PATIENT: Brain L.

Davis

ID: #70251

DOB: 06/21/1953

DOV: 01/18/2018

HISTORY OF PRESENT ILLNESS:

Mr. Davis returns for his routine followup noting that he has been using his Dexcom sensor, but has
had some issues with the sensor, so we do not have totally reliable data. A1c has jumped from 7.3 to
8.1. Patient’s review of systems are reasonably stable, but even though he feels he is doing a good
job with diet and exercise, weight has gone up for over 10 pounds. He indicates this could reflect the
holidays. He denies any other active complaints. Of concern, despite lack of symptoms, is a report of
an abnormal carotid ultrasound, although no blockage was reported. Patient has had no active chest
pain at this time, but will see Dr. Trakhtenbroit for further followup. He is basically frustrated with
his “body,” even though he is making reasonable efforts.

PHYSICAL EXAMINATION

Weight and vital signs per EMR. Again, weight has gone up unexpectedly, though he is fully dressed .
Eye exam recently was normal with no diabetic changes. No obvious hepatomegaly. Mildly
protuberant abdomen. Intact peripheral pulses, trace edema, diminished vibratory sense.

In this setting, we need to readdress his home glucose testing log and we can get better data.
Consider options for weight reduction. These would include medications, Qsymia, Contrave, Belviq,
and also consider surgical intervention. He is agreeable to this. We will set him up with one of the 2
groups.