Endocrinology Consultation Note (April 15, 2018, 09AM -0500)

Patient Theodore LEVEN Date of Birth: March 22, 1942 (76yr) Gender: Male Patient-ID:  M20190410134857.7 (2.16.840.1.113883.3.4988), Ted.Leven@direct.MyPHD.us (1.3.6.1.4.1.41179.2.4)
Encounter ID: bcd9da3b-b6dc-4bf5-9dca-5cc44a07d4ab (86fc7731-ce04-4fca-a588-a2a111ecda9d) , Date/Time: at April 15, 2018, 09AM -0500
In Fulfillment Of Order ID: 424242 (1.2.3.4.5)
Author Elinor ENDO, Organization: Endocrinology Group of Chicago, Authored On: April 15, 2018, 09AM -0500
Author MaxMD C-CDA Creator, Authored On: April 15, 2018, 09AM -0500
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Reason for Visit Section

Diabetes Management

History of Present Illness Section

Ted Leven is a 75 year old man with type 2 diabetes and peripheral artery disease s/p amputation of left foot 5 years ago who is here for follow up for diabetes management. Ted has had diabetes for 12 years and was originally on oral medications but switched to insulin 4 years ago. His regimen is Lantus 14 units/day. He denies any hypoglycemic episodes and checks his blood sugar daily. He said his most recent HbA1c was checked at his PCP’s office last month. Ted denies polydipsia and polyuria. Ted reports no change in vision, but has not seen ophthalmologist in 2 years.

Chief Complaint Section

Follow Up visit

Review of Systems Section

Denies fever, chills, sweats, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain, shortness of breath, difficulty breathing, dyspnea on exertion or change in exercise tolerance. He is not having painful urination or blood in the urine. He does not reporting polyuria, polydipsia or polyphagia. Reports no issues with Left lower extremity stump.

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 2013

Allergies and Intolerances History Section

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
3/10/2018
Cholesterol 196
triglycerides 114
HDL 40
LDL 136
Spot microalbumin 9.2 micrograms of protein

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. Started smoking in 1960 quit in 2010
Smoking Status
  • Former Smoker Started: 1960 Stopped: 2010 Recorded April 15, 2018 9:00am
Alcohol Use: 1-2 beers per week
Drug Use: No history of drug use

Family History Section

Negative for diabetes

Procedures History Section

Left foot amputation 2013

Medical Equipment Section

Crutches; Wheelchair; Prosthetic Left Leg.

Vital Signs Section

9/25/2017 Weight: 170 lbs
Height: 5ft10inches
Blood Pressure:125/65
BMI: 24
4/15/2018 Weight: 181 lbs
Height: 5ft10inches
Blood Pressure:125/70
BMI: 26

Physical Exam Section

General: Elderly male in no acute distress
HEENT: Normal cephalic, atraumatic, EOMI, conjunctiva clear. Sclera non-icteric. PERRLA. Fundi not well visualized due to possible presence of cataracts. Tympanic membranes intact and clear. Nasal mucosa moist and pink. No discharge. No sinus tenderness. No lesions, erythema or exudate in throat
NECK: Supple. Full ROM. No LAD.
CARDIAC: RRR. No murmurs, rubs, or gallops.
RESPIRATORY: CTA.
ABDOMEN: Soft, nontender. No HSM and no masses.
NEURO: Significant for lower extremity numbness throughout. Microfilament test shows more than 3 regions without sensation bilaterally. Awake, Alert and oriented x3
SKIN: Bottoms of right foot appear calloused and dry. Skin is intact on left stump

Assessment Section

  1. Type 2 Diabetes Mellitus in good control with HbA1c pf 7.2 on lantus
  2. Peripheral artery Disease

Plan of Treatment Section

  • Diabetes mellitus - Continue current dose of Lantus and Lisinopril.
  • Refer to nutritionist since weight is increasing.
  • Refer to ophthalmology since 2 years since last eye exam.
  • Follow up in 6 months

Instructions Section (V2)

Printed diabetic diet and weight loss patient instructions

Encounter Diagnosis Section

Outpatient endocrinology visit on 4/15/2018
Document
ID 1a2fa2b6-8c8d-443f-b8d9-740675b1ddbd (86fc7731-ce04-4fca-a588-a2a111ecda9d)
Version 1
Created On April 15, 2018, 09AM -0500
Custodian Endocrinology Group of Chicago Contact Details 123 Healthcare Ave.
Chicago, IL 60602
US
Tel Workplace: 312 222 1234
 
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 (76yr) Gender Male
Patient-IDs M20190410134857.7 (2.16.840.1.113883.3.4988)
Ted.Leven@direct.MyPHD.us (1.3.6.1.4.1.41179.2.4)
 
In Fulfillment Of Order: 424242 (1.2.3.4.5)
Encounter
ID bcd9da3b-b6dc-4bf5-9dca-5cc44a07d4ab (86fc7731-ce04-4fca-a588-a2a111ecda9d)
Encounter Date at April 15, 2018, 09AM -0500
Responsible Party Elinor ENDO of Endocrinology Group of Chicago Contact Details 123 Healthcare Ave.
Chicago, IL 60602
US
Tel Workplace: 312 222 1234
 
Author Elinor ENDO, Organization: Endocrinology Group of Chicago Contact Details 123 Healthcare Ave.
Chicago, IL 60602
US
Tel Workplace: 312 222 1234
Contact Details (Organization) 123 Healthcare Ave.
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