[doctor] amanda taylor , birth date october 31st 1949 . patient is a 72 year old woman who comes for followup for hypertension . her history includes significant alcohol use disorder and mi- mild hypercholesterolemia . at last visit on april 16th her blood pressure was 130 over 90 . after presenting at 150 over 100 she was prescribed hydrochlorothiazide 12.5 milligrams by mouth once daily , and lisinopril 20 milligrams by mouth once daily . cmp and cbc were essentially unremarkable .
[doctor] hi miss taylor , how are you today ?
[patient] hi , i'm- i'm good , thank you .
[doctor] thanks for coming in today .
[patient] yeah , no problem .
[doctor] so how have things been going for you ?
[patient] uh , they've been all right . i'm struggling with not drinking . i wanted to discuss that , uh , shot that you had mentioned last time , but we did n't get to discuss it too much .
[doctor] okay , well i'll be happy to provide you with more information . so tell me when did you last have a drink ?
[patient] on monday .
[doctor] okay , so you've gone a couple days without it ?
[patient] yeah , yeah i have .
[doctor] yeah , and had you been drinking for a while ?
[patient] yep .
[doctor] how much had- how much had you been drinking ?
[patient] um , four or five times a week hard alcohol , so , you know .
[doctor] okay . well it will certainly help your blood pressure if you're able to stop drinking .
[patient] yeah , yeah i- i- i agree with you .
[doctor] okay . are you taking your blood pressure medications ?
[patient] yeah , but i'm only taking half of the lisinopril .
[doctor] okay .
[patient] i- b- well , the first time i took it i felt lethargic and tired , so i only took a half dose the next time . i felt much better and i did n't have the headaches or the swooshing that started in my left ear . so i feel like it's definitely helping but i do n't know ... i know it's not gon na be okay until i stop drinking .
[doctor] and are you also taking the full dose of the hydrochlorothiazide ? do you have any , um , chest tightness or pressure or any shortness of breath ?
[patient] yeah i'm taking the full dose of that medicine too , and no none of those symptoms .
[doctor] okay . anything else i should be aware of or that we should be checking ?
[patient] mm , no .
[doctor] okay , good . are you doing the blood pressure checks at home ?
[patient] yes . yes i am .
[doctor] okay good . what kind of numbers are you seeing ?
[patient] well , in the morning i'm seeing lower numbers than in the evening , um , where i run anywhere from like 130 to 145 or 150 over 95 to 100 on the bottom .
[doctor] okay .
[patient] but in the evenings if i sit there for a while and then take it , it goes down . kind of like when i come here it's always high but then it goes down . in the mornings it's generally more normal where it's supposed to be .
[doctor] uh- .
[patient] mm , also i'm taking my medicine in the morning when i get up instead of in the evening .
[doctor] yeah , so it sounds like we are not too far out of where we wan na be .
[patient] right , mm-hmm .
[doctor] okay . well let me get a listen to your heart , go ahead and hop up here .
[patient] okay .
[doctor] use my general exam template . all right , go ahead and take some deep breaths . okay , good . any fever , cough , shortness of breath or sore throat ?
[patient] no .
[doctor] any recent travel or contact or exposure to the coronavirus ?
[patient] nope .
[doctor] have you received your coronavirus vaccine ?
[patient] yes , on february 9th .
[doctor] okay , great . all right well i'm just going to look at your ankles and feet , i'm looking for any signs of swelling .
[patient] okay .
[doctor] all right , well everything looks good . you can go ahead and sit up miss taylor . all right , so the good news is everything is looking okay . i think we both agree if you were able to stop drinking your blood pressure would cease to be an issue for you .
[patient] yeah i agree with that .
[doctor] so let us discuss the potential medicine to help you with that . what it does is it blocks some of the brain receptors that alcohol stimulates and it tricks the brain into thinking it does not need alcohol , thereby cutting down the urges .
[patient] the urge to drink or the constant thinking about it ?
[doctor] it actually will help with both .
[patient] okay . so is it like a one-time thing ?
[doctor] generally the shot is given about once a month , it can also be given as a daily pill , but the shot does tend to work a bit better .
[patient] yeah i've taken things like this in the past and if it is a pill , i know i wo n't take it . with a shot , it's not like you can un-take it .
[doctor] yeah that's true . and the shot has been shown to work , it is more just a matter of getting you in to get your shot a month later with the nurse .
[patient] yeah , sure , sure .
[doctor] okay , so it's called naltrexone . i think the other name might be vivitrol . like i've said , the research on it is pretty good .
[patient] i think i may have taken the naltrexone before .
[doctor] okay , yeah , maybe you have .
[patient] yeah , if it was available in a pill form then i'm almost certain i've tried it b- before .
[doctor] okay . if this sounds good though , we can go ahead get you started with the shot . i am looking and it looks like we have you coming back in on may 17th for your first shot , does that sound good ?
[patient] yeah , yeah , that sounds great . are there any possible side effects ?
[doctor] yeah , some people will experience some nausea , headache , dizziness , anxi- anxiety , tiredness and trouble sleeping , but generally the side effects are mild and should go away within a few days .
[patient] okay .
[doctor] then we can schedule you for a follow-up in june to see how you are doing .
[patient] all right that sounds good .
[doctor] all right great . well otherwise stay with your current medicines , keep checking your blood pressure , and let's see if we can stop the alcohol for good . let us know if you have any questions or any issues come up after you receive the first dose .
[patient] all right , sounds good , thank you .
[doctor] you are welcome , have a good rest of your day .
[patient] you too .
[doctor] miss taylor is drinking alcohol four to five days per week to excess . no tobacco , no substance abuse , skin is moist , good trigger . on exam she is alert , pleasant , in no acute distress . she is not diabetic , there is no tremor , no cva tenderness , chest clear to percussion and auscultation , unlabored breathing , cardiac rhythm regular , no murmur , no gallop , jvp flat , with a head at 90 degrees . she does not appear anxious , agitated or depressed . my impression , alcohol use disorder . she would like to start naltrexone which we have previously discussed . she will take the injectable form and start on may 17th . we reviewed side effects and risks . the potential benefit of alcohol cessation would be highly beneficial to her for many reasons . hypertension , she is taking lisinopril 10 milligrams daily and hydrochlorothiazide 12.5 milligrams daily . quite possibly her blood pressure will improve completely with cessation of alcohol . her target bp is 130 to 140 over 70 to 80 . i will see her back week of june 14th , which is likely around the time of her second naltrexone injection . i recommend upgrading influenza vaccination and shingrix . number two , she did defer this .


Medical orders:
description: once a month naltrexone injectable start on may 17th
order_type: medication
reason: alcohol use disorder
description: see her back week of june 14th
order_type: followup