SUBJECTIVE: The patient presents today for followup of poor blood pressure control. Unfortunately, he did not take his dose before coming here. He states he is temporarily staying with his son and that has created some confusion in terms of taking pills and doing them on time. He states he has generally been taking them. We have suspected compliance issues in the past with him. The patient also had abnormal blood count. In the past, he was found to have some atrophic gastritis, and when we placed him consistently on a proton pump inhibitor, his count got better, but he stopped the medication we suspect because it cost too much for him in the past.
The patient states he is willing to do it if he needs to today. His main concern in life right now is his wife’s health. She apparently has metastatic cancer and is undergoing extensive evaluations with a variety of specialists, and he is always shoveling her back and forth appointments. His gout is currently under control. He stopped coffee, which he thought was contributing to it and for whatever reason that seems to be better. Otherwise, he has no new concerns other than his diffuse arthritis, which he had for years.
OBJECTIVE: The patient is an elderly man in no acute distress. His vitals are documented on the chart. Recent labs reviewed.
ASSESSMENT AND PLAN:
1. The patient has hypertension, which is still not controlled because of noncompliance with medication. We told them that he needs to be compliant with his medications and certainly needs to do so when he is coming in specifically for a blood pressure check, not much point in coming if he has not taken his pills. He will get back on his medications, and we will set up a followup in a few weeks.
2. The patient has anemia, again it is normocytic. He is on oral B12 supplementation. The patient has no clear evidence of iron deficiency. He does have some atrophic gastritis, and when it is active, his count tends to be lower, so we will try and get him back on Protonix again consistently and see if his count improves again; if not, consider hematology evaluation at some point. We re-prescribed the Protonix today.
3. Gout, currently under control. Check uric acid next lab to make sure the level is sufficiently low.
4. The patient has a new issue, which is recurrence of prior seborrheic dermatitis. He has been on ketoconazole shampoo in the past and ran out. He wants to know what he should take, and we told him the best thing would be to go back on this medication as he has been on it before, so we prescribed it for him.
We did note that his chronic renal insufficiency is stable; in fact, his creatinine is pretty good today. We will see him in a few weeks to follow up blood count on Protonix and reassess his blood pressure. We told that it is very important to take his pills when he is coming in for this type of appointment.
