6/3/2011

Betty J Pendegrass-

Carl D. Paige MD 1023 New Moody Lane Ste 201 LaGrange, KY 40031 P:502-225-4480

Betty J Pendegrass 23 Glen Drive LaGrange, KY 48994 Account Number: MRN: 2342342

Printed: Patient Name: SSN: DOB: Age: Rendering Provider:

06/3/2011 Betty J Pendegrass 090-98-7765 01/23/1935 76 Dr. Carl D. Paige, MD

DOS: June 2, 2011

Preliminary Note - has not been signed off by provider

Reason for Visit
The purpose of this visit is the Medicare Annual Wellness Visit for the initial (first) annual wellness visit.

Problem(s)
06/03/2011 250.5 - Diabetes with ophthalmic manifestations (Chronic) 06/03/2011 362.0 - Diabetic retinopathy (Chronic) The patient reports the following problems: obesity, poor vision, dizziness, forgetfulness, sleep disorder, joint pain, HTN, stroke or TIA and headaches.

Allergy History
05/31/2011 05/31/2011 Rash (Medication (Demerol HCl 100 mg oral tablet)) Peanuts (Food) Medication Qty Dosage & Frequency Rfl Synthroid 150 mcg (0.15 mg) oral tablet tab 1 tab(s) orally once a day 0 aspirin 162 mg oral enteric coated tablet tab 1 tab(s) orally once a day 0 Flonase 0.05 mg/inh nasal spray 1 spray(s) intranasally once a day 0

Medication History
Date 05/31/2011 05/31/2011 05/31/2011

Constitution
- No fever, chills, malaise, fatigue, weakness, allergies, or insomnia. No recent change in appetite or recent weight change.

Vitals
Date 06/02/2011 05/31/2011 Time 10:03 AM 07:58 PM LMP EDD Height (in) 65 65 Weight BMI BP (lb) 160 26.68 136/84 180 30.02 120/90 Resp. 20 15 Pulse 70 69 Temp. O2 Sat. (F) 98.8 98 98.4 98 Head Cir. (cm) Waist (in) 39 41

Complications, Morbidity or Mortality

Previously recorded problems and diagnoses: 250.5 Diabetes with ophthalmic manifestations 362.0 Diabetic retinopathy

Current Providers and Suppliers of Medical Care

The patient's providers and suppliers of medical care are as follows: John Deere, MD, Marcus Welby, MD Geriatrician and Dr Fixott, Ophthalmologist.

Diet
The patient's diet consists of 1-2 servings of nuts or berries per week, no servings of fruit per week, 3 or more servings of fish per week, 12 servings of green, leafy vegetables per week, 3 or more servings of soda with sugar per week, 3 or more servings of fried food per week, 1-2 servings of saturated fat food per week, 3 or more cups of coffee per day, no cups of tea per day and 1 aspirin each day.

Exercise and Activity Level

The patient's exercise and activity level consists of moderate exercise level, gardening, card games, dining out, volunteer work, gatherings with friends, bowling, church or other social functions and gambles at Atlantic City on Fridays.

Functional Capacity
The patient was evaluated for his or her functional capacity. Pass/Fail results are as follows: sitting (passed), standing (passed), lifting (passed), carrying (passed), pushing (failed), pulling (failed), bending (passed), stooping (passed), squatting (passed), kneeling (passed), reaching (passed) and hand use (failed).

Safety
The patient's safety was evaluated. The evaluation shows that the patient's safety awareness is as follows: the patient does not have handrails in his or her home and is not able to stabilize when walking at all times (failed), the patient sometimes or frequently walks on slippery surfaces without the ability to stabilize (fails), the patient drives quite a lot even though it may pose a safety threat to him or her (fails), the patient locks his/her doors and windows and keeps lights on at night, the patient does not maintain steady contact with his/her family (fails) and the patient has a number of friends with whom s/he stays in contact.

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MCI/Cognitive
The patient was assessed for MCI/Cognitive responses and the results are as follows: eye movement (passed), walking and balance (failed), sense of touch (passed), draw clock face with hands showing time (passed), name today's date and location (passed), ability to copy a design (passed), ability to follow a 3-step command (passed), remembering a list of 3 words (passed), ability to follow a written instruction (passed), ability to write a complete sentence (passed) and ability to count backwards from 100 by 5 (passed).

Mental State and Potential for Depression (PHQ-9)

Pt sts. she is not speaking with her family b/c they are upset about her gambling. The patient reports that s/he is unhappy with his/her family life. The patient's outlook on life is positive. The patient appears to be moody, uneasy, anxious with a depressed state of mind, sad, empty and in a ready state of tears. The patient appears to has a lack of interest in activities that used to be enjoyable. The patient reports that s/he has gained or lost weight recently. The patient reports that s/he has little to no appetite and does not enjoy eating food. The patient's sleeping patterns are abnormal and s/he has difficulty sleeping. The patient appears to be normal, calm, not agitated.. The patient reports that s/he is able to think clearly and remember names and places. S/he does have an occasional "senior moment" but they are rare and having difficulty remembering people, places and things and the details surrounding them. The patient is showing a reduction in his or her ability to move normally. The patient reports that he or she feels fatigued frequently and has a constant lack of energy. The patient feels good about him or herself and does not suffer any feelings of guilt. The patient's concentation is poor. The patient is able to make decisions freely. The patient does not have thoughts of death or suicide normally.

Risk Factors
The patient's risk factors are shown in the following table .

RISK FACTOR
Diabetes CHD/CF COPD Lung Cancer Colon Cancer Breast Cancer Prostate Cancer Depression Cognitive Impairment Functional Capacity and Safety

LEVEL
High Low Low Low High Low N/A High High

TREATMENT OPTIONS
Exercise regimen and monitoring to reduce waist size Registered Dietician Counseling concerning saturated fat intake and fried food intake N/A N/A Registered Dietician Counseling about red meat intake N/A Psychologist/Psychiatrist Obtain counseling Primary Care Physician Follow-up with additional medical attention Primary Care Physician Follow-up with additional medical attention

ASSOCIATED RISKS
Blindness (Retinopathy) Limb amputation Stroke/TIA

Safety Safety

High

Hospitalization due to falls

Written screening schedule - 5 year Plan

The patient's written screening schedule and 5-year plan is as follows .

CATEGORY
Office Visit

YEAR 1
HbA1C Check if value GTR 7.0 else 6 months later. Goal is: 6.5

YEAR 2
HbA1C Check if value GTR 7.0 else 6 months later. Goal is: 6.5

YEAR 3
HbA1C Check if value GTR 7.0 else 6 months later. Goal is: 6.5 Every visit goal: Systolic < 120 Diastolic < 80 Every visit goal: BMI 18-25

YEAR 4
HbA1C Check if value GTR 7.0 else 6 months later. Goal is: 6.5 Every visit goal: Systolic < 120 Diastolic < 80 Every visit goal: BMI 18-25

YEAR 5
HbA1C Check if value GTR 7.0 else 6 months later. Goal is: 6.5 Every visit goal: Systolic < 120 Diastolic < 80 Every visit goal: BMI 18-25

Blood Pressure

Every visit Every visit - goal: goal: Systolic < 120 Systolic < 120 Diastolic < 80 Diastolic < 80 Every visit Every visit - goal: goal: BMI 18-25 BMI 18-25

Weight/BMI

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Standing Lab Orders

CBC, CMP, TSH, U/A, Microalbumin, HbA1C, Lipid Plus

CBC, CMP, TSH, U/A, Microalbumin, HbA1C, Lipid Plus

CBC, CMP, TSH, U/A, Microalbumin, HbA1C, Lipid Plus

CBC, CMP, TSH, U/A, Microalbumin, HbA1C, Lipid Plus

CBC, CMP, TSH, U/A, Microalbumin, HbA1C, Lipid Plus

Immunizations

Seasonal Flu Pneumovax (once after age 65) Seasonal Flu Tdap (every 10 years) Gastroenterologist Registered Dietician Optomistrist or Ophthalmologist Podiatrist Registered Dietician Optomistrist or Ophthalmologist Podiatrist

Seasonal Flu

Seasonal Flu

Seasonal Flu

Referrals

Registered Dietician Optomistrist or Ophthalmologist Podiatrist

Registered Dietician Optomistrist or Ophthalmologist Podiatrist

Registered Dietician Optomistrist or Ophthalmologist Podiatrist

Personalized Health Advice

The patient's personalized health advice is as follows .

CATEGORY
Weight Loss Nutrition Smoking Cessation

RECOMMENDATION
Reduce intake of fried and saturated fats Exercise daily, walking or gardening. Meet with your Registered Dietician every 6 months You have reported that you quit smoking years ago...congratulations! Hold handrails in your house. Install handrails in bathroom and around tub. If you feel lightheaded or dizzy, call your doctor right away. Discuss current events with friends and family. Play a musical instrument. Play card games, chess or checkers. Do crosswords and puzzles. Meet with your psychologist or psychiatrist and discuss your depression. If you experience mood change, call your primary care physician right away. Lift a 10 lb weight 20 times a day. Walk around the block twice a day. See your Registered Dietician as noted above. See your podiatrist soon. See your optomistist or ophthalmologist soon. Consult with your psychologist or psychiatrist if you feel depressed. See your primary care doctor if you experience dizziness, depression, mood swings or have memory lapses.

ACCOMPLISH BY:
Every day November 2011 N/A

Fall Prevention

As soon as possible

Cognitive Improvement

As soon as possible

Depression

As soon as possible

Physical Strength

Every day

Referrals

As needed

Not Signed Off

Dr. Carl D. Paige, MD

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