SUBJECTIVE: The patient comes in for a followup appointment. She is a (XX)-year-old Hispanic female with a past medical history of achondroplastic dwarfism, DM2, normal pressure hydrocephalus status post VP shunt, and also seizure disorder and dyslipidemia. The patient comes in for a followup appointment.
MEDICATIONS:
1. K-Dur.
2. Glucophage.
3. Avandia.
4. Florinef.
5. Topamax.
6. Relafen.
7. Darvocet p.r.n.
8. Ditropan XL.
9. Klonopin 0.5 mg b.i.d.
10. Macrobid 100 mg daily.
11. Zocor 40 mg.
12. Dilantin 600 mg daily.
13. Phenergan 25 mg q.h.s. p.r.n.
REVIEW OF SYSTEMS: See form.
OBJECTIVE:
VITAL SIGNS: T: 97.6. P: 74. R: 18. BP: 112/72.
HEENT: NC/AT. PERRLA. No icterus or conjunctival inflammation. TMs clear B/L. Nasal mucosa pink, no exudate. Oropharyngeal mucosa normal. No lesions or exudates.
NECK: Supple. No JVD, adenopathy or bruits.
LUNGS: Clear to auscultation bilaterally.
HEART: S1/S2, RRR.
ABDOMEN: Soft, nontender. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema. Diffuse deformities due to achondroplastic dwarfism.
ASSESSMENT AND PLAN:
1. We will call in her Dilantin at 500 mg and 100 mg totaling 600 mg a day. These are extended release tablets.
2. The patient will have her Topamax increased back up to 4 tablets a day from 3. She states that in the recent past Dr. John Doe has evaluated her VP shunt and that there was no evidence of malfunction. However, we will get a CT of her brain to make sure that there are no problems there as the last one was done around a year back.
3. Lab work from earlier this month was reviewed. HbA1C is 5.2 denoting excellent control of diabetes. However, phenytoin level was 5.9, which prompted the recent change in her Dilantin level. We feel her headaches are probably due to recurrent low-grade seizures and not due to any problem with the VP shunt as she has been fairly asymptomatic after the change in the dose. Hopefully, increasing the Topamax to 4 a day will also help. Her LFTs are normal. We will see her again in 6 weeks and see how she is doing and review the CT of the brain.
DIAGNOSES:
1. Seizure disorder.
2. Diabetes mellitus type 2.
3. Normal pressure hydrocephalus.
4. Achondroplastic dwarfism.
