description of motor vehicle accident, onset of pain, aggravating/relieving factors, ankle X-ray
What is ankle X-ray and the objective section?
PMH: T2DM, HTN, hypothyroidism
What is subjective?
Pt's abx are appropriate, cont vanc + gent x10d.
What is "Patient's antibiotics are appropriate, continue vancomycin and gentamicin for 10 days"?
This season is a favorite of both Dr. Cillessen and Dr. Burney
What is summer?
smoking history, home blood glucose logs, blood pressure, home medication list
What is blood pressure and the objective section?
Follow-up with pharmacy team in 1 month to check BP and weight.
What is plan?
HR > 100 bpm on BB tx, inc to 25 mg BID, ck HR in 1 wk
What is "Heart rate is over 100 beats per minute on beta-blocker therapy, increase to 25 mg twice daily and check heart rate in 1 week"?
This preceptor has quite the green thumb, she spends her weekends landscaping, mowing, and planting when she has the time.
Dr. Burney
drug recommendation, guideline reference, staged medical problems
What is drug recommendation and the plan section?
A1c above ADA goal of <7%. Home fasting BG above goal of 80-130 mg/dL and postprandial BG readings above goal of <180 mg/dL.
What is assessment?
T2DM uncont, FBG > ADA goal 80-130 mg/dL
What is "Type 2 diabetes mellitus uncontrolled, fasting blood glucose greater than American Diabetes Association goal 80 to 130 milligram per deciliter"?
Dr. Cillesssen
serum creatinine, last BP, caffeine intake, diabetic foot exam
What is caffeine intake and the subjective section?
CT w/o contrast: no hemorrhage or midline shift
What is objective?
Pt c/o RUQ abd pain. Suggest Pepcid PO BID. F/u in 2 wks.
What is "Patient complains of right upper quadrant abdominal pain. Suggest Pepcid by mouth twice daily. Follow up in 2 weeks"?
Fun fact: this preceptor has competed in the Junior Olympics not once, not twice, but three times!
Dr. Cillessen
monitoring parameters, patient education, therapeutic goal, nondrug therapy recommendation
Padua Score = 7 indicating patient is at a high VTE risk (reduced mobility, recent surgery, elderly, prior stroke)
What is assessment?
CBC WNL, IDA controlled c FeSO4 325 mg TID PC
This preceptor jams to 21 pilots, while this preceptor prefers Broadway musicals.
Dr. Cillessen, Dr. Burney