Pediatric Hypertension Evaluation Note

Date/Time: [Date and time]

Patient: [Full name]; [DOB]; [Age in years and months]; [MRN]

Location: [primary care / nephrology / cardiology consult / emergency / other]

Clinician: [Name, credentials]

Chief Concern

[One-line reason for evaluation of elevated BP or suspected hypertension]

History Source

[Historian(s): patient / parent-guardian / records]; [Interpreter used: language and modality / not used]; [Reliability qualifier if needed]

Referral Question

[Specific consult question from referring clinician] (Include only for consultations; omit section entirely for primary care encounters.)

History of Present Illness

[Narrative HPI covering onset and timeline of elevated BP readings, prior evaluation or treatments completed, symptoms suggestive of severe HTN or target-organ effects, and relevant comorbidities affecting thresholds or urgency]

BP Measurement Context

(Required subsection. For any item not available, state "Not documented" rather than leaving blank.)

• Prior clinic BP readings: [Date – SBP/DBP, limb, position, method] (List each relevant prior reading.)
• Today's measurement protocol:
  • [Rest period before measurement in minutes]
  • [Patient position: seated with back supported / feet flat / arm at heart level / other]
  • [Cuff size confirmed appropriate and on bare arm: yes / no]
  • [Device type: auscultatory / oscillometric]
  • [Number of readings obtained and whether averaged]
  • [If oscillometric elevated, auscultatory confirmation performed: yes / no / not applicable]
• Classification method: [Age <13: percentile-based | Age ≥13: adult thresholds]
• Assigned category: [Normal / Elevated BP / Stage 1 HTN / Stage 2 HTN] based on [specific dates and values]
• Out-of-office BP data:
  • Home BP monitoring: [Device, technique training status, log summary with dates and averages]
  • ABPM: [Date, adequacy, 24-hr/daytime/nighttime averages, phenotype: ambulatory HTN / white coat HTN / masked HTN, dipping status] (Include if available.)

Symptom Screen

• Renal: [hematuria / edema / recurrent UTIs / none]
• Sleep-disordered breathing: [snoring / witnessed apneas / daytime sleepiness / none]
• Endocrine/autonomic: [palpitations / diaphoresis / episodic headaches / weight change / none]
• Cardiovascular: [exercise intolerance / chest pain / syncope / none]
• Neurological/visual: [severe headache / visual changes / focal deficits / none]

Past Medical History

• Birth/perinatal: [prematurity / NICU / umbilical arterial catheterization / neonatal kidney disease / unremarkable]
• Kidney disease: [type and status / none]
• Cardiac disease/coarctation: [history and status / none]
• Endocrine/metabolic: [thyroid / adrenal / diabetes / other / none]
• Obesity/OSA/inflammatory conditions: [specify / none]
• Surgical history: [cardiac / urologic / renal interventions / other / none]

Medications

• Current medications: [List with doses and schedules]
• BP-raising exposures: [stimulants / steroids / decongestants / NSAIDs / hormonal contraception / caffeine-energy products / nicotine / none]
• Antihypertensives: [agents, doses, timing, adherence, side effects / none]

Allergies

[Allergen and reaction type / No known drug allergies]

Family History

• Hypertension in first-degree relatives: [yes with age of onset / no / unknown]
• Premature cardiovascular disease or sudden death: [yes with relation and age / no]
• Heritable kidney or endocrine conditions: [specify / none]

Social and Lifestyle History

• Diet: [overall pattern, sodium intake, processed foods, sugar-sweetened beverages, caffeine/energy drinks]
• Physical activity: [type/frequency/duration, sedentary/screen time]
• Sleep: [duration, snoring/OSA risk]
• Tobacco/vaping/substance exposure: [yes with details / no]
• Psychosocial factors: [stressors, access barriers, family support relevant to adherence]

Review of Systems

(Focused; include positives and pertinent negatives only.)

• Neurological/vision: [findings]
• Cardiovascular/respiratory: [findings]
• Renal/urinary: [findings]
• Endocrine: [findings]
• Sleep: [findings]

Objective

Vitals and Growth

• Height/Weight/BMI: [values with percentiles]
• Heart rate: [value] bpm
• BP readings today: [List each with time, SBP/DBP, limb, position, method; identify final reported BP and whether averaged]

Physical Exam

• General: [well-appearing / distress / anxiety / pain]
• Eyes: [fundoscopic findings / not examined]
• Thyroid: [normal / enlarged / nodules]
• Cardiovascular: [rate/rhythm, murmurs, femoral pulses present and symmetric / diminished, radiofemoral delay present / absent, four-extremity BP comparison if obtained]
• Abdomen: [masses / bruits / normal]
• Skin: [acanthosis nigricans / striae / normal]
• Extremities: [edema: yes / no]
• Neurological: [grossly intact / focal deficits]

Data Reviewed

• Outside BP readings: [dates and values]
• Laboratory results: [UA, electrolytes, BUN/Cr, lipids, A1c with dates and key findings]
• Imaging: [renal ultrasound, echocardiogram with dates and pertinent findings]
• ABPM report: [summary if not already detailed above]

Assessment

(Problem-oriented; list highest acuity first.)

Problem 1: [Elevated blood pressure / Hypertension]

Current category/stage: [Normal / Elevated BP / Stage 1 HTN / Stage 2 HTN] based on [specific readings and dates]; [percentile-based / adult thresholds]

• Chronicity: [new / persistent] across [number] visits over [timeframe]
• Symptom status: [asymptomatic / symptomatic with details]
• Phenotype: [primary HTN / secondary HTN / white coat HTN / masked HTN] (Include only if supported by documented data.)
• Secondary cause differential: [renal parenchymal / renovascular / coarctation / endocrine / OSA / medication-induced] (Tailor to clinical findings.)

Problem 2: [Additional relevant problem]

[Assessment of additional problem relevant to BP management] (Include only if discussed.)

Plan

Problem 1: Elevated BP / Hypertension

Confirmation and Monitoring

• Repeat office BP: [timing and technique instructions]
• ABPM: [indicated / ordered / completed / not indicated with rationale]
• Home BP: [device recommendation, training provided, logging instructions, frequency]

Diagnostic Evaluation

• Baseline screening: [UA, chemistry/renal function, lipid profile] – [ordered / completed / pending]
• Conditional testing: [renal ultrasound, A1c/LFTs, sleep evaluation, renovascular or endocrine testing] – [ordered / not indicated with rationale]
• Coarctation screening: [four-extremity BP comparison, femoral pulse assessment, echo/cardiology referral status]

Target-Organ Evaluation

• Echocardiography: [not indicated / ordered / completed with date and findings including LV mass and LVH status] (If deferring, state rationale.)
• Retinal evaluation: [not indicated / ordered / completed] (Consider for stage 2 HTN.)
• Urinalysis: [proteinuria/hematuria status]

Lifestyle Counseling

• Nutrition: [DASH-style guidance, sodium reduction, sugar-sweetened beverage reduction]; dietitian referral [placed / declined / not indicated]
• Physical activity: [prescription with type, frequency, duration]; restrictions [yes with details / no]
• Weight management: [plan if BMI elevated]
• Sleep: [sleep hygiene counseling, OSA referral if indicated]
• Substance avoidance: [caffeine/energy products, nicotine/vaping counseling]
• Patient/family response: [understanding, barriers identified, commitment to changes]

Pharmacologic Therapy

• Status: [not starting / starting / adjusting]
• If not starting: [rationale and triggers for future initiation]
• If starting/adjusting: [indication, agent and rationale, dose and schedule, titration plan, BP targets, lab monitoring, adverse effect counseling, adherence plan]

Follow-up

• Interval: [specific timeframe based on BP severity]
• Reassess: [BP control, adherence, side effects, pending results]
• Escalation instructions: [seek urgent care for severe headache, vision changes, chest pain, neurological symptoms, or very high home BP readings]

Referrals

• [Nephrology / Cardiology / Sleep medicine / Nutrition / Ophthalmology] – [placed / pending / not indicated]

Problem 2: [Additional problem]

• [Plan for additional problem] (Include only if applicable.)

Orders

• Labs: [List with status / None]
• Imaging: [List with status / None]
• Medications: [New or changed medications with dose/schedule / None]
• Referrals: [List services / None]