Blood Pressure Case Summary

The patient is a 63-year-old woman who presents for follow up after hospitalization at [Place], because of GI bleeding. The patient had presented here after years of living away, complaining of a history of progressive bloody diarrhea. Lab work was markably abnormal with significant anemia, with hypoalbuminemia, hypokalemia. The patient underwent a full evaluation, and was found to have colitis. She was treated with IV steroids, and has noted marked improvement in her condition. At the time she became ill with her diarrhea her blood pressure went down, and she discontinued antihypertensive. Now that she has improved, she has noted that her blood pressure has been going up, and she did resume her medications. It is unclear that she needs to resume them both, at the time of her discharge from the hospital on prednisone.

The patient has a significant amount of fluid _____(on board), this seems to have

OBJECTIVE

Blood pressure 98/62. Pulse 72. Temps 35.7. Weight _____(115, stated 118 above) pounds. The patient is very pleasant in no acute distress. Full hospital records are reviewed.

ASSESSMENT AND PLAN

1. Colitis. Undetermined etiology. Workup for infection has been negative. The patient has responded to IV steroids, and is adhering to recommended diet. She will follow up with GI next week.

2. Hypertension. Requirement decreased when she was ill. She did have some borderline high _____(breathings) off medications when she was discharged. She has resumed her antihypertensives. It is unclear that she _____ of them. We discussed options. She will continue lisinopril and hold the _____(HETT). We will monitor her blood pressure. I am concerned about the combination of _____(HETT) and prednisone, and with regards to her potassium.

3. Health maintenance. The patient is up to date. Has had workup in [Place], and is not due until the Spring. The return appointment is given for 1 month. She will call me in the meantime if any