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Practice Facilitation Handbook
Sample Medical Record: Billy Gato
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 Gato | Home Phone: 555-555-5555 |
| Address: 5555 Mountain Blvd Animal, California |
Office Phone: |
| Patient ID: 0000-55555 | Fax: |
| Birth Date: 05/05/1955 | Status: Active |
| Gender: Male | Marital Status: Married |
| Contact By: Phone | Race: Hispanic |
| Soc Sec No: 555-55-5555 | Language: 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 |
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 |
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 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 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 |
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 Exam | Complete |
| Eye Exam | Complete |
Page originally created May 2013
