Clinical note · #40
Consultation
Patient: Linda Matthews
Age: 62
Place of Service: Office – Outpatient
Patient Status: Established Patient
Insurance: Medicare (Traditional / Part B)
Referring Provider: Dr. R. Collins (Primary Care)
Reason for Visit: Follow-up visit after prior consultation for chronic disease management.
Chief Complaint: Follow-up evaluation of blood pressure control.
History of Present Illness (HPI):
The patient is a 62-year-old female presenting for follow-up after a prior consultation visit. She was previously evaluated for diabetes management and noted to have elevated blood pressure readings at that time.
Since the last visit, antihypertensive therapy was adjusted by her primary care physician. She reports partial improvement, with home blood pressure readings still averaging in the 140s/90s range. She denies headaches, chest pain, dizziness, shortness of breath, or visual changes.
Review of Systems (ROS):
- Cardiovascular: Denies chest pain or palpitations
- Neurologic: Denies dizziness or headaches
- Respiratory: Denies shortness of breath
- All other systems reviewed and negative
Past, Family, and Social History:
- PMH: Hypertension, type 2 diabetes mellitus, hyperlipidemia
- PSH: Appendectomy
- FH: Father with hypertension
- SH: Non-smoker; denies alcohol use
Physical Examination:
- General: Alert, no acute distress
- Vital Signs: BP 146/92 mmHg, HR 76 bpm
- Cardiovascular: Regular rate and rhythm
- Extremities: No edema
Assessment:
- Essential hypertension – suboptimally controlled
Plan:
- Increase antihypertensive medication dosage
- Reinforce dietary sodium restriction and lifestyle modification
- Recommend continued home blood pressure monitoring
- Continue follow-up with primary care provider