SUBJECTIVE: The patient is in for a routine 4-month followup of several issues. She has absolutely no complaints. She is feeling great. Her hypertension, hypothyroidism and dyslipidemia have been quiet. She is tolerating all her medications.
She has not had any chest pain, shortness of breath, cough, myalgias or fatigue. She has no complaints whatsoever.
Past medical history includes hypertension, hyperlipidemia, diastolic congestive heart failure, heart murmur. Echocardiogram showed mitral valve calcification, EF of 60% last year, hypothyroidism, vitamin D deficiency, anxiety, postherpetic neuralgia, just resolved, glaucoma.
Medications include Coreg 25 mg twice daily, clonidine 0.2 mg twice daily, furosemide 20 mg daily, lisinopril 40 mg daily, Lovastatin 40 nightly, Os-Cal 500/200 mg twice daily, potassium 20 mEq daily, vitamin D 50,000 units weekly, aspirin 81 mg daily, Synthroid 112 mcg daily.
Allergies are to PENICILLIN, AMLODIPINE, and HYDROCHLOROTHIAZIDE.
In terms of social history, the patient is married. She does not smoke.
OBJECTIVE: GENERAL: She is in absolutely no distress. VITAL SIGNS: The patient’s weight is down 2 pounds to 132 pounds, blood pressure 132/82, and pulse 78. HEENT: Normocephalic and atraumatic. Sclerae anicteric. Conjunctivae are pink. Mucous membranes are moist. NECK: Supple without thyromegaly, lymphadenopathy or supraclavicular nodes. CHEST: Clear and equal throughout. Respirations easy. CARDIAC: Regular rate and rhythm without murmurs, rubs or gallops. ABDOMEN: No hepatosplenomegaly, masses or tenderness. EXTREMITIES: No clubbing, cyanosis or edema. SKIN: Warm and dry. Good color and turgor. NEUROLOGIC: Alert and oriented. Affect normal. Gait normal.
ASSESSMENT AND PLAN:
1. Dyslipidemia. Recent lab work looked great. Triglycerides 172, HDL 42, LDL 106. Continue on her statin.
2. Hypertension. Well controlled.
3. Vitamin D deficiency. Recent level of vitamin D is 37. Continue on the 50,000 units weekly.
4. Health maintenance. Already received a flu vaccine. Continue her aspirin and Os-Cal. Followup will be in 4 months.
