IINTERVAL HISTORY: The patient’s HTN has worsened since our last
visit. Also, he continues to have knee pain from OA for which he has recently
increased his use of NSAIDs. Hyperlipidemia remains stable on generic
statin therapy.
ROS: CV: Negative for CP/Orthopnea/PND. GI: Negative for abdominal
pain, melena, hematochezia.
PFSH: Negative for smoking.
Exam: Awake, alert, NAD. BP 156/78, HR 56, RR 20. Lungs CTA. Heart:
RRR, no MRGs. No extremity edema.
Labs: Creatinine 1.0, K 4.2, Hgb 13.4, LDL 77
IMPRESSION:
1. Worsening HTN possibly due to increased NSAID use.
2. Stable hyperlipidemia.
3. Worsening OA.
PLAN:
1. Increase AMLODIPINE to 10 mg PO QD.
2. Patient will try to alternate TYLENOL with ADVIL.
3. BP check in two weeks.
4. RTC in six months with the usual labs.
