Monday, September 3, 2012

Office Visit 01-10-12

Banner, Elizabeth MD    Signed 01-10-12 4:34 PM
 
CC: Follow-up for labs
 
Subjective
Patient comes in to office today accompanied by daughter for review of her most recent labs
1. DM
Taking medications as prescribed
Not compliant with diabetic diet, still snacking on sweets frequently
testing blood sugar 1 to 2 times a day and seeing high numbers
Denies hypoglycemia

2. Hyperlipidemia
Taking medications as prescribed, no c/o of myalgias

3. OA
Reporting stiffness in knees and hands, not using anything currently to treat pain, uses heating pad at night on knees with some relief

4. HTN
Taking meds as prescribed

5. COPD
Using albuterol 3 to 4 times per week
Continues to smoke about 1/2 ppd
Recent bronchitis in December treated with abx

6. AFib
Denies any palpitations, chest pain. On coumadin and taking medication as prescribed
 
Objective
Vitals: BP 132/88 mmHg Pulse: 68  RR: 16  SpO2: 97% Wt: 207 lb Ht: 5'6"
Constitutional: She appears well-developed and well-nourished. No distress.
overweight
HENT:
Head: Normocephalic and atraumatic.
Cardiovascular: Normal rate, irregularly irregular rhythm and normal heart sounds. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has mild wheezing noted bilaterally. She has no rales.
Abdominal: Soft, nontender, no guarding
Musculoskeletal: normal gait and station, some difficulty rising from chair
Skin: no cyanosis, clubbing, or varicosities
Psychiatric: oriented x 3, normal mood and affect, judgment intact.


POCT INR: 2.3

Assessment/Plan
1. DM
Uncontrolled, A1c 10.2%
Start Lantus 15 units QHS, titrate by 2 units every 3 days until fasting blood glucose 70 to 130 mg/dl

2. Lipids
Controlled on current regimen
Continue simvastatin 20 mg QHS

3. OA
Not taking any medication currently
Trial of acetaminophen 325 mg 1 to 2 tablets every 4 to 6 hours as needed

4. HTN
Well-controlled, continue current regimen

5. COPD
Begin Spiriva 1 capsule via handihaler daily
Strongly encouraged to quit smoking

6. Atrial Fibrillation
INR within range today, continue current regimen

Return for INR in 4 weeks
Return for office visit in 3 months


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