EF is a 40 YO AA female that presents on a return visit to your primary care clinic for continued back and shoulder pain
Posted: Tue Sep 07, 2021 8:16 am
EF is a 40 YO AA female that presents on a return visit to your
primary care clinic for continued back and shoulder pain x 3
weeks. EF is a truck driver and loads/unloads trucks on a daily
basis and delivers nationally often. Patient currently
is uninsured
Vitals 8/29/2020: wt 230lbs, Ht 71
inches, T 97.8, BP 218/108, HR
83, RR 14
PMH: HTN, T2DM, Scoliosis, migraine, angioedema
SH: ETOH (+) Tobacco ½ ppd recently stopped, h/o of cocaine
use
FH: HTN mother and sister Cancer: mother and father
Medication:
Amlodipine 10mg 1 po q day
Hydrochlorothiazide 25mg 1 po q day
Lisinopril 10 mg 1 po q day
Simvastatin 40mg 1 po qhs
Metformin 500mg 1 tablet po bid
Propranolol 20mg 1 po q day
On Call Plus Meter and Strips
Labs 06/18/2020:
Glucose 101 Cl 103 ALT 25
BUN 11 CO2 23 Micro/Creat 40
Scr 1.4 Ca 9.8 A1c 6.4
Na 142 Alb 4.5
K 5.0 AST 18
primary care clinic for continued back and shoulder pain x 3
weeks. EF is a truck driver and loads/unloads trucks on a daily
basis and delivers nationally often. Patient currently
is uninsured
Vitals 8/29/2020: wt 230lbs, Ht 71
inches, T 97.8, BP 218/108, HR
83, RR 14
PMH: HTN, T2DM, Scoliosis, migraine, angioedema
SH: ETOH (+) Tobacco ½ ppd recently stopped, h/o of cocaine
use
FH: HTN mother and sister Cancer: mother and father
Medication:
Amlodipine 10mg 1 po q day
Hydrochlorothiazide 25mg 1 po q day
Lisinopril 10 mg 1 po q day
Simvastatin 40mg 1 po qhs
Metformin 500mg 1 tablet po bid
Propranolol 20mg 1 po q day
On Call Plus Meter and Strips
Labs 06/18/2020:
Glucose 101 Cl 103 ALT 25
BUN 11 CO2 23 Micro/Creat 40
Scr 1.4 Ca 9.8 A1c 6.4
Na 142 Alb 4.5
K 5.0 AST 18