[doctor] all right , new patient , jordan roberts . date of birth : 3/2/1972 . he's a 49 year old , uh hm , with hypertension and palpitations . please copy forward his thyroid profile from march 1st , 2021 .
[doctor] hello mr. roberts , how are you doing today ?
[patient] i'm fine , thank you .
[doctor] good . good . so , i saw you were recently in the emergency room with high blood pressure and some palpitations .
[patient] yeah . that was back in march i think , but my girlfriend and i , we talked about it , and on that day i had a few cups of coffee , and no breakfast . so , i think it was probably more of a panic attack than anything else .
[doctor] yeah . have you , uh , have you felt it again since ?
[patient] uh , no .
[doctor] okay . uh , so tell me about the blood pressure then .
[patient] well , i've had issues with my blood pressure since i was young .
[doctor] do you have a family history of this ?
[patient] yeah . a lot of my family does have high blood pressure .
[doctor] i see .
[patient] yeah , i thought it was getting better , and , uh , i have a new primary doctor , and she put me on a new medication about a month ago .
[doctor] uh , can you tell me which medications you're taking ?
[patient] my new med is , uh , a combo med , something 40-25 .
[doctor] okay . um . yes , i see that in your chart . the benicar hct . it has hydrochlorothiazide in it .
[patient] yeah , that's it . my water pill i call it .
[doctor] okay . are you still taking the amlodipine , 10 milligrams daily ?
[patient] uh , yes i am .
[doctor] that's- that's a good start on a regimen . are you checking your blood pressure at home , and if yes , what numbers are you seeing ?
[patient] um , every day .
[doctor] awesome .
[patient] yeah . every morning , i take it when i get up , and it's been running at about , uh , 146 to 155 lately .
[doctor] so you're not down in the 120s yet ?
[patient] no , not yet . well , we're trying to get there though .
[doctor] okay . uh , how are you doing with your salt intake ?
[patient] i'm trying to back off of it . i think i'm doing good with it , not eating too much .
[doctor] good , uh , it plays a huge part in lowering your pressure and , uh , staying away from salt is important . um , i'll give you some information on the dash eating plan , which is the only eating plan that has been shown to lower blood pressure .
[patient] sounds good .
[doctor] are you doing any exercise ?
[patient] i do try to walk on the treadmill when i can .
[doctor] okay , great . um , all right . so , let's take a look .
[patient] all right .
[doctor] uh , you're gon na hear me talk throughout your exam , just so i can make sure i get everything documented .
[patient] okay .
[doctor] so , use my general physical exam template . let me take a listen to you and make sure everything sounds good .
[patient] all right .
[doctor] your heart and lungs sound good , so that's great .
[patient] good to hear .
[doctor] all right . go ahead and lie down . uh , and let me know if anywhere i press hurts .
[patient] nope . nowhere .
[doctor] all right . so , i'm gon na take a look at your ankles and feet . i'm just gon na look for some swelling .
[patient] all right .
[doctor] all right . it all looks good . go ahead and sit up . so , in terms of getting that pressure down , you're on three meds that are maxed out and your blood pressure is still not down . and , the question is what do we need to do to get your- to get it down . uh , your potassium one week ago was 4.0 . uh , has it been redone since in the last week ?
[patient] uh , no .
[doctor] okay . uh , four is good for your potassium level , some people have what is called resistant hypertension that is driven by something else in their body , uh , often it is a form , uh , hormonal response . if i were to take 10 people under the age of 50 who have high blood pressure who developed it at a young age , eight out of 10 would respond to reduced salt in their diet with a lower blood pressure . but , for the two out of 10 , there is something else driving it , uh , parathyroid levels or something called your adrenal glands overproduce , um , aldosterone , which we call hyperaldosterone .
[patient] okay . so , is there something we can do about it ?
[doctor] um , in these cases , there's medicine called , uh , spironolactone , that is very effective at dropping the ald- aldosterone level , and your blood pressure , and i think we should give that a try .
[patient] all right . i mean , i'm willing to give it a try .
[doctor] okay . so , let's discuss the piss- the possible risk of , uh , being on hydrochlorothiazide , which is the fluid med that you're now on . and , the spironolactone . one issue is that they can affect your electrolyte balance . um , they can also cause dehydration . so , when ... so , you got ta make sure that you hydrate . if you do not hydrate , and you get dehydrated , you will know it because you will get dizzy standing up . um , second thing is the spironolactone can raise your potassium too far , it's rare , but it can . uh , you're starting with your potassium at four , so that gives us some room .
[patient] all right . i guess that makes me feel a little bit better .
[doctor] yeah . and then the third thing is that spironolactone combined with hydrocholorozide- chlorothiazide can cause your sodium levels to go down . now , this does not mean- mean that you need to be eating more salt , okay ? but , it does mean that you will need to do blood tests in two weeks to make sure that it's okay .
[patient] all right . no , that i can do . um , are there any other side effects i need to worry about ?
[doctor] uh , dizziness possibly , as well as , uh , one in 100 guys might develop tenderness in their chest , swollen breasts , or enlarged breasts . this is a rare side effect , um , called gynecomastia , and if it happens , you just cut the medication and you let me know , but it is very uncommon .
[patient] i'll definitely let you know if that happens .
[doctor] okay . uh , we'll keep working at it until your blood pressure gets better . um , it can be tricky when your blood pressure starts to go up at a young age though , it is important to get it under control because it can lead to your heart getting bigger or enlarged . um , same thing that happens when you lift weights and your muscles get bigger , uh , and if your heart pumps against high blood pressure , it can eventually lead to heart failure .
[patient] i understand .
[doctor] yeah , so getting that under control is really important to help prevent kidney failure , strokes , and- and things like that- that you're at high risk for with high blood pressure .
[patient] okay .
[doctor] um , the american heart association has a website called heart.org , it has a lot of really good information about blood pressure to teach- to teach you about it and how to control your diet with exercise . um , if you do your treadmill routinely for 30 minutes or so most days , that could be seven to 10 points off your blood pressure .
[patient] really ? i did n't realize that .
[doctor] yeah , yeah . it's very important to be active , lower your salt , and increase your potassium . um , the goal is to keep your salt under 2000 milligrams a day , the actual recommendation is- is 1500 milligrams per day , but most people have a hard time with that . um , so just take a look at the website and the dash diet information . um , that will give you a lot of tips and information to help you start learning about this stuff .
[patient] okay . i'll definitely check that out .
[doctor] all right . so , we'll try the spironolactone and schedule a followup in two weeks to check your blood pressure and electrolytes . uh , if the new med does n't work , the next up is going to be the resistant hypertension clinic .
[patient] all right .
[doctor] all right . so , there they will look into secondary causes of your hypertension . they have access to newer procedure based technologies that can lower your blood pressure without medication , uh , for example , there is something called a renal , uh , denervation , uh , where they go inside the artery that feeds your kidney with almost like a little coil and heat that artery up . when they do that , they can block the nerve endings that get into your kidneys and lower your blood pressure .
[patient] that's interesting .
[doctor] yeah . so , that procedure has been shown to lower blood pressure by 10 points . um , there are of course some risks , so not everyone is a candidate . uh , but we'll cross that road , uh , when we need to , and let's just- let's just see how you do with the addition of the medication .
[patient] sounds good to me .
[doctor] all right . so , we will see you in two weeks then .
[patient] sounds good . thanks doc .
[doctor] yeah , you're welcome . let me know if you have any questions .
[patient] will do .
[doctor] all right . have a great day mr. roberts .
[patient] you too .
[doctor] mr. roberts presents with resistant hypertension . he's on three meds and maximum dose . i have added spironolactone to his regiment . we will need to monitor his potassium and sodium . he will have a metabolic panel and blood pressure check in two weeks . uh , next medication would be carvedilol , uh , which i try to avoid giving , it's potential for erectile dysfunction . i have talked to the patient about that , and the potential side effects of spironolactone , including the gynecomastia and electrolyte disturbances . if he is not controlled on spironolactone , the next step would be sending him to resistant hypertension clinic .

Medical orders:
description: blood sodium
order_type: lab
reason: hypertension
description: blood in two weeks metabolic panel
order_type: lab
reason: hypertension
description: spironolactone
order_type: medication
reason: hypertension
description: followup two weeks
order_type: followup
reason: to check your blood pressure electrolytes
description: blood in two weeks electrolytes
order_type: lab