Communication #9 - Referral Note to Ophthalmology from Optometry (March 13, 2020, 11:00AM -0400)

Patient Legal: Clare M TESCA Date of Birth: February 14, 1952 (68yr) Gender: Female Patient-ID:  123456789 (SSN), 404.1 (1.3.6.1.4.1.115)
Encounter ID: 20200210100000 (2.16.840.1.113883.3.2820.10.1.3.10) , Date/Time: from March 13, 2020, 10AM -0400
Documentation Of Care provision, Patient referral (procedure), Date/Time: from March 13, 2020, 10:00AM -0400 to April 10, 2020, 11:00AM -0400, Performer: Yul SEEMORE
Author Dr Yul SEEMORE, Authored On: March 13, 2020, 11:00AM -0400
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REASON FOR REFERRAL

Request Procedures Reason for Referral Referred By Contact Referred To Contact Specialty
Evaluation for cataract extraction left eye Referral to ophthalmologist (308479007) Patient complaints of blur and glare in left eye is very bothersome since having the cataract surgery in the right eye which is doing well. Seemore, Yul

25 Fall St.

Atlanta, GA 30308

Phone: 843-555-9876

 Stedyhan, Stan

33 Front St.

Atlanta, GA 30308

Phone: 843-555-9898

 Ophthalmologist
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ASSESSMENTS

No Information
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HEALTH CONCERNS

Health Concerns
Type Health Concern Date Related Problem
Patient
The patient is doing well with the right eye that had cataract surgery. The vision in the left eye is blurry and the glare at night in the left eye is very bothersome so is still interfering with work 03/13/2020 Age-related nuclear cataract, bilateral
Provider
None 03/13/2020 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
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GOALS

Goals were updated to better meet patient's lifestyle and encourage better compliance.

Problem Addressed Goal Goal Type Author
Diabetes Determine the cause of visual complaint. Patient stated Joseph Gooddoc, M.D.
Diabetes Get HbA1c below 8 within 6 months. Provider Joseph Gooddoc, M.D.
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PLAN OF CARE

Date of Planned Services Type of Intervention Rationale Provider Location
(02/10/2020 - Referral for evaluation of cataract extraction The patient is experiencing distance blur and glare at night especially when driving. Since the patient’s occupation requires considerable traveling the glare at night is significantly interfering with work. Stedyhan, Stan
33 Front St.
Atlanta, GA 30308
843-555-9898
(02/10/2020 - Referral to a Diabetic Educator After the patient understood how control has more of an influence on the risk of developing retinopathy, she expressed concern that she wants to improve her control but has a number of dietary challenges including eating better when traveling and getting unexpected glucose spikes after some meals.

The patient was shown images of how retinopathy develops and what factors influences the rate of development were discussed with emphasis on better control significantly reduces risk and potentially slows the development of retinopathy. The education was aimed at showing her that her control is a much more important factor in determining risk of developing retinopathy than genetics

 Felgood, Maka
1450 Main St.
Atlanta, GA 30308
843-555-9878
(02/10/2020 - Coordination on education Coordination of educational efforts with primary care physician to empower the patient to get better control of her diabetes Gooddoc, Joseph
800 Spring St.
Atlanta, GA 30308
843-385-3448
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SOCIAL HISTORY

No Information
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VITAL SIGNS

No Information
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PROBLEM LIST

Problem Onset Date Resolved Date Status
Problem data included from 05/08/2006 to 02/10/2020 only
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral (1551000119108) 02/10/2020 active
Age-related nuclear cataract, bilateral (678601000119100) 02/10/2020 active
Type 2 diabetes mellitus without complications (111552007) 04/20/2014 active
Obesity, unspecified (414916001) 05/08/2006 active
Familial hypercholesterolemia (398036000) 04/20/2014 active
Essential (primary) hypertension (59621000) 07/28/2019 active
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ALLERGIES AND ADVERSE REACTIONS

Time Substance Reaction Severity Status
01/20/1998 egg Hives Moderate Active
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MEDICATIONS

Surgical Medications (Right Eye)
Name Code Instructions Start Date Stop Date Status
ketorolac tromethamine 5 MG/ML 860107 (RxNorm) qid for 2 weeks - right eye 2020-03-05 2020-03-19 Active
moxifloxacin 5 MG/ML 403818 (RxNorm) qid for 2 weeks - right eye 2020-03-05 2020-03-19 Active
prednisolone acetate 10 MG/ML 1376335 (RxNorm) qid for 2 weeks then taper - right eye
tid for 1 week - right eye
bid for 1 week - right eye
qd for 1 week - right eye		 2020-03-05
2020-03-20
2020-03-28
2020-04-05		 2020-03-19
2020-03-27
2020-04-04
2020-04-12		 Active
Active Medications
Name Code Instructions Start Date Stop Date Status
Crestor 5 mg 859426 (RxNorm) 1 tablet by mouth once a day for 90 2019-07-28 Active
metformin 1,000 mg 861004 (RxNorm) 1 tablet by mouth twice a day for 180 2014-04-20 Active
Invokana 100mg 50458-140-01 (NDC) 1 tablet by mouth once a day for 90 2019-07-28 Active
lisinopril 10 mg 314076 (RxNorm) 1 tablet by mouth once a day for 90 2019-07-28 Active
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DIAGNOSTIC TESTS/LABORATORY RESULTS

Lab Results
Order Test Ref. Range Flags Result Units Obs. Date Performing Laboratory
Hemoglobin A1c
Hemoglobin A1c [Mass/volume] in Blood (41995-2) LESS THAN 7.0% (NORMAL) H 10.5 % 2020-01-14 09:33:00
Lipid Panel (24331-1)
Triglyceride [Mass/volume] in Blood (3043-7) LESS THAN 150 MG/DL (NORMAL) H 250 mg/dL 2020-01-14 09:33:00
Cholesterol in HDL [Mass/volume] in Serum or Plasma (2085-9) LESS THAN 50 MG/DL (NORMAL) 28 mg/dL 2020-01-14 09:33:00
Cholesterol in LDL [Mass/volume] in Serum or Plasma (2089-1) LESS THAN 100 MG/DL (NORMAL) H 180 mg/dL 2020-01-14 09:33:00
Cholesterol [Mass/volume] in Serum or Plasma (2093-3) LESS THAN 200 MG/DL (NORMAL) H 280 mg/dL 2020-01-14 09:33:00
Liver Panel (24324-6)
Albumin [Mass/volume] in Serum or Plasma (1751-7) 3.5-5.5 G/DL (NORMAL) H 6.0 g/dL 2020-01-14 09:33:00
Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma (1920-8) 9-50 U/L(NORMAL) H 60 U/L 2020-01-14 09:33:00
Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma (1742-6) 5-50 U/L(NORMAL) H 65 U/L 2020-01-14 09:33:00
Creatinine
Creatinine [Mass/volume] in Serum or Plasma (2160-0) LESS THAN 1.3 MG/DL H 1.5 mg/dL 2020-01-14 09:33:00
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PHYSICAL EXMAMINATION

Clinical Findings
System Finding
Ocular History No significant previous ocular history with no history of prior ocular surgery
The patient does not wear contact lenses
2+ nuclear sclerosis in each eye
Current Spectacle Rx OD: -3.50 - 1.25 X 090 VA Dist 20/40
OS: -3.75 - 1.00 X 090 VA Dist 20/40+
Current Subjective refraction OD: -4.00 - 1.25 X 090 VA Dist 20/30+
OS: -4.25 - 1.00 X 090 VA Dist 20/30
IOP by applanation OD 16 mmHg
OS 17 mmHg
Results of dilated eye exam C/D ratio OD: .3/.3
OS: .3/.4
Cornea Otherwise the cornea is clear
Anterior Chamber Anterior chamber angle- Grade 4 Shaffer OU
Iris- flat with mild bilateral iris atrophy
Lens 2+ Nuclear Sclerosis OU
Vitreous PCVD OD
Asteroid hyalosis OS
Optic nerve evaluation The Optic nerve is flat and pink
Macula evaluation Flat and with normal pigmentation
Normal foveal reflex
Peripheral retinal evaluation Normal vasculature
Normal flat retina
No retinal tears or detachments
Temporal lattice degeneration OD, no retinal holes or tears
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PATIENT CARE TEAMS

  • Long Term Care Team ( Active) (01/01/2005 - )
    Member Role on Team Status Date
    Dr. Joseph Gooddoc, MD (NPI: 2734441159 ) Primary Care Physician (Active) 2005 - current
    Maka Felgood Diabetic Educator (Active) 2014 - current
    Dr. Arthur Feetler, DPM (NPI: 8402871106) Podiatrist (Active) 2018 - current
    Dr. Donald Singletooth, DDS (NPI: 8477778822) Dentist (Active) 1990 - current
    Dr. Yul Seemore, OD (NPI: 1973535929) Optometrist (Active) 2020 - current
    Dr. Stan Stedyhan, MD (NPI: 2173512387) Ophthalmologist (Active) 2020 - current
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PAYERS

No Information
Document
ID 4d6cd037-b3d4-40e0-8765-a1444357d49a
Created On March 13, 2020, 11:00AM -0400
Custodian Wood River Health Services, LLC Contact Details Workplace: 800 Spring St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-2234
 
Patient Legal: Clare M TESCA Contact Details Home Primary: 3704 Irish Lane
Atlanta, GA 30301
US
Tel Home Primary: +1(843)-758-0515
Date of Birth February 14, 1952 (68yr) Gender Female
Race Black or African American Ethnicity Not Hispanic or Latino
Patient-IDs 123456789 (SSN)
404.1 (1.3.6.1.4.1.115) 		Language Communication
en, Expressed spoken, Excellent, preferred: yes
Provider Organization
Wood River Health Services, LLC
ID 9999999999 (NPI), jgrue@directaddress.net (1.3.6.1.4.1.41179.2.1), 2.16.840.1.113883.1.111.12345
Contact Details (Organization) 800 Spring St.
Atlanta, GA 30308
US
Tel Workplace: +1-843-555-2234, Mail Workplace: jgrue@directaddress.net
 
Documentation Of - care provision Patient referral (procedure)from March 13, 2020, 10:00AM -0400 to April 10, 2020, 11:00AM -0400
Performer - Yul SEEMORE Contact Details Workplace: 25 Fall St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-9876
Encounter
ID 20200210100000 (2.16.840.1.113883.3.2820.10.1.3.10)
Encounter Date from March 13, 2020, 10AM -0400
Encounter Location Dr. Yul Seemore (Workplace: United States
Atlanta, GA 30308
25 Fall St.)
Responsible Party Legal: SEEMORE Yul Contact Details Workplace: United States
Atlanta, GA 30308
25 Fall St.
 
Author Dr Yul SEEMORE Contact Details 25 Fall St.
Atlanta, Georgia 30308
US
Tel Workplace: +1-843-555-9876
Information Recipient Stan STEDYHAN Contact Details Workplace: 2598 Main St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-9898