Professional Documents
Culture Documents
Format: Level 2
Patient: John Doe Client: Law Offices of Laurel Hardy & Associates
Chron
Client Case Ref:
DOB: October 20, 1925 Docket / Case#: 23456.4567.345
342356
Current Age 93 Social Security Number
473-89-1457
Gender Male Insurance Carrier The New American Insurance Inc.
Date Provider / NPI Source Document Type File Name: Page Chart Treatment Record Comments
Memory Loss
June 23, 2015 1245789013 St Laurent Hospital Neurology Consult Difficulty finding words, Anomic aphasia
Some difficulty with memory, more forgetful. Brain
MRI revealed no acute intracranial process. No
enhancing lesions. Chronic small vessel ischemia
and involutional changes. MRA revealed no
evidence of any significant stenosis. There is
July 7, 2015 1245789013 St Laurent Hospital Neurology Consult
development variation of dominant right, small left
vertebral arteries as well as what appears to be a
congenitally absent A1 segment of the right
anterior cerebral artery. No specific Tx
recommended.
Sleep Apnea
Sleep concern and sleep disordered breathing.
Suspected sleep apnea and snoring. Sleep study
on 11/06/2017 revealed severe obstructive sleep
November 3, 2017 1579246780 Lady Marion Health Center Pulmonology Consult
apnea with AHI of 72.8/hour. No REM sleep was
seen on this study. Treatment with CPAP. CPAP
titrated to level 12.
Back Pain
Chronic midline low back pain w/o sciatica.
January 31, 2018 1879632014 Lakewood Healthcare Orthopedic Consult
Lumbar x-ray ordered.
L-spine x-ray showed multilevel degenerative
February 12, 2018 1287698532 Lakewood Healthcare X-ray report. changes of the lumbar spine. Recommended to
continue with PT and Tylenol p.r.n.