SUBJECTIVE
The offender is in clinic today to follow up on her diabetes, headaches, and thyroid. She reports that she has not been feeling well for the past few days. She has had a lot of nasal congestion, and drainage. She has been blowing green yellow mucus out of her nose and she has developed pain in her right forehead and cheek. She does have chronic headaches that usually are more bitemporal, please see the note from 12/12/2016 describing her headaches. She has not exactly had a fever, but is wondering if she has a sinus infection which she has had before. She is not watching her diet. She does exercise. She is still planning on going to CIP in February. Her foot is better. She has been working with PT and the CIP trainer. She has been …show more content…
Weight is 197.9 pounds. The HEENT exam shows her fundi are normal. Pupils and EOMS are intact. She does have some tenderness in her frontal sinus and her right maxilla sinus. The ears, nose, and throat otherwise are negative. Her lymphatics are negative. Her neck is normal. Chest is clear and equal. Cardiovascular exam is normal. Her abdomen is benign. Back and extremities are negative. The laboratory shows that her glucose is 225 on a fasting specimen and her A1c is up to 6.9, it was 5.7 previously. Her TSH is 6.6 and her T4 is low at …show more content…
I recommended increasing her insulin, which I will change to 15 units in the evening on the NPH after reviewing her blood sugars in the computer. The readings have been 2-300 for the most part. Although she has had a few in the 100s. I will change her Synthroid to 75 mcg daily up from 50 and I will write for Keflex 500 mg twice a day for her sinuses. Will check another A1c in three months along with a urine microalbumin and I will plan to see her back in clinic at that time. Will also check her thyroid. In the meanwhile, she knows she can kite or sign up for sick call if she needs
The offender is in clinic today to follow up on her diabetes, headaches, and thyroid. She reports that she has not been feeling well for the past few days. She has had a lot of nasal congestion, and drainage. She has been blowing green yellow mucus out of her nose and she has developed pain in her right forehead and cheek. She does have chronic headaches that usually are more bitemporal, please see the note from 12/12/2016 describing her headaches. She has not exactly had a fever, but is wondering if she has a sinus infection which she has had before. She is not watching her diet. She does exercise. She is still planning on going to CIP in February. Her foot is better. She has been working with PT and the CIP trainer. She has been …show more content…
Weight is 197.9 pounds. The HEENT exam shows her fundi are normal. Pupils and EOMS are intact. She does have some tenderness in her frontal sinus and her right maxilla sinus. The ears, nose, and throat otherwise are negative. Her lymphatics are negative. Her neck is normal. Chest is clear and equal. Cardiovascular exam is normal. Her abdomen is benign. Back and extremities are negative. The laboratory shows that her glucose is 225 on a fasting specimen and her A1c is up to 6.9, it was 5.7 previously. Her TSH is 6.6 and her T4 is low at …show more content…
I recommended increasing her insulin, which I will change to 15 units in the evening on the NPH after reviewing her blood sugars in the computer. The readings have been 2-300 for the most part. Although she has had a few in the 100s. I will change her Synthroid to 75 mcg daily up from 50 and I will write for Keflex 500 mg twice a day for her sinuses. Will check another A1c in three months along with a urine microalbumin and I will plan to see her back in clinic at that time. Will also check her thyroid. In the meanwhile, she knows she can kite or sign up for sick call if she needs