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:
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:
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:
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)