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Correctional Managed Care

PROVIDER CHRONIC CLINIC NOTE

Individualized Treatment Plan

Patient Name: GREEN, MARCUS TDCJ#: 1118?^ iiPatel2/12/2014 12:34 Facility: NEAL (KN)

Age: 46 year Race: B Sex: male

Most recent vitals from 9/2/2014: BP: 106/71 (Sitting); Wt: 158 Lbs.; Height: 68 In.; Pulse: 70 (Sitting); Resp: 20 /

min; Temp: 97.8 (Oral) BMI: 24

CURRENT PEAK FLOWS: PF1:; PF 2: ; PF 3:

PRIOR PEAK FLOWS: PF1 : ; PF 2: ; PF 3:

DOI: 9/13/2002

Allergies: NO KNOWN ALLERGIES

Patient Language: ENGLISH Name of interpreter, if required:

CURRENT MEDICATION:

ATORVASTATIN 10MG TABLET

1 TABS ORAL DAILY for 30 Days KOP

ORDERING FACILITY: NEAL (KN)

ORDERING PROVIDER': BASSE, DAVID R

LAST DATE GIVEN KOP: 10/07/2014 10:14:11

REFILLS: 8/11

EXPIRATION DATE: 3/29/2015 01:01:00PM

Ch ronic Clinic (select a 1 applicable):

Asthma/COPD CAD CHF ESLD Active Hepatitis B HCV HIV HTN

Hyperlipidemia IDDM NIDDM Active TB Seizure Close Monitoring

Miscellaneous:

% TDCJ Regular. HSM-82 signed 10/08/10 for DFH

%

COMPLIANCE:

Medication:

Diet:

Exercise:

SUBJECTIVE: Patient NO SHOWED for today's CCC appointment. EMR reviewed, patient last

seen in CCC on 10/28/13 by this Provider. He also NO SHOWED his CCC appt. on 11/10/14.

OBJECTIVE:

block, Abnormal ECG.

02/14/13 ECG: NSR w/sinus arrhythmia, Incomplete RBBB, left anterior fascicular

03/24/14 UA: WNL; CMP: WNL; Lipids: LDL 100H; TSH 1.870

03/19/13 UA; WNL; CBC: WNL; CMP: Sodium 146H; Lipids: LDL 104H; TSH 1.510

03/30/12 CXR 1V: Normal examination.

Pulmonary

Heart

Lung fields clear to auscultation

RRR without murmur or gallop PMI nl placement and magnitude

Extremities

No clubbing cyanosis or edema

Abdomen

Nl bowel sounds in all 4 quadrants Soft, non-tender to palpation

Vascular

Upper exts intact Carotids intact w/o bruit

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