eight/30/22, 12:49 PM Print Preview
1/four
Present Medicines
Taking
Donepezil HCl 10 MG Pill 1 pill
at bedtime Orally As soon as a day
Meloxicam 7.5 MG Pill 1 pill
Orally As soon as a day
Losartan Potassium 50 MG Pill 1
pill Orally As soon as a day
Ibandronate Sodium 150 MG Pill 1
pill Orally As soon as a month
Treatment Record reviewed and reconciled
with the affected person
Previous Medical Historical past
Important (main) hypertension.
Dementia in different illnesses categorized
elsewhere with behavioral disturbance.
Different polyosteoarthritis.
Mattress confinement standing.
Dependence on wheelchair.
Weight problems (BMI 30.Zero-34.9).
Osteoporosis with out present
pathological fracture, unspecified
osteoporosis kind.
Surgical Historical past
Denies Previous Surgical Historical past
Household Historical past
Father: deceased
Mom: deceased
Social Historical past
Tobacco Use:
Tobacco Use/Smoking
Tobacco use: nonsmoker
Allergic reactions
N.Ok.D.A.
Hospitalization/Main
Diagnostic Process
Denies Previous Hospitalization
Evaluate of Methods
Purpose for Appointment
1. Preliminary analysis
Historical past of Current Sickness
Examination:
70-year-old feminine with a previous medical historical past important for
dementia, mattress/wheelchair confinement, hypertension, osteoarthritis,
osteoporsis and weight problems was seen for an preliminary examination (telehealth) to
focus on her persistent medical circumstances, consider for medical providers, and
focus on distant affected person monitoring. Restricted subjective Assessment as a consequence of
persistent analysis of dementia, medical considerations addressed by daughter.
The sufferers daughter states that she eats a comparatively nutritious diet and is
minimally bodily energetic all through the day nevertheless does require an
Helpive gadget to ambulate (wheelchair). She complains of occasional
bilateral knee pains; nevertheless, she states that she is cautious when
ambulating and has not fallen not too long ago. She presently is beneath the care of
main care doctor uncertain of title additionally has a caretaker seven days a
week for a number of hours (roughly 7 hours every day). Her caretaker
helps her dress, maintain mild housekeeping, help with common
hygiene, put together meals and infrequently exit for brief walks. The sufferers
caretaker states she is taking and tolerating all of her medicines as
prescribed with none hostile results. Daughter denies any chest pains,
palpitations, shortness of breath, stomach ache, nausea, vomiting,
diarrhea, constipation, fevers, chills, night time sweats, dizziness, acute visible
abnormalities, complications, syncopal episodes, latest recognized infections,
latest antibiotic use, or every other acute complaints or abnormalities.
Important Indicators
Wt 190 lbs, Wt-kg 86.18 kg, Ht 65 in, Ht-cm 165.1 cm, BMI 31.61 Index,
Physique Floor Space 1.99.
Examination
Basic Examination:
TeleHealth Go to.
Bodily Examination
Check with examination.
Assessments
1. Important hypertension – I10 (Major)
2. Major osteoarthritis involving a number of joints – M89.49
DARIUS, YVESROSE DOB: 05/08/1951 (70 yo F) Acc No. 24515 DOS: 12/30/2021
DARIUS, YVESROSE
70 Y previous Feminine, DOB: 05/08/1951
Account Quantity: 24515
750 OCEAN AVE, APT 1C, BROOKLYN, NY-11226-5308
House: 718-282-4651
Guarantor: DARIUS, YVESROSE Insurance coverage: Medicare of New
York Payer ID: NYMRE
Appointment Facility: telehealth
12/30/2021 Progress Notes: Gina M Marotto, PA-C, MPAS
Progress Note: Gina M Marotto, PA-C, MPAS 12/30/2021
Note generated by eClinicalWorks EMR/PM Software program (www.eClinicalWorks.com)
eight/30/22, 12:49 PM Print Preview
2/four
GENERAL/CONSTITUTIONAL:
Affected person denies change in urge for food
, chills , fatigue , fever , headache ,
lightheadedness , night time sweats ,
sleep disturbance , weight acquire ,
weight reduction , weak spot.
RESPIRATORY:
Affected person denies cough , shortness
of breath.
CARDIOVASCULAR:
Affected person denies chest ache ,
dizziness , palpitations , shortness
of breath , weak spot.
Feedback Important Hypertension.
MUSCULOSKELETAL:
Affected person denies historical past of gout ,
swollen joints, trauma. Affected person
complains of arthritis / arthralgia,
joint stiffness and ache , painful
joints , weak spot.
NEUROLOGIC:
Affected person denies dizziness ,
fainting. Affected person complains of lack of
power , reminiscence loss.
Three. Gait abnormality – R26.9
four. Counseling and coordination of care – Z71.89
5. Dementia in different illnesses categorized elsewhere with behavioral
disturbance – F02.81
6. Dependence on wheelchair – Z99.Three
7. Weight problems (BMI 30.Zero-34.9) – E66.9
Remedy
1. Important hypertension
Notes: I reminded the caregiver of the significance of following a
DASH food plan and monitoring their sodium consumption (under 2-Three g per
day). The DASH food plan consists of fruits, greens, entire grains, poultry,
and fish whereas limiting sugars, pink meat, and alcohol. As well as, I
inspired the caregiver to watch blood strain not less than
as soon as per day. Proceed present medicine(s) as prescribed. Mentioned
dangers and problems of non compliance with medical suggestions
together with however not restricted to myocardial infarction, cerebrovascular
accident and demise.
2. Major osteoarthritis involving a number of joints
Notes: The affected person’s complaints are in keeping with osteoarthritis, a
breakdown of cartilage from the joints inflicting the bone to grind on bone. I
defined to the affected person that osteoarthritis often assaults massive
joints; nevertheless, it could additionally have an effect on smaller joints such because the
hand. As well as, painful bone spurs are frequent with osteoarthritis.
Threat components embody age, weight problems, feminine intercourse, a earlier joint harm, and a
household historical past of arthritis.Proceed present medicine as prescribed.
Three. Counseling and coordination of care
Notes: I had an in depth dialog with the sufferers
caretaker, finishing the required standards to invoice for CCM /
RPM providers. After finishing an Assessment and CCM care planning, I
initiated CCM providers, assembly the excellent Assessment and care
planning necessities. I mentioned the supply of CCM providers in
relevant name sharing. I made it clear that just one practitioner might
furnish and be paid for CCM providers throughout a calendar month. The affected person
has the suitable to cease CCM providers at any time. Lastly, I supplied distant
affected person monitoring providers, which I defined would Help us
handle the affected person remotely. Our care managers will report any
abnormalities inside an inexpensive period of time. Based mostly on the affected person’s
values, I’ll focus on if additional intervention is required. CCM objectives and
anticipated outcomes: 1) Tight glycemic management with a hemoglobin A1c much less
than 6.5 (American Diabetes Affiliation), 2) Blood strain management with a
goal studying under 130/80 (American Coronary heart Affiliation), Three) Vitamin D
degree higher than 30, four) LDL under 70, triglycerides under 150, 5) Weight
discount, 6) Remaining updated with immunizations together with flu,
pneumococcal, Tdap, shingles, COVID-19, and Hepatitis. The affected person’s
persistent circumstances are steady, and with continued monitoring
and encouragement, the objectives set forth are achievable
A) The affected person requires frequent reminders and reinforcements
to realize the objectives we set forth, hopefully optimizing their
common well being as finest as doable. B) I mentioned the care plan with
the affected person’s nurse, aide, and different suppliers. C) I suggested that we
often monitor the affected person’s blood pressures and set up a development to
DARIUS, YVESROSE DOB: 05/08/1951 (70 yo F) Acc No. 24515 DOS: 12/30/2021
Progress Note: Gina M Marotto, PA-C, MPAS 12/30/2021
Note generated by eClinicalWorks EMR/PM Software program (www.eClinicalWorks.com)
eight/30/22, 12:49 PM Print Preview
Three/four
confirm efficacy and stability. D) Routine lab work. E) Continued
encouragement, dietary counseling, and adherence to life-style
modifications, primarily focusing on weight problems. F) I hope that the sufferers
caretaker will proceed to observe the above suggestions.
Nevertheless, the prognosis relies on the affected person’s
intervention and cooperation with the above pointers.
four. Dementia in different illnesses categorized elsewhere with
behavioral disturbance
Medical Notes: Reiterated significance of medicine compliance, routine
observe up with neurology, implementation of reorientation workout routines and
verbal communication to gradual development and exacerbation of signs.
Mentioned dangers and problems of non compliance with medical
suggestions together with however not restricted to failure to thrive and demise.
5. Dependence on wheelchair
Medical Notes: Hospital mattress requested, prescribed. Reiterated significance
of repositioning and implementation of supportive medical gear
together with however not restricted to wheelchair cushion and hospital mattress to
lower threat of pores and skin breakdown/pores and skin ulcerations. Fall threat Assessment
accomplished, affected person is a excessive fall threat. Reiterated significance of ambulating
with Helpive gadget for help and to lower threat of falls. Mentioned
dangers and problems of non compliance with medical suggestions
together with however not restricted to fracture, hemorrhage, deep venous
thrombosis, respiratory failure, osteomyelitis, sepsis and demise.
6. Weight problems (BMI 30.Zero-34.9)
Medical Notes: Reiterated significance of continued implementation of food plan
modification. Keep away from meals with excessive fats content material to lower threat of
potential problems and dangers together with however not restricted to myocardial
infarction, cerebrovascular accident and demise.
Process Codes
G0447 FCE-FCE BEHAVRL CNSL OBESITY 15 MIN
99443 PHONE E/M BY PHYS 21-30 MIN
G8427 DOC MEDS VERIFIED W/PT OR RE
0518F FALL PLAN OF CARE DOCD
3288F FALL RISK ASSESSMENT DOCD
G8938 BMI CALC BUT PT NOT ELIG F/U PLAN
Observe Up
2 Weeks (Purpose: wheelchair dependence)
Electronically signed by Gina Marotto , PA-C,MPAS on
12/30/2021 at 03:37 PM EST
Log off standing: Accomplished
DARIUS, YVESROSE DOB: 05/08/1951 (70 yo F) Acc No. 24515 DOS: 12/30/2021
Progress Note: Gina M Marotto, PA-C, MPAS 12/30/2021
Note generated by eClinicalWorks EMR/PM Software program (www.eClinicalWorks.com)
eight/30/22, 12:49 PM Print Preview
four/four
telehealth
1573 E 22ND ST
BROOKLYN, NY 11210-5109
Tel: 646-919-0757
Fax:
DARIUS, YVESROSE DOB: 05/08/1951 (70 yo F) Acc No. 24515 DOS: 12/30/2021
Progress Note: Gina M Marotto, PA-C, MPAS 12/30/2021
Note generated by eClinicalWorks EMR/PM Software program (www.eClinicalWorks.com)

Published by

Essays

View all posts