SUBJECTIVE: The patient is a (XX)-year-old Hispanic female with a past medical history significant for type 2 diabetes mellitus, hypertension, dyslipidemia, heart murmur, history of ruptured appendix as a child, history of a large scar hernia located in the right lower quadrant. The patient is here for a followup evaluation and to check on her most recent blood test results. The patient states that she is doing fine. She denies any blurred vision, double vision, chest pain, shortness of breath, abdominal pain, constipation or diarrhea. She has gained 4 pounds since her last appointment. She has been checking her blood sugars at home, and they average around 130 to 150. She denies intermittent claudication.
MEDICATIONS: Tiazac, Ecotrin, Univasc, Zetia, Celebrex, Lescol, Glucophage, and Bextra.
ALLERGIES: NKDA.
SOCIAL HISTORY: She is not presently smoking or drinking.
OBJECTIVE:
GENERAL: Awake, alert, in no acute distress.
VITAL SIGNS: T: 97.8. P: 82. R: 18. WT: 154. BP: 132/62.
HEENT: PERRLA. There is no jaundice, cyanosis or pallor. Funduscopic evaluation shows a flat optic disk with normal retinas. She does have bilateral implanted lenses.
NECK: Supple. Negative JVD. Negative carotid bruit. No thyroid enlargement.
LUNGS: Clear to auscultation bilaterally.
HEART: RRR. No murmurs.
ABDOMEN: Soft, positive bowel sounds. No hepatosplenomegaly.
EXTREMITIES: Negative clubbing, cyanosis or edema. Good range of motion.
LYMPHATICS: Negative lymphadenopathy in the cervical, axillary or inguinal areas.
SPINE: Normal curvature and normal range of motion.
SKIN: Some scattered seborrheic keratoses, but there are no signs of skin cancer or melanomas.
NEUROLOGIC: Nonfocal.
LABORATORY DATA: We reviewed her laboratory reports. CMP was fine with the only exception of glucose of 128. Lipid panel meets ATP III criteria. CBC with platelets is within normal limits. HbA1c was 6.4, which denotes very good control.
ASSESSMENT AND PLAN:
1. Type 2 diabetes mellitus. She is having a very good response to Glucophage, medication that she is to continue. It has been more than a year since her last diabetic evaluation. The patient wants to be sent to see Dr. John Doe. We will repeat HbA1c and also urine microalbumin before her next visit.
2. Dyslipidemia, cholesterol very well controlled. She is on the combination of Lescol and Zetia, medications that she is to continue.
3. Hypertension, very well controlled. She is using an ACE inhibitor in the form of Univasc, and she is also taking Tiazac. We will continue on these medications.
4. History of right lower quadrant hernia. This is an incisional hernia from her previous appendectomy. This is not giving her any problem. We will just observe.
5. Health maintenance. She had a mammogram, which was category 2. She had a colonoscopy four years ago that was within normal limits, done with Dr. Jane Doe, and she refuses to have screening Pap smears.
6. Follow up in March.
