Question

Robert Greenwood, a 70-year-old male, arrives at the clinic for blood pressure checkup. he denies pain. his vital sign are TPR 97.4-66-20, BP 158/90, O2 sat 96%. He is 69 3/4 inches tall and 165 lbs. His previous records indicate that he is allergic to "sulfa drugs". He states that he is currently taking Lipitor, 20 mg, on every day; atenolol, 50 milligrams, one every day; and 81 mg of asprin daily. He denies using alcohol, tobacco, and recreational drugs and does not know when he had his last tetanus shot. progress note documentation

Answer 1

Progress note documentation

S- Subjective

He is not having pain.  He is currently taking Lipitor, 20 mg, every day; atenolol, 50 milligrams, one every day; and 81 mg of aspirin daily. He doesn't use alcohol, tobacco, and recreational drugs. He is unaware of the last tetanus shot.

O - Objective

He is allergic to "sulfa drugs. His vital sign is TPR 97.4-66-20, BP 158/90, O2 sat 96%. He is 69 3/4 inches tall and 165 lbs.

A- Assessment

His BP is not within limits, which is a risk factor for CHD. Meanwhile, he is 70 years old and so there is physical inactivity which further increases the risk. His goal should be <130/80 mmHg. Even though he takes Lipitor and Atenolol, BP is not optimal. It could be because of noncompliance with a low sodium diet. According to the above findings, his blood pressure medication needs to be reviewed further and should cover medications with effective indication to decrease the possibility of CHD morbidity and death.

P- Plan

Stress the significance of a low Na diet. Introduce him to a dietitian.

Encourage physical activity.

Teach him about hypertension, the purpose of medications and low Na diet, exercise, and attending clinic meetings.

Plan a check-up in 2 weeks.