Office Visit 04-12-12

BANNER, ELIZABETH MD 6:34 PM Signed

CC: Returns for follow-up of chronic problems 

Subjective 
Patient comes in to office today accompanied by daughter to follow-up for her chronic problem list 

1. DM 
Taking medications as prescribed 
Increased up to 27 units of Lantus on her own 
Denies any episodes of hypoglycemia, forgot to bring her blood sugar log today 
2. Hyperlipidemia 
Taking medications as prescribed, no c/o of myalgias 

3. OA 
Has been using Tylenol, getting some relief, taking 2 tablets twice a day 

4. HTN 
Taking meds as prescribed

5. COPD 
Feeling much better with addition of Spiriva
Still smoking but has cut down to 5 to 6 cigs/day 
6. AFib 
Denies any palpitations, chest pain. On coumadin and taking medication as prescribed, has been following with nursing for INR checks, all but 1 at goal.  
 
Objective 
Vitals: BP 117/80 mmHg Pulse: 64  RR: 16  SpO2: 97% Wt: 204 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. No wheezing. 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: 2.8 

Assessment/Plan 
1. DM 
Uncontrolled, last A1c 10.2%, on Lantus 27 units QHS. Advised to keep checking blood sugar and increase dose by 2 units every 3 days until fasting BG 70 to 130 mg/dl 
Hemoglobin A1c ordered today 

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

3. OA 
Advised to take Acetaminophen on a scheduled basis, 

4. HTN 
Well-controlled, continue current regimen 

5. COPD
Strongly encouraged to quit smoking 
Refills given for albuterol and spiriva 

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

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