Video Case of the Week

An established office visit...

CC: F/U HTN and DM2

INTERVAL HISTORY: The patient’s HTN remains well controlled on current medications. Diabetes is stable as well, with no symptomatic hypoglycemia of severe hyperglycemia. Dyslipidemia remains stable on statin therapy.

PFSH is remarkable for CAD, s/p CABG in 2001

ROS CV: Negative for chest pain, orthopnea or PND. Neuro: Negative for paresthesias

Vitals: 120/80, 18, 82, 98.6
General: NAD, conversant
Lungs: Clear to auscultation
CV: RRR, no MRGs
Abdomen: Soft, non-tender
Ext: No peripheral edema

Assessment

1. Well controlled DM2
2. Well controlled HTN
3. Stable dyslipidemia

Plan

1. Continue LISINOPRIL unchanged for HTN
2. Renal profile, urine microalbumin, CBC on return
3. Also check LFTs due to ongoing statin therapy
4. Return visit in four months

This week's answer (video)

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