John s Labs & Tests (for December 1, 2012)
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1 4 John s Labs & Tests (for December 1, ) Page 1 of 2 You had the following labs/studies performed: Ankle Brachial Pressure Index is the ratio of blood pressure in your legs divided by the blood pressure in your arms. Low values are considered a sign of arterial disease, such as seen in peripheral vascular disease. Your TIMELINE of values 0.72 Severe arterial disease Moderate arterial disease Normal range 1.2 Abnormal vessel hardening /2 5/13 5/13 Fasting Blood Sugar is the amount of sugar in your blood after fasting for more than 8 hours Normal Pre-Diabetes Diabetes /2 5/13
2 4 John s Labs & Tests for December 1, Page 2 of 2 Lipid Panel is a series of tests including: Cholesterol: molecule in blood linked to damage of arteries at high levels LDL: a subtype of cholesterol most responsible for damage to arteries HDL: a good subtype of cholesterol that removes bad cholesterol from blood Triglycerides: type of fat found in blood Cholesterol Desirable Borderline High High 175 5/13 2/2 12/1 LDL g/dl 130g/dl 160mg/ Ideal Near ideal Borderline High High /13 2/2 12/1 HDL Poor Better Best /2 5/13 12/1 Triglyceride Desirable 150 Borderline High High /13 2/2 12/1
3 2 John s Background (as of December 1, ) Your 2-year history PVD Past Medical History: Peripheral vascular disease (4/3/2010) PVD Hyperlipidemia (2/5/2004) Gonococcal urethritis (11/3/1992) Appendicitis (4/12/1990) Streptococcal pharyngitis (3/13/1987) Arnold-Chiari malformation (02/08/1964) Past Social History: Smoking: 20 year ppd history; quit smoking in 5/2010 Alcohol: None Living: Single Other substances: None Family History: Mother: Ovarian Cancer (2003) Father: Hypertension, Diabetes, Stroke (1994), Lung cancer (May 2011) Procedures Appendectomy (4/14/1990) Allergies: Latex Immunizations: Date I Date II Future MMR 3/1958 Td 3/1958 4/1965 Influenza Varicella 12/1964 Hepatitis A 1/ /1968 Hepatitis B 1/ /1968 MMR 3/1965 4/1967 Other Demographics: Full Name: John Doe Gender: Male Marital Status: Single Religious Affiliation: Roman Catholic Language spoken: English Address: 555 E. Jefferson, Telephone: (313) Birthday: 1/12/1957
4 1 John s Visit Summary (for December 1, ) You came in for a follow-up appointment today. History of Present Visit: Mr. Doe is a 55 y/o male with a history of PVD. He presents today for a 6 month follow-up visit since his last exam. He continues to endorse symptoms of claudication in his left leg after 3 steps. He denies all other associated symptoms including chest pain, ulcers, cyanosis, temperature change in extremities, and diminished hair/nail growth in lower legs. You have the following ACTIVE conditions: Peripheral vascular disease: chronic obstruction of large arteries, particularly in the lower extremities Age of onset: 54 y/o (2010) Status: Moderate arterial disease Risk factors: Hyperlipidemia, Former Smoker Which we addressed by: -Fasting blood sugar -Lipid Profile (below) -Ankle Brachial index Hyperlipidemia: an abnormal amount of cholesterol molecules in the blood, increasing risk for other cardiovascular events Age of onset: 47 y/o (2004) Status: Decreased HDL, increased triglycerides -Lipid Profile Cholesterol LDL HDL Triglycerides Major Depressive Disorder (depression): Age of onset: Status: active Please see your psychiatrist for management Your Notes:
5 5 John s Health Schedule (as of December 1, ) Psychiatrist Cardiologist Emergency Department General Medicine Dr. John Psychiatry 555 E. William St. Suite 1 (last appointment: 11/3/) Dr. John Cardiology 555 E. William St. Suite 2 (last appointment: 1/3/) Dr. John Internist 555 E. William St. Suite 3 (last appointment: 10/25/2009) Dr. John Emergency Community Emergency (last appointment: 11/20/2009) Your next steps: December 4, appointment 2x/day: Buproprion Daily: wellness diary Schedule referral appointment with therapist Your next steps: December 31, appointment Daily: 30 minutes of exercise (low-cardio, exercise bike) Daily: Hydrochlorothiazide Daily: Lisinopril Next Appointment November 10, 2010!! (past due)
6 3 John s Medications (as of December 1, ) 40mg 80mg Hydrochlorathiazide: Take 1 tablet (80 mg) every 24 hours; Date initiated: 3/21/2010 Prescribed by: Dr. Cardiologist mg 25mg 2011 Simvastatin: Take 2 tablets (120 mg) every 24 hours; Date initiated: 2/20/2003 Prescribed by: Dr. Cardiologist mg 40mg mg Buproprion: Take 1 tablets (100 mg) every 2 days; Date initiated 7/20/2010 Prescribed by: Dr. Psychiatrist
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