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Valencia College *
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1611C
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Medicine
Date
Dec 6, 2023
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Uploaded by BrigadierFang12455
Internal Medicine Geriatrics Clinic Follow up Note.
Patient Name
: Paul DuBose
PCP
: Martha C. Eaton, MD
Date of Exam
:
3 Feb ----
Age/Sex
: 84/Male
ID#
: M-94
CHIEF COMPLAINT
: Mr. DuBose presents in routine follow up to discuss
diabetes mellitus, type 2.
HISTORY OF PRESENT ILLNESS
1.
Diabetes mellitus, type 2: All of his blood sugars have been in an excellent
range, from 113 to 126. He feels well and most days he does not take
glyburide. If his blood sugar rises above 130, he will generally take 1
tablet.
2.
Sinus bradycardia: He had a pacemaker placed on the 30
th
of August last
year. He continues to do well. Has excellent energy. No signs of
congestive heart failure has regained all of his weight loss during his
overriding illness. He is active, healthy, and will follow up with Cardiology
in 3 weeks' time.
3.
Atrial fibrillation: Continues with a controlled ventricular rate and feels
well. No angina or congestive heart failure.
4.
Iron-deficiency anemia, for which he had a full workup last year: He had
an esophagogastroduodenoscopy and colonoscopy. He was seen by
Hematology/Oncology and started on Procrit. He was given intravenous
iron twice. His last several blood counts showed good replacement of lost
blood volume. Coumadin was stopped briefly but has been reinstituted,
and he continues to take iron.
5.
Hypertension: Excellent control on the current medications. He did not
bring in blood pressures today but says most of them are in the 120 to
140 range.
6.
Benign prostatic hypertrophy: He takes Flomax for this and is doing well.
MEDICATIONS
1.
Isordil 20 mg t.i.d.
2.
Flomax 0.4 mg daily.
3.
Lasix 60 mg in a.m. and 40 mg in p.m.
4.
Zocor 80 mg h.s.
5.
Candle sultan 32 mg h.s.
6.
Lopressor 100 mg b.i.d.
7.
Iron 325 mg b.i.d.
Internal Medicine Geriatrics Clinic Follow up Note.
Patient Name: Paul DuBose
Date of Exam: 3 Feb ----
ID#: M-94
Page 2
8.
Coumadin as directed by the Coumadin Clinic.
9.
Lisinopril 40 mg daily.
10. Calcitriol 0.25 mcg daily.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fevers, chills, or weight
change. RESPIRATORY: No shortness of breath, cough, or hemoptysis.
CARDIOVASCULAR: No chest pain, palpitations, or edema.
GASTROENTEROLOGY: No abdominal pain, nausea, vomiting, diarrhea,
constipation, melena, or hematochezia. No hematemesis.
GENITOURINARY:
No dysuria, incontinence, or hematuria.
PHYSICAL EXAMINATION
: Found a pleasant 84-year-old gentleman with
blood pressure 155/70, heart rate 78, respirations 18, temperature 97.1,
height 71 inches, weight 88 kg. He is in no pain and is not a smoker.
HEENT: Exam found extraocular muscles intact. Pupils are equal, round, and
reactive. No scleral icterus. Oral exam is benign with moist mucous
membranes. No pharyngitis. NECK: Supple with no adenopathy or
thyromegaly. LUNGS: Clear to auscultation bilaterally with no wheeze, rails,
or rhonchi. HEART: Irregularly irregular with a 2/6 systolic murmur best heard
in the upper left sternal boarder. ABDOMEN: Soft, nontender, with
normoactive bowel sounds. EXTREMITIES: Without edema. NEUROLOGIC:
Exam is non-focal, with normal gait and stands. No abnormal movements. He
is fully intact cognitively. Mood is euthymic.
DIAGNOSTIC DATA:
On 11 January showed: iron 61, total iron-binding
capacity 225, ion saturation 27%, ferritin normal at 342. PT and INR 27.1 and
2.5, respectively. Hemoglobin 14.6, hematocrit 42.1. Previous H&H on 30
November were 15.2 and 43.8.
Internal Medicine Geriatrics Clinic Follow up Note.
Patient Name: Paul DuBose
Date of Exam: 3 Feb ----
ID#: M-94
Page 3
ASSESSMENT
1.
Diabetes mellitus, type 2: Excellent control without medication. He takes a
small dose of glyburide as needed if blood sugars become elevated, most
likely from dietary indiscretions. Will continue the current plan and follow.
2.
Bradycardia with a pacemaker and overall doing well. No signs of
congestive failure or angina.
3.
Atrial fibrillation with a controlled ventricular rate. Overall doing well.
4.
Iron-deficiency anemia, for which he has remained with an excellent
hemoglobin and hematocrit off Procrit.
PLAN
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1.
Stop iron.
2.
In 2 months will recheck hemoglobin and hematocrit and ion panel to
determine whether he still needs to be taking iron. If a significant
decrease is noted in either H&H or iron levels, will reconsider starting.
3.
Hypertension: Blood pressures appear from his description to be in good
control, but blood pressure is elevated today. Cheek blood pressure for 1
week, then contact me.
4.
Benign prosthetic hypertrophy for which he takes Flomax. That is being
changed to Uroxatral alfuzosin. Will change over his medication today.
5.
Health care maintenance: Up to date. Follow up with me in 2 to 3 months,
sooner as needed.
____________________________________
Jean W. Mooney, PA, Internal Medicine
JWM:ncb
D: 2/3/----
T: 2/4/----
c:
Martha C. Eaton, MD, Family Practice/Geriatrics