Practice Facilitation Handbook

Use for January 2011 abstraction

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

Tom Gellato

Home: 666-666-6666 Male   DOB: 06/06/1938

0000-66666

Ins: Commercial xxxxx

                                                     

Patient Information

Name: Tom Gellato	Home Phone: 666-666-6666
Address: 5555 Flavor Avenue                 Ice Cream, California	Office Phone:
Patient ID: 0000-66666	Fax:
Birth Date: 06/06/1938	Status: Active
Gender: Male	Marital Status: Divorced
Contact By: Phone	Race: White
Soc Sec No: 666-66-6666	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 (04/27/2010)

Directives

DO NOT RESUSCITATE

Allergies and Adverse Reactions (! = critical)

! CODEINE

Services Due

FLU VAX, PNEUMOVAX, MICROALB URN,

11/13/2010 - 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
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

Tom Gellato
Male   DOB: 06/06/1938 0000-66666 Ins: Commercial xxxxx	Home: 666-666-6666

Ht: 66 in.  Wt: 195  lbs.   T: 98.0 degF. T site: oral  P: 70   Rhythm: regular R: 16 BP: 131/94

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):  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.

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

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

Tom Gellato
Male   DOB: 06/06/1938 0000-66666 Ins: Commercial xxxxx	Home: 666-666-6666

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    11.0%
(3) Lipid Profile
Cholesterol, Total   210 mg/dl
Triglycerides  236 mg/dl
HDL Cholesterol 36
LDL Cholesterol 102

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

Tom Gellato
Male DOB: 06/06/1938 0000-66666 Ins: Commercial xxxxx	Home: 666-666-6666

Flowsheet

	Date 12/18/2010
HEIGHT  (in)	66
WEIGHT (lb)	195
TEMPERATURE (deg F)	98
TEMP SITE	oral
PULSE RATE (/min)	72
PULSE RHYTHM
RESP RATE (/min)	16
BP SYSTOLIC (mm Hg)	131
BP DIASTOLIC (mm Hg)	94
CHOLESTEROL (mg/dL)
HDL (mg/dL)	102
LDL (mg/dL)	125
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