APSO

Assessment & Plan: 1. Hypertension Likely etiology: Genetic predisposition and lifestyle factors Management plan: Initiate lifestyle modifications including a low-sodium diet and regular exercise. Prescribe Lisinopril 10 mg daily. Follow-up instructions: Re-evaluate blood pressure in 4 weeks. 2. Type 2 Diabetes Mellitus Current status: HbA1c at 7.5% Treatment options: Continue Metformin 500 mg twice daily, consider adding a GLP-1 receptor agonist. Follow-up instructions: Monitor blood glucose levels daily and follow up in 3 months. 3. Hyperlipidemia Likely classification: Primary hyperlipidemia Review of previous results: LDL cholesterol at 160 mg/dL Referral: Consider referral to a dietitian for nutritional counseling. Subjective: Patient reports fatigue and occasional headaches for the past 3 months. No recent travel or exposure to infectious diseases. Recent blood tests show elevated fasting glucose levels. Denies chest pain or shortness of breath. Eating habits include high intake of processed foods. Currently taking Metformin and Lisinopril. Additional symptoms include occasional dizziness. Review of Systems: Constitutional: Reports fatigue, denies fever or weight loss. Eyes: No visual changes or eye pain. Ears, Nose, Mouth, Throat: Occasional sore throat, no ear pain. Respiratory: Denies cough or shortness of breath. Gastrointestinal: Reports occasional constipation. Objective: Lung examination: Clear to auscultation bilaterally. Heart examination: Regular rate and rhythm, no murmurs. Ear examination: Tympanic membranes intact, no effusion.