Medication Refill

Patient Info

• Robert Jenkins, 58-year-old male
• Dr. Sarah Miller, MD
• PMH: History of essential HTN, T2DM, and hyperlipidemia.

Reason For Visit

• Medication refill for HTN, T2DM, and hyperlipidemia regimens.

Prior HPI/Last OV Notes

• Seen 6 months ago for routine chronic disease management; BP was mildly elevated and home BP log was advised.
• Lisinopril (Prinivil®) increased from 10 mg to 20 mg PO daily 6 months ago due to suboptimal BP readings.
• Seen by ophthalmology (Dr. Patel) on 12/09/2023 for annual diabetic retinal exam; no retinopathy noted, routine 1-year f/u advised.

Any Problems With Current Treatment Plan

• Reports occasional mild GI upset if metformin (Glucophage®) is taken on an empty stomach; resolves when taken with meals. No issues with antihypertensive or statin therapy.
• PRELABS
  • CMP: Glucose 132 mg/dL, BUN 18 mg/dL, Cr 0.9 mg/dL, eGFR > 60 mL/min/1.73m², K 4.3 mmol/L, AST 22 U/L, ALT 25 U/L
  • Lipid Panel: Total Chol 168 mg/dL, Triglycerides 140 mg/dL, HDL 45 mg/dL, LDL 95 mg/dL
• A1c: 6.8 %
• Fasting glucose mildly elevated at 132 mg/dL.
• BP 134/82 mmHg

Any New Information/Health Concerns Since Last Visit

• No recent hospitalizations, ER visits, or acute illnesses.
• Reports mild bilateral knee stiffness in the mornings lasting < 15 minutes, improving with movement.
• Patient viewpoint: Satisfied with current glycemic and lipid control; hopes to avoid adding more daily medications and prefers managing knee stiffness conservatively.

Social Hx

• Lives with wife in a single-family home, works full-time as an accountant. Never smoker, drinks 1-2 beers on weekends, walks 30 minutes 3x/week.

ROS

CONSTITUTIONAL: no fever, no weight loss, no malaise

EYES: no visual change

EARS: NONE reported

NOSE: NONE reported

MOUTH/THROAT: NONE reported

CV: no chest discomfort, exertional dyspnea, palpitations, or ankle edema

RESP: no cough, wheezing, or dyspnea

GI: no abdominal discomfort, nausea, vomiting, or diarrhea

GU: no urinary difficulty or increased urinary frequency

MSK: Mild bilateral morning knee stiffness; no myalgias, muscle weakness, or back pain

SKIN: no rash or non-healing lesion

NEURO: no numbness, dizziness, or headache

PSYCH: no depression, sleep disturbance, or anxiety

ENDOCRIN: no fatigue

HEME/LYMPH: NONE reported

ALLERGY: NONE reported

Objective

• BP 134/82 mmHg, HR 74 bpm, RR 14 breaths/min, Temp 36.8 °C, SpO2 98 % on RA, Wt 88.5 kg, BMI 27.8 kg/m²
• POC A1c: 6.8 %
• Bilateral lower extremities without pitting edema; pedal pulses 2+ bilaterally; monofilament sensation intact.

GENERAL: Appears well, NAD.

EYES: PERRL, EOMs intact.

NECK: Supple.

RESP: Breathing unlabored, CTA.

CV: RRR, without murmur.

SKIN: Warm and dry, without rash.

NEURO: Alert and oriented.

PSYCH: Calm and cooperative.

Discussion

• Robert Jenkins, 58 yo male, presents for routine 6-month follow-up and medication refills for T2DM, HTN, and hyperlipidemia.

• POC A1c today is 6.8 %. Prelabs from 10/03/2024 show stable renal function (Cr 0.9 mg/dL), normal potassium (4.3 mmol/L), and LDL at goal (95 mg/dL).

Impression & Plan

1. Type 2 diabetes mellitus without complications

• STABLE
• ORDERED: Urine microalbumin/creatinine ratio.
• POC: CONTINUE metformin (Glucophage®) 1,000 mg PO BID with meals (90-day supply with 1 refill).
• INSTRUCTIONS: Continue low-carbohydrate diet, regular aerobic exercise, and taking medication with food to minimize GI upset.

2. Essential hypertension

• STABLE
• ORDERED: BMP in 6 months prior to next visit.
• POC: CONTINUE lisinopril (Prinivil®) 20 mg PO daily (90-day supply with 1 refill).
• INSTRUCTIONS: Continue low-sodium diet and monitor BP at home weekly; call clinic if readings consistently > 140/90 mmHg.

3. Hyperlipidemia

• STABLE
• ORDERED: Lipid panel in 12 months.
• POC: CONTINUE atorvastatin (Lipitor®) 20 mg PO daily (90-day supply with 1 refill).
• INSTRUCTIONS: Report any unexplained muscle pain or weakness.

Preventative Care:

CANCER SCREENINGS:

• Colon Cancer Screening: Colonoscopy completed 14/05/2021, normal; repeat due in 2031.
• Prostate Cancer Screening: Discussed PSA screening; patient deferred at this time.

VACCINES:

• Shingles Vaccine: Shingrix series completed in 2022.
• Flu Vaccine: Administered October 2023.

Follow Up

• 6 months

Plan For Future

• Complete fasting CMP, A1c, and urine microalbumin 1 week prior to next scheduled appointment in 6 months.

DM Quality Measures

• DM Foot Exam: Performed today; normal monofilament sensation, 2+ pedal pulses, skin intact.
• Microalbumin: Ordered today.
• DM Eye Exam: Completed 12/09/2023 by Dr. Patel (normal).