IBUTM Case summary for Innovative Brokers
Case#: / Name: Mary Smith
Age: 72 / Gender: Female
Plan term: / Face Amt:
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Case Summary:
Significant History (Briefly list significant Medical History. Also include significant Family History, Foreign Travel, Avocations, Occupations and ADL's) |
72 year old female with hypertension, difficult control on multiple meds, but ave for last year is only 151/85. She is followed by a cardiologist for an arrhythmia - we don't currently have records of that treatment. She also has impaired fasting glucose - treated with diet only, and her latest build in the APS is 5'6" 235 lbs. She was hospitalized for atypical chest pain in 2006, had a stress test done at that time which was reportedly negative, and was later treated for gastritis/GERD by her regular physician.
EKG date 05-05-06: Two tracings done on the same date, the 1st two pages were ran at a speed of 50ms so it prolongs the tracing to capture more beats in each lead. This was probably done, as the tracing on pg 70 is ran at 25ms speed which is typical. There is noted sinus bradycardia with a rate of 45. There is some minor T wave changes in the inferior and to a lesser extent the lateral leads, of equivocal significance. Changes are minor so would code as suspected. If these changes were present in her 2006 cardiac stress test, would not debit the EKG tracing.
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| PREFERRED GUIDELINES: |
| Tobacco |
None |
| Height/Weight |
5'6" 235 in APS |
| Cholesterol Profile |
need current |
Current Labs Normal? |
need |
| Regular Medications |
Atenolol, clonidine, lisinopril, avalide. |
| Family History |
Mother died age 45 - cause not given, but had HTN. Father died 83, cause not given. |
Blood Pressure
(only if not on BP medication) |
On BP Meds |
Cardiac Tests within 2 years
(50 and over only) |
Reportedly had a stress test 5/06 - results reported as negative. |
Normal Stress Test
(with good exercise capacity) |
5/06 |
Normal Chest Xray
(within 5 years, 50 and over) |
None |
PFT
(within 5 years, 50 and over) |
None |
| REQUIREMENTS RECEIVED (Include date received): |
| APS 1 |
| RISK FACTORS SUMMARY: |
| Arrhythmia - followed by cardiologist - those records not in file. |
| Hypertension - controlled on meds. |
| Impaired Fasting Glucose - controlled by diet. A1C ave. for last year = 6.4 |
| build |
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| DATE: |
SOURCE: |
(Include page numbers) |
| 2007-2008 |
APS 1 |
P81, 1/2/08 lab, glucose 124, chol 128, hdl 48, ldl 68, microalb. WNL, HGBA1C 6.4
P2, 1/2/08 visit: 140/82, 150/90, 5'6" 235lbs, P 78, HTN, Arrhythmia, hypercholesterolemia - rx lipitor, IFG. Doing well. No CP/dyspnea/HA, no edema. Repeat colonoscopy due to poor bowel prep.
P83, 11/26/07 mammogram - benign, stable from 2006.
P3, 10/25/07 visit: 156/84, 150/80, 5'6" 230lbs, P56. HTN, IFG, hypercholesterolemia, Arrhythmia,. Colonoscopy planned 11/07. Seen by cardiologist, MRA? Negative for stenosis. Diet, weight reduction.
P41, 10/25/07 - continued, A: IFG - behavior/dietary modification, Hypercholesterol - lipitor, Arrhythmia - continue with cardiologist.
P80, 9/24/07 - MRA of abdomin - result negative/WNL.
P79, 8/30/07 lab, glucose 102, chol 179, hdl 56, ldl 103, HGBA1C 6.3 H.
P4, 8/30/07, 140/90, 160/100, P 60, Wt. 237. Meds: Atenolol, Clonadine, lisinopril, ?maline or maxzide? Uncontrolled HTN with mult meds - R/O Renal Artery Stenosis. Plan MRA - Renal Arteries. F/U with cardiology.
P5, 5/31/07, 160/80, 160/78, P 80, wt. 235, compliant with meds. No chest pain, etc. IFG - plan diet mod, Htn - plan atenolol, clonidine, lisinopril, avalide.
P77, 4/11/07 lab, glucose 105, chol 192, hdl 73, ldl 103
P6, 4/11/07, 160/80, 170/95, 180/?, wt. 237. Hx HTN, IFG, in for routine f/u. 2+ pitting edema Bilat feet - pulses 2+ bil. A: HTN, P: dietary couns. Increase clonidine, referral to cardiology.
P75-76, 1/9/07 lab, glucose 105, chol 172, hdl 59, ldl 93, HGBA1C 6.5
P7, 1/9/07 visit: 130/84, 130/80, wt. 239, P 70, routine f/u. Awaiting GI consult. Mild non pitting edema noted to bilat legs. IFG, constipation - f/u with GI.
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| 2005-2006 | APS 1 | P71-72, 9/29/06 lab/Fasting - N, glucose 83, chol 182, trig 169, hdl 58, ldl 90, microalbumin/creatinine ratios WNL, HGBA1C 6.1.
P8, 9/29/06, 130/80, wt. 230, routine f/u. Meds: avelide, clonidine, atenolol, K dur, lisinopril. A: IFG, HTN, Constipation - consult with GI.
P73-74, 6/30/06 lab, glucose 106, chol 180, trig 69, Hdl 70, ldl 96. Hepatitis panel - negative. A1C 6.2 - H.
P9, 6/30/06, 150/90, wt. 240, Meds adjusted. GI consult for constipation - has not followed thru. HTN, IFG, run labs.
P64, 5/19/06 lab, glucose 101, chol 192, hdl 60, ldl 116, fasting = N.
P10, 5/19/06, 150/90, 240 lbs, Hx IFG, constipation, HTN, here for follow up visit S/P hospitalization 5/06 for chest pain. Had stress test - result negative. No chest pain since but has burning sensation to chest, increased flatulence, symptoms worse with certain foods. A: Gastritis/GERD - dietary mod, rx protonix. HTN - DASH diet & meds: Atenolol, lisinopril, clonidine, HCTZ. Atypical chest pain. Return 3 months/prn.
P63, 5/5/06 lab, glucose 129
P68-70, 5/5/06 EKG - See Case Summary
P11, 5/5/06, 160/70, 138/70, wt. 240, here for medical clearance for eye surgery - pteryguim rescission. Doing well. EKG - sinus brady. No edema, A: sinus brady - cardiology consult. Eye - opthamology f/u. HTN - diet meds.
P12, 4/17/06, 160/90, 160/90. Hx HTN, IFG, constipation, here for routine f/u. Was given GI ref, but never followed through. Intermit constipation, no abd pain, diarh, bleeding, weight loss. Saw ENT, states hearing has improved significantly. A: hx constipation, increase bulk/fiber/fluids, GI consult. IFG.
P61-62, 1/17/06, glucose 100, chol 174, hdl 64, ldl 95, microalbumin/creatinine ratio - WNL.
P13, 1/17/06, 150/80, 150/90, 242 lbs. routing f/u. Constipation, OTC meds tried without much success - GI consult planned. HTN - continue current meds. Opth. consult.
P14, 11/20/05, 150/90, 140/86, wt. 237. Routine f/u. Decreased hearing. + edema with heavy legs, no pitting. Uncontrolled HTN with decreased hearing. Diet, renew meds, keep BP log.
P34, 10/10/05 phone note - BP 180/98. Second phone note: BP 140/90.
P15, 9/27/05, 170/90, 160/100, wt 235. Htn & IFG. Htn uncontrolled - increase atenolol.
P16, 8/23/05, 200/100, 198/100, routing f/u. Uncontrolled HTN, DASH diet, weight red. Increase avelide & cont other meds.
P58, 5/24/05 lab, chol 169, hdl 67, ldl 86, HGBA1C 5.3.
P60, 5/18/05 mammogram - neg, no change since 10/03.
P17, 3/24/05, 140/90, 140/90, no clonidine today. Wt. 227, P 70. Routine F/U. IFG, HTN, - diet mod & continue meds: Lotrel, clonidine, avelide, atenolol.
P55, 2/22/05 lab, glucose 106 H, chol 155, hdl 49, ldl 84, HGBA1C 6.3 H.
P18, 2/22/05, 150/80, doing well. Htn, IFG.
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| 2003-2004 | APS 1 | P56, 11/23/04, glucose 105 H, chol 164, hdl 66, dld 84, HGBA1C 6.4 - H.
P19, 11/23/04, 120/80, wt. 230, f/u visit. Eval by cardiologist 11/04 - no med adj. A: Impaired glucose - dietary control. Htn - meds & diet.
P20, 10/5/04, 130/80, 138/80. Wt. 225. Followed by cardiologist. Routine f/u. Mother died age 45 - Hypertensive. Father died age 83. Past hx total hystr. HTN - DASH diet, wt reduction, exercise & cont RX.
P51, 8/28/04 lab, glucose 97, calcium normal.
P31 8/21/04 phone note: ca+ elevated on labs - she admits to dietary supp., will repeat lab.
P52, 8/17/04 lab, glucose 97, calcium high 10.7, chol 194, hdl 66, ldl 104. HGBA1C 6.1 - H.
P21, 8/17/04, 170/100, 150/90. Htn - uncontrolled, P: diet, weight reduction, same rx.
P47, 6/15/04 lab, HGBA1C 5.9
P48-50, 5/18/04 lab, hemoccult slides negative x 3, blood glucose 131 - H, chol 164, HDL 62, LDL 86.
P22, 5/18/04, 140/90, 150/90, 226 lbs. - uncontrolled Htn. F/U with cardiologist.
P23, 2/17/04, 140/88, 150/90, routine f/u. HTN - current meds, diet. Weight reduction.
P24, 11/17/03, 140/90, 140/80. Wt. 227. Meds adjusted by cardiologist. Htn.
P43, 8/18/03 lab, chol 208, hdl74, ldl 119
P25, 8/18/03, 160/94, 150/100, HTN, compliant with meds.
P26, 7/14/03, 140/86, took no BP meds today. Followed by cardiologist, s/p stress test. Allergic rhinitis.
P27, 5/12/03, 150/90, 130/82, Atypical chest pain, gastritis/GERD - Rx prevacid & cardiology consult.
P28, 2/10/03, 158/90, 140/80, 224 lbs. Htn. reduce weight.
P29, 1/13/03, 150/90, 160/90. HTN, has been getting good BP on self monitor - 130s/70s. 160/90. HTN - stable but uncontrolled. Cont meds, reduce weight.
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