Progress Notes by Rajani S Tadimalla at 9/26/2022 8:30 AM
Subjective:
Antonio Valerio is a 59 y.o.male.presents with
Chief Complaint
Follow-up; Med Refill
HPI – patient is here for follow-up
Hypertension – doing well on the medication. No side effects.
Denies any headache, dizziness, nausea, vomiting, chest pain or shortness of breath.Has not been taking the medication everyday.Misses 2-3 days a week last 2 weeks.
Missed yesterday but took the meds today
Checks BP at home and 3 weeks ago it was 120/70-80
Has been under a lot of stress at home since lost his job but things are improving. He had lost his insurance for a while.
Hyperlipidemia – Taking the meds daily. doing well on the medications. No side effects.
Diabetes – Has not been taking medications. Not been Checking the BS at home.No polyuria, polydipsia or polyphagia.
Non compliant.
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
•
Elevated LFTs
•
Non-compliance
Current Outpatient Medications:
• aspirin 81 MG tablet, Take 81 mg by mouth daily., Disp: , Rfl:
• blood sugar diagnostic strip, TEST STRIPS, Disp: , Rfl:
• atorvastatin (LIPITOR) 40 MG tablet, Take 1 tablet (40 mg total) by mouth daily., Disp: 90 tablet, Rfl: 0
• losartan-hydrochlorothiazide (Hyzaar) 100-25 mg per tablet, Take 1 tablet by mouth daily., Disp: 90 tablet, Rfl: 0
• SITagliptin-metformin (JANUMET) 50-1,000 mg per tablet, Take 1 tablet by mouth 2 (two) times a day with meals., Disp: 180 tablet, Rfl: 0
Review of Systems
Constitutional:Negative.
HENT:Negative.
Eyes:Negative.
Respiratory:Negative.
Cardiovascular:Negative.
Gastrointestinal:Negative.
Genitourinary:Negative.
Neurological:Negative.
Psychiatric/Behavioral:Negative.
Objective:
Allergies
Allergen
Reactions
•
No Known Drug Allergies
Other reaction(s): Info Not Available
Vitals:
09/26/22 0846
09/26/22 0908
BP:
(!) 150/100
(!) 134/90
Pulse:
68
Temp:
36.9 °C (98.4 °F)
TempSrc:
Temporal
SpO2:
99%
Weight:
156 lb
Height:
5' 10"
Body mass index is 22.38 kg/m².
Physical Exam
Vitals reviewed.
Constitutional:
General: He is not in acute distress.
Appearance: Normal appearance. He iswell-developed. He is notill-appearing,toxic-appearing or diaphoretic.
HENT:
Head: Normocephalic and atraumatic.
Eyes:
Conjunctiva/sclera: Conjunctivae normal.
Pupils: Pupils are equal, round, and reactive to light.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Pulses: Normal pulses.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds.
Abdominal:
General: Abdomen is flat. Bowel sounds arenormal.
Musculoskeletal:
Cervical back: Normal range of motion and neck supple.
Neurological:
General: No focal deficit present.
Mental Status: He is alert.
Psychiatric:
Mood and Affect: Mood 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
Medium
Elevated LFTs
DM w/o complication type II - Primary
Overview
7.8- Not taken the medications for few months
Diet,excercise
Resume janumet
Intolerant to Metformin
Relevant Medications
SITagliptin-metformin (JANUMET) 50-1,000 mg per tablet
Other Relevant Orders
POCT Hemoglobin A1C (Completed)
CBC with Automated Differential
Comprehensive Metabolic Panel
Albumin, Random Urine with Creatinine
Ambulatory referral to Optometry
Essential hypertension
Overview
Uncontrolled
Non complaint with meds
Change to losartan hydrochlorothiazide
Stop lisinopril and hctz
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
Comprehensive Metabolic Panel
Lipid Panel with Reflex Direct Low-Density Lipoprotein
Colon cancer screening
Overview
Colonoscopy 2018
H/O polyps
Was due in 2021
Referral made and urged him to see the GI.
Relevant Orders
Ambulatory referral to Gastroenterology
Non-compliance
Other Visit Diagnoses
Colon polyps
Relevant Orders
Ambulatory referral to Gastroenterology
Screening for prostate cancer
Relevant Orders
Prostate Specific Antigen Screen
Refused covid booster
Urged to be complaint with meds and follow up.
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.
