As Per Guidelines,
Modifying Factor- A description of steps taken by the Patient or things that make the Symptom(s) better or worse.
For following conditions Can we take DRUGS as Modifying Factor ?
on lisinopril, Continue BP monitering.
Continue MetforminHbA1c -6,
3. In Pre-OP Visits,
52 Y f here for pre op evaluation- Bartolin gland removal. Pt feels wells she denies fever, chills, cough, sob, cp, palpitation, N.V.D,. GU symtoms. PT denies MI, stroke, angina in the past .
Medical h/o- Hypothyroidism, HTN , Uterine fibroids , Surgery- uterine suspension
Meds- amlodipine . Levothyroxine Diclofenac a
Labs- hgb 11.9 PLT-229 tsh 0.78 CR-0.6 , Chest x ray may 2012---normal
EKG may 2012 - Sinus Bradycardia ---
PE- Stable Vitals , AAOX3, no focal deficit , Chest- b/l air entry, no added sounds
Heart- s1s2 Sinus brady systolic murmur+, Abd- benign , Ext no edema no calf tenderness
A/P - Pt meets low risk for proposed surgery , Recommend- D/c diclofenac, do not take nsaids, asa 5 days before surgery
- take amlodipine and synhtroid on day of surgery
- early ambulation, adequate hydration ,
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