Initial Dr Visit on 6/27/17

I had my initial doctor visit on 6/27/2017 and this is the summary from that visit.  

Assessment and Plan

The following list includes any diagnoses that were discussed at your visit.

1. Dyspnea on exertion

• ·         CBC w/ auto diff
• ·         CMP, serum or plasma
• ·         pulmonary function test
• ·         US, echocardiogram, transthoracic, complete

2. Eczema

• ·         triamcinolone acetonide 0.1 % topical cream

3. Neuropathy

• ·         neuropathic pain: care instructions
• ·         HbA1c (hemoglobin A1c), blood
• ·         vitamin B12 + folate, serum or blood

4. Menorrhagia

• •         heavy menstrual periods: care instructions
• •         TSH, ultra- sensitive, serum
• •         estradiol, serum
• •         progesterone, serum

5. Hyperlipidemia screening

• •         lipid panel, serum

6. Disorder of connective tissue

• •         ANA (antinuclear antibodies) screen, serum

Labs / Tests

1. HbA1C (Hemoglobin a1C), Blood 06/27/2017
2. Vitamin B12 + Folate, Serum or Blood 06/27/2017
3. CBC W/ Auto Diff 06/27/2017
4. CMP, Serum or Plasma 06/27/2017
5. Lipid Panel, Serum 06/27/2017
6. TSH, Ultra- sensitive, Serum 06/27/2017
7. Estradiol, Serum 06/27/2017
8. Progesterone, Serum 06/27/2017
9. ANA (Antinuclear Antibodies) Screen, Serum 06/27/2017
10. Pulmonary Function Test
11. Imaging US, Echocardiogram, Transthoracic, Complete

Current Medications

triamcinolone acetonide 0.1 % topical cream

APPLY A THIN LAYER TO THE AFFECTED AREA(S) BY TOPICAL ROUTE 2 TIMES PER

DAY 06/27/2017

Medications Administered

None recorded.

Vitals

Height       Weight     BMI              Blood Pressure      Pulse       O2 Saturation                  Temperature     Respiration Rate

5 ft 6.5 in   252 lbs   40.7 kg/m2   124/82 mm[Hg]     89 bpm   96% Room Air at Rest    97.1 F°              14

Allergies

NKDA

Procedures

Date Name Performed by

01/01/1999 Tubal Ligation Information not available

01/01/1992 Other

Notes: Chest tube from car crash

Information not available

06/27/2017 US, Echocardiogram, Transthoracic,

Vaccine List

Here is a copy of your most up-to-date vaccination list.

None recorded.

Smoking Status

Smoking Status Never Smoker

Past Encounters

06/27/2017

Dyspnea on Exertion; Ecz ema; Neuropathy; Menorrhagia; Hyperlipidemia Screening; Disorder of Connective Tissue

Demographics

Sex: Female Ethnicity: Not Hispanic or Latino

Race: Native Hawaiian or Other Pacific Islander

Preferred language: English Marital status: Married