlargement
the aorta is neither dilated nor tender no aortic bruit heard
abdomen examination it revealed a somewhat soft obese abdomen
no tenderness listed no palpation no liver and spleen enlargement noted
extremities examination it reveals intact thermal and pedal pulses
no femoral bruits noted
no dependent edema found
neurologic examination it reveals normal agitation orientation and mentation
skin examination it does not reveal a status change
plan at a counseling session with this patient regarding hypertension its implications and its management
on the basis of that discussion i believed that she should be on antihypertensive medication
i have taken the liberty of starting a hyzaar fifty over twelve point five milligram three times a day and we will followup with her in one month to see if it seems to improve the situation
a basic metabolic panel (BMP) will be obtained in two weeks and on that same occasion a fasting lipid profile will be obtained
lastly an echocardiogram will be obtained to evaluate left ventricular performance and wall fitness in this moment with newly diagnosed hypertension
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