CHART NOTE
Initial examination for this obese 42-year-old female patient with a 2-year history of mild hypertension and NIDDM, controlled by diet. Medications include Ortho-Novum 10/11. Patient was started on hydrochlorothiazide 50 mg 2 weeks ago because of elevated diastolic pressures. Present complaints are increasing fatigue, nocturia, and vaginal pruritus. Blood sugar by glucose meter is 417. Urine negative for ketones. Apical pulse of 90. Blood pressures are 144/94 and 140/98. Height 5 feet 2 inches, weight 186. History and physical unremarkable.
Recommendations to include the following: Instruction to patient to push fluids for the next several days. Discontinue hydrochlorothiazide and birth control pills to end possible
drug-induced hyperglycemia. Start Micronase 2.5 mg o.d. and Capoten 25 mg b.i.d. Set up appointment on Friday for FBS and for patient to see the nurse practitioner for fitting of a diaphragm and nutritional counseling on a 1200-calorie ADA diet.
drug-induced hyperglycemia. Start Micronase 2.5 mg o.d. and Capoten 25 mg b.i.d. Set up appointment on Friday for FBS and for patient to see the nurse practitioner for fitting of a diaphragm and nutritional counseling on a 1200-calorie ADA diet.
FOOTNOTE
Line 7. Exam was expanded to examination.
Line 9. The slang term meds was changed to medications.
Line 14. BPs was changed to blood pressure.
Line 15. H&P was expanded to history and physical.
Line 18. The slang term DC was translated as discontinue.
Line 20. The abbreviation o.d. means every day, not to be confused with O.D., right eye.
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