Court Opinion

ID: 4048943
Source: CourtListenerOpinion
Date Created: 2016-09-29 00:48:25.764503+00
Date Added: 2024-06-11T14:26:17.231894
License: Public Domain

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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                        ORDERING FACILITY: NEAL (KN)                     LAST DATE GIVEN KOP: 10/07/2014 10:14:11
 1 TABS ORAL DAILY for 30 Days KOP               ORDERING PROVIDER': BASSE, DAVID R               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:
COMPLIANCE:
         Medication:
         Diet:                   % TDCJ Regular. HSM-82 signed 10/08/10 for DFH
           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:                  02/14/13 ECG: NSR w/sinus arrhythmia, Incomplete RBBB, left anterior fascicular
block, Abnormal ECG.
                            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
        Lung fields clear to auscultation
Heart
         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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