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
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
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.
History reviewed. No pertinent past medical history.
History reviewed. No pertinent surgical history.
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.
No Known Allergies
Social History
Smoking status:
Former
Types
Cigarettes
Quit date:
4/30/2009
Years since quitting:
15.0
Smokeless tobacco:
Never
Alcohol use:
Not Currently
Sexual Activity
Yes
Partners
Male
Birth control/protection:
Pill
Occupation:
marketing for a beauty company
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
As per HPI
Body mass index is 24.13 kg/m².
PHYSICAL EXAMINATIONGeneral 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
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 |
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:
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Auto-release
C-Reactive Protein (CRP)
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Answer:
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CBC+Platelet+Differential
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Answer:
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Comprehensive Metabolic Panel
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Answer:
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Answer:
Fasting
No
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Ferritin
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Answer:
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Hemoglobin A1C
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Answer:
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Iron + TIBC
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Answer:
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Lipid W/ Direct LDL
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Prothrombin Time/INR
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Answer:
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Is patient on Coumadin
No
Rheumatoid Factor
Sed Rate (ESR)
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Answer:
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TSH w/reflex to T4 (preferred for screening and management)
Sed Rate (ESR)
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Answer:
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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.