renifejn
Guru
This case is up on emuniversity and there are some discrepancies....before you look on their website for the answer--what do you get?
A New Office Patient
CC: The patient is here to establish care.
HPI: The patient is a 67 YOWM with NIRDM for 10 years. He states his sugars have been stable recently. He also has hyperlipidemia whch has been effectively managed with statin therapy and HTN which has been easy to control on routine medications. In addition, he has documented CAD which has been quiescent with no active chest pain.
MEDICATIONS: As reviewed in the medication list.
ALLERGIES: NKDA
ROS/PFSH: Reviewed using a questionnaire. Note is made of intermittent dyspnea with exertion and history of CAD s/p CABG in 2002. For more details, please refer to the ROS/PFSH portions of today's intake form located in this chart.
PHYSICAL EXAM.
CONSTITUTIONAL: NAD, somewhat obese white male.
Vitals: BP 144/85, HR 84, RR 22
EYES: Anicteric sclerae; no lid-lag or proptosis .
ENMT: Unremarkable.
CARDIOVASCULAR: RRR, no MRGs, normal PMI.
RESPIRATORY: Bii-basilar crackles; no wheezes.
GI: Unremarkable.
MUSC: Unremarkable except for 1+ bipedal edema.
PSYCH: A&OX4 with a cordial affect.
SKIN: Unremarkable.
NEURO: Unremarkable.
LABORATORY INFORMATION: Shows a BUN of 22 with a creatinine of 1.8, sodium 141, potassium 4.8, bicarbonate 21, calcium 8.3, phosphorous 3.9, hemoglobin of 12.7, HGBA1c 7.7, LDL 74
IMPRESSION:
Ischemic cardiomyopathy with moderate symptoms of CHF.
Sub-optimally controlled NIRDM.
Stage III CKD with GFR of 40.2 mls/min.
Stable hyperlipidemia.
Sub-optimally controlled HTN.
PLAN:
D/C METFORMIN.
Start GLUCOTROL 5 mg PO BID.
Increase LISINOPRIL to 40 mg PO BID.
Increase LASIX to 40 mg PO BID
Increase KCL to 20 mEq PO BID.
Echocardiogram this week.
RTC next week with renal profile, CBC, spot urine prot/creat.
A New Office Patient
CC: The patient is here to establish care.
HPI: The patient is a 67 YOWM with NIRDM for 10 years. He states his sugars have been stable recently. He also has hyperlipidemia whch has been effectively managed with statin therapy and HTN which has been easy to control on routine medications. In addition, he has documented CAD which has been quiescent with no active chest pain.
MEDICATIONS: As reviewed in the medication list.
ALLERGIES: NKDA
ROS/PFSH: Reviewed using a questionnaire. Note is made of intermittent dyspnea with exertion and history of CAD s/p CABG in 2002. For more details, please refer to the ROS/PFSH portions of today's intake form located in this chart.
PHYSICAL EXAM.
CONSTITUTIONAL: NAD, somewhat obese white male.
Vitals: BP 144/85, HR 84, RR 22
EYES: Anicteric sclerae; no lid-lag or proptosis .
ENMT: Unremarkable.
CARDIOVASCULAR: RRR, no MRGs, normal PMI.
RESPIRATORY: Bii-basilar crackles; no wheezes.
GI: Unremarkable.
MUSC: Unremarkable except for 1+ bipedal edema.
PSYCH: A&OX4 with a cordial affect.
SKIN: Unremarkable.
NEURO: Unremarkable.
LABORATORY INFORMATION: Shows a BUN of 22 with a creatinine of 1.8, sodium 141, potassium 4.8, bicarbonate 21, calcium 8.3, phosphorous 3.9, hemoglobin of 12.7, HGBA1c 7.7, LDL 74
IMPRESSION:
Ischemic cardiomyopathy with moderate symptoms of CHF.
Sub-optimally controlled NIRDM.
Stage III CKD with GFR of 40.2 mls/min.
Stable hyperlipidemia.
Sub-optimally controlled HTN.
PLAN:
D/C METFORMIN.
Start GLUCOTROL 5 mg PO BID.
Increase LISINOPRIL to 40 mg PO BID.
Increase LASIX to 40 mg PO BID
Increase KCL to 20 mEq PO BID.
Echocardiogram this week.
RTC next week with renal profile, CBC, spot urine prot/creat.