athena

11-01-2023 12:49 PM ET 611-201294962

ba 1 of 18

Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Medical Records - CONFIDENTIAL

FROM: WV - AccessHealth

Yufredia B

202 Bill Baker Way, BECKLEY, WV 25801-3503
Phone: <PRESIDIO_ANONYMIZED_PHONE_NUMBER>

Fax: (304) 254-9811

TO:

Name: SCRUGGS, SANDRA M
DOB: 11/24/1951
Date Range: 04/01/2023 to 11/01/2023

This document contains the following records of the patient:
*® Admin Documents
e Encounters and Procedures

This fax may contain sensitive and confidential personal health information that is
being sent for the sole use of the intended recipient. Unintended recipients are
directed to securely destroy any materials received. You are hereby notified that the
unauthorized disclosure or other unlawful use of this fax or any personal health
information is prohibited. To the extent patient information contained in this fax is
subject to 42 CFR Part 2, this regulation prohibits unauthorized disclosure of these
records.

If you received this faxin error, please visit www.athenahealth .com/NotMyFax to
notify the sender and confirm that the information will be destroyed. If you do not
have internet access, please call 1-888-482-8436 to notify the sender and confirm

that the information will be destroyed. Thank you for your attention and cooperation.

[ID:416044-A-14333]



athena 11-01-2023 12:49 PM ET 611-201294962 pq 2 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Admin Documents



athena 11-01-2023 12:49 PM ET 611-201294962 ba 3 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503

SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

CardinalHealth’

To,
Dr. BILLY COLE, DO
202 BILL BAKER WAY BECKLEY, WV 25801

11/01/2023
Hello,

(am writing you to request office visit notes regarding our mutual patient SANDRA SCRUGGS
11/24/1951. We just received a copy of the Dr. Written Order that we have faxed out the other day
signed hy the physician. Our patient is being seen Dr. BILLY COLE, DO

We require a copy of patient fast 2 office visit notes to support the refill request, Patient is under the care of
Dr. BILLY COLE, DO to fulfill the refi! request, we require copy of patient office notes as it will
expedite the process and we can go ahead with the shipment process.

1am attaching a copy of a verification form that we received. Please send us office notes of the patient to
the fax number — 786-686-4146 at earliest.

if you have any questions please feel free to call us on (786) 544-8797

Best regards,

Medical Records Department
Cardinal Health, Inc.
Phone: <PRESIDIO_ANONYMIZED_PHONE_NUMBER>

Fax: (786) 686-4146

FAX REQUIRED DOCUMENTS TO: 1- 786-686-4146

For any assistance or question please call 1-(786) 855-8221 (?) NABP




athena 11-01-2023 12:49 PM ET 611-201294962 pq 4 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503

SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Fram: W/OW2Z023 10:23 #675 P.001/002

©  Oct30, 2023 18:07 {UTCHOS) From: <PRESIDIO_ANONYMIZED_PHONE_NUMBER> (Cardinal Health, Inc} To: 113042549810 @ 1 of2

CardinalHealth”

To: Br, BILLY COLE, DO From: Cardinal Health, Inc.
Fax: (304) 254-9816 Fax: (786) 686-4146
Phone: <PRESIDIO_ANONYMIZED_PHONE_NUMBER> Phone: <PRESIDIO_ANONYMIZED_PHONE_NUMBER>
Subject: Glucose Monitor Date: 16/30/2023

No. Pages: 2

Comment:

To Whom It May Concern:

Your Patient has contacted us requesting a Continuous Glucose Monitor. Your
patient has said the chief complaint is having to prick their fingers so many times
a day.

We have let your patient know that you would need to sign the request and send
us back the order for us to approve and fulfill the request. Thank you far helping
us serve your patient and please feel free to call us with any questions.

Thank you!

Cc) Abbott * required by the Health Insurance Portability and Accountability Act (HIPAA), Abbott

Diabetes Care (ADC, we, us or our) is providing you with this Notice of Privacy Practices

life. to the fullest: (Notes) describing the uses and disclosures of health information that may be made by
ADC



athena

11-01-2023 12:49 PM ET 611-201294962

pa 5 of 18

Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

gD

Oct 39, 2023 18:07 {UTC+95) From: <PRESIDIO_ANONYMIZED_PHONE_NUMBER> (Card nal Health, Inc) To: + 13042549810

Medicare Detailed Written Order FreeStyle Libre 2)

instructions

Complete all fletds on this Detatied Written Order.

Use the Noridian November 2017 Physician Resource Letter (Continuous Glucose Monitors) to contitm coverage criteria and medical
necessity documentation requirements are met.

Fax both this order and the patient's most recent medical records that demonstrete coverage criteria are met to. a OME supplier that
provides the FreeStyle Lipre 2 28-day system.

Patient Information

Patient Name: SANDRA SCRUGGS Date of Birth: 13/24/1951

Phone: <PRESIDIO_ANONYMIZED_PHONE_NUMBER> Emaik >

Address: 45 STONE LN City: FAYETTEVILLE State: WV ZIP: 25840
Primary insurance: MEDICARE Primary insutance Member 'D: ~~ 2YUSN?4PX52__

Secondary Insurance: - Secondary Insurance Memper ID: -

Notes: SEND BACK THE SIGNED COPY OF THE PRESCRIPTION ALONG WITH THE MOST RECENT OFFICE

VISITNG NOTES OF THE PATIENT AT (786) 686-4146

Physician Information

Physician Name’ Dr_BIELY COLE, DO Phone: <PRESIDIO_ANONYMIZED_PHONE_NUMBER>

NPI: 1336233626 Fax: 3042549810

Address; 202 BILL BAKER WAY. City: BECKLEY. State: WV ZIP: 280%
Order Detail

Order Date: 10/30/2023

£2103 (Free Style Libre2 Reader) A4239 (Free Style Libre2 Sensors)

Required for new prescription, raader lite ~ 3 years 28 dey suppty, filled monthly

Diagnosis (1CD10):
E109 OE (81065 1) EN ens Other:
Prescribed Number of Glucose Tests Per Day: Y4

Current insulin Regimen:
CG Insulin Pump 1 Multiple Daily Injactions-Number Per Day: 2 Other:

| certify that am the physician identified in the "Physician Information” section ahove and hereby attest that the medical necessity
information is Tue, accurate, and complete fo the best of my Anowledge. f understand that any laisification, ormssion, of concealment of
material fact may subject me to administrative, civ, or criminal llabéty, The patiant/caregiver is cepable and has successfully compisted
or will be trained on the proper use of the products prescribed on this order.

Physician Signature:

{v 38 ultimately the responsibilty of fhe healthcare professionalipersons associated with the patient's care to determine and document the approonate
dlagneisis {es} anc ende{s} for the patient's condition. Abbott dees not quarantee that the use of any information provided in this fore will result in coverage
of payment by any third-party payer, Each hestticars provides is ultimately responsible for veriying codes, coverage, and payment oolicies used 16 ensure
that they are accurate for the services and ems provided.

See reverse for indications ang important Safely Information,

From: WW/OW/2023 10:23 #675 P.ce2/o02

E 20f2




athena 11-01-2023 12:49 PM ET 611-201294962

6 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503 ated
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Encounters and Procedures
Clinical Encounter Summaries



athena 11-01-2023 12:49 PM ET

611-201294962 pq 7 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503

SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)
Encounter Date: 10/12/2023
Patient

Name SCRUGGS, SANDRA (71yo, F) ID#

416044
11/24/1951
BILLY COLE, DO

Appt. Date/Time 9/12/2023 07:45AM

DOB Service Dept. AccessHealth Bill Baker Way

Provider

Insurance Med Primary: MEDICARE-WV (MEDICARE)

Insurance # ; 2YUSN74PX52
PCP ; COLE, BILLY J, Il
Referring Provider Name : COLE, BILLY J, Il
Employer Name : S AND V
Med Secondary: BANKERS FIDELITY (MEDICARE SUPPLEMENT)
Insurance # : 6160900649
Policy/Group # : PLAN F
PCP ; COLE, BILLY J, Il
Referring Provider Name : COLE, BILLY J, Il
Employer Name : S AND V
Med : MEDICARE-W - PART A - RHC-FQHC (MEDICARE)
Insurance # : 2YU5N74PX52
PCP ; COLE, BILLY J, Il
Referring Provider Name : WOLFE, ROY R, JR
Employer Name : S AND V
Prescription: CVS|CAREMARK - Member is eligible. details

Chief Complaint

6 month follow up, fasting. agarrick Lpn

Patient's Care Team
Primary Care Provider (Primary Insurance): COLE, BILLY J, Il; 202 BILL BAKER WAY, BECKLEY, WV 25801-2812,
Ph (304) 252-8555, Fax (304) 254-9810

Referring Provider (Primary Insurance): COLE, BILLY J, Il: 202 BILL BAKER WAY, BECKLEY, WV 25801-2812, Ph
(304) 252-8555, Fax (304) 254-9810

Referring Provider (Reference Package): WOLFE, ROY R, JR: 200 VETERANS AVE, BECKLEY, WV 25801, Ph
(304) 255-2121, Fax (304) 256-5301

Patient's Pharmacies

NEW RIVER HEALTH FAYETTEVILLE PHARMACY (ERX): 217 W MAPLE AVE, FAYETTEVILLE, WV 25840, Ph
(304) 574-3991, Fax (304) 574-3651

KROGER PHARMACY 02900780 (ERX): 411 MALL RD, OAK HILL, WV 25901, Ph (304) 465-0321, Fax (304) 469-8892
Vita : Be 2 : oe a ike oe is

Ht: 5 ft 7 in Stated
IO/1272023 08:26
am

BP: 120/84 sitting L
arm 10/12/2023
08:30 am

T: 96.9 F° temporal
artery 10/12/2023
08:36 am

Allergies
Reviewed Allergies
BACTRIM: Flushing (Moderate)
NO KROWN SLLERGIES

Medications

Wt: 255 Ibs With BMI: 39.9 10/12/2023
clothes 10/22/2023 08:30 any
08:30 am
Pulse: 69 bom regular RR: 18 26/12/2623

10/12/2023 05:36
am

08:30 am

O2Sat: 98% Room Air at
Rest 16/12/2023
06:36 am



athena 11-01-2023 12:49 PM ET 611-201294962 ba 8 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Reviewed Medications

acyclovir 800 mg tablet 05/27/21 filled
TAKE ONE TABLET 5 times a day for 7 days

allopurinoL 100 mg tablet 08/10/23 filled
TAKE ONE TABLET BY MOUTH EVERY DAY

aspirin 81 mg tablet,delayed release 03/20/18 entered
Take 1 tablet(s) every day by oral route.
Internal Note: OTC per cardiologist

colchicine (gout) 0.6 mg tablet 08/10/23 filled
TAKE ONE TABLET BY MOUTH ON DAY ONE with THE start of allopurinol AND TAKE
ONE TABLET BY MOUTH ON DAY THREE

escitalopram 10 mg tablet 10/12/23 prescribed
TAKE ONE TABLET EVERY DAY

glimepiride 4 mg tablet 10/12/23 prescribed
TAKE ONE TABLET TWICE DAILY

iHealth COVID-19 Antigen Rapid Home Test kit 03/31/23 filled
AS DIRECTED
Januvia 100 mg tablet 10/12/23 prescribed

TAKE ONE TABLET EVERY DAY

lisinopril 5 mg tablet 10/12/23 prescribed
TAKE ONE TABLET EVERY DAY

metoprolol succinate ER 50 mg tablet,extended release 24 hr 10/12/23 prescribed
TAKE ONE TABLET EVERY DAY
multivitamin 03/20/18 entered

Internal Note: otc

nitrofurantoin monohydrate/macrocrystals 100 mg capsule 02/06/23 filled
TAKE ONE CAPSULE BY MOUTH TWICE DAILY take with food or a meal

pantoprazole 40 mg tablet,delayed release 10/12/23 prescribed
TAKE ONE TABLET EVERY DAY

pioglitazone 30 mg tablet 10/12/23 prescribed
Take 1 tablet(s) every day by oral route.

rosuvastatin 5 mg tablet 10/12/23 prescribed
Take 1 tablet(s) every day by oral route.

traZODone 50 mg tablet 08/23/23 filled
TAKE ONE TABLET BY MOUTH EVERY DAY



athena 11-01-2023 12:49 PM ET 611-201294962 pa 9 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

triamcinolone acetonide 0.1 % dental paste 02/22/22 filled
Apply 3 times a day by dental route as directed.

Vitamin D2 1,250 mcg (50,000 unit) capsule 10/12/23 prescribed
TAKE ONE CAPSULE once weekly

Vaccines
Reviewed V

Problems

Reviewed Problems

e Chronic kidney disease - Onset: 02/22/2022

® Gastroesophageal reflux disease without esophagitis - Onset: 02/22/2022

e Depressive disorder - Onset: 06/21/2018

e Vitamin D deficiency - Onset: 03/20/2018

© Anemia - Onset: 06/19/2017

® Influenza-like symptoms - Onset; 03/16/2017

® Sciatica - Onset: 04/05/2016 - Entered By: Billy J Cole Il, DO; Signed By: Billy J Cole Il, DO

e Disorder of pelvic region of trunk - Onset: 01/14/2014 - Entered By: Roy R Wolfe MD; Signed By: Roy R Wolfe MD :

® Dyspnea - Onset: 09/25/2014 - Entered By: Billy J Cole Il, DO; Signed By: Billy J Cole Il, DO

® Mixed hyperlipidemia - Onset: 10/16/2012 - Entered By: Billy J Cole Il, DO; Signed By: Billy) Cole Il, DO

e Adult health examination - Onset: 02/25/2009 - Entered By: Roy R Wolfe MD; Signed By: Roy R Wolfe MD

© Knee pain - Onset; 09/23/2015 - Entered By: Billy) Cole Il, DO; Signed By: BillyJ Cole Il, DO

@ Type 2 diabetes mellitus without complication - Onset: 02/26/2016 - Entered By; BillyJ Cole Il, DO; Signed By:
Billy J Cole Il, DO

e Acute vulvitis - Onset: 01/12/2016 - Entered By: David M Rainey MD; Signed By: David M Rainey MD

e Hypertensive disorder - Onset: 10/17/2007 - Entered By: Billy J Cole Il, DO; Signed By: Billy J Cole Il, DO

® Obesity - Onset: 10/17/2007 - Entered By: Billy J Cole Il, DO; Signed By: Billy] Cole Il, DO

® Blood leukocyte number below reference range - Onset: 10/20/2011 - Entered By: Tammy Morgan LPN; Signed
By: Billy J Cole Il, DO

e Inadequate immune status - Onset: 10/17/2007 - Entered By: Billy Cole Il, DO; Signed By: Billy J Cole Il, DO

® History of polyp of colon - Onset: 10/17/2007 - Entered By: Billy] Cole Il, DO; Signed By: Billy J Cole Il, DO

® Hyperglycemia - Onset: 02/23/2016 - Entered By: Billy) Cole Il, DO; Signed By: Billy) Cole Il, DO

® Gynecologic examination - Onset: 05/13/2010 - Entered By: Roy R Wolfe MD; Signed By: Roy R Wolfe MD

04/05/2016: GLUCOSE INTOLERANCE, HX OF (V12.2) ; OnsetDate: 10/17/2007; Entered By: Billy J Cole Il, DO;
Signed By: Billy J Cole II, DO

Family History
Family History not reviewed (last reviewed 07/09/2019)

he patient indicates family history of lung cancer (brother), heart disease (father), coronary artery disease
(father). Other family history includes: CA involving neck-mother. No family history of anesthesia problems

Social History

Reviewed Social History

Substance Use

Do you or have you ever smoked tobacco?: Never smoker

How much tobacco do you chew?: none

Do you or have you ever used any other forms of tobacco or nicotine?; No
What was the date of your most recent tobacco screening?: 10/12/2023
Has tobacco cessation counseling been provided?: No

What is your level of alcoho! consumption?: None

Do you use any illicit or recreational drugs?: No

Which illicit or recreational drugs have you used?; NONE

What is your level of caffeine consumption?: Occasional

Other

Education: 12

Legally blind in one or both eyes?: No

Live alone or with others?: alone

Performs monthly self-breast exam?: Y

Seat belts used routinely: Yes

Smoke alarm in home: Yes

General stress level: Medium

Home and Environment



athena 11-01-2023 12:49 PM ET 611-201294962 pq 10 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Are you passively exposed to smoke?: No

Do you use sunscreen routinely?: Yes

Education and Occupation

Are you currently employed?: No

What is your occupation?: RETIRED

Marriage and Sexuality

What is your relationship status?: Widowed

Are you sexually active?: No

Do you use protection during sex?: No

How many children do you have?: 3

Diet and Exercise

What type of diet are you following?: Regular

What is your exercise level?: Moderate

Activities of Daily Living

Are you able to walk?: Yes: walks without restrictions
Advance Directive

Do you have an advance directive?: Yes (Notes; Full Code)
Is blood transfusion acceptable in an emergency?: Yes
Gender Identity and LGBTQ Identity

Gender identity: Identifies as Female

Assigned sex at birth: Female

Sexual orientation: Straight or heterosexual

Negative tobacco, alcohol, or drugs. Homemaker. No disability or workers compensation. .Widowed,

Surgical History
Surgical History not reviewed (last reviewed 05/24/2021)
~ Colonoscopy

Colonoscopy, 2014, 2017.
TVH BSO secondary to uterine prolapse per Dr. Wolfe, 12/05.

Anterior colporrhaphy, cystoscopy, Dr. Wolfe 1/15/14.

GYN History

GYN History not reviewed (last reviewed 07/09/2019)
LMP: Unknown.

Menses Monthly: N.

Age at First Child: 20.

Current Birth Control Method; Hysterectomy.

If Post Menopausal, Age at Menopause: 54.

Obstetric History _ : a
Obstetric History not reviewed (last reviewed 07/09/2019

AB. | AB. S ECTOPICS MULTIPLE

Past Medical History

Past Medical History not reviewed (last reviewed 07/09/2019)
Anemia: ¥

GI Problems: ¥ - diverticulosis

Notes: hypertension,

borderline Type Il DM

cold sores

normal DEXA 5/8/17.

HPI
Patient presents today for routine clinical follow up regarding chronic medical conditions as outlined. In the
interim since last visit reports tolerating maintenance medications without side effect. No report of fever or

chills. Discussed statin therapy, will begin trial of rosuvastatin. Discussed previous A1C of 5.9. Recent oncology
notes reviewed,

ROS

Patient reports GERD. She reports no fever and no night sweats. She reports no chest pain and no armpain on :
exertion. She reports no cough, no wheeang, and no shortness of breath. She reports no incontinence and no
difficulty urinating. She reports no loss of consciousness and no seizures, She reports no swollen glands and no
bruising.

Physical Exam
Constitutional: General Appearance: well-nourished and well-developed. Level of Distress: NAD.

Psychiatric: Mental Status: normal mood and affect.



athena 11-01-2023 12:49 PM ET 611-201294962 bq 11 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503

SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Head: Head: normocephalic and atraumatic.

Eyes: Pupils: PERRLA. EOM: EOMI.

ENMT: Ears: TMs clear. Nose: nares patent. Oropharynx: no erythema.
Neck: Neck: supple. Lymph Nodes: no cervical LAD.

Lungs: Auscultation: breath sounds normal and good air movement.
Cardiovascular: Heart Auscultation: normal S1 and $2 and RRR.

Abdomen: Bowel Sounds: normal. Inspection and Palpation: soft, non-distended, and no tenderness. Liver:
non-tender and no hepatomegaly. Spleen: non-tender and no splenomegaly.

Musculoskeletal:: Motor Strength and Tone: normal tone and motor strength. Joints, Bones, and Muscles: no
bony abnormalities. Extremities: no edema,

Neurologic: Cranial Nerves: grossly intact.
Assessment / Plan

1. Type 2 diabetes mellitus without complication
E11.9: Type 2 diabetes mellitus without complications
® glimepiride 4 mg tablet - TAKE ONE TABLET TWICE DAILY Qty: (180) tablet Refills: 3) Pharmacy: NEW
RIVER HEALTH FAYETTEVILLE PHARMACY
® Januvia 100 mg tablet - TAKE ONE TABLET EVERY DAY Qty: (90) tablet Refills: 3. Pharmacy: NEW RIVER
HEALTH FAYETTEVILLE PHARMACY
® pioglitazone 30 mg tablet - Take 1 tablet(s) everydaybyoralroute. Qty: (90) tablet Refills: 3
Pharmacy: NEW RIVER HEALTH FAYETTEVILLE PHARMACY
%ALCWB- Specimen source: Blood venous
COMPREHENSIVE METABOLIC PANEL- Specimen source; Blood venous
CBC W/ AUTO DIFFERENTIAL- Specimen source: Blood venous
UPID PROFILE- Specimen source; Blood venous
TSH- Specimen source: Blood venous

2. Hypertensive disorder
110: Essential (primary) hypertension
¢ lisinopril 5 mg tablet - TAKE ONE TABLET EVERY DAY Qty: (90) tablet Refills: 3. Pharmacy: NEW RIVER
HEALTH FAYETTEVILLE PHARMACY
® metoprolol succinate ER 50 mg tablet,extended release 24 hr - TAKE ONE TABLET EVERY DAY Qty:
(90) tablet Refills: 3. Pharmacy: NEW RIVER HEALTH FAYETTEVILLE PHARMACY

3. Vitamin D deficiency
E55.9: Vitamin D deficiency, unspecified
e Vitamin D2 1,250 meg (50,000 unit) capsule - TAKE ONE CAPSULE once weekly Qty: (13) capsule — Refills:
3. Pharmacy: NEW RIVER HEALTH FAYETTEVILLE PHARMACY
* VITAMIND- Specimen source: Blood venous

4. Mixed hyperlipidemia
E78.2: Mixed hyperlipidemia
® rosuvastalin 5 mg tablet - Take 1 tablet(s) every day by oral route. Qty: (90) tablet — Refills: 3
Pharmacy: NEW RIVER HEALTH FAYETTEVILLE PHARMACY

5. Anemia
D64.9: Anemia, unspecified

6. Depressive disorder
F32.9; Major depressive disorder, single episode, unspecified
e® escitalopram 10 mg tablet - TAKE ONE TABLET EVERY DAY (Qty: (90) tablet Refills: 1 Pharmacy: NEW
RIVER HEALTH FAYETTEVILLE PHARMACY

7. Gout
M10.9: Gout, unspecified

8. Gastroesophageal reflux disease without esophagitis
K21.9; Gastro-esophageal reflux disease without esophagitis
@ pantoprazole 40 mg tablet,delayed release - TAKE ONE TABLET EVERY DAY Qty: (90) tablet Refills: 3
Pharmacy: NEW RIVER HEALTH FAYETTEVILLE PHARMACY

Discussion Notes
Continued f/u with consultants as scheduled



athena 11-01-2023 12:49 PM ET 611-201294962 ba 12 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Return to Office
e to see Billy Cole, DO at AccessHealth Bill Baker Way on or around 04/12/2024
¢ Billy Cole, DO for BF EST/New 30 Fasting at AccessHealth Bill Baker Way on 04/12/2024 at 08:00 AM
Encounter Sign-Off
Encounter signed-off by Billy Cole, DO, 10/12/2023,

Encounter performed and documented by Billy Cole, DO
Encounter reviewed & signed by Billy Cole, DO on 10/12/2023 at 9:07am



athena 11-01-2023 12:49 PM ET 611-201294962 ba 13 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)



athena 11-01-2023 12:49 PM ET 611-201294962

pa 14 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503

SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Encounter Date: 04/18/2023
Patient
Name SCRUGGS, SANDRA (71yo, F) ID# Appt. Date/Time 94/1/2023 09:00AM
416044

DOB 11/24/1951 Service Dept.

AccessHealth Bill Baker Way
Provider BILLY COLE, DO
Insurance Med Primary: MEDICARE-WV (MEDICARE)
Insurance # ; 2YU5N74PX52
PCP ; COLE, BILLY J, Il
Referring Provider Name : COLE, BILLY J, Il
Employer Name : S AND V
Med Secondary: BANKERS FIDELITY (MEDICARE SUPPLEMENT)
Insurance # ; 6160900649
Policy/Group # : PLAN F
PCP ; COLE, BILLY J, Il
Referring Provider Name : COLE, BILLY J, Il
Employer Name : S AND V
Med : MEDICARE-W - PART A - RHC-FQHC (MEDICARE)
Insurance # : 2YU5N74PX52
PCP ; COLE, BILLY J, Il
Referring Provider Name : WOLFE, ROY R, JR
Employer Name ; S AND V
Prescription: CVS|CAREMARK - Member is eligible. details

Chief Complaint
6 month follow up, fasting. agarrick LPN

Patient's Care Team
Primary Care Provider (Primary Insurance): COLE, BILLY J, Il; 202 BILL BAKER WAY, BECKLEY, WV 25801-2812,
Ph (304) 252-8555, Fax (304) 254-9810

Referring Provider (Primary Insurance): COLE, BILLY J, Il: 202 BILL BAKER WAY, BECKLEY, WV 25801-2812, Ph
(304) 252-8555, Fax (304) 254-9810

Referring Provider (Reference Package): WOLFE, ROY R, JR: 410 CARRIAGE DR, BECKLEY, WV 25801-2806, Ph
(304) 255-1541, Fax (304) 253-7067

Patient's Pharmacies
NEW RIVER HEALTH FAYETTEVILLE PHARMACY (ERX): 217 W MAPLE AVE, FAYETTEVILLE, WV 25840, Ph
(304) 574-3991, Fax (304) 574-3651
KROGER PHARMACY 02900780 (ERX): 411 MALL RD, OAK HILL, WV 25901, Ph (304) 465-0321, Fax (304) 469-8892
Vita : Be 2 : oe a ike oe is

Ht: 5 ft 7 in Stated Wt: 252 Ibs With BMI: 39.5 04/18/2023
O4/18/ 2023 09:29 clothes 64/18/2023 99:29 am
am 09:29 am

BP: 124/72 sitting L Pulse: 54 bom regular RR: 18 64/18/2023
arm 04/18/2023 04/16/2023 09:25 09:29 am
09:29 am ait

T: 98.1 F° temporal O2Sat: 95% Room Air at

artery 04/18/2023 Rest 04/18/2023
09:29 am 05:36 am

Allergies

Allergies not reviewed (last reviewed 02/09/2021)
BACTRIM: Flushing (Moderate)
NO KROWN SLUERGIES

Medications



athena 11-01-2023 12:49 PM ET 611-201294962 pq 15 of 18

Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Reviewed Medications

acyclovir 800 mg tablet 05/27/21 filled
TAKE ONE TABLET 5 times a day for 7 days

aspirin 81 mg tablet,delayed release 03/20/18 entered
Take 1 tablet(s) every day by oral route.
Internal Note: OTC per cardiologist

colchicine 0.6 mg tablet 10/18/22 filled
TAKE ONE TABLET BY MOUTH THREE TIMES DAILY

ergocalciferol (vitamin D2) 1,250 mcg (50,000 unit) capsule 03/07/23 filled
TAKE ONE CAPSULE BY MOUTH once weekly

escitalopram 10 mg tablet 04/17/23 filled
TAKE ONE TABLET BY MOUTH EVERY DAY

glimepiride 4 mg tablet 01/11/23 filled
TAKE ONE TABLET BY MOUTH TWICE DAILY

iHealth COVID-19 Antigen Rapid Home Test kit 03/31/23 filled
AS DIRECTED
Januvia 100 mg tablet 04/17/23 filled

TAKE ONE TABLET BY MOUTH EVERY DAY

lisinopril 5 mg tablet 04/17/23 filled
TAKE ONE TABLET BY MOUTH EVERY DAY

metoprolol succinate ER 50 mg tablet,extended release 24 hr 01/11/23 filled
TAKE ONE TABLET EVERY DAY
multivitamin 03/20/18 entered

Internal Note: otc

nitrofurantoin monohydrate/macrocrystals 100 mg capsule 02/06/23 filled
TAKE ONE CAPSULE BY MOUTH TWICE DALLY take with food or a meal

pantoprazole 40 mg tablet,delayed release 02/14/23 filled
TAKE ONE TABLET EVERY DAY

pioglitazone 30 mg tablet 03/07/23 filled
TAKE ONE TABLET BY MOUTH EVERY DAY

triamcinolone acetonide 0.1 % dental paste 02/22/22 filled
Apply 3 times a day by dental route as directed.

Vaccines
Vaccines not reviewed (last reviewed 02/09/2021)



athena 11-01-2023 12:49 PM ET 611-201294962 bq 16 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Bi i

Problems

Reviewed Problems

® Chronic kidney disease - Onset: 02/22/2022

® Gastroesophageal reflux disease without esophagitis - Onset: 02/22/2022

@ Depressive disorder - Onset: 06/21/2018

e Vitamin D deficiency - Onset: 03/20/2018

@ Anemia - Onset: 06/19/2017

® Influenza-like symptoms - Onset; 03/16/2017

@ Sciatica - Onset: 04/05/2016 - Entered By: Billy) Cole Il, DO; Signed By: Billy J Cole Il, DO

e Disorder of pelvic region of trunk - Onset: 01/14/2014 - Entered By: Roy R Wolfe MD; Signed By: Roy R Wolfe MD

@ Dyspnea - Onset: 09/25/2014 - Entered By: Billy] Cole Il, DO; Signed By: Billy J Cole Il, DO

e Mixed hyperlipidemia - Onset: 10/16/2012 - Entered By: Billy J Cole Il, DO; Signed By: Billy J Cole Il, DO

e Adult health examination - Onset: 02/25/2009 - Entered By: Roy R Wolfe MD; Signed By: Roy R Wolfe MD

® Knee pain - Onset: 09/23/2015 - Entered By: Billy J Cole Il, DO; Signed By: Billy J Cole Il, DO

© Type 2 diabetes mellitus without complication - Onset: 02/26/2016 - Entered By: BillyJ Cole Il, DO; Signed By:
Billy J Cole Il, DO

® Acute vulvitis - Onset: 01/12/2016 - Entered By: David M Rainey MD; Signed By: David M Rainey MD

e Hypertensive disorder - Onset: 10/17/2007 - Entered By: Billy] Cole Il, DO; Signed By: Billy] Cole Il, DO

® Obesily - Onset: 10/17/2007 - Entered By: Billy J Cole Il, DO; Signed By: Billy J Cole Il, DO

@ Decreased blood leukocyte number - Onset: 10/20/2011 - Entered By; Tammy Morgan LPN; Signed By; Billy J
Cole Il, DO

e Inadequate immune status - Onset: 10/17/2007 - Entered By: Billy] Cole Il, DO; Signed By: Billy] Cole Il, DO

@ History of polyp of colon - Onset: 10/17/2007 - Entered By: Billy} Cole Il, DO; Signed By: Billy J Cole Il, DO

e Hyperglycemia - Onset; 02/23/2016 - Entered By: Billy] Cole Il, DO; Signed By: Billy] Cole Il, DO

e Gynecologic examination - Onset: 05/13/2010 - Entered By: Roy R Wolfe MD; Signed By: Roy R Wolfe MD

04/05/2016: GLUCOSE INTOLERANCE, HX OF (V12.2) ; OnsetDate: 10/17/2007; Entered By: Billy J Cole Il, DO;
Signed By: Billy J Cole Il, DO

Family History
Family History not reviewed (last reviewed 07/09/2019)

he patient indicates family history of lung cancer (brother), heart disease (father), coronary artery disease

(father). Other family history includes: CA involving neck-mother. No family history of anesthesia problems
Social History

Social History not reviewed (last reviewed 10/18/2022)

Diet and Exercise

What type of diet are you following?:; Regular

What is your exercise level?: Moderate

Marriage and Sexuality

What is your relationship status?: Widowed

Are you sexually active?: No

Do you use protection during sex?: No

How many children do you have?: 3

Activities of Daily Living

Are you able to walk?: Yes: walks without restrictions

Education and Occupation

Are you currently employed?: No

What is your occupation?: RETIRED

Substance Use

Do you or have you ever smoked tobacco?: Never smoker

How much tobacco do you chew?: none

Which illicit or recreational drugs have you used?: NONE

What was the date of your most recent tobacco screening?: 10/18/2022

What is your level of alcoho! consumption?: None

What is your level of caffeine consumption?: Occasional

Home and Environment

Are you passively exposed to smoke?: No

Do you use sunscreen routinely?; Yes

Other

Education: 12

Legally blind in one or both eyes?: No

Live alone or with others?: alone

Performs monthly self-breast exam?: Y

Seat belts used routinely: Yes



athena 11-01-2023 12:49 PM ET 611-201294962 ba 17 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

Smoke alarm in home: Yes

General stress level: Medium

Advance Directive

Do you have an advance directive?: Yes (Notes: Full Code)

Is blood transfusion acceptable in an emergency?: Yes

Gender Identity and LGBTQ Identity

Gender identity: Identifies as Female

Assigned sex at birth: Female

Sexual orientation: Straight or heterosexual

Negative tobacco, alcohol, or drugs. Homemaker, No disability or workers compensation. .Widowed,

Surgical History

Surgical History not reviewed (last reviewed 05/24/2021)
Colonoscopy

Colonoscopy, 2014, 2017
TVH BSO secondary to uterine prolapse per Dr. Wolfe, 12/05,

Anterior colporrhaphy, cystoscopy, Dr. Wolfe 1/15/14.

GYN History

GYN History not reviewed (last reviewed 07/09/2019)
LMP: Unknown.

Menses Monthly: N.

Age at First Child; 20.

Current Birth Control Method: Hysterectomy.

If Post Menopausal, Age at Menopause: 54.

ECTOPICS MULTIPLE

Past Medical History

Past Medical History not reviewed (last reviewed 07/09/2019)
Anemia: ¥

GI Problems: Y - diverticulosis

Notes: hypertension,

borderline Type II DM

cold sores

normal DEXA 5/8/17.

HPI

Patient presents today for routine clinical follow up regarding chronic medical conditions as outlined, In the
interim since last visit reports tolerating maintenance medications without side effect. No report of fever or
chills. Denies interest in statin therapy at this time. Discussed previous Al1C of 6.1. Recent oncology notes
reviewed.

ROS

Patient reports GERD. She reports no fever and no night sweats. She reports no chest pain and no arm pain on
exertion, She reports no cough, no wheeang, and no shortness of breath. She reports no incontinence and no
difficulty urinating. She reports no loss of consciousness and no seizures. She reports no swollen glands and no
bruising.

Physical Exam
Constitutional: General Appearance: well-nourished and well-developed. Level of Distress: NAD.

Psychiatric: Mental Status: normal mood and affect,

Head: Head: normocephalic and atraumatic.

Eyes: Pupils: PERRLA. EOM: EOMI.

ENMT: Ears: TMs clear. Nose: nares patent. Oropharynx: no erythema.
Neck; Neck: supple. Lymph Nodes: no cervical LAD.

Lungs: Auscultation: breath sounds normal and good air movement.
Cardiovascular: Heart Auscultation; normal $1 and $2 and RRR.

Abdomen: Bowel Sounds: normal. Inspection and Palpation: soft, non-distended, and no tenderness. Liver:



athena 11-01-2023 12:49 PM ET 611-201294962 bq 18 of 18
Community Health Systems Inc + 202 Bill Baker Way, BECKLEY WV 25801-3503
SCRUGGS, Sandra M (id #416044, dob: 11/24/1951)

non-tender and no hepatomegaly. Spleen: non-tender and no splenomegaly.

Musculoskeletal:: Motor Strength and Tone: normal tone and motor strength. Joints, Bones, and Muscles: no
bony abnormalities. Extremities: no edema.

Neurologic: Cranial Nerves: grossly intact.
Assessment / Plan

1. Type 2 diabetes mellitus without complication
E11.9: Type 2 diabetes mellitus without complications
COMPREHENSIVE METABOLIC PANEL

CBC W/ AUTO DIFFERENTIAL

LIPID PROFILE

%ALCWB

2. Hypertensive disorder
110: Essential (primary) hypertension

3. Vitamin D deficiency
E55.9: Vitamin D deficiency, unspecified
e VITAMIN D

4. Mixed hyperlipidemia
E78.2: Mixed hyperlipidemia

5. Anemia
D64.9: Anemia, unspecified

6. Depressive disorder
F32.9; Major depressive disorder, single episode, unspecified

7. Gout
M10.9: Gout, unspecified

Discussion Notes
Continue Rx as outlined

Return to Office
* to see Billy Cole, DO at AccessHealth Bill Baker Way on or around 10/18/2023

Encounter Sign-Off
Encounter signed-off by Billy Cole, DO, 04/18/2023.

Encounter performed and documented by Billy Cole, DO
Encounter reviewed & signed by Billy Cole, DO on 04/18/2023 at 9:5lam

I have uploaded a medical record file. Can you analyze it and determine if the file is suitable for:

CGM (Continuous Glucose Monitoring) or
Brace (Knee/Lower Back)?
Please provide a yes or no answer for each option, followed by a brief explanation of why it is suitable or not (e.g., due to insulin dependency, blood sugar fluctuations for CGM, or musculoskeletal issues for a brace).