[doctor] okay . maria martin , date of birth 03/05/1946 , has been informed and consents to have this visit recorded . the patient is here for follow-up .
[doctor] hi , maria . how have you been doing ?
[patient] same i guess . pretty good .
[doctor] okay , so you got my letter last time on the results . your sugars are not very well controlled .
[patient] yeah , i got them .
[doctor] okay . so did you increase your glimepiride ?
[patient] did i increase it ?
[doctor] yeah .
[patient] i'm still taking the two milligrams .
[doctor] yeah . so we want you to , as the letter said , from the last time , when your a1c was 9.9 , we wanted you to increase it to four milligrams twice a day , so let's start that .
[patient] okay , sure . so you want me to take two of the pills , now twice a day ?
[doctor] yes . uh , how much of it do you have ?
[patient] well , i just filled it .
[doctor] okay , good . so yeah , you can take two of them twice a day , of what you have . the new prescription will be for four milligrams twice a day .
[patient] okay .
[doctor] great . and are you trying to eat healthier : less sugars , less carbohydrates ?
[patient] uh , well ...
[doctor] not really ?
[patient] . well , i have n't had any pasta ; i just do n't really like it , so we do n't have any in the house . we do n't often have bread , and if we do , we buy wheat bread .
[doctor] okay . but even the wheat bread , try to cut down on the number of slices you eat per day .
[patient] i just usually have two in the morning . i do n't care for sandwiches much ; maybe peanut butter sandwiches once in a while .
[doctor] yeah .
[patient] i hardly drink , drink any sodas .
[doctor] well , that's great .
[patient] i drink club soda .
[doctor] okay .
[patient] seltzer water , that's what i prefer , so that's my water . i do n't drink regular water .
[doctor] okay , that's fine . how about your eye exams ? are they up-to-date ?
[patient] yep . i just got new glasses .
[doctor] okay . who do you go see ?
[patient] i go to liberty road , the group up there .
[doctor] okay . the , um , the optimum optometrists , right ?
[patient] they keep changing doctors each time i go .
[doctor] a new doc each time ?
[patient] yeah . i got a really nice one i used to see a year ago .
[doctor] was that dr. sanchez ?
[patient] yeah .
[doctor] okay . and you saw him not too long ago ?
[patient] yeah . i just got my prescription from him . well , see , i had the iodine for my eyes .
[doctor] cataracts , yep , okay .
[patient] so he did that and then i had to wait for a month to get healed up and then he wrote my prescription .
[doctor] perfect . and then you've got the high blood pressure .
[patient] yeah . a couple of weeks ago , it was 116 on the dot .
[doctor] okay . well , we will recheck it . you're on a combination of medications . you are on the met- met- uh , metoprolol , 50 milligrams once a day , you're on the lisinopril with hydrochlorothiazide , at 20 , with 25 milligrams once a day , and you're on the amlodipine , 10 milligram once a day . are you taking all of those ?
[patient] well , yeah .
[doctor] perfect . and then you've got the high cholesterol and the vascular disease in your legs . you're on atorvastatin . are you tolerating it okay ?
[patient] yeah , but honestly , my feet feel like hell .
[doctor] yeah .
[patient] all the time , my legs are bugging me ; i ca n't do much walking .
[doctor] okay . yeah , the feet i think is what we call peripheral neuropathy .
[patient] also , i have the pain up to my hip .
[doctor] okay . you have pain in the hips and upper legs ?
[patient] yeah , all of it .
[doctor] okay . so those do seem relatively stable , right ? and are you trying to get the walking in ?
[patient] yeah .
[doctor] okay . and you are smoking still ?
[patient] yeah , still smoking .
[doctor] not ready to quit ?
[patient] no , not really .
[doctor] it's a bad combination .
[patient] i know . i'll think about it .
[doctor] okay . now , let's do my review of systems . you're not having any headaches or dizziness ?
[patient] headaches or dizziness , no .
[doctor] okay .
[patient] nothing , feeling totally normal .
[doctor] good , good . and the vision is better with the cataract surgery ? that's been good ?
[patient] yeah . not happy with this lens ; it's kinda funny . the other one is good .
[doctor] hmm , sometimes they can go in and clean up the eye with laser , but we'll see what they say .
[patient] okay .
[doctor] okay . no shortness of breath or coughing ?
[patient] i've been coughing here lately because i've been congested .
[doctor] what does it look like when it comes up ?
[patient] it's relatively clear .
[doctor] no fever , chills , no shortness of breath ?
[patient] no .
[doctor] okay . no chest pains or pressure or tightness ?
[patient] no .
[doctor] nausea , vomiting , gi symptoms ?
[patient] no .
[doctor] okay . peeing okay ?
[patient] not good . it's , you know , i'm old ; it takes me a little more time .
[doctor] slower stream but stable ?
[patient] yes , but i do pee ...
[doctor] okay .
[patient] . several times per day .
[doctor] mm-hmm . how many times do you have to get up at night ?
[patient] not too bad , just once in a while .
[doctor] okay .
[patient] then i have to pee by morning . i do tend to drink my drinks in the evening .
[doctor] okay . all right , let's have a look at you .
[patient] okay .
[doctor] physical exam : carotids are normal , pulse is no buits . heart exam : rhythm is regular , normal rate , s1 and s2 are crisp . i do not hear any murmurs today , okay . have you lean forward for me . take some deep breaths , in and out . okay , lungs are clear . i do n't hear any rasps or wheezing today .
[patient] my coughing got better this morning .
[doctor] you cleared out the lungs ? all right , let me take a look at your feet .
[patient] okay .
[doctor] okay . extremities are without edema . pulses are palpable on the dorsalis pedis posterial tibial . she has thickened nails .
[patient] yeah .
[doctor] yeah . mildly dry skin , no skin breakdown . l- let me know if you can feel this .
[patient] okay . i closed my eyes . yeah , yeah , okay .
[doctor] mildly decreased sensation in the tips of the first and second toes . okay , we're done with your exam .
[patient] okay .
[doctor] okay . so again , try to keep the feet moisturized .
[patient] yeah .
[doctor] you do have a little bit of periphe- peripheral neuropathy . um , there is a medication we can use if they get really bad , but you're already on so many medications .
[patient] my girl that i talk to and stuff , she uses on her feet ; she really likes it . it's , like , a foot scrub or some type of cream . i put it on when i think of it after the shower . so i could get my own instead .
[doctor] that sounds good . so for now , your sugars , we're gon na check your ... we're going to recheck your blood work today , but the sugars last time we checked , the a1c , your blood sugar average was above nine . i really want you to increase the glimepiride . so the ones you have at home , the two milligram , take two of them twice a day .
[patient] okay .
[doctor] okay . watch for low sugars , weak , shaky , sweaty . if that happens , let us know , and i do n't expect it to .
[patient] okay .
[doctor] okay . the new prescription that i'm going to write is gon na be for the , uh , four milligram pill . so when you get the new one , just one pill twice a day . also , continue the metformin , okay ? blood pressure , when i rechecked it , i got 140 over 60 s- so the numbers at home are better , so we're gon na continue the combination of medications . we'll check kidney function today .
[doctor] for your cholesterol though , you're on the high dose of atorvastatin or lipitor to protect the arteries , so we really wan na keep you on that .
[patient] yeah , no problem .
[doctor] i want you to quit smoking , but we've had this battle before .
[patient] yeah .
[doctor] hmm . and then , we will leave everything else the same . we'll get the labs today and we'll see you back here in four months . sound good ?
[patient] okay .
[doctor] great . have a good day , ma'am . take care of yourself .
[patient] thank you . you too .
[doctor] bye .

Medical orders:
description: glimepiride four milligrams twice a day pill
order_type: medication
reason: a1c was 9.9
description: blood today kidney function
order_type: lab
reason: a1c was 9.9
description: see you back in four months
order_type: followup
description: blood today a1c
order_type: lab
reason: a1c was 9.9