Sample Medical Record: Cherie Amore

Use for October 2010 abstraction

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

Cherie Amore

Home: 333-333-3333
Female DOB: 03/03/1940

0000-33333

Ins: Commercial xxxxx

Patient Information

Name: Cherie Amore	Home Phone: 333-333-3333
Address: 3333 Wonder Ave Famous, California	Office Phone:
Patient ID: 0000-33333	Fax:
Birth Date: 03/03/1940	Status: Active
Gender: Female	Marital Status: Married
Contact By: Phone	Race: White
Soc Sec No: 333-333-3333	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.)

Medications

HUMULIN INJ 70/30 (INSULIN REG & ISOPHANE (HUMAN)) 20 units ac breakfast
Last Refill: #600 u x 0 : Carl Savem MD (01/27/2010)

Directives

Allergies and Adverse Reactions (! = critical)

Services Due

FLU VAX

10/18/2010 - 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: Quit smoking 10 years ago

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: 63 in. Wt: 130 lbs. T: 98.0 degF. T site: oral P: 72 Rhythm: regular R: 16 BP: 118/60

Physical Exam

General Appearance: well developed, well nourished, no acute distress
Eyes: conjunctiva and lids normal
Ears, Nose, Mouth, Throat: TM clear, nares clear, oral exam WNL
Respiratory: respiratory effort normal
Cardiovascular: regular rate and rhythm

Problems (including changes):

She is following diet, by her account. 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.

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

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

10/19/2010 - Lab Report: Metabolic Panel Provider: Carl Savem MD
Location of Care: Millennium Health System

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 18.0%
(3) Lipid Profile
Cholesterol, Total   210 mg/dl
Triglycerides           236 mg/dl
HDL Cholesterol    36
LDL Cholesterol     125

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

103-TEST011 Insurance: BHI (Futura) Group: BHI1595

Female DOB: 03/03/1940 0000-33333 Ins: Commercial xxxxx

	Date 09/25/2010
HEIGHT (in)	63
WEIGHT (lb)	130
TEMPERATURE (deg F)	98
TEMP SITE	oral
PULSE RATE (/min)	72
PULSE RHYTHM
RESP RATE (/min)	16
BP SYSTOLIC (mm Hg)	118
BP DIASTOLIC (mm Hg)	60
CHOLESTEROL (mg/dL)
HDL (mg/dL)
LDL (mg/dL)
BG RANDOM (mg/dL)
CXR
EKG
PAP SMEAR
BREAST EXAM
MAMMOGRAM
HEMOCCULT	neg
FLU VAX
PNEUMOVAX
TD BOOSTER	0.5 ml g
Foot Exam
Eye Exam

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