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Progress Notes

Angela Lee, DO at 05/20/24 0800

Mount Sinai Doctors 200 West 57th St 15th Fl 212-247-8100 PROGRESS NOTE

05/20/2024

PATIENT:
DOB:
SEX:
MRN:
Katy Younger-Hadwiger
10/2/1986
female
A136304
ASSESSMENT AND PLAN
1. Annual physical exam
  • - CBC+PLT+DIFF; Future
  • - COMPREHENSIVE METABOLIC PANEL; Future
  • - TSH RFX ON ABNORMAL TO FREE T4; Future
  • - LIPID W/DIRECT LDL; Future/li>
  • - HEMOGLOBIN A1C; Future
  • - CBC+PLT+DIFF
  • - COMPREHENSIVE METABOLIC PANEL
  • - TSH RFX ON ABNORMAL TO FREE T4
  • - LIPID W/DIRECT LDL
  • - HEMOGLOBIN A1C/li>
2. Plantar fasciitis
  • Comments: discussed exercise
  • consider OTC foot inserts
  • podiatry evaluation if persistent
3. Chronic bilateral low back pain without sciatica
  • Comments: discussed stretching core exercises
  • desk ergonomics
  • NSAIDS PRN
  • consider PT eval NV
4. Need for immunization against influenza
  • - influenza vaccine 2022-23, 6 MONTHS+,, PF, 60 mcg/0.5 mL syringe; Inject 0.5 mLs intramuscularly once for 1 dose. Dispense: 0.5 mL; Refill: 0
  • - ADMINISTER FLU VACCINE
  • Given on left deltoid.
  • Tolerated well.
  • No adverse reactions.
  • Vaccine side effects discussed.

  • Send routine labwork today.
  • See below for HCM, cancer screening and immunizations.
  • Dental UTD 11/2022
  • Vision 1/2023 UTD for contacts
  • Derm FBSE will arrange
  • C/w exercise
Routine cancer screening recommendations:
  • Pap (21-65) UTD 1/2023 wnl, periods wnl, not heavy
Adult immunizations:
  • Flu: today
  • COVID19: bivalent booster UTD
  • Tetanus: deferred
HCM
  • Ophthalmology - discussed importance of routine eye exams
  • Dentist - discussed importance of routine dental care
  • Skin exam - discussed important of skin cancer screening, discussed ABCD of skin lesions, counseled to monitor all skin lesions for changes, to wear sunscreen and hats for routine sun protection against sun damage/burns all in an effort to lower risk of skin cancer
  • Annual well care including importance of exercise and healthy diet were reviewed with patient.
HPI:
  • Katy Younger-Hadwiger is a 37 y.o. female who presents for annual exam.
  • Last annual Dr. Chuey 4/2018.
  • Mild weight gain 10 lbs but losing with increasing exercise
  • New patch of dry skin b/l chin and ear developed few years ago. Does not bother. Father hx psoriasis. Not using topicals.
  • Mood stable, denies MDD/GAD, seeing therapist intermittently.
  • Health care maintenance, past medical history, surgical history, social history and family history reviewed.
Active Ambulatory Problems
  • Diagnosis
  • Date Noted

• No Active Ambulatory Problems

Resolved Ambulatory Problems
  • Diagnosis
  • Date Noted

• No Resolved Ambulatory Problems

Past Medical History:

History reviewed. No pertinent surgical history.

quit 2012 or 2013, prior social 1 pack q 2wk
  • Substance Use Topics

Alcohol use:

Not Currently

Comment: rare, few times a month, 1 drink/ month
Social History
  • Occupational History

Occupation:

marketing for a beauty company

  • Tobacoo

Smoking status:

Former

Types

Cigarettes

Quit date:

4/30/2009

Years since quitting:

15.0

Smokeless tobacco:

Never

quit 2012 or 2013, prior social 1 pack q 2wk
  • Substance Use Topics

Alcohol use:

Not Currently

Comment: rare, few times a month, 1 drink/ month
  • Substance and Sexual Activity

Sexual Activity

Yes

Partners

Male

Birth control/protection:

Pill

Comment: monogamous
Social History
  • Occupational History

Occupation:

marketing for a beauty company

FAMILY HISTORY
  • Problem
  • Relation
  • Age of Onset

Diabetes Mellitus:

Mother

Obesity

Mother

COPD

Mother

smoker

Arrhythmia

Father

Hypercholesteremia

Father

COPD

Father

smoker

High Cholesterol

Father

Breast Cancer

Maternal Grandmother

70

Cancer

Maternal Grandmother

Colon Cancer

Family History Negative for

Hypertension

Family History Negative for

Heart Disease

Family History Negative for

REVIEW OF SYSTEMS

As per HPI

VITAL SIGNS
Vitals:
  • 05/20/24 0812
  • BP:
  • Pulse:
  • SpO2:
  • Weight:
  • Height:
  • 122/84
  • 92
  • 100%
  • 65.8 kg (145 lb)
  • 5' 5" (1.651 m)

Body mass index is 24.13 kg/m².

PHYSICAL EXAMINATION

General appearance: Well appearing, well groomed, well nourished, NAD, alert, awake HEENT: NCAT, EOMI, oral mucosal lesion along right inner cheek 0.5cm without surrounding erythema, white plaque along tongue able to scrape off, mildly enlarged tonsils b/l, no cervical LAD, thyroid normal to palpation Skin: ecchymosis 4cm long left inner knee, no other ecchymosis noted MSK: no CVA tenderness Neuro: no gross deficits Psych: normal behavior and mood

Pertinent labs and imaging reviewed. No visits with results within 6 Month(s) from this visit. Latest known visit with results is: Office Visit on 03/24/2023

Office Visit on 03/24/2023
Component Date Value Ref Range Status
WHITE BLOOD CELL 03/24/2023 3.5 3.4 - 10.8 x10E3/uL Final
RBC BLOOD CELL 03/24/2023 4.34 3.77 - 5.28 x10E6/uL Final
Hemoglobin 03/24/2023 13.3 11.1 - 15.9 g/dL Final
HEMATOCRIT 03/24/2023 40.7 34.0 - 46.6 % Final
MEAN CORP. VOLUME 03/24/2023 94 79 - 97 fL Final
MEAN CORP. HGB 03/24/2023 30.6 26.6 - 33.0 pg Final
MEAN CORP. HGB CONC. 03/24/2023 32.7 31.5 - 35.7 g/dL Final
RED DISTRIB. WIDTH 03/24/2023 12.7 11.7 - 15.4 % Final
PLATELET 03/24/2023 252 150 - 450 x10E3/uL Final
NEUTROPHIL % 03/24/2023 54 Not Estab. % Final
LYMPHOCYTE % 03/24/2023 32 Not Estab. % Final
MONOCYTE % 03/24/2023 11 Not Estab. % Final
EOSINOPHIL 03/24/2023 2 Not Estab. % Final
BASOPHIL % 03/24/2023 1 Not Estab. % Final
NEUTROPHIL # 03/24/2023 1.9 1.4 - 7.0 x10E3/uL Final
LYMPHOCYTE # 03/24/2023 1.1 0.7 - 3.1 x10E3/uL Final
MONOCYTE # 03/24/2023 0.4 0.1 - 0.9 x10E3/uL Final
EOSINOPHIL # 03/24/2023 0.1 0.0 - 0.4 x10E3/uL Final
BASOPHIL # 03/24/2023 0.1 0.0 - 0.2 x10E3/uL Final
IMMATURE GRAN% 03/24/2023 0 Not Estab. % Final
IMMATURE GRAN# 03/24/2023 0.0 0.0 - 0.1 x10E3/uL Final
GLUCOSE 03/24/2023 94 70 - 99 mg/dL Final
UREA NITROGEN 03/24/2023 8 6 - 20 mg/dL Final
CREATININE 03/24/2023 0.96 0.57 - 1.00 mg/dL Final
eGFR 03/24/2023 79 >59 mL/min/1.73 Final
BUN/CREAT 03/24/2023 8 (L) 9 - 23 Final
NA 03/24/2023 140 134 - 144 mmol/L Final
POTASSIUM-SERUM 03/24/2023 4.6 3.5 - 5.2 mmol/L Final
CHLORIDE 03/24/2023 106 96 - 106 mmol/L Final
CARBON DIOXIDE, TOTAL 03/24/2023 20 20 - 29 mmol/L Final
CALCIUM 03/24/2023 9.8 8.7 - 10.2 mg/dL Final
Protein Total, Serum 03/24/2023 7.7 6.0 - 8.5 g/dL Final
ALBUMIN, BLD 03/24/2023 4.8 3.8 - 4.8 g/dL Final
GLOBULIN 03/24/2023 2.9 1.5 - 4.5 g/dL Final
A/G RATIO 03/24/2023 1.7 1.2 - 2.2 Final
BILIRUBIN TOTAL 03/24/2023 0.6 0.0 - 1.2 mg/dL Final
ALKALINE PHOSPHATASE 03/24/2023 43 (L) 44 - 121 IU/L Final
AST (SGOT) 03/24/2023 19 0 - 40 IU/L Final
ALT(SGPT) 03/24/2023 12 0 - 32 IU/L Final
TSH 03/24/2023 1.980 0.450 - 4.500 uIU/mL Final
CHOLESTEROL 03/24/2023 188 100 - 199 mg/dL Final
TRIGLYCERIDES 03/24/2023 81 0 - 149 mg/dL Final
HDL CHOLESTEROL 03/24/2023 54 >39 mg/dL Final
CHOL/HDL CHOL RATIO 03/24/2023 3.5 >39 mg/dL Final
HDL CHOLESTEROL 03/24/2023 3.5 >39 mg/dL Final
LDL (DIR.)/HDL RATIO 03/24/2023 2.1 0.0 - 3.2 ratio Final
LDL CHOL. (DIRECT) 03/24/2023 113 (H) 0 - 99 mg/dL Final
HEMOGLOBIN A1C 03/24/2023 5.2 4.8 - 5.6 % Final
Orders Placed in This Encounter Excluding Historical Medications

AMB REF TO ORAL MAXIOFACIAL SURGERY

Referral Priority:

Referral Type:

Number of Visits Requested:

Patient Convenience

Consultation

1

ANA Screen W/Titer

APTT

Order Specific Question:

Answer:

Release to MyMountSinai (MyChart)?

Auto-release

C-Reactive Protein (CRP)

Order Specific Question:

Answer:

Release to MyMountSinai (MyChart)?

Auto-release

CBC+Platelet+Differential

Order Specific Question:

Answer:

Release to MyMountSinai (MyChart)?

Auto-release

Comprehensive Metabolic Panel

Order Specific Question:

Answer:

Order Specific Question:

Answer:

Fasting

No

Release to MyMountSinai (MyChart)?

Auto-release

Ferritin

Order Specific Question:

Answer:

Release to MyMountSinai (MyChart)?

Auto-release

Hemoglobin A1C

Order Specific Question:

Answer:

Release to MyMountSinai (MyChart)?

Auto-release

Iron + TIBC

Order Specific Question:

Answer:

Release to MyMountSinai (MyChart)?

Auto-release

Lipid W/ Direct LDL

Order Specific Question:

Answer:

Release to MyMountSinai (MyChart)?

Auto-release

Prothrombin Time/INR

Order Specific Question:

Answer:

Order Specific Question:

Answer:

Release to MyMountSinai (MyChart)?

Auto-release

Is patient on Coumadin

No

Rheumatoid Factor

Sed Rate (ESR)

Order Specific Question:

Answer:

Release to MyMountSinai (MyChart)?

Auto-release

TSH w/reflex to T4 (preferred for screening and management)

Sed Rate (ESR)

Order Specific Question:

Answer:

Release to MyMountSinai (MyChart)?

Auto-release

Plan of care discussed with a patient in details, as well as orders and appropriate follow up. Pt verbalizes understanding. Discussed for results of labs/ imaging orders, I will reach out via message over Mount Sinai Portal, advised to log in to review results and explanation of results. If unable to do so, please call office to arrange discussion or leave message. Angela Lee D.O.