SUBJECTIVE: This is a (XX)-year-old male known to have hypertension, renal failure, diabetes mellitus and has been a chronic smoker. The patient comes in again with complaints of upper respiratory tract infection.
The patient was given amoxicillin a week ago. The patient stated that he used his last medication today.
He is feeling better but still he is bringing up greenish-yellowish phlegm and still feels like he has chest congestion.
CURRENT MEDICATIONS: Clonazepam 1 mg once a day, minoxidil 10 mg t.i.d., enalapril 10 mg t.i.d., clonidine 0.3 mg t.i.d., PhosLo and Cozaar 50 mg once a day.
ALLERGIES: HCTZ AND HYDROXYZINE.
REVIEW OF SYSTEMS: As above. Pain is none.
OBJECTIVE:
GENERAL APPEARANCE: The patient is alert and oriented, not in distress.
VITAL SIGNS: Temperature 97.4, blood pressure 160/96, respiratory rate 18 and pulse rate 72.
LUNGS: Good air entry bilaterally. The patient, however, had congestion present.
HEART: Regular rate and rhythm. S1, S2 normal.
EXTREMITIES: No edema, cyanosis or clubbing.
ASSESSMENT:
1. Upper respiratory tract infection in a patient who is immune compromised.
2. Diabetes mellitus with renal failure. The patient is still having the symptoms. Even the symptoms have been improved, and we will give another course of the antibiotics.
3. Hypertension is slowly coming down compared to the previous values. The patient is compliant with his medications at this time.
PLAN:
1. Start the patient on Z-Pak and the patient to be followed up as scheduled.
2. The patient will be monitoring the blood pressure at home; if still not controlled, he needs to follow up with us. The patient verbalized understanding.
3. We will check the A1c and the PSA.
