A routine established office pateint...
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CC: HTN and DM2
INTERVAL HISTORY: Patient is here for follow-up for HTN and diet controlled diabetes. Feels fine today.
NAD. BP 130/80, HR 82, RR 28.
No thryomegaly.
Lungs are clear.
HEART is RRR.
No edema.
Labs: sodium 136, potassium 4.9, BUN 24, creatinine 0.8, HGB 12, HCT 36, HGBa1c 6.2.
Impression
- Stable diet controlled DM2.
- Stable HTN.
Plan
- Continue LISINOPRIL.
- No changes needed.
- RTC in six months with BMP, CBC, lipid panel, urine microalbumin and HGBa1c.
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