Office Visit 08-06-12

CC: Returns for follow-up of labs 

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

1. DM 
Taking medications as prescribed Currently on Lantus 45 units QHS 
Denies any episodes of hypoglycemia, blood sugar shows mildly elevated fasting with very elevated post-prandials 
Patient does not want to increase insulin any further  

2. Hyperlipidemia 
Currently not taking simvastatin, stopped several months ago due to reports of increased diabetes risk with statins, denied any problems with myalgias 

3. OA 
Using Tylenol 2 to 3 grams per day in divided doses, heating pads. Having some stiffness when rising from seated position. Wants to know if she can take Advil 

4. HTN 
Taking meds as prescribed

5. COPD 
Currently taking Spiriva, using Albuterol once per week 
Quit smoking with cold turkey 

6. AFib 
Denies any palpitations, chest pain. On coumadin and taking medication as prescribed, has been following with nursing for INR checks 
 
Objective 
Vitals: BP 128/74 mmHg Pulse: 66  RR: 16  SpO2: 98% Wt: 205 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: 2.3 

Assessment/Plan 
1. DM 
Uncontrolled, last A1c 9.3%, on Lantus 45 units QHS. 
Increase Lantus to 50 units QHS
Add Januvia 100 mg daily
Refer to pharmacy clinic for diabetes education and medication review  

2. Lipids 
Advised to resume simvastatin 20 mg daily, patient resistant 
Discuss with pharmacist at upcoming pharmacy visit for DM 

3. OA 
Advised against use of Advil. Continue tylenol, refer to physical therapy for exercise evaluation, weight loss 

4. HTN 
Well-controlled, continue current regimen 

5. COPDCongratulated on quitting smoking, continue Spiriva and Albuterol PRN 

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

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