okay first patient is Spongebob Squarepants. Date of birth July 1st 1946.

Chief complaint: Patient is here

for management of blood pressure

Subjective: Patient is here for follow up on his blood pressure management. He has been taking his
medications but found he has that his blood pressure is still with elevated many times when he takes it.
He uses a wrist monitor at home. He has not had any headaches, dizziness, chest pain or shortness of
breath. past medical history is remarkable for ongoing hypertension, hyperlipidemia, and
diabetes.Review systems negative review. Objective: patient awake, alert, very friendly, has no acurte
distress whatsoever. HEENT: normal exam. heart: regular rhythm rate, no s3 and s4 murmurs or rubs.
Lungs: cleared auscultation, bilaterally no rales, no rhonchi, no wheezes. abdomen: normal exam
template. extremities: no cyanosis, no clubbing, no edema, full range of motion. he does have some mild
crepitance to flex and extension of both knees.Plan: we reviewed his blood presure which is obtained at
the office which is at 174/101. We rechecked 2 or 3 times and remained elevated.he's not tachycardic
pulse rate of 80. His current regimen consists of amlodipine and lisonipril and at this point those are
maxed out. Amlodipine 10 mg, lisonipril 40 mg. We will add hydrochlorothiazide 25 mg QD to be taken
with lisonipril. Monitor blood pressure readings at home. 3-4 times per week. Follow up 10-14 days let
us know by telephone if he has any questions, problems or blood rpressure not responding. Laboratory:
he is coming due for his lab next month we ordered a comprehensive metabolic panel CBC, urine
albumin, A1c, fasting lipid panel.He may also follow up here after his lab results as well in a month 10-
214 days first period.

Robert Smith. DOB 08/14/1963. CC: ff up on his cholesterol.Subjective: taking atorvastatin 10mg/day for
the past year.has not had any side effects from the medication. he does feel as though he has changed
his lifestyle and wants to call off the medication.ROS: he is remarkable for occassional knee pain, right
elbow pain, denies any known trauma. negative review of systems. Examination HEENT, heart, lung:
normal, abdomen: normal. Extremities: mild crepitance, left and right knee is normal. Left elbow shows
pain to palpation and resistant supination and pronation over the lateral epicondyle of left elbow.
there's no obvious swelling seen. no erythema. Plan: Due for laboratory again as it has been one year.
Patient says he has changed his lifestyle and has lost some weight since last year. Discontinue
atorvastatin for right now and he can do laboratory in 1 month consisting of comprehensive metabolic
panel and fasting lipid panel. Calls 3-4 days after his results. For right knee: only has occasional pain and
it is not debilitating his left elbow thus have some pain with gripping objects and twisting things like
screw drivers etc. but he does not find it severe enough to cause him to stop his activities. Reassurance
given; told him to avoid twisting motions and very repetitive gripping and pulling motions when it flares
up, he can put some ice on it or use OTC NSAID; ibuprofen or naproxen. If laboratory results are within
normal values, atorvastatin can be discontinued.

Kevin Smith . DOB:12/16/1955. CC:AP Subj: here for AP. no complains, not taking any medications feels
well. ROS: negative. EXAMination: awake, alert, oriented, v friendly,
HEENT: clear, TMs, extra auditory canal cclear, sclera non-icteric, extra-ocular muscles intact. Normal
turbinates, normalnasal mucosa. throat is pink and moist w/o any lesions. oropharynx is clear and
hedoesnt have any tonsils visible

neck: soft, supple, no JVD, no adenopathy, no thyromegaly,normal range of motion

Heart: Regular rhythm and rate, no S3, S4 murmurs, no rubs. Lungs: cleared auscultation,bilaterally no
rales, no rhonchi, no wheezes. no retractions, no use of accessory muscles on respiration. abdomen:
soft, non tender, bowel sounds present times 4 quardants with no organomegaly, no guarding, no
rebound no rigidity,. No mamasses palpable and no abnormal aortic pulsations extremities: no cyanosis,
no clubbing, no edema, pulses are intact x4 extremities Neurologic:

No sxs of any cognitive dysfunction, no confusion. Remains active as far as exercise goes walks 2 or 3
miles per day. Assessment: annual physical ICD 10: z00.00 plan: comprehensive metabolic panel, CBC w
differential, urinalysis complete with reflux culture sensitivity, PSA, Objective: rectal exam reveals no
suspicious lesions, no hemorrhoids, and prostate feels to be normal sized and texture: nontender. Plan:
encourage him to call us 2 or 3 days after laboratory tests are done. 3. he is encouraged to get his
annual eye exam 4. hes never had a screening colonoscopy so a consult referral for screening
colonoscopy is given for gastroentorology 5. continue heqalthy lifestyle and diet as well as regular
exercise. May follow up otherwise annually or sooner PRN. total time spent face to face with greather
than 50% of this time spent in counselling.

Harry Jones. 12/25/1951. CC: ff up on multiple medical issues. Subjective: Hypertension, hyperlipidemia,
CAD, DM. Blood sugar is elevated in the morning 250-280. Also having occasional exertional chest pain
with concomitant SOB. No swelling on legs. no fever nor chills. denies cough, continues to smoke.
Struggling to lose weight and currently at 322 lbs. ROS: Remarkable for chest: excertional chest pain.
Exam:Awake, alert, oriented, does ambulate on his own but slow due to his morbid obesity. He is able to
transition from sitiing to standing position and vv without any assistance. HEENT: shows clear, occular
fundus is benign, narrow oropharynx due to his obesity, mild tonsil hypertrophy. Neck: w some
acanthosis nigricans noted, few scattered skin tags. heart: Heart sounds are somewhat distant due to his
morbid obesity. lungs: normal abdomen: morbidly obese, no obvious organomegaly but difficulty due to
his morbid obesity. Extremities: trace edema in bilateral lower extremities to above mid tibius. No skin
break down though skin is somewhat dry. Neuro: Negative for neuropathy

Plan: increase his dose of glipizide to two 5mg tabs twice a day. Continue checking his blood sugar both
fasting and 1-2 hr post prandial and report what his readings are in the next 10-14 days. Blood pressure:
continue amlodipine, decrease dosage to 5 mg from 10 mg as he may be getting edema in his legs due to
high dose of amlodipine. Otherwise we will increase lisonipril from 20 mg to 40 mg to keep his blood
pressure on a good control. He's due For HbA1C testing as well as chemistry panel and lipid testing in
the next couple of months. he's also behind on his urine microalbumin testing as well. Lab next month
for CMP, fasting lipid panel, and HBa1c and microalbumin. Ff up after those tests arte done in the
meantime you can leave me a message in the front desk of his glucose logs so we can let him know if
further adjustments are needed. on his DM meds. Stress importance of annual dilated eye exams for his
diabetes and he will not be due for that until this coming June. He understands all that we discussed and
total time spent was 28 mins face to face w greater tahn 50 % spent in counselling.