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Annual physical — geriatric cardiometabolic follow-up

Isreal Delbert Howell · 85y · male · 2024-10-07

General examination of patient (procedure)

Chart background

Active conditions

  • Received higher education (finding)
  • Body mass index 30+ - obesity (finding)
  • Prediabetes (finding)
  • Anemia (disorder)
  • Essential hypertension (disorder)
  • Metabolic syndrome X (disorder)
  • Ischemic heart disease (disorder)
  • Abnormal findings diagnostic imaging heart+coronary circulat (finding)
  • Acute non-ST segment elevation myocardial infarction (disorder)
  • History of myocardial infarction (situation)
  • Hyperlipidemia (disorder)
  • Diabetes mellitus type 2 (disorder)

Active medications

  • Simvastatin 20 MG Oral Tablet
  • 24 HR metoprolol succinate 100 MG Extended Release Oral Tablet
  • Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray
  • aspirin 81 MG Oral Tablet
  • 24 HR metoprolol succinate 50 MG Extended Release Oral Tablet
  • atorvastatin 20 MG Oral Tablet
  • losartan potassium 50 MG Oral Tablet
  • Hydrochlorothiazide 25 MG Oral Tablet
  • 24 HR Metformin hydrochloride 500 MG Extended Release Oral Tablet

After-visit summary

Visit summary

What we discussed
• Type 2 diabetes mellitus
• Essential hypertension
• Ischemic heart disease / hyperlipidemia
• Gingivitis
• Anemia
• Health maintenance and geriatric screening

Next steps
• Start 24 hr metformin hydrochloride 500 mg extended-release tablet daily with the evening meal.
• Counseled to avoid skipping breakfast before morning walks; report GI intolerance rather than self-discontinuing.
• Start hydrochlorothiazide 25 mg each morning.
• Continue losartan 50 mg daily and metoprolol succinate ER 100 mg daily.
• Monitor for orthostatic symptoms; repeat basic metabolic panel and potassium at follow-up.
• Consolidate to atorvastatin 20 mg nightly; simvastatin 20 mg removed at reconciliation.
• Continue aspirin 81 mg daily; nitroglycerin 0.4 mg/actuation mucosal spray PRN chest pain.
• Repeat lipid panel at follow-up before dose escalation.

deterministic_extractive_v1 · not_clinically_reviewed

Clinical note

**Subjective:** Mr. Isreal Howell is an 85-year-old man presenting for his annual comprehensive examination. He reports feeling well. He remains active with daily neighborhood walks and regular gardening. He denies chest pain or pressure at rest or with usual exertion, noting only an occasional brief twinge with heavy yard work that resolves promptly with rest; he has not needed his nitroglycerin spray in many months. He denies exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitations, lower-extremity edema, lightheadedness, syncope, and falls over the past year. Appetite is preserved and weight is stable to slightly down. He reports gum bleeding with brushing for several months without tooth pain; he has not seen a dentist since his longtime dentist retired. He retired from a sixty-year bookkeeping career this June and is adjusting well; he lives with his daughter and grandson (three in the household) and denies difficulty affording food, medications, or transportation. Ex-smoker since young adulthood; denies alcohol or drug use. History includes acute non-ST segment elevation myocardial infarction with ischemic heart disease, essential hypertension, hyperlipidemia, type 2 diabetes mellitus, prediabetes progressing to diabetes, metabolic syndrome, anemia, and prior obesity. Medication reconciliation performed with his pill bottles: he takes atorvastatin 20 mg nightly (duplicate simvastatin 20 mg entry from a prior hospitalization removed), metoprolol succinate ER 100 mg daily (outdated 50 mg ER entry removed), aspirin 81 mg daily, losartan 50 mg daily, and nitroglycerin 0.4 mg/actuation spray as needed. No known drug allergies.

**Objective:** BP 107/58 mmHg, HR 96/min, RR 13/min, weight 78.5 kg, height 168 cm, BMI 27.8 kg/m2, pain 1/10. Alert, well-appearing, conversant, steady gait. Gingival erythema and edema along the mandibular gumline with friability. Heart regular; lungs clear; no peripheral edema. Labs: HbA1c 5.45%; glucose 66.82 mg/dL; BUN 18.73 mg/dL; creatinine 0.6 mg/dL; eGFR 148.95 mL/min/1.73m2; sodium 137 mmol/L; potassium 5.16 mmol/L; chloride 104.15 mmol/L; CO2 28.18 mmol/L; calcium 8.74 mg/dL; total cholesterol 226.05 mg/dL; direct LDL 148.61 mg/dL; HDL 57.06 mg/dL; triglycerides 101.87 mg/dL; urine microalbumin/creatinine 15.6 mg/g. Screening: PHQ-2 0; HARK 0; DAST-10 0; Morse Fall Scale 22, low risk.

**Assessment and Plan:**

### Type 2 diabetes mellitus
Excellent glycemic control with HbA1c 5.45%; fasting glucose low at 66.82 mg/dL today. Given the established diagnosis with metabolic syndrome and ischemic heart disease, low-dose therapy was initiated.
- Start 24 hr metformin hydrochloride 500 mg extended-release tablet daily with the evening meal
- Counseled to avoid skipping breakfast before morning walks; report GI intolerance rather than self-discontinuing

### Essential hypertension
Office BP 107/58 today; home readings reportedly more variable. Potassium 5.16 mmol/L at the upper margin on losartan.
- Start hydrochlorothiazide 25 mg each morning
- Continue losartan 50 mg daily and metoprolol succinate ER 100 mg daily
- Monitor for orthostatic symptoms; repeat basic metabolic panel and potassium at follow-up

### Ischemic heart disease / hyperlipidemia
Direct LDL 148.61 mg/dL, above goal for secondary prevention; duplicate statin chart entries likely contributed to inconsistent use.
- Consolidate to atorvastatin 20 mg nightly; simvastatin 20 mg removed at reconciliation
- Continue aspirin 81 mg daily; nitroglycerin 0.4 mg/actuation mucosal spray PRN chest pain
- Repeat lipid panel at follow-up before dose escalation

### Gingivitis
Mandibular gingival inflammation with bleeding on brushing.
- Patient referral for dental care placed; brushing and flossing technique reviewed

### Anemia
Historical and asymptomatic; no fatigue, dyspnea, or bleeding source beyond gums.
- Continue surveillance at next laboratory draw

### Health maintenance and geriatric screening
Not in labor force newly documented following retirement this year.
- Influenza vaccine (split virus, trivalent, preservative-free) administered today
- Depression screening ×2 (PHQ-2 0), domestic abuse screen (HARK 0), substance use assessment and drug abuse screen (DAST-10 0) negative; Morse Fall Scale 22, low fall risk
- Medication reconciliation and assessment of health and social care needs completed
- Return in 6 months with repeat labs; sooner for chest pain, dizziness, or medication intolerance

FHIR resources at this visit

Observation 29Procedure 9DiagnosticReport 7Condition 2MedicationRequest 2Immunization 1

Transcript

DRGood morning, Mr. Howell. Come on in — it is good to see you again. How was the ride over?

PTOh, my grandson brought me. He drives like the road owes him money, but we made it in one piece.

DRHa — glad to hear it. So it has been about a year since your last full checkup. How have you been feeling overall?

PTHonestly, doctor, not bad for an old-timer. I turned eighty-five in March. I get a little slower every year, but I still do my walk around the block most mornings.

DRThat is wonderful. Any chest pain, pressure, or tightness on those walks? Anything like what you felt before your heart attack?

PTNo, nothing like that. Once in a while I get a twinge if I overdo it in the yard, but it passes as soon as I sit down. I have not had to use that little spray in a long while.

DRThe nitroglycerin spray. Good — keep carrying it, but I am glad you have not needed it. Any shortness of breath, swelling in your ankles, waking up at night gasping for air?

PTNo, none of that. No swelling. I sleep like a rock, always have.

DRDizziness, lightheadedness, any falls this past year?

PTNo falls. I hold the rail on the stairs like my daughter makes me promise to.

DRSmart promise. Appetite holding up? Weight steady?

PTAppetite is fine. I eat what the garden gives me, mostly. Tomatoes did well this year.

DRNow, big news in your file — I hear you finally stopped working this year?

PTI did. Sixty years of keeping books for people, and I closed the ledger for good in June. Feels strange. Some mornings I still reach for my briefcase.

DRThat is a big change. How are you filling the days?

PTThe garden, mostly. And my daughter and grandson live with me, so there is always some commotion in the house.

DRThree of you at home, that is right. Any trouble affording food, your medications, getting to appointments — anything like that?

PTNo, we are comfortable. I saved carefully. That was my whole profession, after all.

DRFair enough. Let us go through your medications one by one — it has been a while since we did a proper reconciliation, and I see some duplicates in the chart I want to sort out.

PTI brought the shoebox with all the bottles, like your nurse asked.

DRPerfect. So the chart lists simvastatin twenty milligrams and also atorvastatin twenty — you should not be on two cholesterol pills. Which one is actually in the box?

PTThe atorvastatin. The other bottle is empty — that one was from the hospital, years back.

DRThat is what I suspected. Simvastatin comes off the list today. Same question for the metoprolol — I see a hundred-milligram extended release and an old fifty-milligram one.

PTI take the hundred in the morning. The fifty was the old dose from before.

DRWe will clean that up too. And the baby aspirin, the eighty-one, and the losartan fifty — still every day?

PTEvery day with my oatmeal. Never miss.

DRExcellent. Now your numbers. Blood pressure today is one-oh-seven over fifty-eight, which is quite good, and your heart rate is ninety-six. Weight is seventy-eight and a half kilos, and the body mass index works out to twenty-seven point eight — trimmer than a few years ago.

PTThe gardening keeps me honest.

DRIt shows. Your labs are mostly reassuring. The A1c — that is the three-month sugar average — came back at five point four five percent, which is excellent for someone with type two diabetes.

PTThat is the best it has been, is it not?

DRIt is. Your fasting sugar this morning was actually on the low side, around sixty-six, so I do not want you skipping breakfast before those walks. Kidneys look strong — creatinine is zero point six. Your potassium ran a touch high at five point one six. And the cholesterol panel — total is about two twenty-six with the LDL at one forty-eight, which is higher than I want for a man with your heart history.

PTEven on the pill?

DREven on it — and now that we have sorted out the two-statin confusion, I suspect inconsistent bottles are part of the story. Let us keep the atorvastatin every evening, no missed days, and recheck before we change any dose.

PTI can do that.

DRTwo new medicines today. First, for the diabetes — your control is excellent, but with the diagnosis on the books and the metabolic syndrome alongside your heart disease, I would like to add a gentle dose of metformin, the extended-release kind, five hundred milligrams once daily with dinner.

PTMy brother took metformin. Upset his stomach something awful.

DRThat is the most common complaint, which is exactly why we use the extended-release and pair it with food. If it bothers you, call me — do not just quit it quietly.

PTAll right, fair.

DRSecond, the blood pressure. Your office reading today is good, but the home readings you described to the nurse have been bouncier, and your potassium is riding high. I want to add hydrochlorothiazide, twenty-five milligrams each morning — a mild water pill. It smooths the pressure out, and it tends to nudge that potassium down a notch alongside the losartan.

PTA water pill. Will I be running to the bathroom all night?

DRTake it in the morning and you will mostly be running before lunch. If you feel dizzy or washed out, especially when you stand up, I want to hear about it right away.

PTUnderstood.

DRThe nurse ran through the screening questions with you — the mood ones twice over, the safety-at-home questions, the alcohol and drug ones. Every score came back a zero, and your fall-risk score was twenty-two, which sits in the low-risk range.

PTI told her the strongest thing I take is black coffee.

DRHa — I believe it. Your anemia has been quiet too — no new blood count today, but nothing in how you feel suggests trouble, so we will keep watching it at the next round of labs.

PTIt has never bothered me that I could tell.

DROne thing I do want handled: open wide for me... yes, there it is. Your gums are red and puffy along the lower teeth, and you mentioned they bleed when you brush.

PTJust a little pink in the sink, most mornings.

DRThat is gingivitis. Very treatable, but I do not want it smoldering — gum disease and heart disease are unfriendly neighbors. I am sending a referral to the dental clinic for a proper cleaning and exam.

PTMy dentist retired before I did, so I have been putting it off.

DRThen the timing is right. Last thing — flu shot. It is October, the season is coming. Any bad reactions before?

PTNever. Just a sore arm and my daughter's sympathy.

DRThen we will do it before you leave.

NURSEQuick pinch coming, Mr. Howell... and done. Keep the sleeve loose — the arm might be sore tomorrow.

PTPainless. You have a gentler touch than my grandson's driving.

DRSo, the recap. Keep taking the atorvastatin at night, the metoprolol hundred in the morning, the losartan, the little aspirin, and keep the nitro spray in your pocket. We are adding metformin extended-release at dinner and the water pill with breakfast. Simvastatin and the old fifty-milligram metoprolol are off the list. Dental clinic for the gums, flu shot done, and no skipped breakfasts.

PTMetformin at supper, water pill with the coffee. I will write it on the calendar the minute I am home.

DRPerfect. I will see you back in about six months for repeat labs — sooner if there is any chest pain, dizziness, or if the new pill argues with your stomach.

PTThank you, doctor. I will bring you a tomato next summer if the garden cooperates.

DRI will hold you to that, Mr. Howell. Take care now.