Metro Health Inc.
Progress Notes
Mr. PETER IBEOTH

Patient ID: 22222D2

D.O.B: 07-23-1957

Age: 66 years G Gender: M

02/09/24

02/09/24 : 09:50am

OFFICE VISIT

Patient seen at:

Metro Health of Metro West

6150 Metro West Blvd, Suite 307 Orlando, FL 32835

Phone: (407)294-1014 Fax: (407)294-7732

Patient Phone: (231) 946-1485

Vital Signs:
BP: 122/82
Pulse: 75
Temperature: 97 F
Height: 5’4”
Weight: 191 lbs
BMI: 32.78 kg/m2
O2 Sat: 95 %
Respiratory: 17
Subjective:

This 58 Years old male is here 3 months F/U and to discuss chronic medical conditions.

*Pt denies any new complains.

*Pt stated she is taking all meds from update list today

Medications reviewed and updated.

RR.

Review of Systems:
Constitutional: negetive
Nose/Mouth/Throat: has upcoming dentist appointment for dentures
Cardiovascular: negative
Respiratory: negative
Gastrointestinal: negetive
Genitourinary: negetive
Bladder Controlled: yes
Psychiatric: Patient stressed out due to his son in NC recently being arrested for not having housing, he also helps care for his grandchild.
Past Medical History:

Hypertension

Psychological/Emotional Disorders - depression

MDD Symptoms include depressed mood, anxiety, excessive worrying, difficulty sleeping, difficulty concentrating and lack of energy. Continue with sertraline.

Current Medication Conditions:

Hypertension

Tobacco dependence

Tobacco abuse counseling

Major depression, in remission

Insomnia

Polyarthritis

Hypertension with chronic kidney disease

Chronic kidney disease, stage 2 (mild)

Major depressive disorder, recurrent, mild

Surgical History:

tubal Ligation 1992

COLONOSCOPY 5/25/15

Social History:

Smoking Status: Current every day smoker

Alcohol Use: none

Drug Use:

Family History:

Lina Ibeoth (Mother) Age: 55 Gender: Female (Demised)

Cause of death: Noncommunicable (chronic) and injuries.

Symptoms: Chickenpox typically begins with a mild fever, headache, and fatigue, followed by the development of an itchy rash. The rash progresses from red spots to fluid-filled blisters, which eventually form scabs as the illness runs its course. Other symptoms may include loss of...

Current Medication:

Name: Acetaminophen 200mg Dosage: 1 Duration: Every 2 weeks

Name: Adderall 50mg Dosage: 2 Duration: Every 3 weeks

Medication Allergies:

Cetirizine (Zyrtec, Zyrtec Allergy) Desloratadine (Clarinex) Fexofenadine (Allegra, Allegra Allergy)

Medication Allergies:
General: Well appearing.
Skin: Normal
Hair: Normal
Nails: Normal
Head: Normal
Heart: RRR, no murmur
Lungs: CTA free text
Abdomen soft, NT/ND, normal bowel sounds, no HMS, no masses.
Extremities: No deformities.
Psychiatrics: Intact memory, judgment and insight, normal mood and affect, Speech normal rate and tone.
Teste Labs Completed and Reviewed:

ORGAN OR DISEASE PANELS

(144000) Acute Viral Hepatitis (HAV, HBV, HCV) (80074)

(322758) Basic Metabolic Panel (8) (80048)

ORGAN OR DISEASE PANELS

(005009) CBC w Diff w Pit (85025) (LAV)

HGB A1C: 5.5 on 02/22/2023

PSA: 6.8 on 02/22/2023

Lab Reviewed:

July 2022 GFR 87 LDL 143 HDL 49 Vitamin D 23.4 TSH 0.62 Hemoglobin A1c 5.6

Assessment Plan:

Well adult exam: ICD10 = 200.00/CDW

patient is being seen to establish care. Encourage patient to continue with medical compliance, diet, and exercise.

Hypertension with chronic kidney disease: ICD10 = 112.9/ ICD9 = 403.10 / SNOMED = 104931000119100

Chronic kidney disease, stage 2 (mild): ICD10= N18.2 / ICD9 = 585.2 / SNOMED = 431856006

patient has hypertension with chronic kidney disease stage II. Blood pressure is under control. Continue with a low-salt diet. Continue with lisinopril

Hyperlipidemia: ICD10 = E78.5/ ICD9 = 272.4 / SNOMED = 55822004

patient has hyperlipidemia. Continue with low-fat diet. Continue with atorvastatin.

Morbid obesity due to excess calories: ICD10 = E66.01 / ICD9 = 278.01 / SNOMED = 83911000119104

patient has morbid obesity due to excess calories with comorbid conditions of hypertension and hyperlipidemia. Discussed with patient that he needs to slowly increase his physical activity and go on a low caloric diet so he could lose weight

Obstructive sleep apnea: ICD10= G47.33 / ICD9 = 327.23 / SNOMED = 78275009

patient has obstructive sleep apnea. He is not using his CPAP machine regularly. We will continue to monitor.

Lumbar DDD: ICD10 M51.36 / ICD9 = 722.52 / SNOMED = 26538006

patient has degenerative disc disease of the lumbar spine. X-rays confirm it. Patient refusing to do MRI at this time. We will do home physical therapy. If no improvement patient agreed to do the MRI and possibly epidural injection.

Lymphedema: ICD10 = 189.0/ ICD9 = 457.1 / SNOMED = 234097001

patient has lymphedema of both legs. Patient will benefit from doing lymphedema therapy

Benign prostatic hypertrophy with lower urinary tract symptom: ICD10 N40.1 / ICD9 = 600.01 / SNOMED = 30041000119101

patient has benign prostatic hypertrophy with lower urinary tract symptoms. Continue with Tamsulosin. Will monitor PSA levels which he states was higher before

15 minutes spent with patient, greater than 50% of the office visit was dedicated to counseling, reviewing tests & labs, treatment options and follow up plans.

Wellness/Health Maintenance:

Colonoscopy overdue

BMI Plan: Y

Discussed high BMI with patient. Reviewed risk factors, and behavior modifications including a diet rich in fruits. vegetables, whole grains, and low-fat foods. Also discouraged soda, fruit juice and energy drinks. Stressed the importance of regular exercise.

Follow-up: 3-4 weeks

This dictation was performed using voice recognition to text. While we try to be as proficient as possible, there may be spelling or typo errors. If there are any questions, please contact our office

Rx: Tamsulosin 0.4 mg capsule, 90, Ref: 1, take 1 capsule (0.4 mg) by oral route once daily 1/2 hour following the same meal each day

Rx: lisinopril 40 mg tablet, 90, Ref: 3, TAKE 1 TABLET BY MOUTH 1 TIME EACH DAY.

Rx:

Rx: gabapentin 100 mg capsule, 30, Ref: 3, TAKE 1 CAPSULE BY MOUTH EVERY NIGHT

Rx: celecoxib 200 mg capsule, 60, Ref: 3, TAKE 1 CAPSULE BY MOUTH TWICE A DAY

Rx: bumetanide 1 mg tablet, 90, Ref: 0, take 1 tablet (1 mg) by oral route once daily

Rx: atorvastatin 10 mg tablet, 90, Ref: 3, TAKE 1 TABLET BY MOUTH EVERY DAY

# SIGNED BY Cesar R Quililan, MD, Doctor (CRQ) 02/27/2023 (03:03pm)

# REVISED BY Cesar R Quililan, MD, Doctor (CRQ) 03/01/2023 (04:01pm)