BANNER, ELIZABETH MD 1:25 PM Signed
Labwork reviewed for Ms. Betes, A1c improved from January but still elevated. Called patient and advised her to increase Lantus by 10 units. Continue metformin, will d/c glipizide. Next office visit scheduled for July.
Monday, September 3, 2012
Labwork 04-12-12
HALPERT, JIM MA 2:30 PM Signed
Hemoglobin A1c 9.4% (High)
Estimated Average Glucose: 223 mg/dl (High)
Hemoglobin A1c 9.4% (High)
Estimated Average Glucose: 223 mg/dl (High)
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"
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
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: overweight
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
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"
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
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: overweight
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
Subscribe to:
Posts (Atom)