Medication Renewal

HISTORY:

Presents for a medication renewal



Medications:

‍

Adherence: ‍goodaveragepoor

Tolerance: ‍adverse effects

Current symptoms: ‍noneno changes in health



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU

Caffeine: ‍ daily

Diet: ‍goodaveragepoor, ‍high in salt, ‍high in carbs, ‍high in fat, ‍vegan

Physical activity: ‍adequateaveragesedentary

Weight: ‍ ‍lbskg, ‍gainunchangedloss



Labs:

‍



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍



ASSESSMENT:

‍Stable conditions ‍likelysuspectedpossible



PLAN:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍LFTs, ‍albumin, ‍TSH, ‍lipid profile, ‍fasting glucose, ‍HbA1c

- Medications renewed for ‍61224 months

- Follow-up in ‍ ‍monthsyears

- Return if side effects occur or condition worse