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
• No Active Ambulatory Problems
• No Resolved Ambulatory Problems
History reviewed. No pertinent surgical history.
Alcohol use:
Not Currently
Occupation:
marketing for a beauty company
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:
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.