Annual Examination - Visit Summary (March 5, 2018, 10:30AM -0500)

Patient Theodore LEVEN Date of Birth: March 22, 1942 (75yr) Gender: Male Patient-ID:  M20190410115528.3 (2.16.840.1.113883.3.4988), Ted.Leven@direct.MyPHD.us (1.3.6.1.4.1.41179.2.4)
Encounter ID: bae897fc-f448-45d6-9b6d-52c12aa559e3 (a23fffac-c5a3-4a67-8f3e-4cd6ead8de60) , Date/Time: at March 5, 2018, 10:30AM
Author John Smith, MD, Organization: John Smith, MD, LLC, Authored On: March 5, 2018, 10:30AM
Author MaxMD C-CDA Creator, Authored On: March 5, 2018, 10:30AM
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Reason for Visit Section

Annual Wellness Exam

History of Present Illness Section

Ted Leven is a 75 year old Caucasian man with long history of type 2 diabetes and peripheral artery disease s/p amputation of left foot 5 years ago who is here for his annual physical with his adult son. He has no complaints of polyuria or polydipsia. He denies any vision changes. Ted states his blood sugars have not been elevated but he says he sometimes forgets to check his blood sugar every day since his wife passed away a year ago.

Chief Complaint Section

No complaints, annual wellness exam

Review of Systems Section

General: No change in appetite, fevers, chills, or nausea. HEENT: Denies changes in vision. Last eye exam 2 years ago. CV: Denies chest pain at rest or with exertion. Pulm: No shortness of breath or cough GI: No abdominal pain or change in bowel habits GU: No dysuria, or hematuria. Musculoskeletal: No weakness. Pain in knees from osteoarthritis when walking up stairs. Has prosthesis for left foot and uses crutch or wheelchair for ambulation occasionally when fatigued. Denies any pain with ambulation. Skin: No rashes Neuro: No numbness or tingling reported. Reports forgetting to take his blood sugars on occasion, but no memory loss

Past Medical History

Pneumonia resolved 2015

Problem History Section (entries optional)

Type 2 Diabetes Mellitus, Active, diagnosed in 2006
Osteoarthritis diagnosed in 2010
Peripheral Artery Disease diagnosed in 2013
Amputated Left Foot 2014

Allergies and Intolerances History Section (entries optional)

No Known Allergies

Medication History Section

Atorvastatin 20mg PO daily for peripheral artery disease
Lantus 14 units subcutaneous injection daily for diabetes
Lisinopril 10mg PO daily for peripheral artery disease and diabetes
Aspirin 81mg PO daily for peripheral artery disease
Tylenol 650mg PO Q8hr as needed for arthritis pain

Immunizations History Section (entries optional)

Influenza vaccine administered 10/2017 Tdap vaccine administered 2009

Test Results History Section (entries required)

3/5/2018
Hemoglobin A1c 7.2
9/20/2017
Hemoglobin A1c 7.0
2/17/2017 Liver function tests:
Total Protein 7.7
Albumin 4.1
Tbili 0.3
ALT 13
AST 15
AlkPhos 110

Social History Section

Widowed in 2017, Lives alone, but son lives in same area. Goes to senior center during the day to keep busy.
Smoking history: previous history of smoking ½ pack per day quit in 2010
Alcohol Use: 1-2 beers per week
Drug Use: No history of drug use

Family History Section

Father died at age 79, history of heart disease
Mother died at age 85, history of stroke

Procedures History Section

Left foot amputation 2013

Medical Equipment Section

Crutches Wheelchair Prosthetic Left Leg

Vital Signs Section

2/5/2017 Weight: 170
Height: 5ft10inches
Blood Pressure:120/70
BMI: 24
3/5/2018 Weight: 180
Height: 5ft10inches
Blood Pressure:130/70
BMI: 25
Temperature: 99 deg F
Pulse: 74
Respiration: 16

Physical Exam Section

General: Elderly male in no acute distress
Head: Normal cephalic, atraumatic
Eyes: EOMI, conjunctiva clear. Sclera non-icteric. PERRLA. Fundi not well visualized due to possible presence of cataracts.
Ears: Tympanic membranes intact. Hearing adequate.
Nose: nasal mucosa pink. No discharge. No sinus tenderness.
Throat: Normal mucosa. No lesions, erythema or exudate
Neck: FROM. No tracheal deviation, jugular venous distention, or lymphadenopathy.
Chest/Lungs: Breath sounds normal and clear.
Heart: Regular rate and rhythm. No murmurs, rubs or gallops.
Abd: normal, no tenderness.
Rectum: Unremarkable.
Extremities: Joints with good mobility. No edema. Left stump intact, no lesions. Prosthesis was taken off during the exam.
Neurologic: Mental Status: Awake, Alert and oriented; normal memory, judgement, mood.
Cranial Nerves: Intact. Normal gait, finger-nose, heel-shin, no tremor.
Motor: Normal grip strength, Deep tendon reflexes (2+) and equal.
Sensory: Reduced sensitivity to touch, pain, vibration in hands and right foot.

Assessment Section

  1. Type 2 Diabetic Mellitus is under control after starting on Lantus last year by Endocrinologist. Hemoglobin A1c is 7.2 today. Concern that he doesn’t always remember to check his blood sugar, but he says his son is starting to check in on him more frequently throughout the week.
  2. Peripheral artery Disease is stable
  3. Osteoarthritis is stable.

Plan of Treatment Section

  1. Diabetes – Continue Lantus and Lisinopril. Refilled prescriptions. Follow up lab tests as outpatient for microalbumin in urine. Repeat HbA1c in 3 months
  2. Refilled Atorvastatin and Aspirin prescriptions. Ordered lipid panel and LFTs since done not since last year.
  3. Continue Tylenol as needed for pain

Encounter Diagnosis Section

Outpatient visit on 3/05/2018 for Annual Wellness Exam
Document
ID 22a62959-aff3-41fa-b339-1cf64833dac0 (a23fffac-c5a3-4a67-8f3e-4cd6ead8de60)
Version 1
Created On March 5, 2018, 10:30AM -0500
Custodian John Smith, MD, LLC Contact Details 40 Heathcare Ave
Suite 100
Chicago, IL 60643
US
Tel Workplace: 312 222 4321
 
Patient Theodore LEVEN Contact Details 123 State Street
Chicago, IL 60601
US
Tel Home Primary: 312 999 4321, Tel Mobile: 312 123 1234, Mail: TedLeven400@gmail.com, Mail Home Primary: Ted.Leven@direct.MyPHD.us
Date of Birth March 22, 1942 (75yr) Gender Male
Patient-IDs M20190410115528.3 (2.16.840.1.113883.3.4988)
Ted.Leven@direct.MyPHD.us (1.3.6.1.4.1.41179.2.4)
 
Encounter
ID bae897fc-f448-45d6-9b6d-52c12aa559e3 (a23fffac-c5a3-4a67-8f3e-4cd6ead8de60)
Encounter Date at March 5, 2018, 10:30AM
Responsible Party John Smith, MD Contact Details 40 Healthcare Ave.
Suite 100
Chicago, IL 60643
US
Tel Workplace: 312 222 4321, Mail Home Primary: JohnSmithMD@gmail.com
 
Author John Smith, MD, Organization: John Smith, MD, LLC Contact Details 40 Healthcare Ave.
Suite 100
Chicago, IL 60643
US
Tel Workplace: 312 222 4321, Mail Home Primary: JohnSmithMD@gmail.com
Contact Details (Organization) 40 Healthcare Ave.
Suite 100
Chicago, IL 60643
US
Author MaxMD C-CDA Creator Contact Details 2200 Fletcher Ave.
Suite 506
Fort Lee, NJ 07024
US
Tel Workplace: 201 963 0005, Mail Home Primary: syntheticDataMaker@max.md