Microsoft word - patientone.doc

Patient One – John Star
11 MONTHS AGO
NO SHOW TO PMD

Also missed nutrition appt.
# SIGNED BY PAUL HO, MD 11 MONTHS AGO
9 MONTHS AND 2 WEEKS AGO
Follow Up

52 yo M w/ PMH of well controlled HTN and poorly controlled DMII. Reports recent fsg's as being between 87-
148. Reports taking Metformin 850 mg BID, but occasionally only taking the AM dose. He reports eating better,
no fruit juice, no sugar in his coffee, more veggies. He also reports recently skipping some doses of Atorvastatin
because he feels is eating better and afraid of liver damage. Reports being compliant with HTN meds.
O:
Bp: 134/72, Pulse: 68
Weight: 207
General: Well-dressed, tall, healthy appearing middle aged male
HEENT: PERRL, EOMI, ears clear, nares clear, OP clear, neck supple, no LAN
Heart - RRR S1, S2
Lungs - CTA b/l
Abd - soft, NT
Extremities - JPS intact b/l, sensation intact b/l
Neuro - no focal deficits
Labs from Last Visit
Lipids 174/200/47/87
LFTs 18/26 0.8/0.1 7.5/4.7 76
HgbA1C 10.5
A/P 52 yo M with well-controlled HTN and poorly controlled DMII.
Major Problem: Hypertension
-Continue HCTZ 25mg QD
-Continue Ramipril 10mg BID
Major Problem:Hypertriglyceridemia
-FHx of chol
-fast chol and LFTs ordered****
-Continue HCTZ 25mg QD
-Continue Ramipril 10mg BID
-Continue Atorvastatin for lipid lowering and cardioprotection
Major Problem: DMII
-Pt counseled on the importance of taking Metformin BID and not QD, especially with most recent HgbA1C of 10.5
-Continue Metformin 850mg BID
-Has podiatry appt next week
-Ophtho referral given
-HgbA1C reordered
Major Problem:HCM
-ppd NEG Last Year
-colonoscopy NEG Last Year
-prostate wnl Last Year
-PLACE FLU VAX 0.5 cc x 1 IM TOMORROW!!!
# SIGNED BY PAUL HO, MD 9 MONTHS AND 2 WEEKS AGO
Consult Note

9 MONTHS AGO
diabetic foot care
oral controlled DM
gross sensation intact
R and L feet
on sharp/dull testing
palpable pedal pulses bil.
brittle thickened discolored and painful
hallux nails bil.
scaling and fissuring plantarly
R and L feet
Diagnosis: onychomycosis/dermatomycosis
tx: debride hallux nails bil.
proper hygiene
topical meds
ptr 6 mths
# SIGNED BY ALAN WASSERMAN, PODIATRY 9 MONTHS AGO
8 MONTHS AGO
Follow Up

52 yo M w/ PMH of well controlled HTN and poorly controlled DMII. Taking all meds faithfully and as directed. No
new issues. Saw podiatry.
O:
Bp: 126/81, Pulse: 64
Cor RRR No M
Abd – S / NT
HgA1C 7.8
NA 139
K 4.8
CL 103
CO2 28
BUN 16
GLUCOSE 125
CREATININE 0.8
CALCIUM 9.0
CHOLESTEROL 143 mg/dl
TRIGLYCERIDES 136
HDL CHOLEST 40
LDL 76
A/P 52 yo M with well-controlled HTN and better controlled DMII.
Major Problem: HTN
-Continue HCTZ 25mg QD
-Continue Ramipril 10mg BID
-LFTs WNL
Major Problem:Hypertriglyceridemia
-FHx of chol
-cont Atorvastatin 10 qHS
-fast chol excellent
DMII
-Pt counseled on the importance of taking Metformin BID and not QD last visit
-Continue Metformin 850mg BID
-Had podiatry appt
-Ophtho referral given
-HgbA1C IMPROVED
Major Problem:HCM
-ppd NEG Last Year
-colonoscopy NEG Last Year
-prostate wnl March Last Year
# SIGNED BY PAUL HO, MD 8 MONTHS AGO
5 MONTHS AGO
Follow Up

52 yo M w/ PMH of well controlled HTN and DMII. Taking all meds faithfully. Doing well. No complaints.
O:
BP 130/80
Weight: 207
No Labs
A/P 52 yo M with well-contolled HTN and moderate controlled DMII.
1. HTN
Major Problem:Hypertriglyceridemia
-FHx of chol
-fast chol, chem 7 and lfts ordered
-Continue HCTZ 25mg QD
-Continue Ramipril 10mg BID
-Conintue Atorvastatin for lipid lowering and cardioprotection
2. DMII
-Continue Metformin 850mg BID
-podiatry prn
-Ophtho fu pending
-HgbA1C ordered***
3. Major Problem:HCM
-ppd due at NEXT VISIT
-colonoscopy NEG last year
-prostate wnl last year
-flu vax 0.5 cc x 1 IM via RN
-Td placed in 1999
# SIGNED BY PAUL HO, MD 5 MONTHS AGO
2 MONTHS AGO
Diabetes

52 yo M with hypertension, hypertriglyceridemia, and worsening DM. Taking all meds now. Mother recently died
after a fall and hip injury. Sleeping ok and denies depression, suicidality. Has support from family.
Needs his refills and referrals to derm and optho.
O:
BP 141/71, Pulse: 86
Lungs CTA B
Cor RRR No M
HgA1C 7.7 (better)
CHOLESTEROL 167 mg/dl
TRIGLYCERIDES 148 30-200 mg/dl
HDL CHOLEST 48 40-59 mg/dL
LDL 89
A/P:
1.
Major Problem:HCM
-ppd NEG last year
-colonoscopy NEG last year
-prostate exam due at next visit
-flu vax for this winter done
2.
Major Problem:Hypertension
-Ramipril 10 mg bid
-cont HCTZ 25 qAM
-RTC 2 mo
-creat ok
3.
Major Problem:Hypertriglyceridemia
-FHx of chol
-cont Atorvastatin 10 qHS
-LDL at target
4.
Major Problem:Diabetes
-recheck HgA1C ordered
-metformin 850 bid
-to ophtho (referral made)
-will fu podiatry at next visit
5. Bereavement
-appears to be adjusting appropriately to loss
-will follow at next visit
# SIGNED BY PAUL HO, MD 2 MONTHS AGO

Source: http://columbiauniversity.net/itc/hs/medical/clerkships/primcare/case/diabetes/exercise/PatientOne.pdf