Issue 1: Hypertension
Subjective:
- The patient, a 55-year-old male, visited for a routine check-up and management of hypertension. He reports occasional headaches and dizziness.
- Past medical history includes hypertension diagnosed 5 years ago and a cholecystectomy 10 years ago.
- Current medications include Lisinopril 20 mg daily and a multivitamin supplement.
- Social history reveals the patient is a non-smoker and consumes alcohol occasionally.
- No known drug allergies.
- ICE: The patient is concerned about his blood pressure levels and expects to maintain them within normal range.
- No red flag symptoms mentioned.
- Direct questions: No chest pain, no shortness of breath.
Objective:
- Blood pressure: 150/95 mmHg, Heart rate: 78 bpm, Weight: 85 kg, Height: 175 cm.
- Physical examination: No abnormalities detected.
- Recent blood tests show normal renal function.
Assessment:
- Uncontrolled hypertension, likely due to non-adherence to medication.
Plan:
- Reinforce the importance of medication adherence.
- Increase Lisinopril to 40 mg daily.
- Schedule follow-up in 4 weeks.
- Consider referral to a dietitian for weight management.
Issue 2: Seasonal Allergies
Subjective:
- The patient reports increased sneezing and nasal congestion over the past two weeks, especially in the mornings.
- No significant past medical history related to allergies.
- No additional medications or supplements for allergies.
- Social history unchanged.
- No new allergies reported.
- ICE: The patient is concerned about the impact of symptoms on daily activities and expects relief with treatment.
- No red flag symptoms mentioned.
- Direct questions: No fever, no cough.
Objective:
- Nasal examination reveals mild swelling of the nasal turbinates.
Assessment:
- Seasonal allergic rhinitis.
Plan:
- Start Loratadine 10 mg daily.
- Advise on allergen avoidance strategies.
- Review in 2 weeks if symptoms persist.
Consented for transcription
