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a 50 yo m with c/o drug refill for DM2,diagnosed 20yrs back,taking glyburide 5mg od ,compliant with medication,regular blood sugar monitoring which ranges between 120-150mg/dl,denies any side effect, any SOB,chest pain,blurry vision,numbness in limbs,edema,abd pain,urinary difficulties.
ros-negative except above
medication-glyburide,lisinopril
allergy-none
pmh-htnX5 yrs ,on lisinopril
fh-nonsignificant
sh-drink 2-3 beer/week,non smoker,no illicit drug use,sexually active with wife,uses condoms intermittently,no stress at home,no change in diet,moderate exercise.
vs-b.p135/95 rest wnl
HEENT-WNL
Neck-supple,no bruise,thyroid N
Chest-clear BS,B/L
heart-rrr,s1/s2 n,no murmur,gallop
abdoment-soft,non distended,NT,no organomegaly,bs+
ext-no edema,pulse good and symmetric,muscle strength good,dtr2+,senstaion intact to soft and crude touch.
DD-1.DM2
2.HTN
W/U-CBC WITH DIFFERENTIAL
BUN/CR
BLOOD GLUCOSE, HBA1C
AST/ALT/BILIRUBIN
THIS IS WHAT i could write in 9 min ,though PE is not prefect but do you really have that much time to write just like FA!!!!😕
ros-negative except above
medication-glyburide,lisinopril
allergy-none
pmh-htnX5 yrs ,on lisinopril
fh-nonsignificant
sh-drink 2-3 beer/week,non smoker,no illicit drug use,sexually active with wife,uses condoms intermittently,no stress at home,no change in diet,moderate exercise.
vs-b.p135/95 rest wnl
HEENT-WNL
Neck-supple,no bruise,thyroid N
Chest-clear BS,B/L
heart-rrr,s1/s2 n,no murmur,gallop
abdoment-soft,non distended,NT,no organomegaly,bs+
ext-no edema,pulse good and symmetric,muscle strength good,dtr2+,senstaion intact to soft and crude touch.
DD-1.DM2
2.HTN
W/U-CBC WITH DIFFERENTIAL
BUN/CR
BLOOD GLUCOSE, HBA1C
AST/ALT/BILIRUBIN
THIS IS WHAT i could write in 9 min ,though PE is not prefect but do you really have that much time to write just like FA!!!!😕
