Soap Note

CC: Im here to discuss my inveigh line test results, get my refills, and I have a business concern for the past couple of days. SUBJECTIVE: HPI: A 59y/o whiteness male w/ HTN and diabetes mellitus (type 2) presents for f/u on his kind test and medication refills. He was diagnosed with DM2 in 2009 and states that he has been in truth compliant with his free-and-easy pabulum and exercise, accu checks, medications, and wound checks. He in either case states my first light glucose has been between 90 and 130. Patient admits to maintaining a humbled carb/sodium/fat diet, doing daily treadmill exercises for about 30 minutes, checking his glucose q AM and throughout the day (at least 5 clock patient states), taking his medication Metformin 500mg 2 confirmations PO BID, and doing daily foot check for wounds. Patient denies any(prenominal) incident of hypoglycaemic reactions such as confusion, abnormal behavior, visual changes, tremor, sweating, dizziness or any episode of syncope. Patient also denies any youthful polyuria, polydipsia, or nocturia. His stretch forth dilated eye exam was 2 months past and was told to have normal results. Patient denies storey of renal diseases. His ultimately serum creatinine was done ~6mos ago and was told to be in injure of appearance normal limits as well.

Patient also denies history of CAD, PAD, transient ischemic attack/CVA, dyslipidemia, peripheral neuropathy, or freq infections/nonhealing wounds. Regarding his HTN, he was diagnosed in Jan 2006 after 3 visits of consecutive elevated set and was immediately put on Lisinopril 10mg 1 tab PO QD. Patient states that his BP has been under control. He measures his h ave BP every(prenominal) day (BID, AM and P! M) and keeps his own record (shown to me, values from last month up to yesterday ranges from 104-138 mmHg systolic/62-83 mmHg diastolic.) Again, patient denies any episodes of syncope, lightheadedness, vertigo, tinnitus or altered vision. The entirely new problem is an ready headache, frontal and bilateral x2 days, and unless occurs in the morning. Patient describes the pain as a hoi polloi of pressure and rates the pain...If you want to get a copious essay, order it on our website: OrderEssay.net

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