Clinical Documentation Template
Chief Complaint: 52 year old male present for three month follow and labs check.
HPI: A 52-year old male with PMH of Hyperlipidemia diabetes presents to the clinic for three month follow up. Patient complained of polyuria, polydipsia and polyphasia. Patient is presently taking plavix and sexagliptin. Patient denies any chest pain, fever and chills.
General: lost 15lbs in last one month, admit weakness, fatigue. Denies depression, suicide throught.
Skin: no rashes, no open wound..
Head: Denies headache, head injury, dizziness.
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred
vision, or blindness.
Ears: no hearing change, tinnitus, infection, discharge.
Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.
Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago.
Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.
Neuro: experience syncope once a week, denies seizures, weakness, paralysis, numbness/tingling, tremors, or involuntary movements.
Pulmonary: negative hemoptysis, dyspnea, wheezing,pleuritic pain
Peripheral vascular: no claudication, leg cramps, varicose veins, history of blood clots,
abdominal, flank, or back pain. Pain in arms or legs. Intermittent claudication, cold, numbness,
pallor legs. Swelling in calves, legs, or feet. No color change in fingertips or toes in cold weather.
Swelling with redness or tenderness.
MS: no muscle, joint pain, or joint stiffness.
GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain,
belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food
intolerance, indigestion, nausea, vomiting, early fullness, odynophagia.
GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria,
nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids.
Past Medical History: Hyperlipidemia, diabetes
Surgeries: Appendectomy, 2000
Hospitalizations: 2000 (for appendectomy)
Food, drug, environmental: None
Medications: Plavix 75 mg daily (prescribed by his PCP in INDIA as a prophylaxis to prevent Heart attack. We use Aspirin 81 mg here in USA)
Sexagliptin 5 mg daily
Family History: Gout (Father) Diabetes (Mother) .
Social History: Denies tobacco/e-cigarette and alcohol use.
Vital Signs: Temp 98.2 BP 128/90 Pulse 64 RR 18 Pain 0 Height 5’ 8” Weight 140 lb BMI 21.3 SpO2 97% @ RA
Labs: Lipid Panel
Cholesterol 272 mg/dl
Triglyceride 175 mg/dl
HDL 28 mg/dl
LDL 135 mg/dl
HEENT: Head: hair normal texture and distribution, no lumps/bumps/lesions noted to scalp. Scalp/skull non-tender with palpation. Skull normocephalic/atraumatic. Eyes: no drainage noted, no hemorrage. Ears: pinna clean, no exudate noted. TM intact and pearly gray with cone of light bilateral . Nose: nasal mucosa pink and moist. Inferior turbinates slightly reddned bilat. Nares patent bilat. No sinus pain upon palpation. Septum midline. Throat: no swelling of the lymph nodes. Neck: non-tender cervical area, no lymph nodes palpable. Non-enlarged thyroid palpated. Trachea midline. Neuro: Alert and oriented x 4, CN I – not tested, II-XII intact. Deep tendon reflexes 2+ Brachioradialis, bicep, triceps, supinator, knee, and ankle with plantar reflexes down-going. No clonus. Muscle strength 5/5. Thorax and lungs: Thorax is symmetric with good expansion. Respirations are even and unlabored. No use of accessory muscles, nasal flaring. Cardio: JVP is 3cm. above the sternal angle with the head of bed elevated to 30 degrees. Carotid upstrokes are brisk without bruits. Temporal arteries have normal pulsation without tenderness. The point of maximal impulse is taping, 8 cm lateral to the mid-sternal line in the 5th intercostal space. Crisp S1 S2 without clicks or murmurs. Extremities are warm and without edema. No variscosities or stasis changes. Calves are supple and non-tender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+ and symmetric. Ca refill <2 secs. Abdomen: soft flat, non-tender and non-distended. Normoactive bowel sounds. No palpable masses or hepatosplenomegaly. Liver span is 7cm in the right midclavicular line. Edge not palpable. Kidneys not felt. No CVA tenderness. MS: Full active range of motion in all joints of the upper and lower ext. No evidence of swelling or deformity .
Skin: dry skin, no open wound, feet look fine Male Genitalia: deferred
Differentials: 1. Diabetes mellitus type 1
2. Latent autoimmune diabetes in adult
3. Chronic renal Insufficiency.
Diagnosis: Diabetes mellitus 2, Hypercholesterolemia.
Plan And treatment : The cornerstone of therapy for all patients with diabetes is a personalized self-management program, usually developed with the patient by a diabetes education nurse or nutritionist. Diabetes self-management education and support facilitates diabetes self-care and assists in implementation and sustainment of lifestyle changes on an ongoing basis. This requires general nutrition and health lifestyle knowledge and an individualized nutrition and exercise plan based on an initial assessment and treatment goal.( ADA, 2018)
Diabetes mellitus: Stop Sexagliptin.
Start Metformin 500 BID, Glipizide 5 mg daily plus Actos 30 mg daily.
Hypercholesterolemia: Stop Plavix.
Start Lipitor 40 mg daily.
Aspirin 81 mg daily ( prophylaxis)
Education: Diabetes education and mentioned above plus regular exercise. For high cholesterol, the adoption of a healthier lifestyle, including a low-fat diet and a reasonable amount of aerobic exercise, will have a large impact on the prevalence of hypercholesterolemia, as well as of obesity and coronary heart disease. Patient should follow with PCP in three month.
Follow up: Three month
American Diabetes Association. Standards of medical care in diabetes – 2018. Diabetes Care. 2018 Jan; 41(suppl 1): S1-159