NR 661 Week 4 All in One: Case Mr. John Seymour- Summary of The Patient's History

Your Advanced Clinical Management Case this week is Mr. John Seymour: History Details HPI John is a 72-year-old African-American male who presents to the office for routine follow-up of c hronic health conditions and for prescription refills. He just completed lab testing that you requested that he get prior to today’s exam. Past Medical Hx Type 2 Diabetes Mellitus (E 11.9) Primary Hypertension (I10) Mixed Hyperlipidemia (E78.2) Coronary Artery Disease (CAD) in Native Artery (I25.10) Benign Prostatic Hyperplasia without Urinary Obstruction (N40.0) GERD without Esophagitis (K21.9) Past Surgical Hx Laparoscopic cholecystectomy, 1992 Coronary Artery PCI X 2, 2015 Past Family Hx (Father deceased @ 84 ) DM T2, HTN, Hyperlipidemia (Mother deceased @ 86) HTN, Dementia Past Social Hx Married, retired psychology professor. Lives at home and is independent in all ADLs. Never smoker. Non-drinker. No drug abuse history. Sedentary lifestyle. Medications Metformin ER 1,000mg PO BID, Farxiga 10mg PO QAM, Bydureon BCise 2mg SQ Q Week Valsartan-HCTZ 160/25mg PO daily, Amlodipine 5 mg PO daily Atorvastatin 40mg PO daily Tamsulosin 0.4mg PO daily Pantoprazole 40mg PO daily Allergies Codeine, Sulfa Vital Signs Height 6’1”, Weight 220 lb, BMI 29, BP 138/84, HR 78, R 16 Most Recent Labs Hemoglobin A1c 8.1%, Total cholesterol 207, HDL 34, LDL-C 129 Prior Health Maintenance Colonoscopy- age 60 PCV13- age 64, PPSV23- age 60, Tdap- age 65, Zostavax- age 58 US AAA Screening- age 65