Sample Medical Record: Billy Gato

Module 8 Appendix B

Use for October 2010 abstraction

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

Billy Gato

Home: 555-555-5555
Male   DOB: 05/05/1955 
0000-55555 Ins: Commercial Orange Shield
                                                     

Patient Information

Name: Billy GatoHome Phone: 555-555-5555
Address: 5555 Mountain Blvd
                Animal, California  
Office Phone:
Patient ID: 0000-55555 Fax:
Birth Date: 05/05/1955Status: Active
Gender: Male    Marital Status: Married
Contact By: Phone Race: Hispanic
Soc Sec No: 555-55-5555Language: English
Resp Prov: Carl Savem  MRN: MR-111-1111
Referred by:Emp. Status: Part-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 (01/27/2010)
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)
! Benadryl
Services Due
FLU VAX, PNEUMOVAX

09/25/2010 - 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
Billy Gato 

Male   DOB: 05/05/1955
0000-55555
Ins: Commercial xxxxx

Home: 555-555-5555

Ht: 65  in.  Wt: 180  lbs.   T: 98.0 degF. T site: oral  P: 70   Rhythm: regular R: 16 BP: 134/92

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.
He will work harder on diet.

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:

Ophthalmology consult
UA
HGBA1C
Metabolic Panel
Lipid Panel

Education/Counseling (time): 5 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
Billy Gato 

Male   DOB: 05/05/1955
0000-55555
Ins: Commercial xxxxx

Home: 555-555-5555

09/19/2010 - Lab Report: Metabolic Panel Provider: Carl Savem MD
Location of Care: Millennium Health System

Tests:                                

(1) Metabolic Panel  (ML-03CHEM)

ALK  PHOS    72  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  TOTAL0.7  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    7.0%
(3) Lipid Profile
Cholesterol, Total   210 mg/dl
Triglycerides  236 mg/dl
HDL Cholesterol 36
LDL Cholesterol 121

WeServeEveryone Clinic

March 24, 2011

1111 First Street California
111-111-11111   Fax: 111-111-1111
Page 2
Chart Summary
Billy Gato 

Male   DOB: 05/05/1955
0000-55555
Ins: Commercial xxxxx

Home: 555-555-5555

Flowsheet

   Date        09/25/2010
HEIGHT  (in)  65
WEIGHT  (lb) 180
TEMPERATURE  (deg F)  98
TEMP SITE   oral
PULSE RATE  (/min)            72
PULSE RHYTHM 
RESP RATE  (/min) 16
BP SYSTOLIC  (mm Hg)   134
BP DIASTOLIC  (mm Hg)    92
CHOLESTEROL  (mg/dL) 
HDL  (mg/dL) 
LDL  (mg/dL)    121
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 ExamComplete
Eye ExamComplete
Page last reviewed May 2013
Internet Citation: Sample Medical Record: Billy Gato: Module 8 Appendix B. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod8appbbillygato.html