SUBJECTIVE: The patient is a (XX)-year-old gentleman who comes in for blood pressure check. The patient saw Dr. Doe back on March (XX)th. At that point, blood pressure in the office was 142/82, and his home numbers have been about 130 to 160/70.
He is diabetic. His amlodipine was increased from 5 mg to maximal dose of 10. He initially felt like he tolerated this okay. He did not really check his blood pressure all that much in March or April. However, in the past month or so, he has been checking his blood pressure and it has been running on the low side for him. He has had readings as low as 98/56.
He is occasionally having some lightheadedness, which he has had a little bit of in the past but it is happening more often. He is feeling somewhat fatigued. He has allergies also, so he was not sure whether this was contributing.
Highest levels recorded in the past month or so has been 130/68.
He denies any new chest pain, palpitations, difficulty breathing or leg edema. He has a history of aortic stenosis. Last echo was in February YYYY. Last regular EKG on record appears to be from YYYY. He has an appointment coming up with Dr. Doe in less than a month but thought he should be seen sooner and see whether he might be on a little too much medication.
He has been under some stress in the recent months. His wife was ill. He states his sugars are stable. His hydration is good. He is not on any other new medication and has had no other changes in medications.
Past medical history includes hypertension, tinnitus, diabetes, hepatitis C, hypothyroid, and history of Hodgkin’s.
His current medications are glyburide and metformin, Prilosec, levothyroxine, Diovan 320 mg, hydrochlorothiazide 25 mg, amlodipine 10 mg, and aspirin.
He has drug allergy to penicillin.
OBJECTIVE: The patient is a slim gentleman in no acute distress. Weight is 184, up from 175 in early March but previously was 186 in December. Blood pressure, to our reading with a small adult cuff, was approximately 130/78 bilaterally, pulse was 88 to 92. Neck without JVD. Lungs are clear. Heart: Regular rate and rhythm with a marked systolic murmur, which is chronic for the patient. It is probably a 4/6. Extremities: Without edema.
ASSESSMENT AND PLAN: Home readings are concerning for him, being on slightly too much blood pressure medication at this point. We are going to try scaling back his amlodipine to 7.5. He has had some mild issues with leg swelling. We did not stop his hydrochlorothiazide at this point. He has to continue good hydration. Continue to monitor home numbers. We are going to update a baseline EKG today and he can discuss with Dr. Doe when he sees him next month, when he should have repeat echocardiogram, but he certainly does not have any acute signs of failure today. He will let us know if he has any significant new symptoms in the interim. We will contact him as needed regarding any results on EKG.
