S:CCHPI:: Hypertension follow upJohn Jenkins is a 45 yr old male who presents to the clinic for a hy
S:CCHPI:: Hypertension follow upJohn Jenkins is a 45 yr old male who presents to the clinic for a hypertension follow up. He was recently started on hydrochlorothiazide as lisinopril was not completely controlling his blood pressure. He notes he has felt a little “off” lately but is unable to give much more detail. He is urinating more often but denies any chest pain, changes in vision. He states he remembers to take his medications “most days” but is not checking his blood pressure at home. He doesn’t remember what it’s been but thinks the top number is “around 130-140.”Past Medical HistoryHTNGERDPast Surgical HistoryAppendectomy at age 21Current MedicationsLisinopril 20 mg dailyHydrochlorothiazide 12.5 mg dailyFamotidine 20 mg dailyAllergiesNKDAROSConstitutional: – fevers, chillsHEENT: No changes in vision, no ear drainage. Cardiovascular: No chest pain, palpitations.Respiratory: No shortness of breath or cough.GI: No n/v/abd pain.Integumentary: No other rashes, wounds.Neuro: – HA, + dizziness.MS: No other red or swollen joints.GU: No dysuria, hematuria. Has been urinating more often lately.O:Physical ExamVS: T 97.6 P 68 R 16 BP 95/50 O2 sat 98% RAGeneral: Comfortable-appearing 45 yo man, appears his stated age. Reliable historian.HEENT: Bilateral ear canals patent. TMs intact and pearly gray with appropriate light reflexes. Nose without purulent drainage. Mouth with moist mucous membranes. Normal dentition. Posterior oropharynx pink and moist without erythema or lesions.Cardiovascular: S1S2 normal. No murmurs, rubs, or gallops.Respiratory: Lungs clear to auscultation. Respirations even and unlabored.Skin: No rashes.MS: No redness or swelling of joints.Extremities: No edema. DP 2+ bilaterally.Labs/Diagnostics (done just prior to today’s appt):Na+ 126Creatinine 0.9K+ 3.0Would you continue the hydrochlorothiazide? Why or why not?Is there a better regimen for this patient? If so, what is it? Health Science Science Nursing NURSING 8150 Share QuestionEmailCopy link Comments (0)
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