INTERVAL HISTORY: The patient’s HTN remains labile and moderately
severe with systolic readings occasionally in the 160s. There has been mild
improvement with low sodium diet. Denies any associated symptoms such
as pounding headaches or chest pain.
ROS: CV: Negative for CP or PND. EYES: Negative for blurry vision.
PFSH is remarkable for dyslipidemia.
Exam: Awake, alert, NAD. BP 158/78, HR 56, RR 20. Lungs CTA. Heart:
RRR, no MRGs. No peripheral edema.
Labs: Creatinine 1.0, K 4.2, Hgb 13.4, LDL 77
IMPRESSION:
1. Worsening HTN.
2. Stable hyperlipidemia.
PLAN:
1. Increase AMLODIPINE from 5 mg to 10 mg PO QD.
2. Continue low sodium diet.
3. BP check in two weeks.
4. Continue SIMVASTATIN.
5. RTC in three months with the usual labs..
