CardX Hypertension Management Use Case, published by Clinical Interoperability Council. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/cardx-ig/ and changes regularly. See the Directory of published versions

Use Cases

Hypertension Use Case Version 0.1

This narrative example illustrates the data values and information captured for patient with hypertension throughout their patient journey.

Initial Clinical Encounter A 68-year old Chinese American male recently moved to your community and is establishing care. He recently retired after 30 years as a high school math teacher. His diet consists of a traditional Chinese food but he admits to enjoy fast food several times per week. He smoked for 10 years but quit in 1980. He has an occasional beer or wine. He has no specific complaints. He has had no major surgery or hospitalizations. He states that he is generally in good health but admits he doesn’t regularly exercise and sees clinicians “only when he has to”. He takes no prescriptions and has no medical allergies. Vital Signs: BP Using appropriate techniques an initial blood pressure was obtained 158/94 Pulse-75, as second blood pressure is taken after sitting quietly for 10 minutes and is 150/92. The physical examination is remarkable only an S4. He is scheduled to see the dietician and return in 4 weeks.

1-month Encounter After dietary counseling, he returns. His blood pressure is now 144/90 initially and 138/88. His ECG suggest left atrial abnormality and left ventricular hypertrophy. His cholesterol studies demonstrate a cholesterol of 200, LDL of 136, and HDL of 40. His ASCVD risk score is 10.2% He is prescribed atorvastatin 20 mg for his cardiac risk factors and chlorthalidone 25 mg daily for his hypertension. He is asked to purchase an American Heart Association approved blood pressure cuff. He is asked to record his blood pressure twice daily for 4 weeks and return to see the APP and nurse. He will also have a blood draw to measure his kidney function, sodium and potassium levels. The patient goal for home blood pressure is less 120/80.

2-month Encounter He returns with his blood pressure log. He is tolerating the medication well. His in-office blood pressure is 132/78. His home blood pressures range from 118-156 systolic and diastolic blood pressures 78-88. His creatinine 1.1 and BUN is 24 (both upper limits of normal) His serum sodium is 138 but his potassium is low at 3.4. Based on these results he is started on Lisinopril 10 mg daily and KCL 20 meq daily. He is asked to continue to trend his home blood pressures and he is scheduled for follow-up in 4 months. 6-month Encounter: On return his blood pressure is 124/76. Home blood pressures range from 108-128 systolic and 70-78 systolic. His labs indicate that his creatinine is 1.2, BUN 24, sodium 136 and potassium 4.0 . His cholesterol is no 142 with an LDL of 70 and an HDL of 42. He is getting at least 150 minutes of exercise weekly and continues to follow a lower sodium diet.