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Patient come for a follow up, what to check, advice

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Based on the image analysis, here is a full clinical summary and follow-up checklist:

Case Summary - Babuben Raman | VED Hospital, Kheda | 25/03/2026

What the Original Visit Shows:

Chief Complaints:
  • Retrosternal chest pain - since 2-3 days
  • Giddiness (Gaucharaman) + Perspiration - 1 day back
Known Case (K/C/O): HTN - newly diagnosed 1 day back
Examination at Presentation:
  • PLITZ: NAD
  • Urine/Stool: WNL (within normal limits)
Vitals at Presentation:
  • BP: 190/100 mmHg (severely elevated)
  • Pulse: 94/min
  • SpO2: 98% on room air
Investigations: 2 ECG done - NAD (no acute changes)
Admission Decision: Yes - admitted for BP monitoring and further management
Referral Note: Patient reliable. Referred to - danger sign education, advised cholesterol/cardiology review.
Medications Prescribed (5-day course):
  1. Tab. Ra-DSR - (Rabeprazole + Domperidone) - likely 1 OD
  2. Cap. Milmi SE 10 MG BD - (likely Amlodipine or similar CCB for BP)
  3. Tab. Tompter 5 OD - (likely Telmisartan 5mg or similar ARB)
  4. Syp. Cyproheptadine 1 OD - 10 mL - (appetite stimulant/antihistamine)

Follow-Up Checklist

1. SYMPTOMS - Ask the Patient

  • Any chest pain now? Retrosternal? Radiation to arm/jaw?
  • Giddiness improved or persisting?
  • Any headache, blurring of vision, breathlessness?
  • Sweating episodes continuing?
  • Nausea/vomiting (Cyproheptadine was given - appetite improving?)
  • Any palpitations, pedal edema?
  • Medication compliance - taking all tablets regularly?

2. VITALS - Measure Now

  • BP (both arms if possible) - target <130/80 mmHg for HTN
  • Heart Rate - target 60-100/min
  • SpO2
  • Weight (baseline for future comparison)
  • Random Blood Glucose (newly diagnosed HTN - rule out DM)

3. INVESTIGATIONS TO ORDER (if not done during admission)

InvestigationReason
ECG repeatRule out NSTEMI, LVH changes - first ECG was NAD but symptoms were cardiac
Fasting lipid profileReferral note mentioned cholesterol check
FBS + PPBS / HbA1cNew HTN + giddiness - rule out DM
RFT (Creatinine, BUN, eGFR)Baseline before ARB/CCB therapy
Serum electrolytes (Na+, K+)ARB can raise K+; baseline needed
Urine R/MMicroalbuminuria - target organ damage check
CBCBaseline
Echo 2DIf LVH or cardiac cause of chest pain suspected
Troponin I/T (if not done)Retrosternal chest pain - rule out missed ACS

4. DRUG REVIEW

  • Check if BP medications are adequate - initial BP was 190/100, recheck response
  • If BP still >140/90: consider uptitration or adding a second agent
  • Cyproheptadine - reassess need; short-term use is acceptable
  • Ra-DSR (PPI) - is it still needed? Any epigastric symptoms?
  • Statins - if lipid profile comes back high, initiate (Atorvastatin 10-20 mg)

5. CARDIOLOGY REFERRAL STATUS

  • The original note says "Cardiology referral" - check if this was done
  • If not yet referred: strongly advise cardiology consultation given:
    • Retrosternal chest pain in a hypertensive patient
    • ECG was NAD but doesn't rule out ACS
    • Newly diagnosed severe hypertension (190/100)

6. PATIENT EDUCATION (Re-enforce)

  • Sodium-restricted diet (<2 g/day)
  • No added salt, avoid pickles/papad
  • Stress reduction
  • Daily BP self-monitoring if possible (home BP diary)
  • Danger signs to return immediately: severe headache, chest pain, breathlessness, facial droop, arm weakness, sudden vision loss
  • Weight management
  • No smoking/alcohol

7. NEXT FOLLOW-UP

  • Schedule next visit in 2-4 weeks after starting antihypertensives
  • Once BP stable, switch to 3-monthly follow-up
  • Cardiology OPD appointment should be given today if not already done
Red Flags - Refer/Admit Immediately if:
  • BP >180/120 with new symptoms (hypertensive emergency)
  • Chest pain returning
  • New neurological symptoms (possible hypertensive encephalopathy or stroke)
  • SpO2 drop
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