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 U.S. Department of Health & Human Services




Medical Record

Patient Information
Name: Michael Johnson
Home Phone: 444-444-4444
Address: 270 3rd Street Los Altos, California 94022
Office Phone:
Patient ID: 27333-44344
Fax:
Birth Date: 04/04/1950
Status: Active
Gender: Female
Marital Status: Divorced
Contact By: Phone
Race: Black
SSN: 690-05-5315
Language: English
Resp Prov: Carl Savem
MRN: MR-828-84294
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)

Medications
PRINIVIL TABS 20 MG (LISINOPRIL) 1 po qd
Last Refill: #30 x 2 : Carl Savem MD (08/27/2010)
HUMULIN INJ 70/30 (INSULIN REG & ISOPHANE (HUMAN)) 20 units ac breakfast
Last Refill: #600 u x 0 : Carl Savem MD (08/27/2010)
Directives
Allergies and Adverse Reactions (! = critical)
Services Due
FLU VAX, PNEUMOVAX, MICROALB URN
3/18/2015 - 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
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
Ht: 64 in. Wt: 140 lbs.T: 98.0 degF. T site: oral P: 72 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
Problems (including changes): Blood pressure is lower. 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. Will work harder on diet. Will increase insulin by 2 units.
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
Treatment: Will have annual foot exam at next visit.
Orders:
UA
Metabolic Panel
Education/Counseling (time): 5 minutes
Coordination of Care (time): 20 minutes
Follow-up/Return Visit: 3 months
Disposition: return to clinic


03/18/2015 - Lab Report: Metabolic Panel Provider: Carl Savem MD
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 6.0%
(3) Lipid Profile
Cholesterol, Total   210 mg/dl
Triglycerides           236 mg/dl
HDL Cholesterol    36
LDL Cholesterol     107


Female  DOB: 04/04/1950                      0000-44444                          Ins: Commercial xxxxx

Date 03/18/2015
HEIGHT (in)
64
WEIGHT (lb)
140
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)

LDL (mg/dL)

BG RANDOM (mg/dL)
125
CXR

EKG

PAP SMEAR

BREAST EXAM

MAMMOGRAM

HEMOCCULT
neg
FLU VAX

PNEUMOVAX

TD BOOSTER
0.5 ml g
Foot Exam

Eye Exam
Complete