MED REFILL

PATIENT INFO: - Patient Name: John Smith, age 68, male - Primary PCP: Dr. Emily Carter - PMH: Hypertension, Hyperlipidemia, Type 2 Diabetes, and Osteoarthritis. REASON FOR VISIT: - Medication refill request. PRIOR HPI/LAST OV NOTES: - Last visit on 10/01/2024, blood pressure was slightly elevated. Patient was instructed to continue current medication regimen and follow up in 3 months. - No recent medication changes. - No recent specialist visits. ANY PROBLEMS w/CURRENT TREATMENT PLAN: - Patient reports no issues with current medications. - PRELABS: A1c 7.2% - Vitals: BP 142/88 ANY NEW INFORMATION/HEALTH CONCERNS SINCE LAST VISIT: - No new health concerns. SOCIAL HX: - Lives with wife, retired, non-smoker, drinks alcohol occasionally. ROS: CONSTITUTIONAL: NONE reported EYES: NONE reported EARS: NONE reported NOSE: NONE reported MOUTH/THROAT: NONE reported CV: NONE reported RESP: NONE reported GI: NONE reported GU: NONE reported MSK: NONE reported SKIN: NONE reported NEURO: NONE reported PSYCH: NONE reported ENDOCRIN: NONE reported HEME/LYMPH: NONE reported ALLERGY: NONE reported OBJECTIVE: - Vitals: BP 142/88, HR 78, RR 16, Temp 98.6, Oxygen Saturation 98% - Point of care test results: A1c 7.2% - Physical assessment findings: General: Well appearing, NAD. Eyes: PERRL, EOMs intact. Neck: supple. Resp: unlabored, CTA. CV: RRR, no murmur. Skin: warm/dry, no rashes. Neuro: alert and oriented. Psych: calm and cooperative. DISCUSSION: - John Smith, 68-year-old male, presents today for medication refills. No new complaints. - A1c 7.2% IMPRESSION & PLAN: 1. Hypertension - STABLE - POC: CONTINUE current medication. - INSTRUCTIONS: Continue home BP monitoring and follow up in 3 months. 2. Type 2 Diabetes - UNCONTROLLED - POC: CONTINUE current medication. - INSTRUCTIONS: Continue home glucose monitoring and follow up in 3 months. 3. Hyperlipidemia - STABLE - POC: CONTINUE current medication. - INSTRUCTIONS: Continue current medication and follow up in 3 months. FOLLOW UP: - 3 months PLAN FOR FUTURE: - Continue current medication regimen and lifestyle modifications. Follow up with PCP in 3 months. DM QUALITY MEASURES: - DM Foot Exam: Completed - Microalbumin: Ordered - DM Eye Exam: Completed