Name: Adeben C.
Address: Sekondi-Takoradi, Ghana
Weight: 114 kg
IBW: 77.6 kg
BMI: 34 kg/m2
A.C is a 58-year old Black Ghanaian who presents at the hypertension clinic for his first consult visit. He was referred to the clinic by his family doctor for drug management of his hypertension. He has already been treated for four weeks. A.C has a few complaints today. He has leg cramps, muscle weakness, persistent cough, and joint pain (in hands and wrists), frequent fevers and is fatigued.
History of Present Illness
A.C’s wife reported that A.C had no complaints prior the last doctor visit other than elevated blood pressure that was not responding to original prescriptions. The family doctor started A.C on three hypertension medications 4 weeks prior. At the time, the doctor used A.C’s ambulatory blood pressure recordings to develop a therapy plan. The doctor was alarm of A.C’s readings and prescribed three medications to treat A.C’s elevated blood pressures. After two weeks of starting the initial therapy, the family doctor added two more medications to treat A.C’s elevated blood pressures. At noon, A.C’s wife discovered him in bed looking ill, tired and walking laboriously to the bathroom; hence, family doctor decided to refer A.C to the clinic.
Past Medical History
Diabetes mellitus type 2 X 18 years
Dyslipidemia X 15 years
Obesity X 15 years
Hypertension X 4 weeks
He is married with three children.
Smokes one pack/day X 34 years.
Has 3-4 drinks every day
A.C works as an assistant manager at an accountant company.
Does not otherwise exercise regularly.
Eats regular meals three times daily
Occasionally adds salt to food
Eats out regularly
Appears to have high-fat, high sodium diet
Both parents have hypertension.
His mother, who is 86 years of age and is still alive. She lives with her eldest daughter. Mother had a stroke 3 years ago.
His father died of myocardial infarction at 60 years of age.
Two younger brothers have type 2 diabetes mellitus also.
No history of cancer.
Review of Systems
(+) fatigue; (+) fever; (+) cough; (+) cramps; (-) weight gain; (-) edema; (-) chills;
GEN: Obese male in who alert, friendly and courteous. A & 0 X 3. He is lethargic and complains of leg cramps and fever.
VS: Blood Pressure 144/88 mm Hg (sitting-left arm 1st), 142/86 mm Hg (sitting-left arm 2nd);
Home reading (mornings) range 130-150/ 80-90 mm Hg. Pulse: 72, Respiratory Rate= 16 breaths/min, Temperature= 39 Celsius(oral), Height= 6’0”, Weight= 114 kg, BMI =34,
Cardiovascular: Heart: regular rate and rhythm, slightly displaced PMI, no murmurs or carotids
Eyes: slight AV nicking, no hemorrhages or exudates
Extremities: No edema, normal reflexes and pulses, leg cramps
Labs and Diagnostic Tests
Sodium = 142 mEq/L
Potassium = 3.1 mEq/L
Chloride = 109 mEq/L
Bicarbonate = 24 mEq/L
Blood urea nitrogen = 28 mg/dL
Serum creatinine = 1.5 mg/dL
Glucose = 105 mg/dL
White blood cells =3500/mm3
Creatinine clearance = 69 min/min
Uric acid = 7.1 mg/dL
(+) Antinuclear antibody (ANA)
Glycosylated hemoglobin = 6.2 %
Urine Analysis: (-) microalbuminuria
Erythrocyte sedimentation rate (ESR) = 45 mm/hour
Total cholesterol = 225 mg/dL
Low-density lipoprotein = 134 mg/dL
High-density lipoprotein = 32 mg/dL
Echo: (last month) No LVH, ejection fraction 45%; EKG (last month) normal sinus rhythm, no LVH
A.C saw his family doctor 4 weeks ago and was diagnosed with hypertension. He has undergone four weeks of therapy. He followed up with his family doctor after starting two weeks of therapy. Today, at hypertension clinic, the clinic specialist has re-confirmed that A.C has hypertension.
Below is the list of medications started from family doctor’s office based on doctor’s understanding of hypertension guidelines. The follow up medications are included in this record too.
Furosemide 60 mg daily X 4weeks
Lisinopril 20 daily X 4 weeks
Losartan 50 mg daily X 2 weeks
Hydralazine 50 mg three times daily X 4 weeks
Metoprolol 25 mg ER daily x 2 weeks
Atorvastatin 40 mg once daily X 14 years
Metformin 1000 mg twice daily X 18 years
Pharmacist Notes and Other Patient Information
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