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Subjective:

CC: "Follow-up for hypertension management."

HPI: Mrs. A., a 56-year-old woman, presents to the hospital for a routine follow-up appointment

for her hypertension. She reports that she has been taking her prescribed medications regularly

and monitoring her blood pressure at home. She denies any specific concerns or new symptoms

related to her hypertension. She mentions that she is committed to making lifestyle changes to

improve her overall health.

Past Medical History:

Hypertension (diagnosed 5 years ago)

Type 2 diabetes (controlled with metformin)

Hyperlipidemia

Obesity

History of smoking (quit 10 years ago)

Allergies:

No known drug allergies

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Medications:

Metformin 1000mg twice daily

Lisinopril 10mg once daily

Atorvastatin 20mg once daily

Social History:

Former smoker (quit 10 years ago)

No alcohol use

Sedentary lifestyle

Family History:

Mother - Hypertension, Type 2 diabetes

Father - Hyperlipidemia

Review of Systems:

Constitutional: Denies fatigue or decreased exercise tolerance.

Respiratory: No cough, wheezing, or shortness of breath.

Cardiovascular: No chest pain, palpitations, or edema.

Gastrointestinal: No abdominal pain, nausea, vomiting, or changes in bowel habits.

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Genitourinary: No urinary symptoms.

Musculoskeletal: No joint pain or swelling.

Neurological: No headaches, dizziness, or focal deficits.

Psychiatric: No signs of depression or anxiety.

Endocrine: History of well-controlled type 2 diabetes.

Objective:

Vital Signs: HR: 78, BP: 130/80, Temp: 98.6, RR: 16, SpO2: 98%, Pain: 0/10

Height: 5 ft 6 in, Weight: 200 lbs, BMI: 32.3

Physical Exam:

General: Patient appears alert and oriented.

Cardiovascular: Regular rate and rhythm, no murmurs or extra heart sounds. No peripheral

edema.

Respiratory: Clear breath sounds bilaterally, no wheezing or crackles.

Abdomen: Soft and non-tender, no organomegaly.

Neurological: Cranial nerves intact, no focal deficits.

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Assessment:

Differential Diagnoses:

1. Controlled Hypertension: Her hypertension appears well-controlled based on the patient's

reported medication adherence and stable blood pressure readings.

2. Cardiovascular Risk Assessment: Considering the patient's comorbidities (type 2 diabetes,

hyperlipidemia, obesity), it is essential to assess her overall cardiovascular risk and ensure

appropriate management.

Diagnosis: Well-controlled Hypertension (I10) (Kearney et al., 2005)

Plan:

Diagnostics:

1. Laboratory tests: Repeat lipid panel and fasting blood glucose to assess cardiovascular risk

factors and overall health status.

Treatment Plan:

1. Medication Continuation: Continue the current medication regimen, including metformin,

lisinopril, and atorvastatin.

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2. Lifestyle Modifications: Reinforce the importance of adhering to a heart-healthy diet,

engaging in regular physical activity, and maintaining a healthy weight(Muntner, 2022).

3. Blood Pressure Monitoring: Encourage regular blood pressure monitoring at home and

emphasize the need to report any significant changes or concerns(Al-Makki, 2022).

4. Patient Education: Provide education on the long-term management of hypertension,

emphasizing the importance of lifestyle modifications and medication adherence(Al-Makki, 2022).

5. Cardiovascular Risk Assessment: Conduct a comprehensive cardiovascular risk assessment,

including calculating cardiovascular risk scores (e.g., Framingham Risk Score), to guide further

preventive measures.

Education:

1. Heart-Healthy Lifestyle: Discuss the benefits of maintaining a healthy weight, following a

balanced diet, exercising regularly, and avoiding tobacco use.

2. Medication Adherence: Emphasize the importance of taking prescribed medications regularly

and on time to maintain blood pressure control and reduce cardiovascular risk.

3. Blood Pressure Monitoring: Educate the patient on the correct technique for measuring blood

pressure at home and stress the significance accurately of recording and reporting the readily.

Follow-up:
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Schedule a follow-up appointment in 6 months to reassess blood pressure control, review

laboratory results, discuss any concerns or changes in symptoms, and make any necessary

adjustments to the management plan.

References.

Kearney, P. M., Whelton, M., Reynolds, K., Muntner, P., Whelton, P. K., & He, J. (2005). Global burden of

hypertension: analysis of worldwide data. The lancet, 365(9455), 217-223.

Al-Makki, A., DiPette, D., Whelton, P. K., Murad, M. H., Mustafa, R. A., Acharya, S., ... & Khan, T. (2022).

Hypertension pharmacological treatment in adults: a World Health Organization guideline executive

summary. Hypertension, 79(1), 293-301.

Muntner, P., Miles, M. A., Jaeger, B. C., Hannon Iii, L., Hardy, S. T., Ostchega, Y., ... & Schwartz, J. E.

(2022). Blood pressure control among US adults, 2009 to 2012 through 2017 to

2020. Hypertension, 79(9), 1971-1980.