Communication #2 - Consultation Note to the referring physician with the results of the examination (February 10, 2020, 10:00AM -0500)

Patient Legal: Clare M TESCA Date of Birth: February 14, 1952 (67yr) Gender: Female Patient-ID:  123456789 (SSN), 404.1 (1.3.6.1.4.1.115)
Encounter ID: 20200210100000 (2.16.840.1.113883.3.2820.10.1.3.10) , Date/Time: from February 10, 2020, 10AM -0500
In Fulfillment Of Order ID: 85fa4b62-e3a9-4385-b064-fe04cca35adb, d56d5938-ab8b-448b-a7e6-ed2f914864b3 (1.2.840.114350.1.13.6289.1.7.3.698084.8) , Code: Diabetic retinal eye exam (procedure)
Author Dr Yul SEEMORE, Authored On: February 10, 2020, 10:00AM -0500
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CONSULTATION NOTES

  • Dear Dr. Gooddoc

    Thank you for referring Clare Tesca for an eye exam. As you know she has a history of diabetes mellitus for approximately 6 years that has not been well controlled. She also had symptoms of blurred distance vision and glare at night.

    Her exam showed moderate bilateral nuclear cataracts accounting for her symptoms of glare and blurred vision. She performed poorly on glare testing. Because her work requires night driving, it was felt appropriate to refer her to Dr. Stan Stedyhan for evaluation for cataract extraction.

    Her exam did not reveal any visible retinopathy on fundus exam or retinal imaging, but there were definitive diabetic changes visible on OCT-A. As you know these changes can be present for 2 years or more before visible retinopathy develops. The patient was shown these changes and was obviously concerned. She then revealed that she is very concerned about losing vision because of an extensive family history of members that have lost vision due to diabetes. She additionally stated that the history is so strong that she feels it is inevitable she will also loose vision and that due to this fear she has been working extra hard to earn income while she still can. In fact she has been emphasizing that over controlling her condition.

    It was explained to her that the risk of developing vision threatening eye changes is much higher by not controlling her condition than it is from her family history. After that explanation and showing her clinical outcomes data, she expressed an interest in getting better control of her condition in order to reduce her risk of losing vision in the future.

    I have referred her to a diabetic educator as she feels that she needs help in better meal planning and better understanding how to get better control. She stated that you had recommended she see a diabetic educator in the past, but she never actually went on the referral. She has agreed to follow your recommendation so my office scheduled her to see Maka Felgood who will let you know what educational program she recommends to the patient.

    Thank you for allowing me to participate in the care of this patient. I have recommended that she return in 6 months to assess any change in her early retinopathy. She understands that we can quantitate the retinal changes and estimate the risk of future changes based on her level of HbA1c control. The patient stated that having the measure will help focus her on getting better control.

REASON FOR VISIT

Referral from Dr. Joseph Gooddoc for Diabetic retinal eye exam

Request Procedures Reason for Referral Referred By Contact Referred To Contact Specialty
Diabetic retinal eye exam Diabetic retinal eye exam (722161008) Diabetes with complaints of blurred vision and halos around lights at night.
Annual dilated diabetic eye exam
Gooddoc, Joseph
800 Spring St.
Atlanta, GA 30308
Phone: 843-385-3448
Seemore, Yul
25 Fall St.
Atlanta, GA 30308
Optometry

INTERVENTIONS

Description Date and Time (Range) Status
Diabetic retinal eye exam 10 Feb 2020 09:00am Completed

ASSESSMENTS

After explaining to the patient that she is at a much higher risk of developing retinopathy in the future by not controlling her diabetes than she is because of her genetic risk, the patient stated they now understand that and expressed a desire to get her diabetes under better control.

She also stated she would appreciate any assistance in meeting that goal. The plan is aimed at providing the patient with the knowledge she needs to get better control of her condition

HEALTH STATUS EVALUATIONS

  • Diabetic retinal eye exam: MET
    • Evaluates Expected Outcome/Goal:
      Early diabetic retinopathy changes on OCT-A findings but not yet visible on fundus exam or retinal images
      Nuclear cataracts sufficiently progressed to refer to Ophthalmology for evaluation for surgical removal accounting for symptoms of blur and glare at night
      The patient has expressed an interest in better controlling her diabetes in order to reduce the risk of developing diabetic retinopathy and potential vision loss
    • Supported by: Physical Exam findings (February 10, 2020 at 09:00)

HEALTH CONCERNS

Health Concerns
Type Health Concern Date Related Problem
Patient
The patient expressed concern that she felt her loss of vision was inevitable based on the history of numerous family members losing vision from diabetes at an early age. She said that she was emphasizing work over control of her diabetes under the fear she wouldn’t be able to work much longer due to loss of vision 02/10/2020 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
Patient states father and uncle both had significant problems with vision from diabetes that started well before they were ready to retire. 01/20/2020 Type 2 diabetes mellitus without complications
She states she is having trouble controlling her glucose at home. She travels a lot for work and has more difficulty maintaining control when traveling. 01/20/2020 Type 2 diabetes mellitus without complications
Provider
The patient is making misguided decisions on managing her condition based on a misunderstanding of what puts her at greatest risk of developing diabetic retinopathy and potential loss of vision 01/20/2020 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
Patient has fears regarding vision loss. 01/20/2020 Type 2 diabetes mellitus without complications
Patient is having difficulty balancing lifestyle changes with work. 01/20/2020 Type 2 diabetes mellitus without complications

GOALS

Goals were updated to better meet patient's lifestyle and encourage better compliance.

Problem Addressed Goal Goal Type Author
Education The patient was shown the early diabetic changes that are visible in her retina through OCT-A Provider Yul Seemore, OD
Education She was also shown how these changes can be measured and quantitated so she will be able to see exactly how change occurs over time. It was also explained that better control of her diabetes will very likely slow or potentially even arrest these changes, potentially reducing her risk of developing significant diabetic retinopathy in the future Provider Yul Seemore, OD.
Diabetes Determine the cause of visual complaint. Patient stated Joseph Gooddoc, M.D.
Diabetes Get HbA1c below 8 within 6 months. Provider Joseph Gooddoc, M.D.

PLAN OF CARE

Date of Planned Services Type of Intervention Rationale Provider Location
(02/10/2020 - 03/10/2020 Referral to Ophthalmologist for Cataract Extraction Evaluation (procedure) Glare at night interfering with work requirements Stedyhan, Stan
33 Front St.
Atlanta, GA 30308
843-555-9898
(02/10/2020 - 03/10/2020 Referral to diabetic Educator PCP originally recommended but for a variety of reasons it was never accomplished
Patient now interested in attending the educational classes
Felgood, Maka
1450 Main St.
Atlanta, GA 30308
843-555-9878
(08/10/2020 - 08/20/2020 OCT-A and evaluation Return in 6 months for repeat test and evaluation Seemore, Yul
25 Fall St.
Atlanta, GA 30308
843-555-9876
02/10/2020 - Cataract Co-management Co-managing option for cataract surgery was explained to patient Seemore, Yul
25 Fall St.
Atlanta, GA 30308
843-555-9876
02/10/2021 - Next scheduled PCP Visit Patient to discuss better control of diabetes during next visit with primary care physician Gooddoc, Joseph
800 Spring St.
Atlanta, GA 30308
843-385-3448

HISTORY OF PRESENT ILLNESS

The patient has symptoms of blur at distance and increasing glare at night over the past 6 months

SOCIAL HISTORY

No Information

VITAL SIGNS

No Information

PROBLEM LIST

Problem Onset Date Resolved Date Status
Problem data included from 05/08/2006 to 02/10/2020 only
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral (1551000119108) 02/10/2020 active
Age-related nuclear cataract, bilateral (678601000119100) 02/10/2020 active
Type 2 diabetes mellitus without complications (111552007) 04/20/2014 active
Obesity, unspecified (414916001) 05/08/2006 active
Familial hypercholesterolemia (398036000) 04/20/2014 active
Essential (primary) hypertension (59621000) 07/28/2019 active

ALLERGIES AND ADVERSE REACTIONS

Time Substance Reaction Status
01/20/1998 egg Hives Active

MEDICATIONS

Active Medications
Name Code Instructions Start Date Stop Date Status
Crestor 5 mg 859426 (RxNorm) 1 tablet by mouth once a day for 90 2019-07-28 Active
metformin 1,000 mg 861004 (RxNorm) 1 tablet by mouth twice a day for 180 2014-04-20 Active
Invokana 100mg 50458-140-01 (NDC) 1 tablet by mouth once a day for 90 2019-07-28 Active
lisinopril 10 mg 314076 (RxNorm) 1 tablet by mouth once a day for 90 2019-07-28 Active

DIAGNOSTIC TESTS/LABORATORY RESULTS

Lab Results
Order Test Ref. Range Flags Result Units Obs. Date Performing Laboratory
Hemoglobin A1c
Hemoglobin A1c [Mass/volume] in Blood (41995-2) LESS THAN 7.0% (NORMAL) H 10.5 % 2020-01-14 09:33:00
Lipid Panel (24331-1)
Triglyceride [Mass/volume] in Blood (3043-7) LESS THAN 150 MG/DL (NORMAL) H 250 mg/dL 2020-01-14 09:33:00
Cholesterol in HDL [Mass/volume] in Serum or Plasma (2085-9) LESS THAN 50 MG/DL (NORMAL) 28 mg/dL 2020-01-14 09:33:00
Cholesterol in LDL [Mass/volume] in Serum or Plasma (2089-1) LESS THAN 100 MG/DL (NORMAL) H 180 mg/dL 2020-01-14 09:33:00
Cholesterol [Mass/volume] in Serum or Plasma (2093-3) LESS THAN 200 MG/DL (NORMAL) H 280 mg/dL 2020-01-14 09:33:00
Liver Panel (24324-6)
Albumin [Mass/volume] in Serum or Plasma (1751-7) 3.5-5.5 G/DL (NORMAL) H 6.0 g/dL 2020-01-14 09:33:00
Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma (1920-8) 9-50 U/L(NORMAL) H 60 U/L 2020-01-14 09:33:00
Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma (1742-6) 5-50 U/L(NORMAL) H 65 U/L 2020-01-14 09:33:00
Creatinine
Creatinine [Mass/volume] in Serum or Plasma (2160-0) LESS THAN 1.3 MG/DL H 1.5 mg/dL 2020-01-14 09:33:00

PHYSICAL EXMAMINATION

Clinical Findings
System Finding
Posterior No visible retinopathy. Retinal vasculature appears normal with no evidence of diabetic changes
IOP 17 mmHg OD, 18 mmHg OS
OCT-A A symmetry of the foveal avascular zone present with early microvascular dropout surrounding the rim of the foveal avascular zone
Anterior Lens - The crystalline lens shows +3 nuclear sclerosis in each eye
Visual Acuities OD: 20/25-
OS: 20/30+
Glare Test fails

PATIENT CARE TEAMS

  • Long Term Care Team ( Active) (01/01/2005 - )
    Member Role on Team Status Date
    Dr. Joseph Gooddoc, MD (NPI: 2734441159 ) Primary Care Physician (Active) 2005 - current
    Maka Felgood Diabetic Educator (Active) 2014 - current
    Dr. Arthur Feetler, DPM (NPI: 8402871106) Podiatrist (Active) 2018 - current
    Dr. Donald Singletooth, DDS (NPI: 8477778822) Dentist (Active) 1990 - current
    Dr. Yul Seemore, OD (NPI: 1973535929) Optometrist (Active) 2020 - current

PAYERS

No Information
Document
ID 0a8d54b5-7d85-4f39-9f58-58cc5036a2c6
Created On February 10, 2020, 10:00AM -0500
Custodian Wood River Health Services, LLC Contact Details Workplace: 800 Spring St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-2234
 
Patient Legal: Clare M TESCA Contact Details Home Primary: 3704 Irish Lane
Atlanta, GA 30301
US
Tel Home Primary: +1(843)-758-0515
Date of Birth February 14, 1952 (67yr) Gender Female
Race Black or African American Ethnicity Not Hispanic or Latino
Patient-IDs 123456789 (SSN)
404.1 (1.3.6.1.4.1.115)
Language Communication
eng, Expressed spoken, Excellent, preferred: yes
Provider Organization
Wood River Health Services, LLC
ID 9999999999 (NPI), jgrue@directaddress.net (1.3.6.1.4.1.41179.2.1), 2.16.840.1.113883.1.111.12345
Contact Details (Organization) 800 Spring St.
Atlanta, GA 30308
US
Tel Workplace: +1-843-555-2234, Mail Workplace: jgrue@directaddress.net
 
In Fulfillment Of Order: 85fa4b62-e3a9-4385-b064-fe04cca35adb, d56d5938-ab8b-448b-a7e6-ed2f914864b3 (1.2.840.114350.1.13.6289.1.7.3.698084.8) Diabetic retinal eye exam (procedure)
Encounter
ID 20200210100000 (2.16.840.1.113883.3.2820.10.1.3.10)
Encounter Date from February 10, 2020, 10AM -0500
Encounter Location Dr. Yul Seemore (Workplace: United States
Atlanta, GA 30308
25 Fall St.)
Responsible Party Legal: SEEMORE Yul Contact Details Workplace: United States
Atlanta, GA 30308
25 Fall St.
 
Author Dr Yul SEEMORE Contact Details 25 Fall St.
Atlanta, Georgia 30308
US
Tel Workplace: +1-843-555-9876
Information Recipient Joseph GOODDOC Contact Details Workplace: 800 Spring St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-385-3448