Communication #5 - Consult note from Ophthalmology to Optometry (March 1, 2020, 10:00AM -0500)

Patient Legal: Clare M TESCA Date of Birth: February 14, 1952 (68yr) Gender: Female Patient-ID:  123456789 (SSN), 404.1 (1.3.6.1.4.1.115)
Encounter ID: 20200301100000 (2.16.840.1.113883.3.2820.10.1.3.10) , Date/Time: from March 1, 2020, 08AM -0500
In Fulfillment Of Order ID: 0f27478e-b1e3-4681-bfeb-f8f62bf3407d (1.2.840.114350.1.13.6289.1.7.3.698084.8) , Code: Discussion of nuclear cataract
Author Dr Stan STEDYHAN, Authored On: March 1, 2020, 10:00AM -0500
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CONSULTATION NOTES

  • The patient requested that the follow up visits be coordinated between our offices if possible. Final arrangements will be made following the surgery which is scheduled for the right eye on 03/05/2020 at 10:30

    The first day post op visit for the right eye will be completed in our office on 03/06/2020

    The one week visit tentatively will be scheduled in your office around 03/12/2020

REASON FOR VISIT

Referral from Dr. Yul Seemore for Evaluation for cataract extraction

Request Procedures Reason for Referral Referred By Contact Referred To Contact Specialty
Evaluation for cataract extraction Discussion of nuclear cataract (56991008) Patient complaints of blurred vision and glare at night especially when driving

Since the patient’s occupation requires considerable traveling the glare at night is significantly interfering with work.

Seemore, Yul
25 Fall St.
Atlanta, GA 30308
Phone: 843-555-9876
Stedyhan, Stan
33 Front St.
Atlanta, GA 30308
Phone: 843-555-9898
Ophthalmologist

ASSESSMENTS

Reporting the results of the pre-op visit

The patient has selected to have the surgical follow-up visits co-managed with your office if possible

INTERVENTIONS

Description Date and Time (Range) Status
Discussion of nuclear cataract 01 Mar 2020 08:00am completed

HEALTH STATUS EVALUATIONS

  • Evaluation for cataract extraction: MET
    • Evaluates Expected Outcome/Goal:
      Patient scheduled for cataract surgery on right eye on 03/05/2020
    • Supported by: Physical Exam findings (March 01, 2020 at 08:00)

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

PLAN OF CARE

Date of Planned Services Type of Intervention Rationale Provider Location
(03/05/2020 - 03/05/2020 Cataract extraction and insertion of intraocular lens right eye (385468004) Bilateral nuclear cataracts causing significant glare Stedyhan, Stan
33 Front St.
Atlanta, GA 30308
843-555-9898
(03/06/2020 - 03/06/2020 First postoperative examination and eye dressing (225685001) First day post operative follow-up Stedyhan, Stan
33 Front St.
Atlanta, GA 30308
843-555-9898
(03/12/2020 - Postoperative follow-up visit (439740005) Patient requested co-management Seemore, Yul
25 Fall St.
Atlanta, GA 30308
843-555-9876

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 Severity Status
01/20/1998 egg Hives Moderate 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
The patient was found to have bilateral nuclear cataracts causing significant glare to warrant surgical extraction with IOLs
The patient selected to have a multi-focal IOL implanted in each eye
The patient selected laser assisted catalys surgery
All other clinical findings were consistent with referral note

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
    Dr. Stan Stedyhan, MD (NPI: 2173512387) Ophthalmologist (Active) 2020 - current

PAYERS

No Information
Document
ID 24e33651-b563-49e2-a51f-bbabd88ebd8a
Created On March 1, 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 (68yr) 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
en, 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: 0f27478e-b1e3-4681-bfeb-f8f62bf3407d (1.2.840.114350.1.13.6289.1.7.3.698084.8) Discussion of nuclear cataract
Encounter
ID 20200301100000 (2.16.840.1.113883.3.2820.10.1.3.10)
Encounter Date from March 1, 2020, 08AM -0500
Encounter Location Dr. Stan Stedyhan (Workplace: United States
Atlanta, GA 30308
33 Front St.)
Responsible Party Legal: STEDYHAN Stan Contact Details Workplace: United States
Atlanta, GA 30308
33 Front St.
attender Legal: PREOP Lucy Contact Details Workplace: United States
Atlanta, GA 30308
33 Front St.
 
Author Dr Stan STEDYHAN Contact Details 33 Front St.
Atlanta, Georgia 30308
US
Tel Workplace: +1-843-555-9898
Information Recipient Yul SEEMORE Contact Details Workplace: 25 Fall St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-9876