| Insurance | Policy type | Insurance ID | Relation | Subscriber |
|---|---|---|---|---|
| MEDICARE A&B (HOSP & MED INS) | Other | 012345678M | SELF | |
| MEDEX DEDUCT/CO-INS | Other | XXM012345678 | SELF |
| Problem | Effective Dates | Problem Status | Provider | Comments |
|---|---|---|---|---|
| POLYP OF NASAL CAVITY - 471.0 | 12/01/10 | Active | DAVID S. CARADONNA MD | Clinic visit diagnosis |
| DIABETES MELLITUS - 250.00 | Active | SAUL NEIMAN WEINGART MD, PhD | multiple hypoglycemic episodes. followed by Dr. Abrahamson at diabetes clinic since 11/94. Ophthalmalogy following. Pt does own foot care. +retinopathy,+neuropathy. Multiple episodes of symptomatic hypoglycemia; family extremely concerned. | |
| HEALTH MAINTENANCE - V70.0 | Active | SAUL NEIMAN WEINGART MD, PhD | ||
| CORONARY ARTERY DISEASE - 414.0 | 08/10/1994 | Active | SAUL NEIMAN WEINGART MD, PhD | has CAD documented at cath, s/p PTCA RCA in 8/94. now with stable exertional angina, ETT in 6/97 with reversible inf-pos changes on thallium, better 10/97. 8/99 ETthal w/o diagnostic ischemia. 6/07 ETecho w/o diagnoistic ischemia, mild MR. Followed by Warren Manning. 12/1/09 - CABGx4 (Left internal mammary artery->Left anterior descending artery, Saphenous vein graft (SVG)->Posterior descending artery, SVG->Diagonal artery, SVG->Obtuse marginal artery.) Presented BIMDC rapid afib with ischemic changes 11/18/10, d/c cardioversion, CK leak, echo ok. |
| INSULIN DEPENDENT DIABETES MELLITUS - 250.01 | Active | MARTIN J. ABRAHAMSON MD | ||
| CERUMINOSIS - 380.4 | 5/96 | Active | MICHELE THERESA MCHUGH NP | |
| PPD POSITIVE - 795.5 | Active | SAUL NEIMAN WEINGART MD, PhD | Rec'd BCG in Russia. PPD 15mm+ in 1/97 with neg CXR. No cough. | |
| BENIGN PROSTATIC HYPERTROPHY - 600 | Active | SAUL NEIMAN WEINGART MD, PhD | exam wnl, but reports nocturia, q4 hrs -> begin prazocin 9/98 | |
| THYROID NODULE - 241.0 | Active | SAUL NEIMAN WEINGART MD, PhD | noted on exam 4/00, scan negative 4/00 | |
| BENIGN PROSTATIC HYPERTROPHY - 600 | Active | SAUL NEIMAN WEINGART MD, PhD | 4/00 u/s with mildly enlarged prostate and 35cc pvr, seen in urology, given ?flomax with good response. Had negative bx in 9/02 under Dr. Staskin for inc'd PSA | |
| NASAL POLYPS - 471.9 | Active | SAUL NEIMAN WEINGART MD, PhD | followed by Dr. Caradonna, recommended flonase, polypectomy 6/9/03 - path suggesting chronic polyposis and sinusitis; eosinophilia resolved. Recurred again (low to moderate) early 2005, Dr. Sheikh recommended annual echocardiogram since this is associated with cardiac thrombi and fibrosis. | |
| ASTHMA - 493.90 | Active | SAUL NEIMAN WEINGART MD, PhD | ||
| ACUTE RENAL FAILURE - 584.9 | Active | SAUL NEIMAN WEINGART MD, PhD | admitted after hypoglycemic spells to St Es, found to be in acute renal failure with creat 4.2mg/dl on 11/29/05. u/s ok, renal bx performed (Dr. Liangos) on 12/2/05 showing calcium phosphage deposition, likely related to colonoscopy bowel prep; also with acute interstitial nephritis and mild diffuse diabetic glomerulosclerosis. Referred to BIDMC nephrology, steroid trial not effective. ACE held due to hyperkalemia. | |
| CORONARY ARTERY DISEASE - 414.0 | Active | WARREN J. MANNING MD | ||
| HYPERTENSION - 401.9 | Active | WARREN J. MANNING MD | ||
| HYPERCHOLESTEROLEMIA - 272.0 | Active | WARREN J. MANNING MD | ||
| ANEMIA - 285.9 | Active | LISA DUMOUCHEL NP | On procrit | |
| ATRIAL FIBRILLATION - 427.31 | Active | AMY C SIGNORE | PAF during 7/08 admit for pericardial tamponade. | |
| DEEP VENOUS THROMBOPHLEBITIS - 451.19 | 07/2008 | Active | SAUL NEIMAN WEINGART MD, PhD | during admission for pericardial effusion, rx'd warfarin 6 months |
| Procedure | Date | Provider | Comments |
|---|---|---|---|
| 12/01/10 | DAVID S. CARADONNA MD | Clinic visit |
| Blood |
|---|
| Hematology | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| COMPLETE BLOOD COUNT | WBC | RBC | Hgb | Hct | MCV | MCH | MCHC | RDW | Plt Ct |
| 09 Dec 2010 03:00PM |
| BASIC COAGULATION (PT, PTT, PLT, INR) | PT | Plt Ct | INR(PT) |
|---|---|---|---|
| 09 Dec 2010 03:00PM | |||
| 09 Dec 2010 03:00PM |
| LAB USE ONLY |
|---|
| 09 Dec 2010 03:00PM |
| Urine |
|---|
| CSF |
|---|
| Other Fluid |
|---|
| Med | Sig | Start Date | Prescriber |
|---|---|---|---|
| USE AS DIRECTED | 10/18/2007 | ||
| USE AS DIRECTED FOR DIABETES MONITOR | 10/18/2007 | ||
| FOR BLOOD SUGAR MONITORING 4-6 TIMES A DAY | 10/18/2007 | ||
| AS DIRECTED | 10/18/2007 | ||
| FOR INSULIN ADMINSTRATION | 10/18/2007 | ||
| TEDS knee high stockings use daily as directed for venous insufficiency | 10/18/2007 | ||
| 1 Capsule(s) by mouth daily | 10/18/2007 | ||
| as directed (generally 6 units am | 03/11/2009 | JULIE KAUFMANN MD, PhD | |
| one Capsule(s) by mouth daily | 04/12/2010 | SAUL NEIMAN WEINGART MD, PhD | |
| one Capsule(s) by mouth three times a day | 04/12/2010 | SAUL NEIMAN WEINGART MD, PhD | |
| 1 puff inhaled twice a day every day | 06/10/2010 | SAUL NEIMAN WEINGART MD, PhD | |
| 1 Tablet(s) by mouth three times a day With meals | 06/25/2010 | CHRISTINA C. WEE-KUO MD | |
| one Tablet(s) by mouth once a day | 06/25/2010 | CHRISTINA C. WEE-KUO MD | |
| one Tablet(s) by mouth daily for allergy | 06/25/2010 | CHRISTINA C. WEE-KUO MD | |
| 2 sprays(s) each nostril three times a day | 08/19/2010 | SAUL NEIMAN WEINGART MD, PhD | |
| 2 puffs inhaled four times a day as needed for shortness of breath or wheezing | 08/20/2010 | SAUL NEIMAN WEINGART MD, PhD | |
| 1 Tablet(s) by mouth once a day every day | 08/20/2010 | SAUL NEIMAN WEINGART MD, PhD | |
| one Capsule(s) by mouth three times a day | 08/20/2010 | SAUL NEIMAN WEINGART MD, PhD | |
| 1 ml s/c every 6 weeks | LISA DUMOUCHEL NP | ||
| one Tablet(s) by mouth daily | 11/05/2010 | SAUL NEIMAN WEINGART MD, PhD | |
| 1 Capsule(s) by mouth once a day | 11/11/2010 | LISA DUMOUCHEL NP | |
| 1.5 Tablet(s) by mouth once a day | 11/23/2010 | LORRAINE L. BRITTING NP | |
| 1 Tablet(s) by mouth DAILY (Daily) | 11/23/2010 | LORRAINE L. BRITTING NP | |
| 2 Tablet(s) by mouth DAILY (Daily) | 11/23/2010 | LORRAINE L. BRITTING NP | |
| 1 (One) Tablet(s) sublingually every 5minutes for chest pain x 3 then call 911 | 11/23/2010 | MICHAEL ALLEN ROBERTS MD | |
| one Tablet(s) by mouth once a day | DIANE N. MCNALLY MD | ||
| 11/29/2010 | |||
| USE AS DIRECTED | 11/29/2010 |
| Letter 12/01/2010 Dr. DIANE MCNALLY Service: General Med/Prim.Care |
|---|
| December 1, 2010 |
| Sample Patient |
| 907 Parkwalk Ave. |
| Brookline, MA 02445 |
| BID#: 012-34-56 |
| Dear Mr. Patient: |
| It was a pleasure seeing you the other day. I am writing to |
| inform you of your laboratory results. |
| Your potassium level was 5.0, which is the upper limit of normal. |
| Please continue to adhere to the low potassium diet as we |
| discussed. |
| Your kidney function was stable. Please be sure you are drinking |
| plenty of water. |
| Your liver function was normal. |
| Your thyroid function (TSH) was slightly off. Sometimes this |
| value can be affected by acute illness (such as your recent |
| hospitalization). Please have this rechecked at your next visit |
| with Dr Weingart to ensure it returns to normal. |
| I see that you have not yet scheduled your follow up with Dr |
| Weingart. As we discussed, I would like you to see him in 1-2 |
| months to follow up all of your medical issues. Please call |
| 617-667-9600 to schedule this appointment. If you have any |
| questions, please let me know. |
| Sincerely, |
| Diane N. McNally, MD |
| Signed electronically: 12/01/10 at 12:12 pm |
| Progress Note 12/01/2010 Dr. DAVID S CARADONNA Service: Otolaryngology |
|---|
| Date: 12/01/10 |
| Signed by DAVID S CARADONNA, MD on 12/13/10 at 3:58 pm Affiliation: HMFP |
| --------------- --------------- --------------- --------------- |
| Active Medication list as of 12/01/10: |
| Medications - Prescription |
| ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 |
| puffs inhaled four times a day as needed for shortness of breath |
| or wheezing |
| AMIODARONE - 200 mg Tablet - 2 Tablet(s) by mouth DAILY (Daily) |
| CALCITRIOL - 0.25 mcg Capsule - one Capsule(s) by mouth daily |
| EPOETIN ALFA [PROCRIT] - (Dose adjustment - no new Rx) - 10,000 |
| unit/mL Solution - 1 ml s/c every 6 weeks |
| FINASTERIDE - 5 mg Tablet - one Tablet(s) by mouth daily |
| FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 2 sprays(s) |
| each nostril three times a day |
| FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk |
| with Device - 1 puff inhaled twice a day every day |
| GLUCAGON EMERGENCY KIT - 1MG Kit - USE AS DIRECTED |
| HUMALOG - 100 U/ML Solution - AS DIRECTED |
| INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - as directed |
| (generally 6 units am |
| IRON POLYSACCH COMPLEX-B12-FA [NIFEREX-150 FORTE] - 150 mg-25 |
| mcg-1 mg Capsule - one Capsule(s) by mouth three times a day |
| ISOSORBIDE MONONITRATE - 30 mg Tablet Sustained Release 24 hr - 1 |
| Tablet(s) by mouth DAILY (Daily) |
| MISCELLANEOUS MEDICAL SUPPLY [T.E.D. SEQUNT COMPRESS DEVICE] - |
| Misc - TEDS knee high stockings use daily as directed for venous |
| insufficiency |
| MOMETASONE - (Prescribed by Other Provider: Caradonna) - Dosage |
| uncertain |
| MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth |
| once a day every day |
| NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 (One) Tablet(s) |
| sublingually every 5minutes for chest pain x 3 then call 911 |
| SEVELAMER HCL [RENAGEL] - 400 mg Tablet - 1 Tablet(s) by mouth |
| three times a day With meals |
| SIMVASTATIN - 40 mg Tablet - one Tablet(s) by mouth once a day |
| WARFARIN - 2 mg Tablet - 1.5 Tablet(s) by mouth once a day |
| Medications - OTC |
| ASPIRIN - (Prescribed by Other Provider; OTC) - 325 mg Tablet - |
| one Tablet(s) by mouth once a day |
| CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s) |
| by mouth once a day |
| DOCUSATE SODIUM [COLACE] - 100 mg Capsule - one Capsule(s) by |
| mouth three times a day |
| FREESTYLE LANCETS - Misc - USE AS DIRECTED |
| FREESTYLE SYSTEM - Kit - USE AS DIRECTED FOR DIABETES MONITOR |
| FREESTYLE TEST STRIPS - Strip - FOR BLOOD SUGAR MONITORING 4-6 |
| TIMES A DAY |
| INSULIN SYRINGES - O Syringe - FOR INSULIN ADMINSTRATION |
| LORATADINE - 10 mg Tablet, Rapid Dissolve - one Tablet(s) by |
| mouth daily for allergy |
| MULTIVITAMIN - (update) - Capsule - 1 Capsule(s) by mouth |
| daily |
| --------------- --------------- --------------- --------------- |
| Mr. Patient returns today in follow-up. He has been using his |
| nasal steroid rinses on a b.i.d. basis. He had been using them |
| over the last several months, but for 10-days he was hospitalized |
| for a heart condition and discontinued. |
| He has no change in his symptomatology. He has a decreased sense |
| of smell; otherwise, he is doing well. He has some mild clear |
| rhinorrhea, but there is no facial pain, facial pressure, or |
| purulent discharge. He can breathe adequately through his nose. |
| Verbal consent was obtained through and interpreter, and a |
| flexible fiberoptic nasal endoscopy was performed bilaterally |
| after adequate decongestant and anesthetic spray was utilized. |
| Examination of the nasal cavity showed persistent stable nasal |
| polyposis emanating from the OMCs as well as superior meatus |
| bilaterally. It was not obstructing the nasal cavity. There was |
| a nasal airway along the floor. No purulence was seen. |
| We have discussed these findings. I have encouraged him to |
| continue the b.i.d. steroid nasal saline rinses for the next |
| several months. I will see him in follow-up at that time. We |
| will utilize this medical management to keep the polyps from |
| expanding. He appeared quite pleased. He was accompanied by his |
| son who was in agreement. |
| David S. Caradonna, MD, DMD, FACS |
| DSC:ts |
| cc: Saul Weingart, M.D. |
| Healthcare Associates |
| 330 Brookline Ave., Atrium Suites |
| Boston, MA 0221 |
| Letter 12/02/2010 LISA DUMOUCHEL Service: Nephrology |
|---|
| December 2, 2010 |
| Sample Patient |
| 907 Parkwalk Ave. |
| Brookline, MA 02445 |
| BID#: 012-34-56 |
| Dear Mr. Patient: |
| I reviewed your recent blood work from 11/23/10. Your hemoglobin |
| was 11.1 and your hematocrit was 31.2. This remains within our |
| target hemoglobin range of 9.5 to 11.5. For this reason, we |
| would like you to continue on your current dose of Procrit 10000 |
| units every 6 weeks. |
| You should get repeat blood work in 4 to 6 weeks. I have |
| enclosed a lab slip for this purpose. You may have this done at |
| the West Specialties Clinic on the first floor of the Deaconess |
| building. Or, if it is more convenient, you may choose to have |
| your blood drawn close to your home and the results will be faxed |
| to our office. |
| Please do not hesitate to call me if you have any questions or |
| concerns. |
| Sincerely, |
| Lisa Dumouchel, NP |
| Signed electronically: 12/02/10 at 11:29 am |
| Telephone 12/11/2010 Dr. BARBARA J. RN LUKER Service: General Med/Prim.Care |
|---|
| Date: 12/11/10 |
| Signed by BARBARA J. LUKER, RN on 12/11/10 at 12:57 pm Affiliation: BIDMC |
| b/p readings |
| Son called to say the patient is having erratic b/p readings |
| This am 225/108 lying |
| 140/78 standing |
| 168/85 p 85 |
| 150/83 |
| 171/85 |
| Patient is not symptomatic. He saw neurology on Thursday for |
| this same complaint. |
| P: |
| Paged neuro on call |