HPI: Patient is a pleasant 56 YOWM with a 10 year history of HTN which
has apparently become more labile over the past few months. BP improved
recently with the addition of HCTZ which was added to previous monotherapy
with LISINOPRIL. The patient thinks that on one occasion, his elevated
BP was associated with a headache.
Pertinent PFSH: Remarkable for moderate alcohol consumption of two to
three drinks per day.
Review of systems: Eyes: Negative for blurry vision. CV: Negative for palpitations
or chest pain.
EXAM: NAD, 136/80, 64, 22. EYES: PERRLA. Neck: No thryomegaly or
carotid bruits. Lungs are CTA with normal respiratory effort. Heart: RRR,
no MRGs. Abdomen: Soft, non-tender, no HSM. Normal aortic pulsations.
Extremities show no cyanosis or edema. Pedal pulses intact.
Labs: BUN 10, creatinine 0.7. UA: benign.
IMPRESSION: Well controlled HTN
PLAN: It looks like this patient’s HTN has stabilized with the addition of
HCTZ. At this point, I do not think we need w/u for secondary HTN. However,
I asked the patient to record BP readings at home at least three times a
week. I also educated him that his BP would likely improve with decreased
alcohol intake. RTC in three months with labs or sooner if BP elevated.
