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CONDITION SPECIFIC MEDICAL CHRONOLOGY

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.

SOCIAL HISTORY FAMILY HISTORY


Hx of 3 ppd for 20 years Quit in
Smoking March 14, 2018 Father Father – heart disease, hypertension and arthritis
2000
Alcohol March 14, 2018 Socially only wine Mother Heart disease
Marital status March 14, 2018 Married 50 year Brother Diabetes and Parkinson’s
One son age 45 and one
Children, ages March 14, 2018 Son Acute leukemia
daughter age 42
CURRENT MEDICATIONS PERSONAL MEDICAL HISTORY
Atorvastatin, aspirin, Lexapro, Calcium carb
Arthritis, total right knee replacement, hearing loss, essential tremor,
elemental, cyanocobalamin, cholecalciferol,
March 14, 2018 mild cognitive impairment, OSA on CPAP, pseudophakia, bilateral
donepezil, fish oil Omega-3 fatty acid, multivitamin PO
cataract surgery, vitamin B12 deficiency and back pain.
and Zolpidem

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.

Mild cognitive impairment with memory loss


(Amnestic MCI), MOCA 25/30. Essential tremor.
December 30, 2016 1245789013 St Laurent Hospital Neurology Consult Exam revealed resting tremor present bilaterally,
decreased vibration at the toes as well as
areflexia at the ankles. TSH and folic acid WNL.

Vitamin B12 deficiency. Vitamin B12 283 (210-


January 4, 2017 1245789013 St Laurent Hospital Neurology Follow up
920). Started on Cyanocobalamin given.

Neuropsych testing confirmed mild cognitive


January 17, 2017 1245789013 St Laurent Hospital Neurology Follow up impairment. Sx too mild to qualify for dementia
diagnosis. – Vitamin B12 537 (200-1100).

Memory slightly improved with B12 supplements Records of 2018 are


July 28, 2017 1245789013 St Laurent Hospital Neurology Follow up
and Aricept. missing
Pericarditis
Pericarditis, cough chest pain. CXR showed
hypoinflation with mild basilar atelectasis. Sed
July 21, 2015 1045712471 Julian Huges Hospital Cardiology Consult
rate 67 (0-20), HGB 11.4 (12.6-17.0). EKG revealed
NSR. RBBB.
Chest pain, palpitation and SOB. Pericardial
effusion. CT chest revealed mild pericardial fluid
August 25, 2015 1045712471 Julian Huges Hospital Cardiology Consult
or thickening. No acute airspace disease seen.
ANA screen negative. Sed rate 63 (0-20)

Acute idiopathic pericarditis, improved. Echo


showed impaired relaxation pattern of diastolic
Records of 2018 are
November 3, 2015 1045712471 Julian Huges Hospital Cardiology Consult filling suggestive of grade I diastolic dysfunction.
missing
Estimated LVEF 50-55%. Trivial pericardial
effusion. Mildly enlarged right ventricle.

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.

Feeling energized since starting PAP therapy.


January 31, 2018 1579246780 Lady Marion Health Center Pulmonology Follow up
Data from PAP showed average AHI of 19.2.

OSA, on CPAP. Not refreshed after waking up.


Issues with mask leakage. Estimated AHI 44.2.
March 14, 2018 1579246780 Lady Marion Health Center Pulmonology Consult
Pressure adjusted to 12-18 cm. Instructed on
weight loss measures.

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.

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