tags:
  - type/patient/encounter
encid: 103-1-1
name: enc103-1-1
counter: 1
status: 1
reason:
patient: pat103
patient_link: "[[pat103.patient]]"
clinical_case_link: "[[cc103-1.clincase]]"
banner: "![[_System/Banners/patient_encounter_banner.jpg]]"
created_at: 2025-09-03T21:27:33+03:00
updated_at: 2025-09-04T13:47:24+03:00
banner_y: 0.26255
weight: 78
weight_unit: kgr
height: 172
height_unit: cm
posture_gait: Normal
iscooperative: true
mood: ANXIOUS
skin:
head:
breast:
resp: No cough, no shortness of breath at rest, no wheezing.
cardio: Headache, palpitations, occasional chest tightness, no syncope.
gastro: No nausea, no vomiting, no abdominal pain.
urin: No dysuria, no hematuria, normal urine output.
genital: ""
periph:
musc: No leg swelling, no muscle weakness.
neuro:
hemo:
endo: No heat/cold intolerance, no polyuria or polydipsia.
systolic: 160
diastolic: 109
pulse_rate: 94
resp_rate: 20
temp: 36.8
temp_unit: °C
spo2: 97
vitals_notes: hypertensive but stable (no acute respiratory or febrile illness, oxygenating normally).
chief_complaint: Severe Hypertension (Hypertensive Crisis — Urgency)
other_symptoms: Persistent severe headache (often reported in patients with very high blood pressure).
disease_course: |-
  Initial presentation: Patient with hypertension, now showing progressive worsening despite lifestyle measures.

  No evidence of acute end-organ damage (so this is not hypertensive emergency).

  BP readings consistently above 160/100 mmHg.

  Risk factors: Age, obesity, sedentary lifestyle, possible family history.
instructions: |-
  Lifestyle measures (always alongside drugs):
  Low-salt DASH diet
  Weight reduction, exercise (150 min/week moderate intensity)
  Alcohol moderation, no smoking, stress management

  Monitoring:
  Home BP diary (twice daily readings)
  Labs: Electrolytes, renal function, fasting glucose, lipid profile (baseline and at follow-ups)

  Review for secondary causes (renal artery stenosis, endocrine disorders) if refractory

  Follow-up:
  Recheck BP in 4 weeks after initiating or adjusting therapy
  Target: <130/80 mmHg (in most patients, per current guidelines)
cssclasses:
  - table-color
  - table-lines
medication:
  - end_date: ""
    start_date: 2025-09-03
    drug: Lisinopril
    dosage: 10mg
  - drug: Titrate
    dosage: 10mg
    end_date: ""
communication: Excellent

enc103-1-1.encounter

tags:
  - type/patient/encounter
encid: 103-1-1
name: enc103-1-1
counter: 1
status: 1
reason:
patient: pat103
patient_link: "[[pat103.patient]]"
clinical_case_link: "[[cc103-1.clincase]]"
banner: "![[_System/Banners/patient_encounter_banner.jpg]]"
created_at: 2025-09-03T21:27:33+03:00
updated_at: 2025-09-04T13:47:24+03:00
banner_y: 0.26255
weight: 78
weight_unit: kgr
height: 172
height_unit: cm
posture_gait: Normal
iscooperative: true
mood: ANXIOUS
skin:
head:
breast:
resp: No cough, no shortness of breath at rest, no wheezing.
cardio: Headache, palpitations, occasional chest tightness, no syncope.
gastro: No nausea, no vomiting, no abdominal pain.
urin: No dysuria, no hematuria, normal urine output.
genital: ""
periph:
musc: No leg swelling, no muscle weakness.
neuro:
hemo:
endo: No heat/cold intolerance, no polyuria or polydipsia.
systolic: 160
diastolic: 109
pulse_rate: 94
resp_rate: 20
temp: 36.8
temp_unit: °C
spo2: 97
vitals_notes: hypertensive but stable (no acute respiratory or febrile illness, oxygenating normally).
chief_complaint: Severe Hypertension (Hypertensive Crisis — Urgency)
other_symptoms: Persistent severe headache (often reported in patients with very high blood pressure).
disease_course: |-
  Initial presentation: Patient with hypertension, now showing progressive worsening despite lifestyle measures.

  No evidence of acute end-organ damage (so this is not hypertensive emergency).

  BP readings consistently above 160/100 mmHg.

  Risk factors: Age, obesity, sedentary lifestyle, possible family history.
instructions: |-
  Lifestyle measures (always alongside drugs):
  Low-salt DASH diet
  Weight reduction, exercise (150 min/week moderate intensity)
  Alcohol moderation, no smoking, stress management

  Monitoring:
  Home BP diary (twice daily readings)
  Labs: Electrolytes, renal function, fasting glucose, lipid profile (baseline and at follow-ups)

  Review for secondary causes (renal artery stenosis, endocrine disorders) if refractory

  Follow-up:
  Recheck BP in 4 weeks after initiating or adjusting therapy
  Target: <130/80 mmHg (in most patients, per current guidelines)
cssclasses:
  - table-color
  - table-lines
medication:
  - end_date: ""
    start_date: 2025-09-03
    drug: Lisinopril
    dosage: 10mg
  - drug: Titrate
    dosage: 10mg
    end_date: ""
communication: Excellent

PROFILE MEDICAL HISTORY MEDICATION MEDICAL LIBRARY

$= await dv.view("js_scripts/display_patient_full_name", {fname: "prf103.profile", folder: "People/Patient/103"})

VISIT -

plannedrescheduledunscheduledin-progresson-holdpendingcompletedcancelled

- Clinical Case - Patient Record Summary

Thursday, October 2, 2025 at 9:27 AM Eastern European Summer Time

Reason for Encounter:

• Review of Symptoms
• General Review
• Vital Signs
• Review of Symptoms
• Medication Administered
• Clinical Course
• Medical Instructions

Review of Symptoms

Primary Symptom/Condition

Other Symptoms

General Review

#_ehrtable
Weight	kgrlb
Height	cmm
Posture and Gait
Cooperative
Communication
Mood	ANXIOUS
Other

Vital Signs

#_ehrtable
Systolic	mmHg
Diastolic	mmHg
Heart Rate	bpm
Respiratory Rate	breaths/min
Temperature	°C°F
Oxygen Saturation (SpO2)	%
Notes/Remarks

Review of Systems (ROS)

#_ehrtable
Skin
Head/Neck
Breast
Respiratory
Cardiovascular
Gastrointestinal
Urinary
Genital
Peripheral
Musculoskeletal
Neurological
Hematologic
Endocrine

Medication Administered

DRUG	DOSE	STARTS	ENDS	OTHER

Add Row

Clinical Course

Stages of Progression

Medical Instructions

...