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WeServeEveryone Clinic |
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1111 First Street California | Chart Summary |
Monica Latte
Home: 444-444-4444 | 0000-44444 | Ins: Commercial xxxxx |
Patient Information
Name: Monica Latte | Home Phone: 444-444-4444 |
Address: 4444 Coffee Ave | Office Phone: |
Patient ID: 0000-44444 | Fax: |
Birth Date: 04/04/1950 | Status: Active |
Gender: Female | Marital Status: Divorced |
Contact By: Phone | Race: Black |
Soc Sec No: 444-444-4444 | Language: English |
Resp Prov: Carl Savem | MRN: MR-111-1111 |
Referred by: | Emp. Status: Full-time |
Email: | Sens Chart: No |
Home LOC:WeServeEveryone | External ID: MR-111-1111 |
Problems
DIABETES MELLITUS (ICD-250.)
HYPERTENSION, BENIGN ESSENTIAL (ICD-401.1)
Medications
PRINIVIL TABS 20 MG (LISINOPRIL) 1 po qd
Last Refill: #30 x 2 : Carl Savem MD (08/27/2010)
HUMULIN INJ 70/30 (INSULIN REG & ISOPHANE (HUMAN)) 20 units ac breakfast
Last Refill: #600 u x 0 : Carl Savem MD (08/27/2010)
Directives
Allergies and Adverse Reactions (! = critical)
Services Due
FLU VAX, PNEUMOVAX, MICROALB URN
3/18/2011 - Office Visit: F/u Diabetes
Provider: Carl Savem MD
Location of Care: WeServeEveryone Clinic
OFFICE VISIT
History of Present Illness
Reason for visit: Routine follow up
Chief Complaint: No complaints
History
Diabetes Management
Hyperglycemic Symptoms
Polyuria: no
Polydipsia: no
Blurred vision: no
Sympathomimetic Symptoms
Diaphoresis: no
Agitation: no
Tremor: no
Palpitations: no
Insomnia: no
Neuroglycopenic Symptoms
Confusion: no
Lethargy: no
Somnolence: no
Amnesia: no
Stupor: no
Seizures: no
Review of Systems
General: denies fatigue, malaise, fever, weight loss
Eyes: denies blurring, diplopia, irritation, discharge
Ear/Nose/Throat: denies ear pain or discharge, nasal obstruction or discharge, sore throat
Cardiovascular: denies chest pain, palpitations, paroxysmal nocturnal dyspnea, orthopnea, edema Respiratory: denies coughing, wheezing, dyspnea, hemoptysis
Gastrointestinal: denies abdominal pain, dysphagia, nausea, vomiting, diarrhea, constipation
Genitourinary: denies hematuria, frequency, urgency, dysuria, discharge, impotence, incontinence
Musculoskeletal: denies back pain, joint swelling, joint stiffness, joint pain
Skin: denies rashes, itching, lumps, sores, lesions, color change
Neurologic: denies syncope, seizures, transient paralysis, weakness, paresthesias
Psychiatric: denies depression, anxiety, mental disturbance, difficulty sleeping, suicidal ideation, hallucinations, paranoia
Endocrine: denies polyuria, polydipsia, polyphagia, weight change, heat or cold intolerance
Heme/Lymphatic: denies easy or excessive bruising, history of blood transfusions, anemia, bleeding disorders, adenopathy, chills, sweats
Allergic/Immunologic: denies urticaria, hay fever, frequent UTIs; denies HIV high risk behaviors
Vital Signs
WeServeEveryone Clinic | March 24, 2011 |
1111 First Street California | Page 2 |
Ht: 64 in. Wt: 140 lbs.T: 98.0 degF. T site: oral P: 72 Rhythm: regular R: 16 BP: 158/90
Physical Exam
General Appearance: well developed, well nourished, no acute distress
Eyes: conjunctiva and lids normal, PERRLA, EOMI, fundi WNL
Ears, Nose, Mouth, Throat: TM clear, nares clear, oral exam WNL
Respiratory: clear to auscultation and percussion, respiratory effort normal
Cardiovascular: regular rate and rhythm, S1-S2, no murmur, rub or gallop, no bruits, peripheral pulses normal and symmetric, no cyanosis, clubbing, edema or varicosities
Skin: clear, good turgor, color WNL, no rashes, lesions, or ulcerations
Problems (including changes): Blood pressure is lower. Feet are inspected and there are no callouses, no compromised skin. No vision complaints.
Impression: Sub optimal sugar, control with retinopathy and neuropathy, high glucometer readings. Will work harder on diet. Will increase insulin by 2 units.
Home Glucose Monitoring:
AC breakfast 110 to 220
AC breakfast mean 142
AC dinner 100 to 250
AC dinner mean 120
Plan
Medications:
HUMULIN INJ 70/30 20 u ac breakfast
PRINIVIL TABS 20 MG 1 qd
Treatment: Will have annual foot exam at next visit.
Orders:
UA
Metabolic Panel
Education/Counseling (time): 5 minutes
Coordination of Care (time): 20 minutes
Follow-up/Return Visit: 3 months
Disposition: return to clinic
WeServeEveryone Clinic | March 24, 2011 |
1111 First Street California | Page 2 |
03/18/2011 - Lab Report: Metabolic Panel Provider: Carl Savem MD
Tests:
(1) Metabolic Panel(ML-03CHEM)
ALK PHOS | 72 | 35-100 |
BG RANDOM | 125 mg/dl | 70-125 |
BUN | 16 mg/dl | 7-25 |
CALCIUM | 9.6 mg/dl | 8.2-10.2 |
CHLORIDE | 101 mmol/l | 96-109 |
CO2 | 27 mmol/l | 23-29 |
CREATININE | 0.7 mg/dl | 0.6-1.2 |
PO4 | 2.9 mg/dl | 2.5-4.5 |
POTASSIUM | 4.5 mmol/l | 3.5-5.3 |
SGOT (AST) | 31 U/L | 0-40 |
BILI TOTAL | 0.7 mg/dl | 0.0-1.3 |
URIC ACID | 4.8 mg/dl | 3.4-7.0 |
LDH, TOTAL | 136 IU/L | 0-200 |
SODIUM | 135 mmol/l | 135-145 |
(2) HbA1c Test
HbA1c level 6.0%
(3) Lipid Profile
Cholesterol, Total 210 mg/dl
Triglycerides 236 mg/dl
HDL Cholesterol 36
LDL Cholesterol 107
WeServeEveryone Clinic | March 24, 2011 |
1111 First Street California | Page 2 |
Female DOB: 04/04/1950 0000-44444 Ins: Commercial xxxxx
| Date 03/18/2011 |
HEIGHT (in) | 64 |
WEIGHT (lb) | 140 |
TEMPERATURE (deg F) | 98 |
TEMP SITE | oral |
PULSE RATE (/min) | 72 |
PULSE RHYTHM |
|
RESP RATE (/min) | 16 |
BP SYSTOLIC (mm Hg) | 158 |
BP DIASTOLIC (mm Hg) | 90 |
CHOLESTEROL (mg/dL) |
|
HDL (mg/dL) |
|
LDL (mg/dL) |
|
BG RANDOM (mg/dL) | 125 |
CXR |
|
EKG |
|
PAP SMEAR |
|
BREAST EXAM |
|
MAMMOGRAM |
|
HEMOCCULT | neg |
FLU VAX |
|
PNEUMOVAX |
|
TD BOOSTER | 0.5 ml g |
Foot Exam |
|
Eye Exam | Complete |