MPM (Internal Medicine)

Physical Exam: Diagnostic Tests: - None HYPERTENSION: The patient, a 58-year-old male, presented with a history of hypertension. He is currently taking Lisinopril 20 mg once daily. The patient reported occasional headaches and dizziness, which prompted this visit. His blood pressure readings at home have been consistently elevated, averaging 150/95 mmHg. A detailed review of symptoms revealed no chest pain, palpitations, or shortness of breath. - Impression: Uncontrolled hypertension - Investigations: Blood tests including renal function and electrolytes planned - Discussion: The patient was advised on lifestyle modifications including a low-sodium diet and regular exercise. The importance of medication adherence was emphasized. - Treatment: Increase Lisinopril to 40 mg once daily - Follow-up: Re-evaluate in 4 weeks or sooner if symptoms worsen TYPE 2 DIABETES: The patient has a 10-year history of type 2 diabetes, currently managed with Metformin 1000 mg twice daily. He reported increased thirst and frequent urination over the past month. His last HbA1c was 8.2%. - Impression: Poor glycemic control - Investigations: HbA1c and fasting glucose levels to be repeated - Discussion: Discussed the need for better glycemic control and potential adjustment of medication. - Treatment: Continue current management - Follow-up: Review in 3 months or sooner if symptoms persist HYPERLIPIDEMIA: The patient is on Atorvastatin 20 mg daily for hyperlipidemia. Recent lipid profile showed LDL levels at 130 mg/dL. - Impression: Suboptimal lipid control - Treatment: Increase Atorvastatin to 40 mg daily - Follow-up: Lipid profile to be repeated in 6 weeks HEALTH MAINTENANCE: - Screening tests: Due for colorectal cancer screening - Immunizations: Up to date - Medication list and allergies reviewed and updated