Running head: DIABETES MELLITUS TYPE TWO/CASE # 2293-20141015-002
Darlene Collins Beck
Adult Gerontology Primary Care Provider MSN/866
Concordia University Wisconsin
October 19, 2014
Chief complaint: Follow up on Diabetes
History of present illness: 50 year old African American female presents to the clinic today to follow up on her Diabetes. Patient diagnosed with Diabetes in 2000. Last Diabetes checkup three months ago. Patient reports that she takes all of her medications as prescribed. Patient is currently on metformin and Lipitor. Patient denies any episodes of hypoglycemia. Patient denies experiencing symptoms of polyuria, polydipsia, and polyphagia. Patient reports that she has been checking her…show more content… Patient is due for her influenza and pneumococcal vaccine. Patient educated on both vaccines especially the pneumococcal vaccine in regards to her having a chronic condition Diabetes. Patient also given literature, patient at this time declines for personal reasons. Patient cervical cancer screening is not due until 12/6/2015. Patient also due for breast cancer screening, order written, patient will call to set up appointment. Patient up to date on tetanus, next vaccination is 1/1/2016
Review of systems:
General: Patient denies fever, chills, malaise, weight loss or weight gain, denies changes in appetite.
Skin: denies blisters, rashes, wounds.
Eyes, ears, mouth: Patient denies difficulty with vision or double vision. Denies any eye pain, inflammation, discharge, denies history of glaucoma or cataracts, denies hearing loss or trouble hearing, denies sore throat, dry mouth, bleeding gums. Reports regular dental visits.
Neck: denies stiffness and pain
Cardiovascular: denies chest pain, palpitations or history of known murmurs
Lungs: denies shortness of breath, or cough or wheezing
GI: denies nausea and vomiting, changes in appetite, constipation and diarrhea
Genito-urinary: Denies urgency, frequency, hematuria. nocturia, hesitancy, or straining.
Musculoskeletal: Denies myalgia, stiffness and problems with joints.
Peripheral vascular: Patient denies pain,