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NUR 811 “CC”: “65 year old male here for follow up appointment for




                Patient was diagnosed with dyslipidemia in 2000. Cardiovascular risk include hypertension,                                            age and high CCRP. Target LDL is less than 130. The most recent LDL was 55 on 1/7/19. The                                       most recent HDL was 44 on 1/7/19. The most recent total cholesterol was 138 on 1/7/19. The most                          recent triglyceride was 193 on 1/7/19. Dyslipidemia is being managed by Statins and diet. The                                 patient denied angina, palpitations, dizziness and lightheadedness.

2. Hypertension

                Patient diagnosed with hypertension in 2000. Risk factors include family history of hypertension,                                   CAD, male gender and age over age of 60. Patient expressed feeling tired. Pertinent negatives                                         include chest pain, dizziness, shortness of breath and lightheadedness.

3. Diabetes

                Patient presents with diabetes- type 2, diagnosed in 2014. There are no disease related                                                       complications. The status of the patients condition is uncontrolled per A1C.Last recorded HbA1C                                                was 10.8 on 1/7/19. Prior to that , HbA1C was 6.2 on 3/5/18. LDL was recorded as 55 on 1/7/19.                                    Last creatinine was 0.70 on 7/17/17. Monofilament exam was last performed on 7/19/18. Sign and                         symptoms include polydipsia and polyuria. Pertinent negatives include: chest pain, dizziness,                                           edema, increased fatigue, headache, paresthesia, shortness of breath, and vision loss.

                Diabetes managed with Metformin, Statin, and diet. Took Metformin for about 2 years and then                                     discontinued due to low A1C 4.9 and is currently not taking Metformin. Patient states diet has                                        been poor lately- tends to binge eat late at night out of  boredom. Patient tries to choose health                                  choices when binging- down 21 lb. from the summer. Patient states he has been thirsty and                                       urinating more frequently.


Amantadine HCL 100 mg 1/2 tab BID by mouth

Aspirin 81 mg chew 1 tablet by mouth daily

B-12 take one tab sublingual daily

Clonazepam 1 mg one tablet by mouth at noon and two tablets at bedtime

duloxetine 60 mg delayed release- take one by mouth daily

Folic acid 800 mug take one tablet by mouth daily

Furosemide 20 mg take one tablet by mouth daily

Klor-Con 10 meq XR- take one tablet by mouth daily

Lipitor 40 mg tablet- take one by mouth daily

Melatonin 1 mg- take one tablet by mouth at bedtime

Methylphenidate 10 mg tablet- take one by mouth daily

Metoprolol tartrate 25 mg tablet- take one tablet twice a day

Mirtazapine 15 mg tablet- take one by mouth at bedtime

Multivitamin tab- take one by mouth daily

Namenda 10 mg tablet- take one by mouth twice a day

Neupro 4mg/24 hour transdermal patch- apply patch once a day- do not apply to same area more than once

Rivastigmine 1.5 mg capsule- take 1 by mouth twice a day with food

Synthroid 50 mug tablet- take one by mouth daily

Viagra 50 mg tablet- take one by mouth as needed one hour before sexual activity

Vitamin B-1 100 mg tablet- take one by mouth daily 

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