PROGRESS NOTE 123 State Street Chicago IL 60601 US Theodore Leven John Smith, MD, LLC 40 Healthcare Ave. Suite 100 Chicago IL 60643 US 40 Healthcare Ave. Suite 100 Chicago IL 60643 US John Smith, MD John Smith, MD, LLC 40 Healthcare Ave. Suite 100 Chicago IL 60643 US
ENCOUNTERS
Encounter Performer Location Encounter date Diagnosis Encounter Diagnosis Status
Office outpatient visit Dr. John Smith Internal Medicine Internal Medicine Office 40 Healthcare Ave. Suite 100 Chicago, IL 60643 February 11, 2019 Acute cholestatic jaundice syndrome (disorder) Other specified diseases of biliary tract Active
Dr. John Smith 1004 Healthcare Dr. Portland OR 97005 Get Well Clinic
REASON FOR VISIT What is the reason for this visit?
Follow-up for refractory nausea, vomiting, and abdominal pain.
ALLERGIES AND INTOLERANCES What are the patient's allergies or intolerances?
Amoxicillin causes rash Phenergan causes restless legs
MEDICATIONS What medications are taken by the patient?
If known, Include the dosage, frequency and timing for taking the medication. Also include the problem(s) addressed by this medication for the patient (Indication)
Medication Name Dose Sig Timing Indication Dates
Reglan 5 mg 1 tablet before meals as needed for nausea (1/1/2019 - )
azithromycin 500 mg for 10 days for sinusitus (1/10/2019 - 1/19/2019)
atorvastatin 20 mg once daily for dyslipidemia (2/10/2018 - )
acetaminophen 1000 mg twice daily as needed for neck pain
PROBLEM LIST What are the patient's previous problems (existed prior to this encounter?


Refactory abdominal pain, nausea, and vomiting. Elevated liver function test (LFTs) with a cholestatic pattern. Antinuclear antibody and elevated ferritin measurements.
HISTORY OF PRESENT ILLNESS What is the history of the patient's present Illness? Mr. Leven was previously seen on 1/11/2019 for evaluation of refractory nausea, vomiting, and abdominal pain. During the interim, laboratory data was obtained confirming improved liver function studies with alkaline phosphatase 443, total billirubin 1.4, AST 36, and ALT 113. Of note, an acute viral hepatitis profile was obtained. documenting no evidence of viral hepatitis. In addition, the iron index is normal, thus refuting hemochromatosis, and prothrombin time is within reference range, suggesting adequate hepatic protein synthesis.

Currently the patient voices nausea, vomiting, and pain are less evident, although there have been 2 episodes since he was last seen. Reglan controls nausea, but his appetite remains suppressed.
HEALTH CONCERNS What are the previous concerns (existed prior to this encounter?


What are the new concerns (added during this encounter)?


What concerns have been removed (removed/completed during this encounter?


Dyslipidemia currently being treated with atorvastatin
Sinusitis currently being treated with azithromycin
Neck pain status: post surgical fusion
PAST MEDICAL HISTORY What is the patient's past medical history at this point in time? Cervical fusion C3-C4 2015
Appendectomy 1952
VITAL SIGNS What were the patient's vital sign measurements during this encounter? (include current date for clarity)?
Blood Pressure: Systolic: 113/ Diastolic: 69
Tempurature: 97.3
Weight: 140 pounds
Height: 5 feet 5 inches
BMI: 23.3
PHYSICAL EXAM What findings were documented in the Physical Exam performed on the patient during this encounter?
LUNGS: Clear to auscultation and percussion.
CARDIOVASCULAR: S1,S2 within normal limits, without gallops or murmurs.
ABDOMEN: Presently benign
ASSESSMENT What was the practitioner's assessment? Regractory nausea, vomiting, and abdominal pain wiht elevated liver function tests. Features appear concerning for cholestatic disease, potentially retained common bile duct gallstone, sphincter of Oddi dysfunction, or other obstructive disease. In addition, drug-induced hepatitis also is a possibility.
GENERAL STATUS What was the practitioner's assessment of the general health status of the patient?
Well-developed, well-nourished Caucasian male in no acute distress.
MENTAL STATUS What is the mental status of the patient?
Mood and affect are normal.
FUNCTIONAL STATUS What is the functional status of the patient?
Not applicable.
GOALS What are the patient's or practitioner's present goals for addressing these problems and concerns?
Shared Goal Resolve nausea
Shared Goal Normal appetite
ADVANCE DIRECTIVES Does the patient have Advance Directives? Yes

Who is the patient's Healthcare Proxy? Spouse

Where are the patient's Advance Directives kept? MyDirectives.com
PLAN OF TREATMENT For each problem or concern being addressed:
What existing planned interventions still need to be completed or have been ordered?
What planned interventions have been removed/completed? (Include the reason for not performing the intervention or point to the intervention performed listed below.)
What new planned interventions have been ordered or need to be completed?
What changes need to be made to the patient's medication list?
What goals have previously been set for addressing concerns by the patient and/or provider?
What new goals have been set during this encounter for addressing concerns by the patient and/or provider?
What goals have been removed/completed by the patient and/or provider?
The patient will be scheduled for an MRCP to determine if there is underlying retained common bile duct stone.
If normal, then anticipate he may require an ERCP with manometry study to evaluate for sphicnter of Occi dysfunction. Lastly, repeat LFTs will be obtained in 1-2 weeks. Further recommendations will follow.
INSTRUCTIONS Might there be instructions that are just a narrative note? Please call the office to confirm dose of atorvastatin.
INTERVENTIONS PERFORMED What interventions were performed? (Include interventions performed during this encounter.)


None.
HEALTH INSURANCE What Payer Information Needs to be included for the patient for this visit?
Medicare Advantage