What should be documented in the HPI (History of Present Illness) for a blood pressure (BP) follow‑up?

Documentation Requirements for Blood Pressure Follow-Up HPI

For a blood pressure follow-up visit, document current BP readings with proper technique, medication adherence and side effects, interval symptoms of target organ damage, lifestyle modification compliance, and any factors that may affect BP control. 1, 2

Blood Pressure Measurements

• Record current BP values using proper technique: patient seated quietly for 5 minutes with back supported, correct cuff size encircling at least 80% of arm, arm supported at heart level, minimum 2 readings at 1-minute intervals averaged together 3
• Document BP stage classification: Normal (<120/80), Elevated (120-129/<80), Stage 1 (130-139/80-89), or Stage 2 (≥140/≥90 mmHg) 4
• Include orthostatic BP measurements if patient is elderly or on multiple antihypertensives, noting any decline >20 mmHg systolic or >10 mmHg diastolic after 1 minute of standing 3
• Compare to previous BP readings to assess trend and rate of change, as gradual increases suggest primary hypertension while abrupt changes warrant investigation for secondary causes 2

Medication History

• Document all current antihypertensive medications with specific doses, frequency, and duration of therapy 2, 3
• Assess medication adherence explicitly, including barriers such as cost, side effects, or complexity of regimen 3
• Record any medication side effects including dizziness, fatigue, cough (ACE inhibitors), ankle edema (calcium channel blockers), or electrolyte disturbances 4, 3
• List all other medications that may elevate BP, including NSAIDs, decongestants, oral contraceptives, and corticosteroids 2

Symptoms and Target Organ Assessment

• Inquire about cardiovascular symptoms: chest pain, dyspnea, palpitations, or orthopnea suggesting heart failure or coronary disease 2
• Ask about neurological symptoms: headaches, visual changes, weakness, or transient ischemic symptoms suggesting cerebrovascular disease 2
• Document renal symptoms: hematuria, nocturia, decreased urine output, or edema suggesting kidney involvement 2
• Screen for symptoms suggesting secondary hypertension: muscle weakness or cramps (hyperaldosteronism), sweating and palpitations (pheochromocytoma), snoring and daytime sleepiness (sleep apnea) 2, 3

Lifestyle Factors

• Document dietary sodium intake and recent changes, as restriction to <1500 mg/day is recommended 1, 3
• Record alcohol consumption in drinks per week, with moderation defined as ≤2 drinks/day for men and ≤1 drink/day for women 1
• Assess physical activity level in minutes per week, with goal of 90-150 minutes weekly 1
• Note recent weight changes and current BMI, as weight gain is independently associated with BP elevation and hypertension development 2, 5
• Identify stress factors: job changes, life events, depression, or anxiety that may affect BP control 2

Interval Events and Complications

• Document any hospitalizations since last visit, particularly cardiovascular events, as SBP <124 mmHg in very frail elderly may predict increased hospitalization risk 6
• Record any falls or syncope, especially in elderly patients where excessive BP lowering may impair perfusion 6
• Note any new diagnoses of diabetes, chronic kidney disease, or cardiovascular disease that would change BP targets to <130/80 mmHg 1

Risk Stratification Elements

• Calculate or update 10-year ASCVD risk using the Pooled Cohort Equations, as this determines treatment intensity for Stage 1 hypertension 1
• Document presence of diabetes or chronic kidney disease, which automatically classify patients as high-risk and warrant combination pharmacologic therapy 1
• Note any target organ damage disproportionate to duration or severity of hypertension, which suggests secondary causes 2, 3

Common Pitfalls to Avoid

• Do not rely on single BP measurement for treatment decisions; confirm with out-of-office monitoring (home or ambulatory) to exclude white-coat hypertension, especially in readings 130-159/80-99 mmHg 1
• Do not overlook medication non-adherence as the most common cause of apparent treatment resistance before pursuing extensive secondary hypertension workup 3
• Do not assume all elderly patients need aggressive BP lowering; those aged ≥70 years show increased MACE risk only at Stage 2 hypertension (≥140/90 mmHg), not Stage 1 7
• Do not document BP control as adequate without specifying the target: <130/80 mmHg for most adults and those with diabetes/CKD, versus <140/90 mmHg using older criteria 4, 1