Generate an HPI for an adult new‑patient establishment and well visit with hypertension, anxiety, chronic left‑knee effusion from childhood injury, who wants weight loss and to restart antihypertensive therapy.

History of Present Illness

This is a new patient establishment and well visit for an adult with a history of hypertension, anxiety, and chronic left knee effusion from a childhood orthopedic injury, now seeking to restart antihypertensive therapy and pursue weight loss.

Chief Concern

The patient presents for establishment of care with three primary goals:

• Restart antihypertensive medication for hypertension control 1
• Initiate weight loss intervention 1
• Routine health maintenance 1

Hypertension History

• Duration and diagnosis: Establish when hypertension was first diagnosed, previous blood pressure readings, and whether the patient has ever achieved target blood pressure control 1
• Previous antihypertensive regimen: Document specific medications previously used (drug class, dose, duration), reason for discontinuation, and any adverse effects experienced 1
• Current blood pressure status: Obtain accurate bilateral arm blood pressure measurements using proper technique after 5 minutes of quiet sitting 2. The 2017 ACC/AHA guideline defines hypertension as ≥130/80 mmHg and recommends initiating drug therapy at this threshold in adults with established cardiovascular disease or 10-year ASCVD risk ≥10% 1
• Target organ assessment: Screen for symptoms of hypertensive complications including headache, visual changes, chest pain, dyspnea, or neurological deficits 2
• Cardiovascular risk factors: Document smoking status, family history of premature cardiovascular disease, diabetes, dyslipidemia, and chronic kidney disease 1

Weight and Metabolic History

• Current weight status: Calculate body mass index (weight in kg/[height in meters]²) to quantify degree of overweight or obesity 3
• Weight trajectory: Document recent weight changes, maximum lifetime weight, and previous weight loss attempts 4
• Dietary patterns: Assess current sodium intake (target <100 mEq/24 hours), alcohol consumption (should be ≤2 drinks/day for men, ≤1 drink/day for women), and adherence to DASH diet principles 1, 5
• Physical activity level: Determine current exercise frequency and duration (goal: minimum 30 minutes most days of the week) 1, 5
• Weight loss expectations: Clarify patient's weight loss goals and motivation. Evidence shows 10 kg weight loss reduces systolic blood pressure by approximately 6 mmHg and diastolic by 4.6 mmHg 6

Anxiety History

• Current symptoms and severity: Document frequency, triggers, and impact on daily functioning
• Treatment history: Note previous or current psychiatric medications, particularly SNRIs which can elevate blood pressure 2
• Relationship to blood pressure: Assess whether anxiety contributes to blood pressure elevation in medical settings (white coat effect) 1, 2

Left Knee Effusion

• Childhood injury details: Document mechanism of original orthopedic injury and any surgical interventions
• Current functional status: Assess pain level, range of motion limitations, and impact on ability to exercise
• Treatment history: Note previous interventions (aspiration, physical therapy, medications)
• Impact on weight management: Determine if knee pathology limits physical activity options for weight loss 3

Medication Restart Considerations

Before restarting antihypertensive therapy, the following must be assessed 7:

• Renal function: Obtain serum creatinine, eGFR, and urinalysis for proteinuria. A 10-20% rise in creatinine after ACE inhibitor initiation is expected and reflects hemodynamic changes rather than injury 7
• Volume status: Assess for orthostatic hypotension, reduced skin turgor, or dry mucous membranes, as volume depletion increases risk of acute renal failure with ACE inhibitors 7
• Drug interactions: Review for concomitant nephrotoxic agents (NSAIDs, aminoglycosides) that increase acute renal failure risk 7
• Vascular screening: In patients with multiple atherosclerotic risk factors, screen for bilateral renal artery stenosis, as ACE inhibitors can cause reversible acute renal failure in this population 7

Patient Education Needs

Patients want specific information about their medications to improve adherence 8:

• All possible side effects and most likely side effects (90% of patients want this information) 8
• Whether drug treatment will keep them well (96% want to know) 8
• Potential for multiple medications and life-long treatment requirements 8
• Drug interactions and lifestyle modifications needed to augment therapy 8

Review of Systems

• Cardiovascular: Chest pain, palpitations, dyspnea on exertion, orthopnea, peripheral edema
• Neurological: Headaches, visual changes, dizziness, syncope, focal weakness
• Renal: Changes in urinary frequency, nocturia, hematuria
• Musculoskeletal: Joint pain, swelling, functional limitations affecting exercise capacity