Medication Renewal

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents for a medication renewal

Last visit was ‍ ‍months ago



Medications:



Adherence: ‍goodaveragepoor

Tolerance: ‍adverse effects



Current symptoms: ‍noneno changes in health



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: ‍unremarkable





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍





ASSESSMENT:

‍Stable conditions ‍likelysuspectedpossible





PLAN:

Investigations:

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

Treatments:

- Medications renewed for ‍ months

Further care:

- Follow-up in ‍ ‍monthsyears

- Return if side effects occur or condition worsen