Internal Medicine - Follow Up

Reason for Referral John Doe, a 58-year-old male, was referred by Dr. Emily Carter for further evaluation of his persistent hypertension and recent episodes of dizziness. Update John Doe has a history of hypertension for the past 10 years, managed with Lisinopril 10 mg daily. Recently, he has experienced increased episodes of dizziness, particularly in the mornings. His blood pressure readings have been consistently high, averaging 150/95 mmHg. He was diagnosed with type 2 diabetes last year and is currently on Metformin 500 mg twice daily. No other significant changes in his medical history were noted. Physical Examination Vital signs: Blood pressure 155/98 mmHg, heart rate 78 bpm, respiratory rate 16 breaths per minute, temperature 36.8°C. Cardiovascular examination revealed a regular heart rhythm with no murmurs. Respiratory examination was unremarkable. Abdominal examination showed no tenderness or organomegaly. Neurological examination was normal. Summary During the consultation, we discussed the importance of blood pressure control and lifestyle modifications. I advised John to monitor his blood pressure at home and maintain a log. We discussed the potential need for medication adjustment. A referral to a cardiologist was made for further evaluation. We will continue with the current diabetes management plan and review in four weeks. Plan 1. Increase Lisinopril to 20 mg daily. 2. Referral to cardiologist for further evaluation. 3. Order blood tests including CBC, renal function, and HbA1c. 4. Schedule follow-up appointment in four weeks.