15231
Office Visit Note
encounter_id
07/29/2005
Subodh
Agrawal
M.D.
BA0365228
Athens Heart Center
logo_2.gif
2005 Prince Avenue
Athens
GA
30606
706-208-9700
706-208-8258
706-208-0806
222222
222-22-2222
Prabhakar
Shyam
P
Mr.
Jr.
Sham
05/07/1970
33
M
706-254-6666
706-999-9999
333Dogs Drive
Apt 604
ATHENS
GA
30606
333Dogs Drive
Apt 604
ATHENS
GA
30606
M
secondary
Asian
Hindu
False
False
English
full time
Athens Heart Center
2005 Prince Avenue
2005 Prince Avenue
Athens
MT
30605
706-208-9700
1
2
MEDICARE PART B
MEDICAL CLAIMS Jon
PO BOX 3018
SAVANNAH
GA
31402
877-567-7271
123
Prabhakar
P
Shyam
222-22-2222
2
550
AETNA LIFE INS CO
MEDICAL CLAIMS
PO BOX 5569
AKRON
OH
44334
800-533-7831
90000023
Prabhakar
P
Shyam
222-22-2222
egetert
g34534534
3
1093
AETNA
MEDICAL CLAIMS
P.O. BOX 9070
TYLER
TX
75711
800-353-9158
4
909090
JON
Almand
David
M.D.
(770) 922-3023
Emergency Medicine
Gibson
Timothy
M.D.
706-227-2027
706-227-2433
Family Practice
Alarcon
Alfredo
(404) 256-5212
Carson's
706-754-4128
Commerce Drug Company
706-335-3111
drug
AMPICILLIN
moderate
Rash
environment
IVP DYE
current
fatal
drug
PENICILLIN
uncertain
severe
drug
TYLENOL
past
mild
hives
SKA
- Backache unspecified
- Hypercholesterolemia
- Chest Pain
- Hypertension
- Shortness of Breath.
- Dilated cardiomyopathy
- Abnormal ECG
- Acute Glomerulonephritis with other specified Pathological Lesion in Kidney
- Something
- Chest Pain
271
93735
ANALYZE PACEMAKER SYSTEM
IP
E
R
False
False
272
75722
ARTERY X-RAYS, KIDNEY
IP
E
R
False
False
206
152792
Intropin injection
40
mg/ml
1
inj
qd
1 inj qd
0
0
intravenous
0
2118
152791
Tasmar tablets
200
mg
1
tab
qd
1 tab qd
0
0
oral
0
152794
206
Intropin injection
40
mg/ml
1
inj
qd
1 inj qd
0
0
intravenous
0
152795
303
Advil
100
mg/5ml
1
susp
qd
1 susp qd
0
0
oral
0
Agrawal
Subodh
152793
2118
Tasmar tablets
200
mg
1
tab
qd
1 tab qd
0
0
oral
0
152796
4
Tylenol extended release
650
mg
1
tab er
qd
1 tab er qd
0
0
oral
0
Agrawal
Subodh
.
<a cancelBubble=true onclick='changMe("hpiCCConditionReason", this)'>Follow</a> <a cancelBubble=true onclick='changMe("hpiCCConditionCondition", this)'>up of abdominal aortic aneurysm, angina, aortic stenosis, aortic valve replacement, dental clearance, and atrial fibrillation</a> status post <a cancelBubble=true onclick='changMe("hpiCCConditionTest", this)'>abnormal stress test</a>.
Cardiac clearance for <a cancelBubble=true onclick='changMe("hpiCCCardiacClearanceReason", this)'>aneurysm removal</a>.
Follow up of recent hospitalization at <a cancelBubble=true onclick='changMe("hpiCCHospitalHospitalization", this)'>BJC - Commerce</a> for <a cancelBubble=true onclick='changMe("hpiCCHospitalReason", this)'>atrial fibrillation</a>.
Mr. Prabhakar is a 35 year old patient of Dr David Almand, Dr Timothy Gibson, and Dr Alfredo Alarcon.
He was <a cancelBubble=true onclick='changMe("hpiFollowUpAdmitted", this)'>admitted</a> <a cancelBubble=true onclick='changMe("hpiFollowUpLoc", this)'>to</a> <a cancelBubble=true onclick='changMe("hpiFollowUpER", this)'>Ty Cobb Memorial</a> by <a cancelBubble=true onclick='changMe("hpiFollowUpPhysician", this)'>Dr</a>. Alfredo Alarcon for bradycardia. He was found to have complete heart block. He was treated with mitral valve replacement. And he did not respond well. The patient was then transferred to Emory. He was admitted to Emory by Dr. Timothy Gibson for angina. He was found to have atrial fibrillation and complete heart block. He was treated with cholecystectomy and he responded well. The patient was then transferred to St. Mary's Hospital.
He is here today for follow up management of <a cancelBubble=true onclick='changMe("hpiActiveConditionsCondition", this)'>arrhythmia, atrial fibrillation, and ICD function</a>. Since his last visit <a cancelBubble=true onclick='changMe("hpiActiveConditionsProblems", this)'>new problems have</a> developed. He <a cancelBubble=true onclick='changMe("hpiActiveConditionsCompliance", this)'>is</a> taking his medications as prescribed. There appear to be <a cancelBubble=true onclick='changMe("hpiActiveConditionsMedSideEffects", this)'>possibly some</a> side effects related to the medications. Overall, he believes that his <a cancelBubble=true onclick='changMe("hpiActiveConditionsCondition", this)'>arrhythmia, atrial fibrillation, and ICD function</a> is <a cancelBubble=true onclick='changMe("hpiActiveConditionsControl", this)'>poorly controlled</a>. He is here today for follow up management of cardiomegaly and coronary artery disease. Since his last visit no new problems have developed. He is taking his medications as prescribed. There appear to be possibly some side effects related to the medications. Overall, he believes that his cardiomegaly and coronary artery disease is stable.
The chest pain is associated with <a cancelBubble=true onclick='changMe("hpiSympCPAssoc", this)'>itchy</a>. He reports that his chest pain is aggravated by <a cancelBubble=true onclick='changMe("hpiSympCPAggr", this)'>bending</a>. The chest pain is relieved by <a cancelBubble=true onclick='changMe("hpiSympCPRelv", this)'>belching</a>.
The patient reports this morning with her spell. Dizziness is associated with palpitations. He states that this symptom is aggravated by <a cancelBubble=true onclick='changMe("hpiSympDznsAggr", this)'>activity, bending, and high blood pressure</a>. The dizziness is relieved by <a cancelBubble=true onclick='changMe("hpiSympDznsRlvd", this)'>sitting down</a>.
He states that the palpitations are aggravated by <a cancelBubble=true onclick='changMe("hpiSympPalpAggr", this)'>position changes</a>.
<a cancelBubble=true onclick='changMe("pfsMedTraumaDesc", this)'>No past trauma</a>.
Mr. Prabhakar has a <a cancelBubble=true onclick='changMe("pfsFamilyHistoryCADChk", this)'>positive family history of coronary artery disease</a>.
The patient's <a cancelBubble=true onclick='changMe("pfsRelation", this)'>crap2</a> is <a cancelBubble=true onclick='changMe("pfsIsLiving", this)'>deceased</a>.
Mr. Prabhakar resides in a <a cancelBubble=true onclick='changMe("pfsHomeType", this)'>apartment</a> home. He is lives with her daughter to hkkl. He has <a cancelBubble=true onclick='changMe("pfsSocialSupport", this)'>excellent</a> social support.
Patient reports <a cancelBubble=true onclick='changMe("rosGenFeverFreq", this)'>daily</a> <a cancelBubble=true onclick='changMe("rosGenFeverSymp", this)'>chills</a> associated with <a cancelBubble=true onclick='changMe("rosGenFeverAssocSymptom", this)'>chest pain</a>. These symptoms <a cancelBubble=true onclick='changMe("rosGenFeverPCP", this)'>have not</a> been worked up by his primary care physician.
Patient reports recent unintentional weight <a cancelBubble=true onclick='changMe("rosGenWtWt", this)'>gain</a>. This problem <a cancelBubble=true onclick='changMe("rosGenWtPcp", this)'>has not</a> been worked up by his primary care physician.
!!error!!
Patient reports recent onset of <a cancelBubble=true onclick='changMe("rosGenSleepSev", this)'>severe</a> <a cancelBubble=true onclick='changMe("rosGenSleepSymptom", this)'>trouble falling asleep</a>. This problem <a cancelBubble=true onclick='changMe("rosGenSleepPcp", this)'>has</a> been working up by his primary care physician.
The patient reports <a cancelBubble=true onclick='changMe("rosHEENTHeadacheMgrn", this)'>migraine</a> headache.
Patient denies dysuria.
Patient complains of <a cancelBubble=true onclick='changMe("rosGUHemaOnset", this)'>recent onset</a> of hematuria.
Patient complains of <a cancelBubble=true onclick='changMe("rosGUHesiOnset", this)'>chronic presence</a> of hesitancy.
Patient denies dribbling.
Patient complains of <a cancelBubble=true onclick='changMe("rosGUBurnOnset", this)'>recent onset</a> of burning with urination.
Patient reports history of blood transfusion as a result of <a cancelBubble=true onclick='changMe("rosHemaTransReason", this)'>anemia</a>. Patient reports he <a cancelBubble=true onclick='changMe("rosHemaTransReact", this)'>did</a> experience a transfusion reaction.
Patient reports <a cancelBubble=true onclick='changMe("rosSkinPruOnset", this)'>frequent</a> of <a cancelBubble=true onclick='changMe("rosSkinPruSeverity", this)'>mild</a> pruritis associated with <a cancelBubble=true onclick='changMe("rosSkinPruAssocSymp", this)'>weakness</a>. This problem <a cancelBubble=true onclick='changMe("rosSkinPruWorkedUp", this)'>has been worked up by the patient's dermatologist</a>.
Patient reports a <a cancelBubble=true onclick='changMe("rosSkinLesionsSize", this)'>walnut-sized</a> <a cancelBubble=true onclick='changMe("rosSkinLesionsType", this)'>keratosis</a> that is located <a cancelBubble=true onclick='changMe("rosSkinLesionsLoc", this)'>over the entire body</a>.
Patient admits to a history of <a cancelBubble=true onclick='changMe("rosPsychProb", this)'>panic attacks</a> that is currently <a cancelBubble=true onclick='changMe("rosPsychManagement", this)'>managed by common mental health</a>. His symptoms are felt to be <a cancelBubble=true onclick='changMe("rosPsychControl", this)'>not under control</a>.
Height: <a cancelBubble=true onclick='changMe("physVitalsHeight", this)'>170</a> Weight: <a cancelBubble=true onclick='changMe("physVitalsWeight", this)'>280</a> lbs BP: <a cancelBubble=true onclick='changMe("physVitalsBP", this)'>120/80</a> Pulse: <a cancelBubble=true onclick='changMe("physVitalsPulse", this)'>80</a> Respirations: <a cancelBubble=true onclick='changMe("physVitalsRespirations", this)'>2</a>0
The patient <a cancelBubble=true onclick='changMe("physicalExamGenAgeAge", this)'>appears the stated age</a>.
\nMODEL: Pacesetter 5346 SERIAL # : 536822.\n\n\n
<a cancelBubble=true onclick='changMe("assessProblemsStatus", this)'>Abdominal</a> <a cancelBubble=true onclick='changMe("assessProblemsProblem", this)'>aortic aneurysm</a>, <a cancelBubble=true onclick='changMe("assessProblemsControl", this)'>asymptomatic</a>. .
<a cancelBubble=true onclick='changMe("assessSymptomsPresent", this)'>Abdominal pain</a> appears to be secondary to <a cancelBubble=true onclick='changMe("assessSymptomsActiveCond", this)'>angina</a>.
Jon is <a cancelBubble=true onclick='changMe("678", this)'>cool guy, guy, nice guy, and super coder</a>.
This throat looks <a cancelBubble=true onclick='changMe("throat", this)'>n</a>ormal