Administration, Work from home
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Document info
Result type: PRIMARY CARE Outpt Clinic Note
Result date: Aug 31, 2023, 04:52 p.m.
Result status: authenticated
Performed by: Catherine Fernandez
Verified by: Catherine Fernandez
Modified by: Catherine Fernandez
Primary Care Office Visit Note
Patient: CYNTHIA
CRAWFORD
DOB: Oct 24, 1953
CRAWFORD, CYNTHIA
SUE
DOB: 10/24/1953
MRN: 1849037
Visit Date: 08/31/2023
Assessment/Plan
_
1. Type II diabetes mellitus E11.9
Patient reports blood sugar under good control with home blood sugar monitoring 100-150. Latest A1c 7% in 7/2022
Denies polydipsia, polyuria, polyphagia, paresthesias Labs ordered as below
Cont Metformin 500 mg BID - refilled
Schedule DM follow up
Ordered:
99214 Established Patient – Level 4 Comprehensive
(Moderate) 30-39 min
Automated Diff
CMR Comprehensive Metabolic Panel Random
Complete Blood Count w/ Differential, Manual if Indicated Estimated Average Glucose
Estimated Glomerular Filtration Rate (eGFR)
Hemoglobin A1c
Lipid Panel Random with Calculated LDL
Microalbumin Urine Random
Problem List/Past Medical History
Ongoing
Abnormal findings on esophagogastroduodenoscopy
(EGD)
Acid Reflux/heartburn
Anxiety
Arthritis, Hip(s)
Arthritis, Knee(s)
Asthma
Atopic dermatitis
Atrophic vaginitis
Attention deficit disorder or ADHD
Back pain
Bariatric surgery status
BMI 38.0-38.9,adult
Chronic constipation
Colon polyps
Degenerative joint disease of left shoulder
Depression
Diverticulitis, colon
Dysphagia, unspecified
Esophageal stricture
Exposure to COVID-19 virus
Frequent falls
2. Lichen sclerosus L90.0
Referral to Gyn as requested
Ordered:
99214 Established Patient – Level 4 Comprehensive
(Moderate) 30-39 min
Referral (amb)
3. Depression F32.9
Patient endorses worsening depression despite current medication management. Currently on Buspirone and
Sertraline. Triggers has been daughter moving in. Also mentioned recently losing job that she's had for 13 years. Had therapist in the past. Wanting to re establish. Expressed interest with Concert health.
Ordered:
busPIRone 10 mg oral tablet, 10 mg = 1 tab(s), PO, TID, # 270 tab(s), # Refill (s): 1 # Total Refill (s): 1
99214 Established Patient – Level 4 Comprehensive
(Moderate) 30-39 min
4. Anxiety F41.9
As above
Ordered:
99214 Established Patient – Level 4 Comprehensive
(Moderate) 30-39 min
5. BMI 38.0-38.9,adult Z68.38
Discussed association of obesity to preventable
diseases and cardiovascular risks
Counselled on heart healthy diet - educational handout given
Counselled on regular exercise, 30 minutes a day, 4-5 days a week
Ordered:
99214 Established Patient – Level 4 Comprehensive
(Moderate) 30-39 min
6. Overactive bladder N32.81
Patient on Trospium 60 mg daily. Declines refill. States has not been noticing improvement. Requesting referral to Gyn.
Ordered:
99214 Established Patient – Level 4 Comprehensive
(Moderate) 30-39 min
Referral (amb)
7. Neuropathy G62.9
Stable
Cont Gabapentin 300 mg TID PRN for pain - refilled Schedule DM follow up
Ordered:
99214 Established Patient – Level 4 Comprehensive
(Moderate) 30-39 min
8. Hypertension I10
States well controlled, consistently below 130/90
Cont Lisinopril 20 mg tab daily
Ordered:
Frequent UTI
Frozen shoulder
Hair loss
Hand arthritis
History of weight loss surgery
Hypercholesterolemia
Hypertension
Incontinence
Inguinal hernia
Iron deficiency anemia
Labia minora agglutination
Left hip pain
Left rotator cuff tear arthropathy
Lichen sclerosus
Low back pain
Mass of chest
Maxillary fracture
Medicare annual wellness visit, subsequent
Neuropathy
Obesity
OSTEOARTHROSIS, LOCALIZED, PRIMARY,
INVOLVING LOWER LEG
Overactive bladder
POSTGASTRIC SURGERY SYNDROMES
Sacral pain
Seasonal Allergies
Sprain of other site of shoulder and upper arm
Type II diabetes mellitus
Urge incontinence
Vulvar irritation
Historical
Acute UTI
Annual physical exam
b/l Sprain of other site of shoulder and upper arm Closed fracture of femoral condyle of femur
Diverticulitis
Hx of laceration of skin
Hyperglycemic coma
Hypokalemia
Hypothyroidism
Injury of ring finger
Mal hy kid w cr kid V
Medicare annual wellness visit, initial
Obstructive sleep apnea Comments: Per patient
please remove from list
OSA (obstructive sleep apnea) Comments: From
Pre-Anesthesia Powerform.
Pharyngitis
Renal hyperten-postpart
right Shin splints
rt PAIN IN JOINT INVOLVING PELVIC REGION AND
THIGH
S/p left hip fracture
Skin eruption
Type 2 diabetes mellitus without complications
Unspecified abdominal pain
Urinary incontinence
Vaginal atrophy
99214 Established Patient – Level 4 Comprehensive
(Moderate) 30-39 min
Automated Diff
CMR Comprehensive Metabolic Panel Random
Complete Blood Count w/ Differential, Manual if Indicated Estimated Average Glucose
Estimated Glomerular Filtration Rate (eGFR)
Hemoglobin A1c
Lipid Panel Random with Calculated LDL
Microalbumin Urine Random
9. Hypercholesterolemia E78.00
Cont Atorvastatin 40 mg daily - meds refilled
Ordered:
99214 Established Patient – Level 4 Comprehensive
(Moderate) 30-39 min
10. Skin exam, screening for cancer Z12.83
Referred to Derm as requested
Encouraged use of sunscreen
Ordered:
99214 Established Patient – Level 4 Comprehensive
(Moderate) 30-39 min
Referral (amb)
11. Encounter to establish care Z76.89
VM Portal activation to communicate health related concerns
Schedule for Annual Physical Exam
Acid excess E87.20
Stable
Cont Omeprazole 20 mg PO daily - refilled
Ordered:
omeprazole 20 mg oral delayed release capsule, 20 mg = 1 cap(s), PO, Daily, # 90 cap(s), # Refill (s): 3 # Total Refill (s): 3
Arthritis M19.90
well controlled
cont Meloxicam 15 mg, 1 tab daily
Denies GI symptoms
CMR ordered to assess liver and kidney function
Ordered:
meloxicam 15 mg oral tablet, 15 mg = 1 tab(s), PO, Daily,
# 90 tab(s), # Refill (s): 3 # Total Refill (s): 3, covering MD Insomnia G47.00
stable
Continue Trazodone 50 mg at bedtime
Ordered:
traZODone 50 mg oral tablet, 50 mg = 1 tab(s), PO, Every Bedtime, # 90 tab(s), # Refill (s): 4 # Total Refill (s): 4, PRN
Screening for thyroid disorder Z13.29
Ordered:
Thyroid Stimulating Hormone, reflex to Free T4 / TSH RFLX T4
Procedure/Surgical History
• DIAGNOSTIC COLONOSCOPY (10/03/2022)
• EGD DILATE STRICTURE (06/10/2022)
• EGD BIOPSY SINGLE/MULTIPLE (12/09/2021)
• EGD DILATE STRICTURE (03/09/2021)
• ESOPH EGD DILATION <30 MM (07/06/2020)
• ESOPH EGD DILATION <30 MM (10/02/2019)
• ESOPH EGD DILATION <30 MM (01/22/2019)
• EGD DILATE STRICTURE (08/10/2018)
• COLONOSCOPY AND BIOPSY (08/14/2017)
• EGD BIOPSY SINGLE/MULTIPLE (08/14/2017)
• Left Total hip replacement by Dr Kieras on
1/18/17 (01/18/2017)
• Revision of LEFT Total shoulder arthroplasty,
general & regional anesthetic. 3/14/2016
(03/14/2016)
• Revision Total shoulder replacement to reverse
total shoulder by Dr kieras on 1/27/16. General
and regional anesthetic (01/27/2016)
• Neuroplasty and/or transposition; median nerve
at left carpal tunnel (06/20/2011)
• Right Hip Replacement (2011)
• Knee Replacement (Right) (2011)
• Carpal Tunnel repair (Left) (2011)
• Rotator Cuff repair (Right) (2011)
• Other and unspecified hysterectomy (2010)
• Excision, benign lesion including margins, except skin tag (unless listed elsewhere),right shoulder
excised diameter 1.1 to 2.0 cm (09/24/2009)
• Repair, intermediate, wounds of right shoulder
(excluding hands and feet); 20.1 cm to 30.0 cm
(09/24/2009)
• Other and unspecified total abdominal
hysterectomy (2008)
• Hysterectomy (2008)
• Arthroplasty of shoulder (2006)
• Breast reduction, bilateral (2004)
• Arthroplasty of knee (2003)
• Endometrial ablation (2003)
• incisional hernia repair/colon (1995)
• Left Ventral hernia repair (1994)
• stomach stappling (1990)
• Oophorectomy (1988)
Medications
Inpatient
No active inpatient medications
Home
atorvastatin 40 mg oral tablet, 40 mg= 1 tab(s), PO, Daily, 4 refills
Bayer Microlet Lancets, 1 EA, MISC, Daily, 3 refills, Refill Requested
busPIRone 10 mg oral tablet, 10 mg= 1 tab(s), PO,
TID, 1 refills
CELEBRATE MULTIVITAMIN, Daily
cetirizine, PO, BID, PRN
Status post total replacement of hip Z96.649
Orders:
atorvastatin 40 mg oral tablet, 40 mg = 1 tab(s), PO, Daily,
# 90 tab(s), # Refill (s): 4 # Total Refill (s): 4 gabapentin 300 mg oral capsule, See Instructions, PRN: Pain, # 540 cap(s), # Refill (s): 3 # Total Refill (s): 3, Take 1-2 capsules PO TID for pain.
lisinopril 20 mg oral tablet, 20 mg = 1 tab(s), PO, Daily, # 90 tab(s), # Refill (s): 4 # Total Refill (s): 4
metFORMIN 500 mg oral tablet, 500 mg = 1 tab(s), PO, BID, # 180 tab(s), # Refill (s): 0 # Total Refill (s): 0 sertraline 100 mg oral tablet, 200 mg = 2 tab(s), PO, Daily, # 180 tab(s), # Refill (s): 4 # Total Refill (s): 4 Shared decision making used in the plan of care. Follow up as discussed or sooner as needed. Patient agreed with plan and verbalized understanding. All questions addressed.
All Ambulatory Referrals (Past 1 Day)
Referral (amb) - Future
-- for skin screening for cancer, Dermatology, Skin exam, screening for cancer Routine, Future Order, 08/31/23 Referral (amb) - Ordered
-- for overactive bladder, lichen sclerosis, Gynecology, Lichen sclerosus Overactive bladder, 11/17/23 8:30:00 PST
Patient Instructions
You have blood works ordered today, please proceed to the lab to complete.
We will communicate results to you through the Virginia Mason Portal, but we may ask to schedule you for an office visit if the results require further management that we will need to discuss.
Please take time to review the educational hand outs provided.
Schedule annual physical exam as discussed
Chief Complaint
I WAS A PATIENT OF ERIN S.
History of Present Illness
Cynthia, very pleasant 69 YO F, presenting to establish care. Previous PCP - Stoy. Denies major disease and hospitalizations since last clinic visit. Describing general health as good. Lives with family - denies safety
concerns. States managing stress well now that she has a new job. Medication list reviewed and updated with patient. Chronic problems addressed.
Patient currently denying symptoms or any other acute concerns.
Review of Systems
CONSTITUTIONAL: No fever or chills. No weight loss NEUROLOGICAL: No dizziness, no headaches
clobetasol 0.05% topical ointment, 1 app, TOPICAL, BID, 1 refills, Refill Requested
d-mannos & cranberry, PO, Daily
ESTRACE VAGINAL 0.1 mg/g vaginal cream, 1 g,
VAGINAL, Q Mon/Thu, 2 refills, Refill Requested
gabapentin 300 mg oral capsule, See Instructions,
PRN, 3 refills
Glucometer, 1 Check, MISC, BID, 1 refills, Refill
Requested
lisinopril 20 mg oral tablet, 20 mg= 1 tab(s), PO, Daily, 4 refills
MELATONIN, PO, Every Bedtime
meloxicam 15 mg oral tablet, 15 mg= 1 tab(s), PO,
Daily, 3 refills
metFORMIN 500 mg oral tablet, 500 mg= 1 tab(s),
PO, BID
omeprazole 20 mg oral delayed release capsule, 20
mg= 1 cap(s), PO, Daily, 3 refills
One Touch Verio Gold Test Strips, 1 EA, MISC, BID, 11 refills, Refill Requested
PROBIOTIC FORMULA oral capsule, 1 cap(s), PO,
Daily
psyllium, 1000 mg, PO, BID
restore, 1 tablespoon, PO, Daily
sertraline 100 mg oral tablet, 200 mg= 2 tab(s), PO, Daily, 4 refills
traZODone 50 mg oral tablet, 50 mg= 1 tab(s), PO,
Every Bedtime, 4 refills
trospium 60 mg oral capsule, extended release, 60
mg= 1 cap(s), PO, Every Morning, 1 refills, Refill Requested
VITAMIN B12
Allergies
Bactrim (rash)
Demerol HCl (nightmares)
Latex (throat swelled shut)
Social History
Smoking Status
Never smoker
Alcohol - No alcohol use
Current, Wine, 1-2 times per year
Employment/School - Full time employment or school Employed. Previous employment/school: Desk, sitting, calling and interviewing new potential hires.
Administration Assistant. Highest education level: High school. Operates hazardous equipment: No. Workplace hazards: Repetitive motion. School concerns: Cultural. Exercise - Occasional exercise
Exercise duration: 45. Exercise frequency: 3-4
times/week. Exercise type: Walking.
Home/Environment
Lives with Alone, Children. Living situation:
Home/Independent.
Nutrition/Health
Type of diet: Cereal, cheese, cold cuts, crackers, fish, some chicken-mostly sandwichs and canned chicken.
Coffee. Regular, Diabetic, Eat small meals, specific things I can't swallow. Meat, fresh vegetables, fruits..
EYES: No blurred vision
ENT: No hearing loss, no sorethroat
CARDIOVASCULAR: No chest pains, no palpitations
RESPIRATORY: No dyspnea, no cough
GASTROINTESTINAL: No abdominal pain, no nausea
and vomiting
GENITOURINARY: No dysuria, no urgency
MUSCULOSKELETAL: No joint or muscle pain
INTEGUMENTARY: No new mole. No rash and lesions
PSYCHIATRIC: Denies feeling hopeless or depressed
ENDOCRINE: Denies polydipsia, polyuria, polyphagia. Denies heat/cold intolerance
HEMATOLOGIC: Denies excessive bruising
IMMUNOLOGICAL: Denies food allergies
Physical Exam
Vitals & Measurements
BP: 124/82
HT: 172 cm WT: 106 kg BMI: 35.83
CONSTITUTIONAL: Well developed, well nourished, not in apparent distress
NEUROLOGICAL: Alert, oriented, memory intact,
communicating appropriately. Steady gait.
LUNGS: Clear to auscultate in all fields, regular unlabored breathing
HEART: S1 S2, regular rate and rhythm, no audible
murmurs, clicks and gallops
ABDOMEN: Soft and non tender. No palpable mass.
MUSCULOSKELETAL: Moving all extremities with equal strength
INTEGUMETARY: pink, warm and dry. no rashes,
abrasions and lacerations
PSYCHOSOCIAL: calm and pleasant. appropriate affect. External Vitals & Measurements
No qualifying data available.
Safety and Function
Fall Risk and Activities of Daily Living
No qualifying data available.
Cognitive Assessments
VMCS/MOCA Results
Event Name Event Result Date/Time
VMCS 1st Trial Train, Egg, Hat,
Chair, Blue
07/20/22 11:47:00
VMCS 2nd Trial Blue, Chair, Egg,
Train, Hat
07/20/22 11:47:00
VMCS Complete
Circle
Yes 07/20/22 11:47:00
VMCS Correct
Time
Yes 07/20/22 11:47:00
Sexual
Sexually active: No. Sexually active at age: 19 YEARS. Gender Identity: Identifies as female [GI06]. Number of current partners: 1. Number of lifetime partners: 3. Sexual orientation: Straight or heterosexual [SL07]. Uses condoms: No.
Substance Abuse - No history of substance use
Tobacco - No Risk
Never smoker
Family History
ADD (attention deficit disorder).: Negative: Mother. Allergies: Mother and Father.
Arthritis: Mother and Father.
Breast cancer: Mother.
Cancer: Mother and Father.
Colon cancer..: Father.
Congestive heart failure: Mother and Father.
Diabetes mellitus: Mother, Father and Brother.
FH: Cholesterol high: Mother and Father.
Heart attack: Brother (Dx at 55).
Osteoporosis: Mother.
Sleep apnea: Brother.
Stroke: Mother.
Health Maintenance
Pending (in the next year)
OverDue
Diabetes - dilated eye exam due 05/26/18 and
every 1 year(s)
Diabetes - foot exam (neuropathy test)
due 07/29/21 and every 1 year(s)
Prevention - fall risk screening due 07/20/23 and
every 1 year(s)
Prevention - wellness visit (65+ y.o.)
due 07/20/23 and every 1 year(s)
Due In Future
Prevention - blood pressure, not at goal not due
until 09/14/23 and every 2 week(s)
Diabetes - HbA1c, prior at goal not due
until 02/29/24 and every 6 month(s)
Cancer screening - breast not due
until 07/26/24 and every 1 year(s)
Depression screening not due until 08/31/24 and
every 1 year(s)
Prevention - measure body mass index not due
until 08/31/24 and every 1 year(s)
Chronic cond - repeat basic chem panel not due
until 08/31/24 and every 1 year(s)
Chronic cond/med - thyroid lab not due
until 08/31/24 and every 1 year(s)
Prevention - lipid panel (high risk) not due
until 08/31/24 and every 1 year(s)
Diabetes - urine test (microalbumin) not due
until 08/31/24 and every 1 year(s)
Satisfied (in the past 1 year)
Satisfied
Cancer screening - breast on 07/26/23.
Chronic cond - repeat basic chem panel
on 08/31/23. Satisfied by SYSTEM, SYSTEM
VMCS Clock
Score
3 07/20/22 11:47:00
VMCS 12 Different
Animals Named
Yes 07/20/22 11:47:00
VMCS Fluency
Score
2 07/20/22 11:47:00
VMCS Recall
Score
5 07/20/22 11:47:00
VMCS Cognitive
Screening Total
10 07/20/22 11:47:00
Behavioral Health
Behavioral Health Scores and Assessments
PHQ/GAD/AUDIT
Scores and
Intepretations
Event Name Event Result Date/Time
Alcohol frequency 0 times 08/31/23 16:40:00
Thoughts of
Self-Harm
0 = Not at all 08/31/23 16:40:00
PHQ-2 Total Score 1 08/31/23 16:40:00
PHQ-8 Total Score 5 08/31/23 16:40:00
PHQ-9 Total Score 5 08/31/23 16:40:00
GAD-2 Total
Score
1 08/31/23 16:40:00
GAD-7 Total Score 3 08/31/23 16:40:00
Chronic cond/med - thyroid lab
on 08/31/23. Satisfied by SYSTEM, SYSTEM
Depression screening on 08/31/23. Satisfied by
Bigornia MA, Dane S
Diabetes - HbA1c, prior above goal
on 08/31/23. Satisfied by SYSTEM, SYSTEM
Diabetes - urine test (microalbumin)
on 08/31/23. Satisfied by SYSTEM, SYSTEM
Prevention - lipid panel (high risk)
on 08/31/23. Satisfied by SYSTEM, SYSTEM
Prevention - measure body mass index
on 08/31/23. Satisfied by Bigornia MA, Dane S
Prevention - screen for hypertension
on 08/31/23. Satisfied by Bigornia MA, Dane S
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