Date/ time Subjective Objective Assessment Plan

April 3, This is a case of O.C. Conscious, DM type II > For HbA1c

2018 72/male, Filipino, coherent, not in Dyslipidemia > Continue
married, catholic, last cardiopulmonary Metformin
8.40 am seen 3/23/2018 with distress 500mg/tab 1 tab
the diagnosis of Vital sign: BP BID
Diabetes mellitus 110/70mmHg, HR Pravastatin
type 2 and 86 bpm, RR 18 10mg/tab 1 tab
Dyslipidemia, came cpm, T 37 °C ODHS
in today for follow up Wt 68 kg, H 160 Vitamin B
with the laboratory cm, BMI complex 1 tab
result 24.09kg/m2 OD
Chemistry: (overweight) > Start Ascorbic
FBS 134.64 mg/dl Skin: brown, acid 1 tab OD
Total cholesterol warm to touch, > therapeutic
179.74 mg/dl good skin turgor, lifestyle change
LDL 92.72 mg/dl capillary refill <2 > Increased
HDL 64.6 mg/dl seconds fluid intake
Triglyceride 112.64 HEENT: > TCB for
mg/dl Anicteric sclera, follow up once
BUN 3.38 mmol/L pink palpebral with result
Creatinine 1.10 mg/dl conjunctiva, (+) > Please refer to
Uric acid 4.20 mg/dl opacity of lens, no dietary for DM
SGPT 40.0 U/L nasoaural diet
SGOT 32.0 U/L discharge, no > Advised
tonsillopharyngeal
congestion, no
cervical
lymphadenopathy
Chest and lungs:
symmetrical chest
expansion, clear
breath sounds, no
retraction
Heart: Adynamic
precordium,
normal rate,
regular rhythm,
no murmur
Abdomen:
Flabby,
normoactive
bowel sound, no
tenderness upon
light and deep
palpation
Extremities:
Grossly normal
extremities, no
deformity, no
edema, no
cyanosis, full and
equal pulses
Neurologic exam
I: not assessed
II: Intact direct
and concentual
light reflexes on
both eyes
III,IV,VI: Intact
extraocular
muscle.
V: Able to clench
teeth and resist
pressure applied
on chin, able to
feel pinrick, light
touch, dull pain
VII: raise
eyebrows, wrinkle
forehead and
open/close eyes,
pout, purse lip,
blow off cheeks
VIII: Rubbing
finger on both
ears
IX, X: uvula in
the midline
XI:can shrug the
shoulder with and
without the
resistance
XII: tongue in the
midline
Motor: (+)
Tremor on left
hand
Sensory: React to
pain, touch,
pressure, position
and vibration
sense
Reflex: +2
Cerebellar: able
to do finger to
nose test
Cerebrum: alert,
relax, oriented to
time , place and
person