Practice Facilitation Handbook

Use for January 2011 abstraction

WeServeEveryone Clinic
1111 First Street California 111-111-11111   Fax: 111-111-1111	Chart Summary

Adam Pie

Home: 888-888-8888 Male   DOB: 08/08/1948

0000-88888

Ins: Commercial xxxxx

                                                     

Patient Information

Name: Adam Pie	Home Phone: 888-888-8888
Address: 1111 Donut Road                 Fast Food, California	Office Phone:
Patient ID: 0000-88888	Fax:
Birth Date: 08/08/1948	Status: Active
Gender: Male	Marital Status: Married
Contact By: Phone	Race: White
Soc Sec No: 111-11-1111	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)
DEPRESSION (ICD-311)
RETINOPATHY, DIABETIC (ICD-362.0)
POLYNEUROPATHY IN DIABETES (ICD-357.2)

Medications

HYTRIN CAP 5MG (TERAZOSIN HCL) 1 po qd
Last Refill: #30 x 0 : Carl Savem (10/27/2010)
PRINIVIL TABS 20 MG (LISINOPRIL) 1 po qd
Last Refill: #30 x 2 : Carl Savem MD (10/27/2010)
HUMULIN INJ 70/30 (INSULIN REG & ISOPHANE (HUMAN)) 20 units ac breakfast
Last Refill: #600 u x 0 : Carl Savem MD (10/27/2010)
PROZAC CAPS 10 MG (FLUOXETINE HCL) 1 po qd
Last Refill: #30 x 2 : Carl Savem MD (10/27/2010)

Directives

DO NOT RESUSCITATE

Allergies and Adverse Reactions (! = critical)

! CODEINE

Services Due

HEMOCCULT or SIGMOID, BP DIASTOLIC, BP SYSTOLIC, FLU VAX, PNEUMOVAX, MICROALB URN, FLU VAX, BP DIASTOLIC, BP SYSTOLIC, FUNDUSCOPY, DIAB FOOT CK, ALBUMIN URIN, TSH, CHOLESTEROL, HGBA1C, CREATININE.

12/18/2010 - 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 to review medications Chief Complaint: No complaints

History

Social History: His wife Marzipan died 5 years ago this month and he is more introspective.

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

Adam Pie
Male   DOB: 08/08/1948 0000-88888 Ins: Commercial xxxxx	Home: 888-888-8888

Ht: 70  in.  Wt: 190  lbs.   T: 98.0 degF. T site: oral  P: 70   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

Assessment

Problems (including changes): Adam is voiding better since increasing Hytrin to 5 mg/day. Blood pressure is lower. He is following his diet, by his account. He has not had any hypoglycemic episodes, no night sweats. 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.
He will work harder on diet. Will increase insulin by 2 units. BP and symptoms of prostatism are better.

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
HYTRIN CAP 5MG 1 qd
PROZAC CAPS 10 MG 1 qd

Treatment: Will have annual foot exam at next visit.

Orders:

Ophthalmology consult
UA
HGBA1C
Metabolic Panel
Lipid Panel
Hemoccult

Education/Counseling (time): 10 minutes

Coordination of Care (time): 10 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

Adam Pie
Male   DOB: 08/08/1948 0000-88888 Ins: Commercial xxxxx	Home: 888-888-8888

Ins: BHI (Futura) Grp: BHI1595

10/31/2010 - Lab Report: Metabolic Panel Provider: Carl Savem MD
Location of Care: Millennium Health System

Tests:                                

(1) Metabolic Panel  (ML-03CHEM)

ALK  PHOS	72  U/L	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 127

WeServeEveryone Clinic	March 24, 2011
1111 First Street California 111-111-11111   Fax: 111-111-1111	Page 2 Chart Summary

Adam Pie
Male DOB: 08/08/1948 0000-88888 Ins: Commercial xxxxx	Home: 888-888-8888

Flowsheet

	Date 12/18/2010
HEIGHT  (in)	70
WEIGHT (lb)	190
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)	127
LDL (mg/dL)
BG RANDOM  (mg/dL)
CXR
EKG
PAP SMEAR
BREAST EXAM
MAMMOGRAM
HEMOCCULT	neg
FLU VAX	0.5 ml g
PNEUMOVAX	0.5 ml g
TD BOOSTER	0.5 ml g
Foot Exam	Complete
Eye Exam	Complete