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| WeServeEveryone Clinic |
|
| 1111 First Street California 111-111-11111 Fax: 111-111-1111 |
Chart Summary |
Monica Latte
| Home: 444-444-4444 Female DOB: 04/04/1950 |
0000-44444 |
Ins: Commercial xxxxx |
Patient Information
| Name: Monica Latte |
Home Phone: 444-444-4444 |
| Address: 4444 Coffee Ave Chocolate, California |
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 111-111-11111 Fax: 111-111-1111 |
Page 2 Chart Summary |
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 111-111-11111 Fax: 111-111-1111 |
Page 2 Chart Summary |
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 111-111-11111 Fax: 111-111-1111 |
Page 2 Chart Summary |
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 |