56 year old gentleman has a history of hypertension, benign Prostatic Hyperplasia, hypercholesterolemia, Depression, cataract and erectile dysfunction. No history of alcohol or nicotine use. Has family history of diabetes. No drug allergies.Came to the clinic today, unscheduled, because of complaint of lightheadedness, leg swelling and erectile dysfunction. His medications include flomax 0.4 mg BID, amlodipine 10 mg daily, simvastatin 80 mg daily, amitriptyline 100 mg at night and lasix 40 mg daily. Results from his last two visits, when he was seen by a covering resident physician showed a blood pressure 160/90 and AUA score of 5. LDL cholesterol of 80, HDL 60, and normal PSA level. Medical assistant evaluations prior to your seeing him today were as follows:Vitals 97.6 -16- 110- 170/90BMI 342++ ankle swellingLooks unusually sad.Identify the problems with possible etiologies and outline your management plans respectively.1. Hypertension, Stage 2. Uncontrolled. Multi-factorial: obesity, non-compliance, psychiatric and poss. unknown acute events. Today in office 170/90. BP last visit: 160/90. On amlodipine 10 mg daily (CYP450, peripherally acting calcium channel blocker). Common SE: leg swelling. Also on Lasix 40 mg daily. Recheck BP now. Investigate non-compliance, secondary to depression. Get STAT CMP with LFTs, CK, Cr, GFR, glucose. See #3. First line HTN agents for whites ACEI. Over 55yo or non-white: HCTZ or CCB. Consider HCTZ for diuretic with ACEI (high renin HTN). Routine advice on risks of HTN and primacy of weight loss when stable.2. Tachycardia. 110 today in office. Recheck pulse now. Investigate chest pain. EKG if heart rate doesnt correct during office visit. Consider BB short term (may exacerbate #7). Explain side effects.3. Polypharmacy. Amlodipine and simvastatin. (With amlodipine, max simvastatin dose 20 mg/day: may increase simvastatin levels, elevated LFTs, myopathy, rhabdomyolysis, hepatic metabolism inhibited). Patient is on alpha blocker (flomax) and NE/serotonion reuptake inhibitor (TCA). STAT CMP with LFTs, CK, Cr, GFR, glucose. Options: change anti-hypertensive, lower simvastatin, or change to Pravastatin.4. Depression. Multi-factorial. Investigate source: financial, family, job, history, trauma. Plan for getting off medication. Investigate compliance. Investigate physical cause: ED, htn, meds. Amitriptyline 100 mg (TCA, inhibits norepinephrine and serotonin reuptake, CYP450). Investigate why hes not on first-line sertraline. 5. Lightheadedness. Investigate cause: vertigo, blood pressure, disequilibrium. Do Romberg's test, coordination tests, gait, orthostatics. Complete neuro and cardio exam, carotid sinus stimulation. Probably multi-factorial to other problems. Reassess 1 week. RTC if symptoms do not improve.6. Leg swelling. Multifactorial to other problems. Elevate legs, mild fluid restriction. Reassess one week.7. Erectile dysfunction, possibly secondary to depression, blood pressure, or flomax SE. Multi-factorial. Educate on microvascular disease. Consider phosphodiesterase inhibitor if BP allows. 8. Benign Prostatic Hyperplasia, mild symptoms based on AUA score of 5. PSA normal. Begin discussion whether to continue PSA screening. Monitor new symptoms. Continue Flomax 0.4 mg BID (peripherally-acting alpha blocker, CYP450). Consider HTN and edema. 9. Hypercholesterolemia. Well controlled on medication. Risk factors for CAD: over-weight, HTN, male, non smoker. Framingham risk 5-6%. LDL 80, HDL 60. Before today, was on Simvastatin 80 mg daily. Possible interaction with amlodipine. STAT CMP with LFTs and CK. Reduce simvastatin to 20mg daily or change to pravastatin if affordable. Recheck lipids in 3mos, and consider Tricor if not at targets.10. Cataract. Fundoscopic exam. Schedule optometrist visit. Esp considering #1 and #12.11. Obesity. BMI 34. Counsel weight loss and diet. Stress that medications can be modified if symptoms improve. Best control of #1, #12, #7.12. Risk of diabetes. Risks: obesity, family history, htn. Possibly source lightheadedness and cataracts. Get A1c and blood glucose.