ID: Joan Smith

DOB: 04/19/1978
Caucasian female
CC: “I’m here for a hypertension follow-up”
HPI: 41 y/o woman presents for medical management of hypertension diagnosed 6
years ago. She is compliant with her medications and is able to afford them. She checks
her blood pressure every other day after supper and she has brought in her last month’s
readings. She does not exercise but does enjoy nature and leisurely strolls with her dog.
She eats mostly fried meats with complex carbohydrates as her mainstay for sides. She
drinks 48 oz of regular soda per day. She drinks at least one 16 oz bottled water per
day. She has no associated symptoms today. Patient denies blurry vision, headaches,
chest pain, palpitations, dyspnea, peripheral edema, and dizziness.
Medications:
 Rosuvastatin 10mg: one tablet by mouth every day at bedtime for cholesterol
 Amlodipine 10mg: one tablet by mouth every day for hypertension
 Ranitidine: one tablet by mouth every 12hrs as needed for GERD symptoms
 Centrum Adult Multivitamin: one tablet by mouth daily as vitamin
supplementation
Allergies:
 Strawberry allergy – hives and facial swelling
 NKDA or seasonal allergies
Past Medical History:
 Hyperlipidemia (8 years)
 Hypertension (6 years)
 Tobacco Dependence in remission (quit 5yrs ago, 15pk yr hx)

 Immunizations:
o Pediatric: “I had all my shots as a child”
o Adult: “Should be up-to-date”

 Past Surgeries: Tonsillectomy age 12

Past Family History:

 Father, 72, living with high blood pressure, high cholesterol
 Mother, 70, living with diabetes, depression and anxiety
 Sister, 42, depression, obesity
 Grandparents:
o PGF: HTN, CVA, HLD, died age 58 from CVA
o MGM: DMII, Bipolar disorder, HLD, died age 60 MVA accident
Past Social History:
 No current tobacco, alcohol, or illicit drug use
 Occupation: BMW assembly line worker
 Marital status: married, two children (boys)
 Exercise: none
 Diet: fair diet consisting of fried/grilled meats, potatoes, pasta, rice, beans, fruits
o Drinks mostly sweet tea (4qty 12 oz glasses per day)
 Safety: wears seat belt, no guns in home, wears sunscreen

Physical Exam:
Vitals: BP: 150/84 HR: 80 TEMP: 98.6 RR: 16 HT: 65” WT: 182 lbs BMI 30.3
General: WD obese Caucasian female in no immediate distress, well dressed and
kempt, AAOx4
Skin: inspection reveals skin dry and warm with normal texture, turgor and temperature
Eyes: fundoscopic exam reveals presence of red reflex bilaterally with no hemorrhage,
papilledema, cotton wool spots, or AV nicking.
Respiratory: LCTAB
Cardio: auscultation reveals s1/s2 split, RRR with no m/g/r/c. auscultation of carotids
reveals no bruits
Abdomen: auscultation reveals normal bowel sounds in all 4 quadrants. No bruits in
renal, aortic or iliac arteries. Abdominal aorta is <3 cm in diameter.
Psych: mood is euthymic and affect is congruent
Immunizations:
UTD with current Influenza vaccination in 2019
Labs/BP home records:
Reviewed home blood pressure readings for last month: blood pressures are
consistently elevated above 140/80
Lipid panel reviewed from 5/15/19: LDL: within normal range Tri: within normal range,
borderline high
Assessment/Plan:
Dx:
1) Primary hypertension type 2: Patients average home monthly blood pressure
readings is consistently elevated above 140/80. Start Lisinopril. A1C and CBC
ordered today and CMP for follow-up visit.
Additional Dx:
1) Obesity stage 1: Most recent BMI is 30.3 and has been steadily increasing since
last recording on 11/01/2017.

Patient education:

1. Start Lisinopril 10 mg once a day as prescribed for uncontrolled hypertension and

cardiac protection. Continue Amlodipine 10mg once a day as prescribed
2. Ensure 6-8 hours of sleep a night
3. Replace soda consumption with water.
4. Recommended patient exercise 5 days a week of moderate intensity for 30
minutes with resistance training. Gave pamphlet with appropriate exercises. Goal
weight loss (desirable BMI < 25)
5. Check blood pressure at home twice a day, in the morning and at night and keep
a log for review at next follow up visit.
a. Aim for target goal of less than 140/90
6. Recommended DASH diet high in fruits & vegetables (4-5 servings/day), and
low-fat dairy products
7. Sodium restriction of less than 1,500 mg a day.

Follow up: Return to clinic in 1 month to assess the medication, diet, and
lifestyle changes. If you experience any concerning symptoms such as change in
vision, heart palpitations, swelling of face or tongue, or increased difficulty
breathing call 911 or go to the emergency department.