mstyus
Guest
Hi Coders,
I am stumped on this example ,So please can someone help with references
An established office patient with hypertension, diabetes and a history of dyslipidemia
CC: Follow-up hypertension and diabetes
Interval History: The patient's hypertension has been well controlled on current medications. Diabetes is stable as well, with no significant hyperglycemia or episodes of symptomatic hypoglycemia. Dyslipidemia remains well controlled on statin therapy.
Medications
Lisinopril 20 mg po qd
Atorvastatin 10 mg po qd
Glyburide 10 mg po bid
ROS
General- Negative for fatigue, weight loss, anorexia
Cardiovascular- Negative for chest pain, orthopnea or PND
Neurologic- Negative for paresthesias
Pertinent PFSH is remarkable for mild OA which has been quiescent
Physical Exam
General: NAD, conversant
Vitals: 120/80, 65, 98.6
HEENT: No JVD or carotid bruits
Lungs: CTA
CV: RRR
Extremities: NO peripheral edema
Labs: BUN 12, creainine 0.8, HGBA1C 6.8, spot microalbumin/creatinine ration is 28 mcg/g; LDL 77
Assessment
1.Well controlled Type 2 NIRDM
2.Well controlled hypertension
3.Stable dyslipidemia
Plan
4.Continue current medications unchanged
5.Repeat renal profile, spot microalbumin/creatinine at next visit, along with cbc
6.Check LFTs at next visit as well due to ongoing statin therapy
7.Continue lifestyle modifications and exercise for weight loss
8.Return visit in four months
I am stumped on this example ,So please can someone help with references
An established office patient with hypertension, diabetes and a history of dyslipidemia
CC: Follow-up hypertension and diabetes
Interval History: The patient's hypertension has been well controlled on current medications. Diabetes is stable as well, with no significant hyperglycemia or episodes of symptomatic hypoglycemia. Dyslipidemia remains well controlled on statin therapy.
Medications
Lisinopril 20 mg po qd
Atorvastatin 10 mg po qd
Glyburide 10 mg po bid
ROS
General- Negative for fatigue, weight loss, anorexia
Cardiovascular- Negative for chest pain, orthopnea or PND
Neurologic- Negative for paresthesias
Pertinent PFSH is remarkable for mild OA which has been quiescent
Physical Exam
General: NAD, conversant
Vitals: 120/80, 65, 98.6
HEENT: No JVD or carotid bruits
Lungs: CTA
CV: RRR
Extremities: NO peripheral edema
Labs: BUN 12, creainine 0.8, HGBA1C 6.8, spot microalbumin/creatinine ration is 28 mcg/g; LDL 77
Assessment
1.Well controlled Type 2 NIRDM
2.Well controlled hypertension
3.Stable dyslipidemia
Plan
4.Continue current medications unchanged
5.Repeat renal profile, spot microalbumin/creatinine at next visit, along with cbc
6.Check LFTs at next visit as well due to ongoing statin therapy
7.Continue lifestyle modifications and exercise for weight loss
8.Return visit in four months
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