Pre-Diabetes: A Case Study

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CC Follow up hypertension, hypercholesterolemia, pre-diabetes. S The patient is a 64-year-old female who states she has been doing fairly well. She did just get back from vacation in British Columbia for the last two weeks. She was not eating well there, but has been trying to eat well in general. She does get concerned about her history of elevated hemoglobin A1C into the pre-diabetes range. She does continue on her medications for her high blood pressure, as well as for her high cholesterol. She did see an eye doctor secondary to allergies of her eyes. She was on a short course of a steroid drop for her eyes. She also continues on Maxalt, but uses it very infrequently. She states she has noticed that when she is getting toward the end of her Estring prescription, she will get a migraine headache. This has become so consistent, she did have her gynecologist start prescribing her Estring every two months instead of every three months. She only needs Maxalt about every three months, half a tablet at a time.…show more content…
She does tell me the pain seemed to get worse and radiated down her arm and she got concerned, she might have heart disease and thus went to the Portsmouth Hospital emergency room this summer. I do not have these records. Medications Reviewed as per chronic medication log. Objective Vital Signs Blood pressure 120/82. Pulse 68. Respiratory 14. Weight 132 pounds, which is stable for patient. General Patient is alert, oriented, no acute distress. A/P Hypertension. Blood pressure well controlled on Zestril 30 mg one p.o. daily. She will continue this. We will check blood work that she had at Portsmouth Hospital this summer. Hypercholesterolemia, continue Lipitor 10 mg one p.o. nightly. She will check lipid panel, CMP prior to her physical in

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