DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
SCHLANEK, MAXIN IVAN (id #2633, dob: 11/01/1941)
Patient
Name
SCHLANEK, MAXIN (75yo, M) ID#
2633
11/01/1941
DONALD W. ROBERTSON, DO
DOB
Provider
Insurance
Appt. Date/Time
04/13/2017 02:30PM
Service Dept.
Main Office
Med Primary: MEDICARE-FL (MEDICARE)
Insurance # : 386389912A
Med Secondary: BCBS-MI (PPO)
Insurance # : UGG921577558
Policy/Group # : 0000714361000001
Prescription: SURESCRIPTS LLC - This member could not be found in the payer's files. Please verify
coverage and all member demographic information.
Chief Complaint
lab follow-up
poor appetite for months, cant smell like he used to, diarrhea every day and inquinal hernia hurts
Patient's Pharmacies
CVS/PHARMACY #8049 (ERX): 4995 HIGHLAND RD., WATERFORD MI 48328, Ph (248) 674-8805, Fax (248) 674-1027
Vitals
Pulse: 50 bpm regular
04/13/2017 02:42 pm
Wt: 182 lbs 04/13/2017
02:42 pm
RR: 20 04/13/2017 02:42
pm
BP: 101/55 sitting R arm
04/13/2017 02:45 pm
T: 97.9 F° oral
04/13/2017 02:41 pm
BMI: 26.9 04/13/2017
02:42 pm
Ht: 5 ft 9 in 04/13/2017
02:40 pm
Measurements
None recorded.
Allergies
Reviewed Allergies
SPIRONOLACTONE: - RAISES POTASSIUM
NKDA
Medications
Reviewed Medications
amiodarone 100 mg tablet
TAKE HALF A TAB DAILY
04/13/17 prescribed
amiodarone 200 mg tablet
Take 1 tablet(s) every day by oral route.
01/05/17 entered
aspirin
81 mg daily
01/05/17 entered
atorvastatin 40 mg tablet
Take 1 tablet(s) every day by oral route.
01/05/17 entered
B12
one tab daily
04/04/17 entered
clopidogrel 75 mg tablet
Take 1 tablet(s) every day by oral route.
01/05/17 entered
furosemide
01/05/17 entered
DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
SCHLANEK, MAXIN IVAN (id #2633, dob: 11/01/1941)
40 mg daily
lisinopril 10 mg tablet
Take 1 tablet(s) every day by oral route.
04/13/17 prescribed
lisinopril 20 mg tablet
Take 1 tablet(s) every day by oral route.
Internal Note: REDUCED TO 10 MG 4/13/17
01/05/17 entered
metoprolol succinate ER 100 mg tablet,extended release 24 hr
Take 1.5 tablet(s) every day by oral route.
01/05/17 entered
Norco 5 mg-325 mg tablet
Take 1 tablet(s) every 6 hours by oral route as needed.
04/04/17 entered
spironolactone 25 mg tablet
Take 0.5 tablet(s) every day by oral route.
Internal Note: STOPPED 4/13/17
01/05/17 entered
temazepam 30 mg capsule
Take 1 capsule(s) every day by oral route as needed.
04/04/17 entered
Vaccines
Vaccines not reviewed (last reviewed 04/04/2017)
none
Problems
Reviewed Problems
Renal failure syndrome - Onset: 04/13/2017
Hyperkalemia - Onset: 04/13/2017 - CAUSED BY SPIRONOLACTONE AND RENAL FAILURE
Ventricular tachycardia - Onset: 03/31/2017 - HAS AICD
Anemia - Onset: 03/31/2017 - FLORIDA CANCER DR ANEJA 941 460 1300
Malignant tumor of colon - Onset: 03/31/2017 - CIRCA 2005 COLECTOMY AND CHEMO
Serum iron raised - Onset: 03/31/2017
Benign hypertension - Onset: 01/05/2017
Cardiomyopathy associated with another disorder - Onset: 01/05/2017 - PATIENT NOT SURE
Hyperuricemia - Onset: 01/05/2017
Congestive heart failure - Onset: 01/05/2017
History of cardiac arrest - Onset: 01/07/2017 - 7/16 WHILE DRIVING A CAR THEN AICD LATER
Automatic implantable cardiac defibrillator in situ - Onset: 01/05/2017
Coronary atherosclerosis - Onset: 01/05/2017
Family History
Family History not reviewed (last reviewed 04/04/2017)
Mother
- Old-age
Father
- Family history of cancer
Social History
Social History not reviewed (last reviewed 01/05/2017)
Smoking Status: Former smoker
Able to Care for Self: Y
Live alone or with others?: alone
Alcohol intake: Occasional
Exercise level: None
Hard of hearing or deaf in one or both ears?: N
Smoke alarm in home: N
Passive smoke exposure?: N
Seat belts used routinely: Y
Sunscreen used routinely: N
Is the patient ambulatory?: Yes: walks without restrictions
Surgical History
Surgical History not reviewed (last reviewed 04/04/2017)
Aicd, dual chamber
DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
SCHLANEK, MAXIN IVAN (id #2633, dob: 11/01/1941)
CABG - X4
hip replacements, intervention RLE
Past Medical History
Past Medical History not reviewed (last reviewed 01/05/2017)
Cancer: Y
Coronary Artery Disease: Y
Gout: Y
Notes: cardiac arrest, dyslipidemia, peripheral arterial disease
HPI
BROUGHT MEDS HAS BEEN A VERY COMPLEX SITUATION THE VBISION PROBLEMS HAVE IMPROVED A LOT SINCE
WE REDUCED THE AMIODARONE THE HEMATOLOGIST WAS NO HELP WITH THE MACROCYTOSIS AND ALL HE DID
WAS GIVE MAX B 12 SHOTS AND A B 12 DEFICIENCY WAS NOT THE ISSUE HE STILL HAS DIARRHEA AND THE C
DIFF AND STOLL CULTURE ANALYSES WERE ALL NEGATIVE
ROS
Patient reports lethargy but reports no fever. He reportsvision change but reports no dry eyes and no irritation;BETTER
NOW WITH REDUCED AMIODARONE. He reports shortness of breath when walking but reports no chest pain, no arm
pain on exertion, and no palpitations; STILL THOUGHT THE STATIN WAS BOTHERING HIM. He reports shortness of
breath but reports no cough; MILD BWETTER. He reports no abdominal pain, no nausea, and no vomiting;LOSS OF
APPETITE DIARRHEA. Genitourinary:: INCONTINENCE. He reports muscle weakness but reports no muscle aches. He
reports weakness but reports no loss of consciousness, no numbness, no seizures, no dizziness, no migraines, no
headaches, and no tremor. He reports fatigue. He reports no swollen glands, no bruising, and no excessive bleeding;SEEING
HEMATOLOGIST NO HELP THERE. He reports no difficulty hearing and no ear pain. He reports no frequent nosebleeds, no
nose problems, and no sinus problems. He reports no sore throat, no bleeding gums, no snoring, no dry mouth, no mouth
ulcers, no oral abnormalities, and no teeth problems. He reports no abnormal mole, no jaundice, no rashes, and no laceration.
He reports no depression, no sleep disturbances, feeling safe in a relationship, no alcohol abuse, no anxiety, no hallucinations,
and no suicidal thoughts. He reports no runny nose, no sinus pressure, no itching, no hives, and no frequent sneezing.
Additionally reports: WE FOUND NAX HAD RENAL FAILURE WHICH HE STATES WAS NEW AND HIS POTASSIUM
WAS VERY ELEVATED TODAY A RECHECK SHOWS THE RENAL FAILURE NOT AS BAD AND POTASSIUM BETTER
AND HE IS ON LISINOPRIL 20 MG AND LOW DOSE SPIRONOLACTONE HE HAS A HX OF COLON CANCER HE HAD A
V TACH AND WAS PLACED ON AMIODARONE 200 MG AND AN AICD
Assessment / Plan
1. Ventricular tachycardia - REDUCE AMIODARONE AGAIN DOWN TO 50 MG NOW
I47.2: Ventricular tachycardia
amiodarone 100 mg tablet - TAKE HALF A TAB DAILY Qty: 45 tablet(s) Refills: 9
#8049
Pharmacy: CVS/PHARMACY
2. Hyperkalemia
E87.5: Hyperkalemia
HYPERKALEMIA: CARE INSTRUCTIONS
3. Renal failure syndrome - MYOGLOBIN NORMAL REDUCE THE LISINOPRIL TO 10 MG SD WILL ORDER A RENAL
ULTRASOUND AND A DOPPLER OF THE RENAL ARTERIES
N19: Unspecified kidney failure
lisinopril 10 mg tablet - Take 1 tablet(s) every day by oral route. Qty: 90 tablet(s) Refills: 99 Pharmacy:
CVS/PHARMACY #8049
4. Anemia - MACROCYTIC AND HE WILL NEED TO SEE A COMPETENT HEMATOLOGIST WHEN HE GETS BACK TO
PONTIAC
D64.9: Anemia, unspecified
ANEMIA: CARE INSTRUCTIONS
5. Serum iron raised
R79.0: Abnormal level of blood mineral
6. Benign hypertension
I10: Essential (primary) hypertension
7. Cardiomyopathy associated with another disorder
I42.9: Cardiomyopathy, unspecified
8. Automatic implantable cardiac defibrillator in situ
Z95.810: Presence of automatic (implantable) cardiac defibrillator
9. Diarrhea - CAUSE UNKNOWN STOOL CULTURE NEGATIVE HE WILL NEED TO SEE A GASTROENTEROLOGIST
WHEN HE GETS HOME
DONALD W. ROBERTSON DO, PA • 2828 SOUTH MCCALL RD SUITE 21, ENGLEWOOD FL 34224-9517
SCHLANEK, MAXIN IVAN (id #2633, dob: 11/01/1941)
R19.7: Diarrhea, unspecified
DIARRHEA: CARE INSTRUCTIONS
Patient Goals
WE WILL SEE HIM BAck one more time before he heads north
Patient Instructions
REDUCE LISINPORIL STOP SPIRONOLACTONE AND USE PEPTOBISMOL CHECK CMP BEFORE WE SEE HIM
BACK REDUCE THE AMIODARONE TO 50 MG HE IS STILL NSR AND I FEEL THE AMIDARONE WAS CAUSING THE
BLINDNESS AND DYSPNEA
Discussion Notes
CHECK A CMP BEFORE NEXT VISIT MAX HAS BEEN A VERY INTERESTING AND COMPLEX MAN AND WE HAVE
MADE A LOT OF PROGRESS... MOSTLY BY REDUCING HIS MEDICATIONS, AND FINDING NEW DIAGNOSES THAT
HE WAS HERETOFOR UNAWARE OF
Return to Office
Donald W. Robertson, DO for ESTABLISHED PATIENT 30 at Main Office on 04/27/2017 at 11:30 AM
Encounter Sign-Off
Encounter signed-off by Donald W. Robertson, DO, 04/13/2017.
Encounter performed and documented by Donald W. Robertson, DO
Encounter reviewed & signed by Donald W. Robertson, DO on 04/13/2017 at 3:35pm
Name:
Pt. Encounter Number:
Date:
Age:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
Sex:
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other
related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
Medications: (list with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
Family History
Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:
lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats,
energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, edema
Skin
Delayed healing, rashes, bruising, bleeding or skin
discolorations, any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, TB
Eyes
Corrective lenses, blurring, visual changes of any
kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, black tarry
stools
Ears
Ear pain, hearing loss, ringing in ears, discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDS
Fe: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, throat pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture
hx, osteoporosis
Breast
SBE, lumps, bumps or changes
Neurological
Syncope, seizures, transient paralysis, weakness,
paresthesias, black out spells
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, previous dx
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, cold or heat intolerance
OBJECTIVE
Weight
BMI
Temp
BP
Height
Pulse
Resp
General Appearance
Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Slightly somber affect at first, then brighter later.
Skin
Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs
intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive
light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.
Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal
distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized.
A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink
and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.
Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.
No adnexal masses or tenderness. Ovaries are non-palpable.
(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )
(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is
smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).
Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though
clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urinalysis – pending
Urine culture – pending
Wet prep - pending
Special Tests
Diagnosis
Include at least 3 differential diagnosis
Final Diagnosis
▪ Evidence for final diagnosis should be documented in your Subjective and
Objective exam.
PLAN including Education
o Plan:
▪ Further testing
▪ Medication
▪ Education
▪ Non-medication treatments
▪ Follow up
o
o
Purchase answer to see full
attachment