HPI:
1.
Hyperlipidemia
Patient was diagnosed with dyslipidemia in 2000. Cardiovascular risk include hypertension, age and high CCRP. Target LDL is less than 130. The most recent LDL was 55 on 1/7/19. The most recent HDL was 44 on 1/7/19. The most recent total cholesterol was 138 on 1/7/19. The most recent triglyceride was 193 on 1/7/19. Dyslipidemia is being managed by Statins and diet. The patient denied angina, palpitations, dizziness and lightheadedness.
2. Hypertension
Patient diagnosed with hypertension in 2000. Risk factors include family history of hypertension, CAD, male gender and age over age of 60. Patient expressed feeling tired. Pertinent negatives include chest pain, dizziness, shortness of breath and lightheadedness.
3. Diabetes
Patient presents with diabetes- type 2, diagnosed in 2014. There are no disease related complications. The status of the patient’s condition is uncontrolled per A1C.Last recorded HbA1C was 10.8 on 1/7/19. Prior to that , HbA1C was 6.2 on 3/5/18. LDL was recorded as 55 on 1/7/19. Last creatinine was 0.70 on 7/17/17. Monofilament exam was last performed on 7/19/18. Sign and symptoms include polydipsia and polyuria. Pertinent negatives include: chest pain, dizziness, edema, increased fatigue, headache, paresthesia, shortness of breath, and vision loss.
Diabetes managed with Metformin, Statin, and diet. Took Metformin for about 2 years and then discontinued due to low A1C 4.9 and is currently not taking Metformin. Patient states diet has been poor lately- tends to binge eat late at night out of boredom. Patient tries to choose health choices when binging- down 21 lb. from the summer. Patient states he has been thirsty and urinating more frequently.
Medications:
Amantadine HCL 100 mg 1/2 tab BID by mouth
Aspirin 81 mg chew 1 tablet by mouth daily
B-12 take one tab sublingual daily
Clonazepam 1 mg one tablet by mouth at noon and two tablets at bedtime
duloxetine 60 mg delayed release- take one by mouth daily
Folic acid 800 mug take one tablet by mouth daily
Furosemide 20 mg take one tablet by mouth daily
Klor-Con 10 meq XR- take one tablet by mouth daily
Lipitor 40 mg tablet- take one by mouth daily
Melatonin 1 mg- take one tablet by mouth at bedtime
Methylphenidate 10 mg tablet- take one by mouth daily
Metoprolol tartrate 25 mg tablet- take one tablet twice a day
Mirtazapine 15 mg tablet- take one by mouth at bedtime
Multivitamin tab- take one by mouth daily
Namenda 10 mg tablet- take one by mouth twice a day
Neupro 4mg/24 hour transdermal patch- apply patch once a day- do not apply to same area more than once
Rivastigmine 1.5 mg capsule- take 1 by mouth twice a day with food
Synthroid 50 mug tablet- take one by mouth daily
Viagra 50 mg tablet- take one by mouth as needed one hour before sexual activity
Vitamin B-1 100 mg tablet- take one by mouth daily
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