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Progress Notes by Rajani S Tadimalla at 1/24/2023  3:15 PM

Telemedicine - Video Visit Progress Note   This appointment with Antonio Valerio was conducted using real-time audio/video telemedicine services. Antonio Valerio was located in the state of Maryland, at home, and I communicated with the patient from GBMC Primary Care at Owings Mills   The patient has consented to billing for a video or telephone visit? Yes   Additional staff participating in the telemedicine service: None   Was video visit completed as a MyChart visit? Yes   Subjective: Antonio Valerio is a 60 y.o. male.presents with ​ HTN- Takign the meds daily. BP at home is good. No HA,dizziness,chest pain or SOB, BP yesterday 107/79 Slept for 2 hrs since worked all night today   DM- Ins did not cover janumet. He is only on glipizide. BS fasting 130-140. No symptoms hbA1c- 7.8 3 m ago   Hyperlipidemia- On Lipitor   Chronic back pain Diagnosed with lumbar stenosis Seeing ortho In PT   Not had the labs since 2021     The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past family history, past medical history, past social history, past surgical history and problem list.   Patient Active Problem List Diagnosis • DM w/o complication type II • Essential hypertension • History of CVA (cerebrovascular accident) • Hyperlipidemia, unspecified • Hx of asbestos exposure • Colon cancer screening • Chronic low back pain • Non-compliance       Current Outpatient Medications: • aspirin 81 MG tablet, Take 1 tablet (81 mg total) by mouth daily., Disp: 90 tablet, Rfl: 0 • atorvastatin (LIPITOR) 40 MG tablet, Take 1 tablet (40 mg total) by mouth daily., Disp: 90 tablet, Rfl: 0 • blood sugar diagnostic strip, Every day use, Disp: 90 strip, Rfl: 0 • cyclobenzaprine (FLEXERIL) 5 MG tablet, Take 1 tablet (5 mg total) by mouth 3 (three) times a day as needed. for muscle spams, Disp: , Rfl: • glipiZIDE (Glucotrol XL) 10 MG 24 hr tablet, Take 1 tablet (10 mg total) by mouth daily., Disp: 30 tablet, Rfl: 0 • losartan-hydrochlorothiazide (HYZAAR) 100-25 mg per tablet, Take 1 tablet by mouth daily., Disp: 90 tablet, Rfl: 0 • traMADoL (ULTRAM) 50 mg tablet, Take 1 tablet (50 mg total) by mouth every 6 (six) hours as needed. for pain, Disp: , Rfl:   Review of Systems Constitutional: Negative. HENT: Negative. Eyes: Negative. Respiratory: Negative. Cardiovascular: Negative. Neurological: Negative. Hematological: Negative.   Objective: Allergies Allergen Reactions • No Known Drug Allergies       Other reaction(s): Info Not Available     There were no vitals filed for this visit. There is no height or weight on file to calculate BMI.   Physical Exam Constitutional: General: He is not in acute distress. Appearance: Normal appearance. He is not ill-appearing, toxic-appearing or diaphoretic. Pulmonary: Effort: Pulmonary effort is normal. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal.     Last 3 PHQ-9 Screenings:   No flowsheet data found.   Last 3 GAD 7 Screenings:   GAD 7 Screening 9/26/2022 Feeling nervous, anxious, or on edge 0 Not being able to stop or control worrying 0 Worrying too much about different things 0 Trouble relaxing 0 Being so restless that it is hard to sit still 0 Becoming easily annoyed or irritable 0 Feeling afraid as if something awful might happen 0 GAD-7 Total Score 0       Results for orders placed or performed in visit on 09/26/22 POCT Hemoglobin A1C Result Value Ref Range   POC Hemoglobin A1c 7.8 %     Assessment/Plan: Problem List Items Addressed This Vist       High   Essential hypertension - Primary   Overview         Continue losartan hydrochlorothiazide Low salt diet Fu in 2 m and advised to bring his monitor to calibrate     Relevant Medications   losartan-hydrochlorothiazide (HYZAAR) 100-25 mg per tablet   Other Relevant Orders   CBC with Automated Differential   Comprehensive Metabolic Panel   Thyroid-Stimulating Hormone   Hyperlipidemia, unspecified   Overview     Labs ordered Fu after the labs Continue lipitor.     Relevant Medications   atorvastatin (LIPITOR) 40 MG tablet   Other Relevant Orders   Lipid Panel with Reflex Direct Low-Density Lipoprotein   DM w/o complication type II   Overview     7.8- Taking meds daily Diet,excercise continue glipizide to 10 mg a day   Intolerant to Metformin Ins wont cover Januvia He refuses GLP Has been referred to endocrinologist.     Relevant Orders   Hemoglobin A1c   Albumin, Random Urine with Creatinine     Medium   Colon cancer screening   Overview     Colonoscopy 2018 H/O polyps Was due in 2021 Referral made again and urged him to see the GI.     Relevant Orders   Ambulatory referral to Gastroenterology     Low   Chronic low back pain   Overview     For over 10 years Manual labor   Handout given for low back exercises. Seen ortho In PT     Other Visit Diagnoses     Prostate cancer screening   Relevant Orders   Prostate Specific Antigen Screen   Colon polyps   Relevant Orders   Ambulatory referral to Gastroenterology   Fu after the labs   Portions of this note may be dictated using MMODAL voice recognition software.  Variances in spelling and vocabulary are possible and unintentional.  Not all areas may be caught/corrected.  Please notify me if any discrepancies are noted or if the meaning of any statement is not correct/clear