Progress Notes: week 4
Client: Lisa Johnson
Date: August 4, 2020
Worker: Clinician
Introduction
About a month ago, Lisa came to the hospital, exhibiting symptoms of hypertension. For now, she has been under hypertension medication, and she had a check-up due today on August 4, 2020. She seems to be doing better; she is calm and not out of breath compared to her last visit. The check-up to be carried out will check on her response to medication, any side effects, and her progress so far.
Background
Lisa was diagnosed with hypertension based on her symptoms, family history, and tests carried out. Among the symptoms noted include high blood pressure, dizziness, she is overweight, and her skin had pallor. Her condition seemed mild, but still needs to be managed. As a result, Lisa was put under medication. Also, she had some dietary changes, stress management, and regular exercise plan.
Progress Interview
The patient said she is in no pain or any problem apart from muscle pain from regular exercise. She is happy she can now run or walk for a while without being out of breath. Also, she says she is still trying to manage her stress and take care of her diet without being monitored. Lisa has also not experienced any reaction to the medication issued. She is no longer feeling dizzy or unable to carry out small tasks. However, she said that she gets quickly tired.
Assessment/Conclusion
Lisa seems to be responding well to her medication, and as a result, she is advised to continue. From the interview, it is clear that she is getting better and has been following the guidelines strictly. However, a blood pressure test will be carried out to confirm the results. Also, another clinical check-up will be scheduled after a month from today.