List of Concerns for Multiple-Issue Consultations Template

1. Hypertension
- Patient presents with high blood pressure readings over the last month, experiencing occasional headaches and dizziness.
- Past medical history includes a diagnosis of hypertension 2 years ago, currently on Lisinopril 10mg daily.
- Blood pressure recorded at 150/95 mmHg, heart rate 78 bpm. No signs of end-organ damage.
- Likely diagnosis: Uncontrolled Hypertension
- Investigations planned: 24-hour ambulatory blood pressure monitoring
- Treatment planned: Increase Lisinopril to 20mg daily, lifestyle modifications including low-sodium diet and regular exercise
2. Type 2 Diabetes Mellitus
- Patient reports increased thirst and frequent urination over the past few weeks.
- Past medical history includes Type 2 Diabetes diagnosed 5 years ago, on Metformin 500mg twice daily.
- Blood glucose level at 11.5 mmol/L, HbA1c at 8.2%.
- Likely diagnosis: Poorly Controlled Type 2 Diabetes Mellitus
- Treatment planned: Add Glimepiride 2mg daily, dietary consultation for diabetes management
- Relevant referrals: Referral to endocrinologist for further management
3. Lower Back Pain
- Patient complains of persistent lower back pain for the past 3 months, worsened by prolonged sitting.
- No significant past medical history related to back pain.
- Physical examination reveals tenderness in the lumbar region, reduced range of motion.
- Likely diagnosis: Mechanical Lower Back Pain
- Differential diagnosis: Lumbar disc herniation
- Investigations planned: MRI of the lumbar spine
- Treatment planned: Physiotherapy referral, NSAIDs for pain management