INTERVAL HISTORY: The patient's HTN remains well controlled with systolic
pressures in the 120s at home. Diabetes appears to have stabilized on current dose of
METFORMIN. CHF remains well controlled on sliding scale of diuretics adjusted
during out last visit.
ROS: CV: Negative for chest pain/PND/orthopnea. Endocrine: Negative for polyuria
or polydipsia.
Pertinent PFSH is remarkable for hyperlipidemia which is stable on statin therapy and
CAD with no symptoms on long-acting oral nitrates.
PHYSICAL EXAM: NAD, conversant. BP 120/80, RR 20, HR 72. Lungs are clear.
Heart is RRR with no MRGs. Extremities show no significant edema.
HGBA1c 6.2, creatinine 0.7, LDL 88
IMPRESSION: DM2, HTN, CHF, hyperlipidemia and CAD all of which are optimally
controlled. Patient is doing remarkably well considering all his chronic medical
problems and co-morbidities.
PLAN: No changes needed. RTC in 3 months with the usual labs.
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