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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. Aphthous ulcer
  • - CBC+PLT+DIFF
  • - SED RATE (ESR)
  • - C-REACTIVE PROTEIN (CRP)
  • - ANA SCREEN W/TITER
  • - RHEUMATOID FACTOR
2. Oral mucosal lesion
  • - AMB REF TO ORAL MAXIOFACIAL SURGERY
3. Easy bruising
  • - CBC+PLT+DIFF
  • - PROTHROMBIN TIME/INR
  • - APTT
  • - IRON + TIBC
  • - FERRITIN
4. Stress
5. Annual physical exam
  • - CBC+PLT+DIFF
  • - COMPREHENSIVE METABOLIC PANEL
  • - TSH W/REFLEX TO T4 (PREFERRED FOR SCREENING AND MANAGEMENT)
  • - LIPID W/DIRECT LDL
  • - HEMOGLOBIN A1C

Screen labs/ autoimmune etiology for oral ulcer without other systemic symptoms Recommend OFMS to evaluate oral lesion and need for biopsy given duration Trial daily lysine 1000mg daily for ppx Stress mgmt reviewed Keep upcoming appts with psych/ therapist Monitor bruising and a/w trauma or scratching Return precautions

SUBJECTIVE
CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS

Katy Younger-Hadwiger is a 37 y.o. female who presents for follow up,

Had annual exam in Charleston 3/2024 and had labs done without results. Was ordered for CBC, iron, CPR, RF, CMP, A1C.

Noted new worsening briusing since past summer only along left leg. Denies trama or pressure. No other bleeding or bruising episodes on trunk or UE. Sleeps on side.

More canker sores over past year, longer duration, more stress. Has one currently lasting over 1 month. No hx oral herpes. Denies joint pain or swelling. Denies fatigue. Denies vision changes.

Intentional weight loss 20lbs since LV with more exercise.

Notes consistent oral thrush? able to brush off, uses albuterol only with allergies in fall. Last abx. Inhaler months ago. Started with initial abx course months ago.

GAD/ life stressors: On lexapro since 2 months, following with psych and therapist. Some dry mouth.

PAST MEDICAL HISTORY

History reviewed. No pertinent past medical history.

PAST SURGICAL HISTORY

History reviewed. No pertinent surgical history.

MEDICATIONS
Outpatient Medications Marked as Taking for the 5/20/24 encounter (Office Visit) with Angela Lee, DO
  • Medication
  • Sig
  • Dispense
  • Refill

esCITalopram (LEXAPRO) 10 mg tablet

TAKE 1 AND 1/2 TABLETS BY MOUTH EVERY DAY

levonorgestrel-ethinyl estradiol (VIENVA) 0.1-20 mg-mcg tablet

Take 1 tablet by mouth once daily.

ALLERGIES

No Known Allergies

SOCIAL HISTORY

Social History

  • 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

OBJECTIVE
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.