This patient has DM Type __ diagnosed in __. __ feels that things are going __. Main concerns today are __.
Current treatment regimen is as noted in the meds list. Recent changes include __.
CV Disease: _
CV: Denies chest pain, dyspnea, PND, DOE, edema, orthopnea
GI: Denies nausea, vomiting, diarrhea, abdominal pain, constipation.
GU: Denies dysuria, urgency, frequency, polyuria, hematuria
Reproductive Men: Denies erectile dysfunction, painful intercourse
Reproductive Women: Denies painful intercourse, vaginal discharge, pelvic pain, menstrual irregularities/missed periods
Neuro: Denies numbness, tingling, pain in feet. Denies sores/ulcers. Denies focal weakness.
PE Vitals including PAV and LWM
General: Healthy, NAD. Mood/Cognition good.
HEENT: Normocephalic, atraumatic. PERRL. EOMI. No peri-orbital edema, exophthalmus, lid lag, conjunctival injection or convergence noted. Dentition in good repair. No lymphadenopathy of the sublingual, submandible or cervical chains.
Thyroid: Palpable, non-tender. No thyromegaly. No distinctly palpable nodules.
Respiratory: No abnormal cough or dyspnea. Clear to auscultation in all fields. No clubbing or cyanosis.
Cardiovascular: RRR without audible murmur, rubs, or thrills. . Radial pulses Dorsalis pedis pulses . No venous stasis or edema.
Gastrointestinal: Abdomen soft, non-tender without HSM or palpable mass. Obese No CVAT. No striae.
Musculoskeletal: Spine erect. No obvious deformities of the extremities.
Neurological: No focal motor deficits Bicep Patellar Achilles DTR Sensate to the monofilament on the plantar surfaces of bilateral feet at Vibratory .
Integumentary: Skin soft, dry. No lesions or rash noted. No acanthosis nigracans or Xanthomas. Feet are without callus or ulcer. . No terminal hair noted.
Reviewed pathophysiology of diabetes and complications associated with hyperglycemia such as retinopathy, cardiovascular disease, nephropathy, and neuropathy. Discussed goals for diet, exercise, and weight loss. Discussed tests/levels that would need to be monitored closely such as blood glucose, HbA1c, blood pressure, cholesterol, BMI, and microalbumin/creatinine ratio. Also discussed routine exams that would need to be done such as annual dilated eye examination, bi-annual dental examinations, and quarterly foot examinations. Discussed recommendations for Reviewed symptoms associated with hypo- and hyperglycemia. Discussed treatment of hypoglycemia by using the rule of 15.
2. High blood pressure: _
3. Dyslipidemia: _
5. __ (other)
Additional labs __
Patient to follow-up in __
Visit Duration: _. >50% of this visit spent in education and counseling of the above conditions.
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