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General Medicine Note: 3/10/25 Nadine Everett … | Wiki Cram

General Medicine Note: 3/10/25 Nadine Everett …

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Generаl Medicine Nоte: 3/10/25 Nаdine Everett DOB: 2/16/1955 CC: “I’m here tо see my new primаry care physician and get my prescriptiоns refilled.” S: HPI: 70-year-old female who presents for evaluation and follow-up of her medical problems. She has no particular complaints today. She feels “okay” today and would like to establish care to get her prescriptions refilled. Patient monitors her blood pressure at home a few times per week using appropriate technique. Takes medication regularly; has not missed a dose of any of them in the last month. Denies side effects from all medications. Recent home BP readings - obtained from home automatic cuff: Date2/242/283/53/9 Blood pressure (mmHg)142/90146/84144/86146/82 PMHObesityHypertensionHyperlipidemia SH Tobacco: smokes 1 pack per day Alcohol: drinks 1-2 glasses of wine every night of the week to unwind Exercise: She walks to the mailbox, about 5-10 minutes/day Salt: She does not pay attention to sodium content of foods. She cooks most of her dinners, and she usually adds table salt to her foods. She eats fast food for lunch (McDonalds, Subway, and Wendy’s) most days of the week. Caffeine: Does not drink caffeine FH Mother had type 2 diabetes, heart disease and died of myocardial infarction at age 72 Father had HTN and hyperlipidemia and died of “old age” at age 88 Allergies/intolerances: amlodipine (leg swelling) Medications:Lisinopril 40 mg daily (started ~3 years ago)Rosuvastatin 10 mg daily (started ~3 years ago) O: ROSStates that overall, she is doing “okay”. Denies chest pain, SOB at rest, hemoptysis, N/V/D or blood in stool. Physical ExamGen: The patient is a WDWN, obese female in NAD.VS: BP = 140/82 (sitting), HR 70 (regular), RR 16, T 37.1 C, Ht. 63", Wt. 83 kgHEENT: NCAT, PERRLA, EOMI. TMs clear throughout and without drainage; sclerae without icterus. Normal fundoscopic exam.Neck: Supple without masses or bruits, no thyroid enlargement or lymphadenopathyLungs: CTA bilaterally; No crackles or wheezing heardHeart: RRR; S1 and S2 present, no S3 or S4.ABD: Soft NTND; no masses, bruits, splenomegaly, hepatomegaly. Normal BS.Rectal/GU: Heme (-) stool.Ext: No clubbing, cyanosis, or edema. Neuro: No gross motor-sensory deficits present. CN II-XII intact. Negative Babinski. Labs (drawn 3/10/25 at 0716) Chem Panel (fasting) 10-yr ASCVD risk: 25.8% (3/10/25)BMI = 32.3 A/P: Will defer to medication management clinic pharmacist for plan moving forward for hypertension and lipid management. Please see information above and indicate assessment/plan in your note. I will review your assessment and plan, as well as orders you have placed. Thank you! Dr. Esposito, MDSigned: 3/10/25 10:42:00

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