病历_3_8_46

Outpatient Medical Record Summary

Basic Information

• Patient: Not specified (male)
• Date of Visit: Not provided
• Physician: Dr. [Your Name]
• ID: Not provided

Chief Complaint

• Episodes of high blood pressure and diabetes mellitus management.

History of Present Illness

• The patient reports having episodes of elevated blood pressure, especially when measured in a medical setting where it can reach up to 160 mmHg. However, at home, his blood pressure often ranges more normally around 150/130 mmHg.
• Patient also manages Diabetes Mellitus with insulin therapy. Reports need for multiple doses of rapid-acting insulin throughout the day, particularly during the weekends due to increased food intake. For weekday evenings, the patient uses 15 units of long-acting insulin along with 8 units of rapid-acting insulin to maintain normoglycemia.

Past Medical History

• Hypertension: Suspected.
• Diabetes Mellitus: Insulin-dependent. Specific type not mentioned.

Personal and Family History

• Not provided.

Physical Examination

• Not conducted during this conversation.

Auxiliary Tests

• Blood tests ordered: Blood sugar levels, lipid profile, creatinine, and Blood Urea Nitrogen (BUN) to assess renal function, and complete blood count (CBC).

Diagnosis and Assessment

• Probable Hypertension: Mixed types, with potential for White Coat Hypertension. Requires confirmation through regular home blood pressure monitoring.
• Diabetes Mellitus: Insulin-dependent, requiring a combination of long-acting and rapid-acting insulin.

Treatment Plan

1. Medication:
   • Antihypertensive medication: Lisinopril 20mg, with potential initiation based on home blood pressure monitoring results.
   • Continue current insulin regimen.
2. Monitoring:
   • Regular home-based blood pressure measurements using an upper-arm cuff for better accuracy.
   • Consistent blood glucose monitoring, particularly during different activities and meals.
3. Follow-Up:
   • Patient is advised to complete the laboratory tests and conduct regular peak blood pressure monitoring.
   • Return visit after results are available for further evaluation and potential initiation of antihypertensive therapy if needed.

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Please note that this needs to be followed up by documentation in the patient's medical record according to the institution's protocol.