What is the current clinical status of a 36-year-old patient with a medical history of Hypertension (HTN), Hyperlipidemia (HLD), anxiety, and Prediabetes, who reports improved anxiety control with new medication, denies Suicidal Ideation (SI) or Homicidal Ideation (HI), and has good adherence to medication?

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From the Research

This 36-year-old male with a past medical history of hypertension, hyperlipidemia, anxiety, and prediabetes presents for medication refills, reporting good anxiety control with his current medication regimen and compliance with taking his medications as prescribed, as well as benefiting from in-house counseling sessions for his mental health, with no suicidal or homicidal ideation, substance use, or new concerns at this visit. The patient's history of present illness (HPI) is crucial in understanding his current condition and making informed decisions about his care 1. Key points in the patient's HPI include:

  • Past medical history of hypertension, hyperlipidemia, anxiety, and prediabetes
  • Current medication regimen and compliance
  • Attendance at in-house counseling sessions for mental health
  • Denial of suicidal or homicidal ideation, substance use, or new concerns The use of digital tools to obtain the HPI from patients has been explored, with varying results 2. However, the most recent and highest quality study on this topic is not directly applicable to this patient's situation, and therefore, the traditional method of taking the HPI is still the most appropriate approach 2. Other studies have investigated the reorganization of the HPI to improve verbal case presenting and clinical diagnostic reasoning skills of medical students, with promising results 3, 4. Additionally, the relationship between anxiety disorders, hypertension, and cardiovascular risk has been reviewed, highlighting the importance of considering these factors in the patient's care 5. Overall, the patient's HPI is a critical component of his care, and a thorough and well-organized HPI is essential for providing high-quality care and making informed decisions about his treatment plan.

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