Waiters Tommie Alajandro 1757 1068397665 Awp PDF

Medical Record
WAITERS, TOMMIE ALAJANDRO DOB: 18 Aug 1970 SSN: ***-**-1757 DoD ID: 1068397665 Created: 27 Dec
2019
MEDICAL RECORD
For
WAITERS, TOMMIE ALAJANDRO
Report Criteria
From: 18 Aug 1970 To: 27 Dec 2019

Operator: ANKEBRANT,EDWARD C
Created On 27 Dec 2019 13:52:21
at Martin ACH, Fort Benning, GA
Non-Sensitive Information Report: Requested
Report Summary
Sections Domain Requested Record Counts Warnings

Allergies  1 0
Problems  78 0
Diagnosis History  248 0
Medications  156 0
Procedures  25 0
Family History  18 0
Resulted Labs  190 0
Radiology  33 0
Immunizations  30 0
Previous Encounters  159 0
Clinical Notes  39 0
Vitals  77 0
*0
*Report generated with no warnings.
2019
THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 1974 (PL-93-579). UNAUTHORIZED ACCESS TO THIS
INFORMATION IS A VIOLATION OF FEDERAL LAW. VIOLATORS WILL BE PROSECUTED. Page 1
Medical Record
2019
Table Of Contents
MEDICAL RECORD .....................................................................................................................................................1
Report Criteria............................................................................................................................................................1
Report Summary ........................................................................................................................................................1
Table Of Contents ...........................................................................................................................................................2
Demographics ...............................................................................................................................................................13
Allergies........................................................................................................................................................................14
NKDA .................................................................................................................................................................14
Problems .......................................................................................................................................................................15
Active Problems .......................................................................................................................................................15
Male erectile disorder on 29 Jul 2019 .................................................................................................................15
MESENTERIC PANNICULITIS on 04 Jun 2013..............................................................................................15
Patient Counseling: on 16 Nov 2012...................................................................................................................15
BURSITIS TROCHANTERIC on 19 Sep 2012 .................................................................................................15
Visit for: military services physical accession on 09 Jul 2012 ...........................................................................15
Counseling About Travel on 09 May 2012 .........................................................................................................15
GASTRITIS on 28 Apr 2012 ..............................................................................................................................15
HYPERGLYCEMIA on 03 Apr 2012 ................................................................................................................15
MCKENZIE POSTERIOR DERANGEMENT SYNDROME on 29 Mar 2012 ................................................16
Patient Counseling Medical Management Five To Eight Patients on 27 Jan 2012 ............................................16
NONORGANIC SLEEP APNEA OBSTRUCTIVE on 25 Jan 2012 .................................................................16
NONORGANIC SLEEP DISORDERS on 15 Dec 2011....................................................................................16
HYPERLIPIDEMIA on 03 Nov 2011 ................................................................................................................16
OVERWEIGHT on 02 Nov 2011 .......................................................................................................................16
HYPERTENSION (SYSTEMIC) on 02 Nov 2011 ............................................................................................16
HYPOGONADISM on 24 Feb 2011 ..................................................................................................................16
ASTIGMATISM on 10 Feb 2011 .......................................................................................................................16
MALE ERECTILE DISORDER on 09 Feb 2011...............................................................................................17
Snoring on 09 Feb 2011 ......................................................................................................................................17
Visit for: vasectomy status on 15 Nov 2010 .......................................................................................................17
Abdominal pain in the left upper belly (LUQ) on 28 Sep 2010..........................................................................17
LUMBAGO on 22 Oct 2009 ...............................................................................................................................17
MAJOR DEPRESSION, RECURRENT IN PARTIAL REMISSION on 27 Apr 2009 ....................................17
ADJUSTMENT DISORDER WITH DEPRESSED MOOD on 08 Apr 2009 ...................................................17
REFRACTIVE ERROR - HYPERMETROPIA on 01 Apr 2009.......................................................................17
GENERALIZED ANXIETY DISORDER on 27 Mar 2009...............................................................................17
MAJOR DEPRESSION, SINGLE EPISODE MODERATE on 27 Mar 2009...................................................18
Abdominal pain around the belly button (periumbilical) on 18 Mar 2009 .........................................................18
ASSESS PATIENT CONDITION WORK-RELATED OCCUPATIONAL DISEASE on 11 Mar 2009.........18
ANXIETY DISORDER NOS on 11 Mar 2009 ..................................................................................................18
MAJOR DEPRESSION, SINGLE EPISODE on 11 Mar 2009..........................................................................18
Blood Pressure Isolated Elevated on 26 Jan 2009...............................................................................................18
Visit for: military services physical on 26 Jan 2009 ...........................................................................................18
Visit for: occupational health / fitness exam on 21 Jan 2009..............................................................................18
Body Mass Index on 14 Jan 2009 .......................................................................................................................18
Patient Education - Dietary on 14 Jan 2009 ........................................................................................................19
GASTRITIS DUE TO H. PYLORI on 23 Dec 2008 ..........................................................................................19
HELICOBACTER PYLORI (H. PYLORI) INFECTION on 23 Dec 2008 .......................................................19
Visit for: preoperative exam on 16 May 2008 ....................................................................................................19
Visit for: follow-up exam on 11 Apr 2008..........................................................................................................19
TESTICULAR NEOPLASM on 20 Mar 2008 ...................................................................................................19
2019
Medical Record
2019
Abdominal pain on 20 Mar 2008 ........................................................................................................................19

Other Physical Therapy on 05 Feb 2008 .............................................................................................................19
Joint pain, localized in the shoulder on 31 Jan 2008...........................................................................................19
CERVICALGIA on 31 Jan 2008 ........................................................................................................................20
Visit for: screening exam on 09 Jan 2008 ...........................................................................................................20
FOLLICULITIS on 09 Jan 2008 .........................................................................................................................20
MIGRAINE HEADACHE on 11 Oct 2007 ........................................................................................................20
BACKACHE on 07 Jun 2007 .............................................................................................................................20
Inactive Problems.....................................................................................................................................................20
PROBLEM CONCERNING BEHAVIOR OF CHILD on 13 Nov 2013 ...........................................................20
Visit for: screening exam cardiovascular disorders on 27 Nov 2012 .................................................................20
Visit for: respiratory exam on 16 Nov 2012 .......................................................................................................21
Vaccines Prophylactic Need Against Viral Diseases on 13 Jul 2012 .................................................................21
Vaccine needed prophylactically against bacterial diseases on 13 Jul 2012.......................................................21
Need For Vaccination Poliomyelitis on 13 Jul 2012...........................................................................................21
Vaccines Prophylactic Need on 13 Jul 2012 .......................................................................................................21
ATYPICAL CHEST PAIN on 16 Jun 2012........................................................................................................21
Need For Vaccination Yellow Fever on 09 May 2012 .......................................................................................21
Need For Vaccination Typhoid on 09 May 2012................................................................................................21
Vaccines Prophylactic Need Against DTP on 09 May 2012 ..............................................................................21
SPRAIN LUMBAR on 26 Mar 2012 ..................................................................................................................21
VIRAL SYNDROME on 23 Jan 2012 ................................................................................................................22
ROUTINE HISTORY AND PHYSICAL on 02 Nov 2011 ................................................................................22
ABRASION OR FRICTION BURN on 14 May 2011 .......................................................................................22
Visit for: sterilization on 27 Oct 2010.................................................................................................................22
X-Ray on 18 Oct 2010 ........................................................................................................................................22
CONSTIPATION on 28 Sep 2010......................................................................................................................22
PANCREATITIS on 28 Sep 2010 ......................................................................................................................22
MULTIPLE BLISTERS on 25 Feb 2010............................................................................................................22
Nausea with vomiting on 13 Oct 2009................................................................................................................22
Observation For Suspected Condition on 21 Aug 2009......................................................................................23
RHINITIS on 03 Apr 2009..................................................................................................................................23
MARITAL PROBLEM on 11 Mar 2009 ............................................................................................................23
Aftercare Following Surgery Of Digestive System on 22 May 2008 .................................................................23
Visit for: administrative purpose on 28 Mar 2008 ..............................................................................................23
Laboratory Studies on 07 Feb 2008 ....................................................................................................................23
Headache on 08 Jul 2007 ....................................................................................................................................23
Visit for: refer patient without exam or treatment on 07 Jun 2007 .....................................................................23
Diagnosis History..........................................................................................................................................................24
Medications...................................................................................................................................................................36
Active Medications ..................................................................................................................................................36
Cancelled Medications .............................................................................................................................................37
Discontinued Medications........................................................................................................................................37
Expired Medications ................................................................................................................................................38
Procedures.....................................................................................................................................................................50
Family History ..............................................................................................................................................................54
Family medical history on 08 Aug 2019 .............................................................................................................54
No family history of supplemental HPI [use for free text] on 08 Aug 2019.......................................................54
No family history [use for free text] on 25 Jan 2018 ..........................................................................................54
Family history of test conclusions [Use for free text] on 01 Jun 2016 ...............................................................54
Daughter's history of test conclusions [Use for free text] on 01 Jun 2016..........................................................54
No family history of bleeding problems on 09 Jan 2015 ....................................................................................54
No family history of cancer on 09 Jan 2015 .......................................................................................................55
No family history of congenital deafness on 09 Jan 2015 ..................................................................................55
2019
Medical Record
2019
Family history of nonorganic sleep apnea on 25 Jan 2012 .................................................................................55

Family history of heart disease on 25 May 2010 ................................................................................................55
No angina pectoris on 25 May 2010 ...................................................................................................................55
Family history of cancer on 25 May 2010 ..........................................................................................................55
Family history [use for free text] on 25 May 2010 .............................................................................................55
No family history of mental illness (not intellectual disabilities) on 13 Mar 2009 ............................................56
No family history of alcoholism on 13 Mar 2009 ...............................................................................................56
No malignant neoplasm of large intestine on 05 Nov 2008 ................................................................................56
Arteriosclerotic cardiovascular disease (ASCVD) on 09 Jan 2008 ....................................................................56
Type 2 diabetes mellitus on 09 Jan 2008 ............................................................................................................56
Resulted Labs................................................................................................................................................................57
Follicle Stimulating Hormone+Luteinizing Hormone on 23 Aug 2019 .............................................................57
Prostate Specific Ag on 12 Aug 2019 .................................................................................................................57
Hemogram+Differential Auto on 12 Aug 2019 ..................................................................................................57
Testosterone Free+Total on 06 Sep 2018............................................................................................................58
Hemoglobin A1c Panel on 18 Jul 2018...............................................................................................................58
Testosterone Free+Total on 18 Jul 2018 .............................................................................................................59
Comprehensive Metabolic Panel on 18 Jul 2018 ................................................................................................59
Lipids on 18 Jul 2018 ..........................................................................................................................................60
Urinalysis on 16 Nov 2017..................................................................................................................................61
Mumps Virus Ab on 16 Nov 2017 ......................................................................................................................61
Rubeola Virus Ab on 16 Nov 2017 .....................................................................................................................61
Varicella Virus Ab on 16 Nov 2017....................................................................................................................62
Hepatitis B Virus Surface Ab on 16 Nov 2017 ...................................................................................................62
Rubella Virus Ab on 16 Nov 2017......................................................................................................................62
Basic Metabolic Panel on 16 Nov 2017 ..............................................................................................................63
Lipids on 16 Nov 2017........................................................................................................................................64
Hemogram+Differential Auto on 16 Nov 2017 ..................................................................................................64
CBC W/Diff Manual on 28 Aug 2017 ................................................................................................................65
Lipase on 28 Aug 2017 .......................................................................................................................................65
Comprehensive Metabolic Panel on 28 Aug 2017..............................................................................................66
Semen Analysis Post Vasectomy on 19 Sep 2016 ..............................................................................................67
TISSUE EXAM on 30 Jun 2016 .........................................................................................................................68
Lipase on 21 Apr 2016 ........................................................................................................................................69
Comprehensive Metabolic Panel on 21 Apr 2016 ..............................................................................................69
Hemogram+Differential Auto on 21 Apr 2016...................................................................................................70
Urinalysis on 21 Apr 2016 ..................................................................................................................................71
Lipids on 07 Jan 2016 .........................................................................................................................................71
Testosterone Free+Total on 07 Jan 2016 ............................................................................................................71
Hemoglobin A1c Panel on 07 Jan 2016 ..............................................................................................................72
Prostate Specific Ag on 07 Jan 2016...................................................................................................................72
Comprehensive Metabolic Panel on 07 Jan 2016 ...............................................................................................72
Mumps Virus Ab on 22 Dec 2015 ......................................................................................................................74
Rubeola Virus Ab on 22 Dec 2015 .....................................................................................................................74
Varicella Virus Ab on 22 Dec 2015 ....................................................................................................................74
Hepatitis B Virus Surface Ab on 22 Dec 2015 ...................................................................................................75
Rubella Virus Ab on 22 Dec 2015 ......................................................................................................................75
Bile Acids Total on 14 Jan 2015 .........................................................................................................................75
Hemogram+Differential Auto on 14 Jan 2015....................................................................................................75
Hepatic Function Panel on 14 Jan 2015 ..............................................................................................................76
Urinalysis on 14 Jan 2015 ...................................................................................................................................76
Urine Culture on 04 Nov 2014 ............................................................................................................................77
2019
Medical Record
2019
Chlamydia+Gonococcus DNA Probe on 04 Nov 2014 ......................................................................................77

Influenza A+B Virus Ag Rapid on 04 Nov 2014................................................................................................78
Streptococcus pyogenes Ag on 04 Nov 2014......................................................................................................79
Throat Culture on 04 Nov 2014 ..........................................................................................................................79
Lipase on 26 Aug 2014 .......................................................................................................................................79
Amylase on 26 Aug 2014....................................................................................................................................80
Helicobacter pylori Ab on 26 Aug 2014 .............................................................................................................80
Cardiac Enzymes Panel on 26 Aug 2014 ............................................................................................................80
Comprehensive Metabolic Panel on 26 Aug 2014..............................................................................................81
Lipase on 31 May 2013 .......................................................................................................................................83
Comprehensive Metabolic Panel on 31 May 2013 .............................................................................................83
Urinalysis on 31 May 2013 .................................................................................................................................84
Hemogram+Differential Auto on 31 May 2013..................................................................................................84
Occult Blood on 07 Feb 2013 .............................................................................................................................85
Hemogram+Differential Auto on 29 Jan 2013....................................................................................................86
Lipase on 29 Jan 2013 .........................................................................................................................................86
Amylase on 29 Jan 2013 .....................................................................................................................................86
Comprehensive Metabolic Panel on 29 Jan 2013 ...............................................................................................87
Hepatitis B Virus Surface Ab on 20 Nov 2012 ...................................................................................................88
MMR Panel on 20 Nov 2012 ..............................................................................................................................88
Varicella Virus Ab on 20 Nov 2012....................................................................................................................89
Basic Metabolic Panel on 20 Nov 2012 ..............................................................................................................89
Lipids on 20 Nov 2012........................................................................................................................................90
Comprehensive Metabolic Panel on 19 Nov 2012..............................................................................................91
Hemoglobin A1c Panel on 19 Nov 2012 ............................................................................................................92
Lipase on 19 Nov 2012 .......................................................................................................................................93
Helicobacter pylori on 19 Nov 2012 ...................................................................................................................93
Urea Nitrogen on 02 Nov 2012 ...........................................................................................................................93
Creatinine on 02 Nov 2012 .................................................................................................................................93
Urinalysis on 31 Oct 2012...................................................................................................................................94
Urine Culture on 31 Oct 2012 .............................................................................................................................94
ABO Group+Rh Type on 06 Jul 2012 ................................................................................................................94
Accession Screening and Immunization Program Ab Panel on 06 Jul 2012 ......................................................95
Coagulation Panel (PT+APTT+INR) on 16 Jun 2012 ........................................................................................95
Hepatic Function Panel on 16 Jun 2012..............................................................................................................96
Troponin I Cardiac on 16 Jun 2012.....................................................................................................................97
Creatine Kinase on 16 Jun 2012..........................................................................................................................97
Basic Metabolic Panel on 16 Jun 2012 ...............................................................................................................97
Creatine Kinase MB on 16 Jun 2012 ..................................................................................................................98
Hemogram+Differential Auto on 16 Jun 2012 ...................................................................................................98
Hemogram+Differential Auto on 28 Apr 2012...................................................................................................99
Lipase on 28 Apr 2012 ........................................................................................................................................99
Comprehensive Metabolic Panel on 28 Apr 2012 ............................................................................................100
Urinalysis on 28 Apr 2012 ................................................................................................................................100
Glucose Fasting on 19 Apr 2012.......................................................................................................................101
Prostate Specific Ag on 28 Mar 2012 ...............................................................................................................101
Comprehensive Metabolic Panel on 28 Mar 2012 ............................................................................................101
2019
Medical Record
2019
Lipids on 28 Mar 2012 ......................................................................................................................................102

Glucose Fasting on 28 Mar 2012 ......................................................................................................................103
Testosterone on 02 Nov 2011............................................................................................................................103
Prostate Specific Ag on 02 Nov 2011 ...............................................................................................................103
Potassium on 02 Nov 2011................................................................................................................................103
Lipids on 02 Nov 2011......................................................................................................................................104
Hemoglobin A1c Panel on 02 Nov 2011 ..........................................................................................................104
Testosterone on 09 Feb 2011 ............................................................................................................................104
Hemogram+Differential Auto on 04 Oct 2010 .................................................................................................105
Magnesium on 04 Oct 2010 ..............................................................................................................................105
Lipase on 04 Oct 2010 ......................................................................................................................................105
Amylase on 04 Oct 2010 ...................................................................................................................................106
Comprehensive Metabolic Panel on 04 Oct 2010 .............................................................................................106
Lipids on 04 Oct 2010 .......................................................................................................................................107
Lipase on 28 Sep 2010 ......................................................................................................................................107
Lipase on 28 Sep 2010 ......................................................................................................................................107
Amylase on 28 Sep 2010...................................................................................................................................108
Chem 7 on 28 Sep 2010 ....................................................................................................................................108
Liver Panel on 28 Sep 2010 ..............................................................................................................................108
Lipase on 28 Sep 2010 ......................................................................................................................................109
Amylase on 28 Sep 2010...................................................................................................................................109
Chem 7 on 28 Sep 2010 ....................................................................................................................................109
Liver Panel on 28 Sep 2010 ..............................................................................................................................110
Hemolysis on 28 Sep 2010................................................................................................................................111
CBC on 28 Sep 2010.........................................................................................................................................111
Urinalysis on 18 Sep 2010 ................................................................................................................................112
Lipase on 18 Sep 2010 ......................................................................................................................................112
Amylase on 18 Sep 2010...................................................................................................................................112
Comprehensive Metabolic Panel on 18 Sep 2010.............................................................................................113
Hemogram+Differential Auto on 18 Sep 2010 .................................................................................................113
Hemogram+Differential Auto on 20 May 2010................................................................................................114
Comprehensive Metabolic Panel on 20 May 2010 ...........................................................................................115
Lipids on 20 May 2010 .....................................................................................................................................115
Magnesium on 21 Aug 2009 .............................................................................................................................116
Hepatic Function Panel on 21 Aug 2009 ..........................................................................................................116
Lipase on 21 Aug 2009 .....................................................................................................................................116
Troponin I Cardiac on 21 Aug 2009 .................................................................................................................116
Phosphorus on 21 Aug 2009 .............................................................................................................................117
Creatine Kinase on 21 Aug 2009 ......................................................................................................................117
Basic Metabolic Panel on 21 Aug 2009 ............................................................................................................117
Creatine Kinase MB on 21 Aug 2009 ...............................................................................................................117
Protime+INR+APTT on 21 Aug 2009 ..............................................................................................................118
Hemogram+Differential Auto on 21 Aug 2009 ................................................................................................118
Urinalysis on 21 Aug 2009................................................................................................................................119
Urea Nitrogen on 18 Mar 2009 .........................................................................................................................119
Creatinine on 18 Mar 2009................................................................................................................................119
Comprehensive Metabolic Panel on 21 Jan 2009 .............................................................................................119
Lipids on 21 Jan 2009 .......................................................................................................................................120
Hemogram+Differential Auto on 21 Jan 2009..................................................................................................120
TISSUE EXAM on 03 Dec 2008 ......................................................................................................................121
Lipase on 26 Nov 2008 .....................................................................................................................................121
Comprehensive Metabolic Panel on 26 Nov 2008............................................................................................122
Hemogram+Differential Auto on 26 Nov 2008 ................................................................................................122
Urinalysis on 26 Nov 2008................................................................................................................................123
2019
Medical Record
2019
Urea Nitrogen on 13 Nov 2008 .........................................................................................................................123

Creatinine on 13 Nov 2008 ...............................................................................................................................124
Lipase on 13 Nov 2008 .....................................................................................................................................124
Helicobacter pylori on 13 Nov 2008 .................................................................................................................125
Lipase on 08 Nov 2008 .....................................................................................................................................125
Amylase on 08 Nov 2008..................................................................................................................................125
Basic Metabolic Panel on 02 Nov 2008 ............................................................................................................128
TISSUE EXAM on 19 May 2008 .....................................................................................................................129
Basic Metabolic Panel on 16 May 2008............................................................................................................129
Hemogram+Differential Auto on 16 May 2008................................................................................................130
Urinalysis on 09 Mar 2008................................................................................................................................130
Hemogram+Differential Auto on 09 Mar 2008 ................................................................................................131
Lipase on 09 Mar 2008......................................................................................................................................131
Amylase on 09 Mar 2008 ..................................................................................................................................132
Comprehensive Metabolic Panel on 09 Mar 2008 ............................................................................................132
Comprehensive Metabolic Panel on 10 Jan 2008 .............................................................................................132
Lipids on 10 Jan 2008 .......................................................................................................................................133
Hemogram+Differential Auto on 10 Jan 2008..................................................................................................133
Wound Culture on 09 Jan 2008.........................................................................................................................134
Hemogram+Differential Auto on 11 Sep 2007 .................................................................................................134
CBC W/Diff Manual on 11 Sep 2007 ...............................................................................................................135
Basic Metabolic Panel on 11 Sep 2007 .............................................................................................................135
Chem 7 on 08 Jul 2007......................................................................................................................................136
Hemolysis on 08 Jul 2007 .................................................................................................................................137
CBC on 08 Jul 2007 ..........................................................................................................................................137
Glucose-6-Phosphate Dehydrogenase Quant on 05 Nov 2004 .........................................................................137
Glucose-6-Phosphate Dehydrogenase on 05 Nov 2004 ....................................................................................138
Glucose-6-Phosphate Dehydrogenase on 06 May 2003 ...................................................................................139
Sickle Cell Screen on 06 May 2003 ..................................................................................................................139
Rapid Plasma Reagin on 06 May 2003 .............................................................................................................139
Physical Panel on 06 May 2003 ........................................................................................................................139
Urinalysis Macroscopic on 06 May 2003 .........................................................................................................140
CBC on 06 May 2003........................................................................................................................................141
Radiology....................................................................................................................................................................142
Chest PA And Lateral Upright Series Report on 11 Dec 2017 .........................................................................142
Duplex Visceral Vessels Limited Report on 21 Nov 2016 ...............................................................................143
Ultrasound Testicular Report on 21 Nov 2016 .................................................................................................143
Chest PA And Lateral Upright Series Report on 16 Sep 2016 .........................................................................144
CT Abdomen/Pelvis With Contrast Report on 21 Apr 2016 ............................................................................145
Chest PA And Lateral Upright Series Report on 21 Apr 2016 .........................................................................146
Chest PA And Lateral Upright Series Report on 09 Jan 2015 ..........................................................................147
CT Neck Without Contrast Report on 02 Nov 2013 .........................................................................................147
Soft Tissue Neck Series Report on 02 Nov 2013..............................................................................................148
CT Abdomen/Pelvis With Contrast Report on 17 Jun 2013 .............................................................................149
Acute Abdomen Series Report on 30 May 2013...............................................................................................150
CT Renal With IVP Report on 28 Nov 2012 ....................................................................................................150
2019
Medical Record
2019
CT Abdomen/Pelvis With Contrast Report on 08 Nov 2012............................................................................151

Acute Abdomen Series Report on 31 Oct 2012 ................................................................................................152
Left Hip Series Report on 19 Sep 2012.............................................................................................................153
Chest PA And Lateral Upright Series Report on 16 Jun 2012..........................................................................153
Ultrasound Abdomen (3 Studies) Report on 29 Oct 2010 ................................................................................154
CT Abdomen/Pelvis With Contrast Report on 28 Sep 2010.............................................................................155
Abdomen With Supine And Upright Series Report on 27 Sep 2010 ................................................................156
CT Abdomen/Pelvis Without Contrast Report on 17 Sep 2010........................................................................156
Chest PA And Lateral Upright Series Report on 21 Aug 2009 ........................................................................157
CT Abdomen/Pelvis With Contrast Report on 30 Mar 2009 ............................................................................157
CT Abdomen With Contrast Report on 26 Nov 2008.......................................................................................158
MRI Abdomen With And Without Contrast Report on 25 Nov 2008 ..............................................................159
MRI Abdomen Without Contrast Report on 17 Mar 2008 ...............................................................................159
MRI Abdomen With And Without Contrast Report on 11 Mar 2008 ..............................................................160
CT Abdomen/Pelvis Without Contrast Report on 09 Mar 2008 .......................................................................161
Right Shoulder Series Report on 28 Jan 2008...................................................................................................162
C-Spine Series Report on 25 Jan 2008..............................................................................................................162
L-Spine (5 Views) With Obliques Series Report on 15 Oct 2007 ....................................................................163
Chest PA And Lateral Upright Series Report on 11 Sep 2007 .........................................................................163
Immunizations.............................................................................................................................................................165
Previous Encounters....................................................................................................................................................167
13 Nov 2019 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by CARR, VANESSA...............167
11 Sep 2019 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by CARR, VANESSA ...............168
04 Sep 2019 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by AGUILAR, MICHAEL
THOMAS...............................................................................................................................................................172
04 Sep 2019 at Martin ACH, Fort Benning, GA, Physical Therapy by MCCAMBRIDGE, ERIN K ..................173
20 Aug 2019 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by AGUILAR, MICHAEL
THOMAS...............................................................................................................................................................178
08 Aug 2019 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by AGUILAR, MICHAEL
THOMAS...............................................................................................................................................................180
29 Jul 2019 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by CAREY, PATRICK M .............187
14 Apr 2019 at Martin ACH, Fort Benning, GA, ER by WRIGHT, GISELE L ...................................................189
28 Mar 2019 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by FOSTER, KAROLYNNE L .190
15 Mar 2019 at Martin ACH, Fort Benning, GA, After Hours Clinic(Fam Med Cl) by CAMPBELL, AVRIL M
................................................................................................................................................................................192
16 Dec 2018 at Martin ACH, Fort Benning, GA, ER by MYRICK, ANGELA M ...............................................200
30 Sep 2018 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by AVERA, CYNTHIA D ...........201
15 Aug 2018 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by GRANJA VASQUEZ, JOCHEN
A.............................................................................................................................................................................203
16 Jul 2018 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by GRANJA VASQUEZ, JOCHEN A
................................................................................................................................................................................205
03 Jul 2018 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by CAREY, PATRICK M .............211
23 Apr 2018 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by WILLIAMS, LILLIAN W ....213
20 Apr 2018 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by MITCHELL, CHARLENE M
................................................................................................................................................................................218
25 Jan 2018 at Martin ACH, Fort Benning, GA, Optometry by MELLING, SCOTT R ......................................224
18 Jan 2018 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by CAIN, LOIS R .......................227
11 Dec 2017 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by CAREY, PATRICK M ...........229
11 Dec 2017 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by GILL, CATHERINE ANN .....231
27 Nov 2017 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by WILLIAMS, LILLIAN W ...235
16 Nov 2017 at Martin ACH, Fort Benning, GA, Cardiology Clinic by WADZINSKI, WILLIAM J.................241
16 Nov 2017 at Martin ACH, Fort Benning, GA, Cardiology Clinic by GRAY, TARSHA R.............................244
16 Nov 2017 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by CAIN, LOIS R......................246
2019
Medical Record
2019
14 Nov 2017 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by HUDSON, JAMISHA A................249
27 Aug 2017 at Martin ACH, Fort Benning, GA, ER by POWELL, STEPHANIE K..........................................251
21 Nov 2016 at Martin ACH, Fort Benning, GA, ER by SMITH, TIFFANY S ...................................................254
30 Sep 2016 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by CAREY, PATRICK M............255
16 Sep 2016 at Martin ACH, Fort Benning, GA, ER by BOGARD, MICHAEL A .............................................257
15 Jul 2016 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by VEGA, JULIAN T....................258
05 Jul 2016 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by VEGA, JULIAN T ...........................260
30 Jun 2016 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by VEGA, JULIAN T ..........................261
27 Jun 2016 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by VEGA, JULIAN T ..........................268
01 Jun 2016 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by CALLAHAN, ROBERT
CHARLES .............................................................................................................................................................273
31 May 2016 at Martin ACH, Fort Benning, GA, Surgery by SALADYGA, ANNE T .......................................278
20 Apr 2016 at Martin ACH, Fort Benning, GA, ER by BOGARD, MICHAEL A .............................................282
23 Mar 2016 at Martin ACH, Fort Benning, GA, ER by SMITH, TIFFANY S ...................................................283
28 Jan 2016 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by WOODS, STEPHANIA ............284
05 Jan 2016 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by MCCOMB, CLARA E.............285
28 Dec 2015 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by THOMAS, ROBERT L..................292
22 Dec 2015 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by THOMAS, ROBERT L..................293
30 Oct 2015 at Martin ACH, Fort Benning, GA, ER by CAVANAUGH, MEAGAN A .....................................294
23 Mar 2015 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by PYLE, SAMANTHA L ..........295
20 Mar 2015 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by THOMAS, ROBERT L..................296
19 Mar 2015 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by PYLE, SAMANTHA L ..........297
20 Feb 2015 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by THOMAS, ROBERT L. .................298
18 Feb 2015 at Martin ACH, Fort Benning, GA, Community Health by MELENDEZ, ELY J...........................299
29 Jan 2015 at Martin ACH, Fort Benning, GA, Community Health by POLLITT, STEPHEN P ......................302
15 Jan 2015 at Martin ACH, Fort Benning, GA, Community Health by POLLITT, STEPHEN P ......................304
12 Jan 2015 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by STARBUCK, AARON K ........307
12 Jan 2015 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by STARBUCK, AARON K ........308
09 Jan 2015 at Martin ACH, Fort Benning, GA, Otorhinolaryngology by ANDREWS, JAMIE NATHAN .......310
19 Nov 2014 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by LANIER, JEFFREY B ...........314
07 Nov 2014 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by STARBUCK, AARON K.......316
04 Nov 2014 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by JONES, RACHEL M .............322
20 Oct 2014 at Martin ACH, Fort Benning, GA, After Hours Clinic(Fam Med Cl) by ROBERTSON,
ROSEMARY T ......................................................................................................................................................328
26 Aug 2014 at Martin ACH, Fort Benning, GA, ER by WILLIAMS, DANISE N .............................................332
15 May 2014 at Martin ACH, Fort Benning, GA, ER by GREEN, TARA R .......................................................333
13 Nov 2013 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by COX-BEVLEY, SHARON B........334
02 Nov 2013 at Martin ACH, Fort Benning, GA, ER by BROWN, REGINA S ..................................................335
28 Jun 2013 at Martin ACH, Fort Benning, GA, AMH P01B Bears by TO, PHUONG N...................................336
04 Jun 2013 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M ................................338
30 May 2013 at Martin ACH, Fort Benning, GA, ER by WILLIAMS, DANISE N ............................................341
03 May 2013 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by STARBUCK, AARON K ......342
30 Mar 2013 at Martin ACH, Fort Benning, GA, ER by WILLIAMS, DANISE N .............................................346
29 Jan 2013 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by ZAGORSKI, KIM J...................347
30 Nov 2012 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by CLAY, EMILY C ....................355
27 Nov 2012 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by POLLITT, STEPHEN P .......357
27 Nov 2012 at Martin ACH, Fort Benning, GA, Cardiology (EKG) by CHATMAN, BERNIECE H ...............362
20 Nov 2012 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by GRIFFIN, STEPHANIE D ......364
16 Nov 2012 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by CAIN, LOIS R......................368
16 Nov 2012 at JB San Antonio Military Treatment Facility, TX 78205, SRP Primary Care Clinic BAMC by
CARTER, AMANDA T ........................................................................................................................................370
07 Nov 2012 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by CLAY, EMILY C ....................372
2019
Medical Record
2019
31 Oct 2012 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by CLAY, EMILY C .....................374
16 Oct 2012 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by NOEL, MARY A ............................379
19 Sep 2012 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by ZAGORSKI, KIM J ..................387
11 Jul 2012 at Reynolds Army Community Hospital Ft. Sill, OK, OST Clinic by ROWE, JOHN D ..................391
11 Jul 2012 at Reynolds Army Community Hospital Ft. Sill, OK, OST Clinic by ZWALKER, CYNTHIA D...392
09 Jul 2012 at Reynolds Army Community Hospital Ft. Sill, OK, OST Optometry by ROSA, JUAN L ............393
16 Jun 2012 at Martin ACH, Fort Benning, GA, ER by SCHMIDT, MELISSA KAY ........................................394
09 May 2012 at Martin ACH, Fort Benning, GA, Community Health by TAYLOR, KEVIN M ........................396
01 May 2012 at Martin ACH, Fort Benning, GA, Physical Therapy by HOUSER, JEREMY D.........................399
28 Apr 2012 at Martin ACH, Fort Benning, GA, ER by CROUCH, ROBERT J .................................................401
03 Apr 2012 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by CALDWELL, JACQUELINE K....403
29 Mar 2012 at Martin ACH, Fort Benning, GA, Physical Therapy by HOUSER, JEREMY D .........................407
28 Mar 2012 at Martin ACH, Fort Benning, GA, Physical Therapy by BRANNIN, JENNIFER A ....................409
26 Mar 2012 at Martin ACH, Fort Benning, GA, ER by SCHMIDT, MELISSA KAY .......................................410
26 Mar 2012 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J ..........................412
20 Mar 2012 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by CALDWELL, JACQUELINE K ...416
19 Mar 2012 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J ..........................417
07 Feb 2012 at Martin ACH, Fort Benning, GA, Internal Med Sleep Clinic by CARTER, KEVIN A ................419
07 Feb 2012 at Martin ACH, Fort Benning, GA, Internal Med Sleep Clinic by CARTER, KEVIN A ................423
27 Jan 2012 at Martin ACH, Fort Benning, GA, Internal Med Sleep Clinic by CARTER, KEVIN A.................427
23 Jan 2012 at Martin ACH, Fort Benning, GA, ER by SCHMIDT, MELISSA KAY ........................................436
15 Dec 2011 at Martin ACH, Fort Benning, GA, Internal Med Sleep Clinic by CARTER, KEVIN A ...............455
07 Nov 2011 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by MARTINEZ, HONEY M .................460
03 Nov 2011 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J ..........................461
02 Nov 2011 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J ..........................463
12 Oct 2011 at Martin ACH, Fort Benning, GA, ER by REEDY, GARY W .......................................................468
13 May 2011 at Martin ACH, Fort Benning, GA, ER by REEDY, GARY W......................................................470
24 Feb 2011 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J ...........................472
10 Feb 2011 at Martin ACH, Fort Benning, GA, Optometry by COSTALES, CESAR A ...................................475
09 Feb 2011 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J ...........................478
15 Nov 2010 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by ADAMS, JOSHUA A....................481
03 Nov 2010 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by MISTRETTA, PATRICIA W ...........483
26 Oct 2010 at Martin ACH, Fort Benning, GA, Gastroenterology Clinic by SIDDIQUI, DABIR A .................485
18 Oct 2010 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by MISTRETTA, PATRICIA W ............486
18 Oct 2010 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by LEE, RACHEL R............................487
04 Oct 2010 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by MISTRETTA, PATRICIA W ............488
28 Sep 2010 at 20th Medical Group, MAHC Immediate Care Clinic by KEIGER, CHRISTINA M ..................493
27 Sep 2010 at 20th Medical Group, MAHC Immediate Care Clinic by KEIGER, CHRISTINA M ..................497
26 Sep 2010 at Martin ACH, Fort Benning, GA, ER by RANDALL, WILLIAM L ............................................502
17 Sep 2010 at Martin ACH, Fort Benning, GA, ER by RANDALL, WILLIAM L ............................................504
20 May 2010 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by HOLTZCLAW, KAREN ROMA .505
26 Apr 2010 at Martin ACH, Fort Benning, GA, Optometry by RAMIREZ, HABY I ........................................508
22 Apr 2010 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by AVERA, CYNTHIA D......................511
25 Feb 2010 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by HOLTZCLAW, KAREN ROMA ......513
24 Feb 2010 at Martin ACH, Fort Benning, GA, Nutrition by WICKER-ARMOLT, JENNIFER C...................515
22 Oct 2009 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J ...........................518
13 Oct 2009 at Martin ACH, Fort Benning, GA, CTMC Ambulatory Primary Clinic by SNODDY, ROBERT O
................................................................................................................................................................................521
21 Aug 2009 at Martin ACH, Fort Benning, GA, ER by REEDY, GARY W ......................................................524
03 Apr 2009 at Martin ACH, Fort Benning, GA, FMC Red Clinic by ZAGORSKI, KIM J ................................529
01 Apr 2009 at Martin ACH, Fort Benning, GA, Optometry by STOWE, JENNIFER S ....................................532
18 Mar 2009 at Martin ACH, Fort Benning, GA, Gastroenterology Clinic by SISK, CHAD M..........................537
2019
Medical Record
2019
26 Jan 2009 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by HIGDON, MARK L ...........................540
21 Jan 2009 at Martin ACH, Fort Benning, GA, FMC Red Clinic by JOYCE, MARK T....................................543
21 Jan 2009 at Martin ACH, Fort Benning, GA, FMC Red Clinic by CANNON, DAPHNE A ..........................546
21 Jan 2009 at Martin ACH, Fort Benning, GA, FMC Red Clinic by CANNON, DAPHNE A ..........................548
14 Jan 2009 at Martin ACH, Fort Benning, GA, Nutrition by WICKER-ARMOLT, JENNIFER C ...................549
09 Jan 2009 at Martin ACH, Fort Benning, GA, Gastroenterology Clinic by SISK, CHAD M ...........................551
23 Dec 2008 at Martin ACH, Fort Benning, GA, Gastroenterology Clinic by SISK, CHAD M ..........................552
02 Dec 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M ...............................555
01 Dec 2008 at Martin ACH, Fort Benning, GA, FMC Red Clinic by HINES, DAVID A..................................559
12 Nov 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M ...............................562
04 Nov 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M ...............................563
19 Jun 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M ................................566
22 May 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M ..............................567
16 May 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M ..............................569
10 Apr 2008 at Martin ACH, Fort Benning, GA, CTMC Ambulatory Primary Clinic by LOYD, CLIFTON D .571
08 Apr 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M................................573
28 Mar 2008 at Martin ACH, Fort Benning, GA, CTMC Ambulatory Primary Clinic by KITCHENS, JEFFERY
A.............................................................................................................................................................................576
20 Mar 2008 at Martin ACH, Fort Benning, GA, CTMC Ambulatory Primary Clinic by KITCHENS, JEFFERY
A.............................................................................................................................................................................577
05 Feb 2008 at Martin ACH, Fort Benning, GA, Physical Therapy by JAMES, KRYSTAL K...........................581
31 Jan 2008 at Martin ACH, Fort Benning, GA, Internal Med Benn by VAUGHN, VEETA M .........................582
31 Jan 2008 at Martin ACH, Fort Benning, GA, Physical Therapy by HUMPHRIES, SHAWN E .....................586
09 Jan 2008 at Martin ACH, Fort Benning, GA, Internal Med Benn by HOLST, KATHLEEN C ......................588
15 Oct 2007 at Martin ACH, Fort Benning, GA, CTMC Ambulatory Primary Clinic by VAILLANT, GEORGE
R .............................................................................................................................................................................591
11 Oct 2007 at Martin ACH, Fort Benning, GA, CTMC Ambulatory Primary Clinic by EASON, LINDA F ....594
11 Oct 2007 at Martin ACH, Fort Benning, GA, CTMC Ambulatory Primary Clinic by GONZALEZ, RODNEY
SHAWN .................................................................................................................................................................596
08 Jul 2007 at 20th Medical Group, MAHC Immediate Care Clinic by PETERSON, JAMES L ........................597
07 Jun 2007 at 20th Medical Group, TMC Physical Therapy by WARING, CHRISTOPHER A........................600
07 Jun 2007 at 20th Medical Group, TMC Ambulatory by LANE, HENDERSON M ........................................601
07 Jun 2007 at 20th Medical Group, TMC Ambulatory by LANE, HENDERSON M ........................................602
Clinical Notes..............................................................................................................................................................603
04 Sep 2019 1355 GMT at , Consultation by MCCAMBRIDGE, ERIN K ..........................................................603
26 Jul 2016 1600 GMT at , Consultation by..........................................................................................................609
05 Jul 2016 1420 GMT at , Consultation by VEGA, JULIAN T ..........................................................................611
27 Jun 2016 1420 GMT at , Consultation by VEGA, JULIAN T .........................................................................613
31 May 2016 1930 GMT at , Consultation by SALADYGA, ANNE T................................................................621
02 Mar 2016 1500 GMT at , Consultation by........................................................................................................627
12 Jan 2015 2154 GMT at , Consultation by .........................................................................................................628
09 Jan 2015 1400 GMT at , Consultation by ANDREWS, JAMIE NATHAN.....................................................629
20 Nov 2014 2000 GMT at , Consultation by........................................................................................................635
02 Nov 2013 1241 GMT at Martin ACH, Fort Benning, GA, Emergency Department Encounter Note by
BROWN, REGINA S ............................................................................................................................................636
02 Nov 2013 1240 GMT at Martin ACH, Fort Benning, GA, Emergency Department Encounter Note by
BROWN, REGINA S ............................................................................................................................................638
31 May 2013 0431 GMT at Martin ACH, Fort Benning, GA, Emergency Department Encounter Note by
WILLIAMS, DANISE N .......................................................................................................................................642
31 Mar 2013 0721 GMT at Martin ACH, Fort Benning, GA, Emergency Department Encounter Note by
WILLIAMS, DANISE N .......................................................................................................................................646
29 Jan 2013 1814 GMT at Martin ACH, Fort Benning, GA, Study Report by MORRIS, TARA C ....................649
18 Oct 2012 0858 GMT at , Consultation by.........................................................................................................651
08 Sep 2012 0100 GMT at , Consultation by ........................................................................................................664
2019
Medical Record
2019
07 Aug 2012 1349 GMT at Martin ACH, Fort Benning, GA, Outpatient Consult by MCCLAIN, RENEE K ....665
01 Apr 2012 0901 GMT at , Consultation by ........................................................................................................667
15 Dec 2011 1828 GMT at , Consultation by ........................................................................................................670
29 Oct 2010 0101 GMT at , Consultation by.........................................................................................................679
25 Nov 2009 0202 GMT at , Consultation by........................................................................................................680
06 May 2009 0400 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by AUGUSTIN, WUN C.......681
08 Apr 2009 0122 GMT at , Consultation by ........................................................................................................686
03 Mar 2009 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by RANDALL, WILLIAM L.691
13 Jan 2009 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by TAMBE, MOSES A ...........696
02 Jan 2009 0201 GMT at , Consultation by .........................................................................................................703
25 Nov 2008 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by TRICKEY, DAVID N.......709
20 Nov 2008 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by KAPLAN, JOSEPH J ........716
13 Nov 2008 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by CASS, DAVID A ..............723
07 Nov 2008 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by KAPLAN, JOSEPH J ........730
01 Nov 2008 0400 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by REEDY, GARY W ...........737
16 Jun 2008 0400 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by HINES, DAVID A..............744
01 Apr 2008 0400 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by FOXWORTH, KIMBERLY L
................................................................................................................................................................................747
01 Apr 2008 0400 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by FOXWORTH, KIMBERLY L
................................................................................................................................................................................748
Vitals ...........................................................................................................................................................................751
2019
Medical Record
2019
Demographics
Name: WAITERS, TOMMIE ALAJANDRO
SSN: ***-**-1757
DoD ID: 1068397665
FMP/Sponsor SSN: 20/***-**-1757
Date of Birth: 18 Aug 1970
Sex: M
Race: Black
Marital Status: Married
Branch: A31 - United States Army (USA) Retired Length of Service (LOS) Enlisted
Rank: SERGEANT 1ST CLASS (E7)
Medicare:
Religion: American Baptist Church
PCM Location: 27783-A1311
Addresses:
8009 HIGHLANDS DR
MIDLAND, GA 31820-5200
***** End of Demographics *****
2019
Medical Record
2019
Allergies
NKDA
Reaction:
Onset: Unknown Info Source:
Clinician: Facility: 20th Medical Group
Allergy Type: No known allergies Origin: Department of Defense
Comment: Reaction(s): Unknown
***** End of Allergies *****
2019
Medical Record
2019
Problems
Active Problems
Male erectile disorder on 29 Jul 2019

Date Onset: 29 Jul 2019 Date Reported: 29 Jul 2019
Source: CAREY, PATRICK M ICD: F52.21
MESENTERIC PANNICULITIS on 04 Jun 2013

Date Onset: Unknown Date Reported: 04 Jun 2013
Source: Encounter ICD: 567.82
Patient Counseling: on 16 Nov 2012

Date Onset: Unknown Date Reported: 16 Nov 2012
Source: Encounter ICD: V65.40
BURSITIS TROCHANTERIC on 19 Sep 2012

Date Onset: Unknown Date Reported: 19 Sep 2012
Visit for: military services physical accession on 09 Jul 2012

Date Onset: Unknown Date Reported: 09 Jul 2012
Counseling About Travel on 09 May 2012

Date Onset: Unknown Date Reported: 09 May 2012
GASTRITIS on 28 Apr 2012

Date Onset: Unknown Date Reported: 28 Apr 2012
HYPERGLYCEMIA on 03 Apr 2012

2019
Medical Record
2019
MCKENZIE POSTERIOR DERANGEMENT SYNDROME on 29 Mar 2012

Date Onset: Unknown Date Reported: 29 Mar 2012
Patient Counseling Medical Management Five To Eight Patients on 27 Jan

2012
Date Onset: Unknown Date Reported: 27 Jan 2012
NONORGANIC SLEEP APNEA OBSTRUCTIVE on 25 Jan 2012

NONORGANIC SLEEP DISORDERS on 15 Dec 2011

Date Onset: Unknown Date Reported: 15 Dec 2011
HYPERLIPIDEMIA on 03 Nov 2011

OVERWEIGHT on 02 Nov 2011

HYPERTENSION (SYSTEMIC) on 02 Nov 2011

HYPOGONADISM on 24 Feb 2011

Date Onset: Unknown Date Reported: 24 Feb 2011
ASTIGMATISM on 10 Feb 2011

2019
Medical Record
2019
MALE ERECTILE DISORDER on 09 Feb 2011

Snoring on 09 Feb 2011

Visit for: vasectomy status on 15 Nov 2010

Abdominal pain in the left upper belly (LUQ) on 28 Sep 2010

LUMBAGO on 22 Oct 2009

Date Onset: Unknown Date Reported: 22 Oct 2009
MAJOR DEPRESSION, RECURRENT IN PARTIAL REMISSION on 27 Apr

2009
ADJUSTMENT DISORDER WITH DEPRESSED MOOD on 08 Apr 2009

REFRACTIVE ERROR - HYPERMETROPIA on 01 Apr 2009

GENERALIZED ANXIETY DISORDER on 27 Mar 2009

2019
Medical Record
2019
MAJOR DEPRESSION, SINGLE EPISODE MODERATE on 27 Mar 2009

Abdominal pain around the belly button (periumbilical) on 18 Mar 2009

ASSESS PATIENT CONDITION WORK-RELATED OCCUPATIONAL

DISEASE on 11 Mar 2009
ANXIETY DISORDER NOS on 11 Mar 2009

MAJOR DEPRESSION, SINGLE EPISODE on 11 Mar 2009

Blood Pressure Isolated Elevated on 26 Jan 2009

Visit for: military services physical on 26 Jan 2009

Visit for: occupational health / fitness exam on 21 Jan 2009

Body Mass Index on 14 Jan 2009

Source: Encounter ICD: V85
2019
Medical Record
2019
Patient Education - Dietary on 14 Jan 2009

GASTRITIS DUE TO H. PYLORI on 23 Dec 2008

HELICOBACTER PYLORI (H. PYLORI) INFECTION on 23 Dec 2008

Visit for: preoperative exam on 16 May 2008

Visit for: follow-up exam on 11 Apr 2008

Comment: f/u afetr rt testicle u/s- rt epididymis head cyst vs spermatocele; pt ed. and be aware of
changes/pain and testicle exams- f/u if worsen/changes/prn
TESTICULAR NEOPLASM on 20 Mar 2008

Abdominal pain on 20 Mar 2008

Comment: Testicular ultrasound (done at Columbus Diagnostic) - no solid testicular mass.
Other Physical Therapy on 05 Feb 2008

Joint pain, localized in the shoulder on 31 Jan 2008

2019
Medical Record
2019
CERVICALGIA on 31 Jan 2008

Visit for: screening exam on 09 Jan 2008

Comment: Routine labs ordered for evaluation. Pt has strong family hx of DM, HTN, and early MI. Will
f/u with pt once labs complete.
No lipid panel for reference.
FOLLICULITIS on 09 Jan 2008

Comment: Left thigh folliculitis. Lanced wound with culture taken. Given pt's history of folliculitis and
pt's son being immunocompromised (liver transplant), will give pt course of keflex.
Understands to call if wound is not improving. Step daughter also has had skin wounds - but
found NOT to have MRSA.
MIGRAINE HEADACHE on 11 Oct 2007

BACKACHE on 07 Jun 2007

Comment: 10 mo. hx
Inactive Problems
PROBLEM CONCERNING BEHAVIOR OF CHILD on 13 Nov 2013

Visit for: screening exam cardiovascular disorders on 27 Nov 2012

2019
Medical Record
2019
Visit for: respiratory exam on 16 Nov 2012

Vaccines Prophylactic Need Against Viral Diseases on 13 Jul 2012

Vaccine needed prophylactically against bacterial diseases on 13 Jul 2012

Need For Vaccination Poliomyelitis on 13 Jul 2012

Vaccines Prophylactic Need on 13 Jul 2012

ATYPICAL CHEST PAIN on 16 Jun 2012

Need For Vaccination Yellow Fever on 09 May 2012

Need For Vaccination Typhoid on 09 May 2012

Vaccines Prophylactic Need Against DTP on 09 May 2012

SPRAIN LUMBAR on 26 Mar 2012

2019
Medical Record
2019
VIRAL SYNDROME on 23 Jan 2012

ROUTINE HISTORY AND PHYSICAL on 02 Nov 2011

ABRASION OR FRICTION BURN on 14 May 2011

Visit for: sterilization on 27 Oct 2010

X-Ray on 18 Oct 2010

CONSTIPATION on 28 Sep 2010

PANCREATITIS on 28 Sep 2010

MULTIPLE BLISTERS on 25 Feb 2010

Nausea with vomiting on 13 Oct 2009

2019
Medical Record
2019
Observation For Suspected Condition on 21 Aug 2009

Date Onset: Unknown Date Reported: 21 Aug 2009
RHINITIS on 03 Apr 2009

MARITAL PROBLEM on 11 Mar 2009

Aftercare Following Surgery Of Digestive System on 22 May 2008

Visit for: administrative purpose on 28 Mar 2008

Laboratory Studies on 07 Feb 2008

Headache on 08 Jul 2007

Comment: Motrin
Visit for: refer patient without exam or treatment on 07 Jun 2007

Comment: To physical therapy
***** End of Problems *****
2019
Medical Record
2019
Diagnosis History
Abdominal pain (789.00)

Encounter Date Clinic Clinician Facility
03 May 2013 AMH M02A Strong Team STARBUCK, AARON K Martin ACH, Fort Benning, GA
29 Jan 2013 AMH M02D Eagle Team ZAGORSKI, KIM J Martin ACH, Fort Benning, GA
22 Oct 2009 FMC Yellow Clinic ZAGORSKI, KIM J Martin ACH, Fort Benning, GA
02 Dec 2008 Surgery MCGUIGAN, REBECCA M Martin ACH, Fort Benning, GA
01 Dec 2008 FMC Red Clinic HINES, DAVID A Martin ACH, Fort Benning, GA
12 Nov 2008 Surgery MCGUIGAN, REBECCA M Martin ACH, Fort Benning, GA
04 Nov 2008 Surgery MCGUIGAN, REBECCA M Martin ACH, Fort Benning, GA
19 Jun 2008 Surgery MCGUIGAN, REBECCA M Martin ACH, Fort Benning, GA
08 Apr 2008 Surgery MCGUIGAN, REBECCA M Martin ACH, Fort Benning, GA
20 Mar 2008 CTMC Ambulatory Primary KITCHENS, JEFFERY A Martin ACH, Fort Benning, GA
Clinic
Abdominal pain around the belly button (periumbilical) (789.05)

18 Mar 2009 Gastroenterology Clinic SISK, CHAD M Martin ACH, Fort Benning, GA
Abdominal pain in the left upper belly (LUQ) (789.02)

30 Nov 2012 AMH M02D Eagle Team CLAY, EMILY C Martin ACH, Fort Benning, GA
20 Nov 2012 AMH M02D Eagle Team GRIFFIN, STEPHANIE D Martin ACH, Fort Benning, GA
07 Nov 2012 AMH M02D Eagle Team CLAY, EMILY C Martin ACH, Fort Benning, GA
31 Oct 2012 AMH M02D Eagle Team CLAY, EMILY C Martin ACH, Fort Benning, GA
27 Sep 2010 MAHC Immediate Care Clinic KEIGER, CHRISTINA M 20th Medical Group
ABRASION OR FRICTION BURN (919.0)

13 May 2011 ER REEDY, GARY W Martin ACH, Fort Benning, GA
ADJUSTMENT DISORDER WITH DEPRESSED MOOD (309.0)

03 Jun 2009 Community Mental Health LUPCHO, THERESA D Martin ACH, Fort Benning, GA
07 May 2009 Community Mental Health LUPCHO, THERESA D Martin ACH, Fort Benning, GA
08 Apr 2009 Community Mental Health LUPCHO, THERESA D Martin ACH, Fort Benning, GA
Aftercare Following Surgery Of Digestive System (V58.75)

22 May 2008 Surgery MCGUIGAN, REBECCA M Martin ACH, Fort Benning, GA
ANXIETY DISORDER NOS (300.00)

11 Mar 2009 Community Mental Health LUPCHO, THERESA D Martin ACH, Fort Benning, GA
Arcus senilis, bilateral (H18.413)

25 Jan 2018 Optometry MELLING, SCOTT R Martin ACH, Fort Benning, GA
2019
Medical Record
2019
ASSESS PATIENT CONDITION WORK-RELATED OCCUPATIONAL DISEASE

(V70.5)
ASTIGMATISM (367.20)
10 Feb 2011 Optometry COSTALES, CESAR A Martin ACH, Fort Benning, GA
ATYPICAL CHEST PAIN (786.59)

16 Jun 2012 ER SCHMIDT, MELISSA KAY Martin ACH, Fort Benning, GA
BACKACHE (724.5)
12 Oct 2011 ER REEDY, GARY W Martin ACH, Fort Benning, GA
15 Oct 2007 CTMC Ambulatory Primary VAILLANT, GEORGE R Martin ACH, Fort Benning, GA
Clinic
07 Jun 2007 TMC Physical Therapy WARING, CHRISTOPHER A 20th Medical Group
07 Jun 2007 TMC Ambulatory LANE, HENDERSON M 20th Medical Group
Blood Pressure Isolated Elevated (796.2)

09 Feb 2011 FMC Yellow Clinic ZAGORSKI, KIM J Martin ACH, Fort Benning, GA
26 Jan 2009 FMC Yellow Clinic HIGDON, MARK L Martin ACH, Fort Benning, GA
Body Mass Index (V85.36)

24 Feb 2010 Nutrition WICKER-ARMOLT, Martin ACH, Fort Benning, GA
JENNIFER C
14 Jan 2009 Nutrition WICKER-ARMOLT, Martin ACH, Fort Benning, GA
JENNIFER C
BURSITIS TROCHANTERIC (726.5)

16 Oct 2012 FMC Specialty Clinic NOEL, MARY A Martin ACH, Fort Benning, GA
19 Sep 2012 AMH M02D Eagle Team ZAGORSKI, KIM J Martin ACH, Fort Benning, GA
CERVICALGIA (723.1)
31 Jan 2008 Physical Therapy HUMPHRIES, SHAWN E Martin ACH, Fort Benning, GA
Chronic migraine without aura, not intractable, without status migrainosus (G43.709)
08 Aug 2019 AMH M02A Strong Team AGUILAR, MICHAEL Martin ACH, Fort Benning, GA
THOMAS
CONSTIPATION (564.00)
Counseling About Travel (V65.49)

09 May 2012 Community Health TAYLOR, KEVIN M Martin ACH, Fort Benning, GA
Earache (388.70)
2019
Medical Record
2019

09 Jan 2015 Otorhinolaryngology ANDREWS, JAMIE NATHAN Martin ACH, Fort Benning, GA
Encounter for administrative examinations, unspecified (Z02.9)

28 Mar 2019 Occupational Health FBGA FOSTER, KAROLYNNE L Martin ACH, Fort Benning, GA
23 Dec 2016 AMH M02A Strong Team CAREY, PATRICK M Martin ACH, Fort Benning, GA
30 Sep 2016 AMH M02A Strong Team CAREY, PATRICK M Martin ACH, Fort Benning, GA
Encounter for examination and observation for unspecified reason (Z04.9)

15 Aug 2018 AMH M02A Strong Team GRANJA VASQUEZ, JOCHEN Martin ACH, Fort Benning, GA
A
30 Oct 2015 ER CAVANAUGH, MEAGAN A Martin ACH, Fort Benning, GA
Encounter for examination of eyes and vision with abnormal findings (Z01.01)
Encounter for general adult medical examination without abnormal findings (Z00.00)
16 Jul 2018 AMH M02A Strong Team GRANJA VASQUEZ, JOCHEN Martin ACH, Fort Benning, GA
A
05 Jan 2016 AMH M02A Strong Team MCCOMB, CLARA E Martin ACH, Fort Benning, GA
Encounter for immunization (Z23)

14 Nov 2017 FMC Specialty Clinic HUDSON, JAMISHA A Martin ACH, Fort Benning, GA
Encounter for issue of repeat prescription (Z76.0)

30 Sep 2018 AMH M02A Strong Team AVERA, CYNTHIA D Martin ACH, Fort Benning, GA
03 Jul 2018 AMH M02A Strong Team CAREY, PATRICK M Martin ACH, Fort Benning, GA
Encounter for observation for other suspected diseases and conditions ruled out (Z03.89)
14 Apr 2019 ER WRIGHT, GISELE L Martin ACH, Fort Benning, GA
16 Dec 2018 ER MYRICK, ANGELA M Martin ACH, Fort Benning, GA
27 Aug 2017 ER POWELL, STEPHANIE K Martin ACH, Fort Benning, GA
21 Nov 2016 ER SMITH, TIFFANY S Martin ACH, Fort Benning, GA
16 Sep 2016 ER BOGARD, MICHAEL A Martin ACH, Fort Benning, GA
20 Apr 2016 ER BOGARD, MICHAEL A Martin ACH, Fort Benning, GA
23 Mar 2016 ER SMITH, TIFFANY S Martin ACH, Fort Benning, GA
Encounter for other administrative examinations (Z02.89)

18 Jan 2018 Occupational Health FBGA CAIN, LOIS R Martin ACH, Fort Benning, GA
15 Jul 2016 AMH M02A Strong Team VEGA, JULIAN T Martin ACH, Fort Benning, GA
28 Jan 2016 AMH M02D Eagle Team WOODS, STEPHANIA Martin ACH, Fort Benning, GA
22 Dec 2015 FMC Specialty Clinic THOMAS, ROBERT L. Martin ACH, Fort Benning, GA
Encounter for pre-employment examination (Z02.1)

23 Apr 2018 Occupational Health FBGA WILLIAMS, LILLIAN W Martin ACH, Fort Benning, GA
27 Nov 2017 Occupational Health FBGA WILLIAMS, LILLIAN W Martin ACH, Fort Benning, GA
Encounter for screening for cardiovascular disorders (Z13.6)

2019
Medical Record
2019
16 Nov 2017 Cardiology Clinic WADZINSKI, WILLIAM J Martin ACH, Fort Benning, GA
16 Nov 2017 Cardiology Clinic GRAY, TARSHA R Martin ACH, Fort Benning, GA
Encounter for screening for respiratory disorder NEC (Z13.83)

16 Nov 2017 Occupational Health FBGA CAIN, LOIS R Martin ACH, Fort Benning, GA
Encounter for screening for respiratory tuberculosis (Z11.1)

11 Sep 2019 Occupational Health FBGA CARR, VANESSA Martin ACH, Fort Benning, GA
28 Dec 2015 FMC Specialty Clinic THOMAS, ROBERT L. Martin ACH, Fort Benning, GA
Encounter for sterilization (Z30.2)

30 Jun 2016 FMC Specialty Clinic VEGA, JULIAN T Martin ACH, Fort Benning, GA
27 Jun 2016 FMC Specialty Clinic VEGA, JULIAN T Martin ACH, Fort Benning, GA
01 Jun 2016 AMH M02A Strong Team CALLAHAN, ROBERT Martin ACH, Fort Benning, GA
CHARLES
Essential (primary) hypertension (I10)

THOMAS
15 Mar 2019 After Hours Clinic(Fam Med Cl) CAMPBELL, AVRIL M Martin ACH, Fort Benning, GA
05 Jul 2016 FMC Specialty Clinic VEGA, JULIAN T Martin ACH, Fort Benning, GA
EXAM, FORMAL OCCUPATIONAL HEALTH PROGRAM INCLUDING HEARING

CONSERVATION PROGRAM, ESTABLISH BASELINE PRIOR TO OCCUPATIONAL
WORKPLACE EXPOSURE (DOD0214)
20 Apr 2018 Occupational Health FBGA MITCHELL, CHARLENE M Martin ACH, Fort Benning, GA
EXAM, FORMAL OCCUPATIONAL HEALTH PROGRAM INCLUDING HEARING

CONSERVATION PROGRAM, PERIODIC FOR CONTINUED SURVEILLANCE FOR
OCCUPATIONAL WORKPLACE EXPOSURE (DOD0215)
11 Sep 2019 Occupational Health FBGA CARR, VANESSA Martin ACH, Fort Benning, GA
FOLLICULITIS (704.8)
09 Jan 2008 Internal Med Benn HOLST, KATHLEEN C Martin ACH, Fort Benning, GA
GASTRITIS (535.50)
20 Nov 2012 AMH M02D Eagle Team GRIFFIN, STEPHANIE D Martin ACH, Fort Benning, GA
28 Apr 2012 ER CROUCH, ROBERT J Martin ACH, Fort Benning, GA
GASTRITIS DUE TO H. PYLORI (535.50)

09 Jan 2009 Gastroenterology Clinic SISK, CHAD M Martin ACH, Fort Benning, GA
23 Dec 2008 Gastroenterology Clinic SISK, CHAD M Martin ACH, Fort Benning, GA
GENERALIZED ANXIETY DISORDER (300.02)

03 Apr 2012 FMC Specialty Clinic CALDWELL, JACQUELINE K Martin ACH, Fort Benning, GA
2019
Medical Record
2019
27 Apr 2009 Multi-D Behavioral Health STREETER, MICHAEL E Martin ACH, Fort Benning, GA
27 Mar 2009 Multi-D Behavioral Health STREETER, MICHAEL E Martin ACH, Fort Benning, GA
Headache (784.0)
08 Jul 2007 MAHC Immediate Care Clinic PETERSON, JAMES L 20th Medical Group
HEARING LOSS (389.9)

07 Nov 2014 AMH M02A Strong Team STARBUCK, AARON K Martin ACH, Fort Benning, GA
HELICOBACTER PYLORI (H. PYLORI) INFECTION (041.86)

23 Dec 2008 Gastroenterology Clinic SISK, CHAD M Martin ACH, Fort Benning, GA
HYPERGLYCEMIA (790.29)
HYPERLIPIDEMIA (272.4)
03 Nov 2011 FMC Yellow Clinic ZAGORSKI, KIM J Martin ACH, Fort Benning, GA
Hypermetropia, bilateral (H52.03)

HYPERTENSION (SYSTEMIC) (401.9)

HYPOGONADISM (257.2)
19 Mar 2012 FMC Yellow Clinic ZAGORSKI, KIM J Martin ACH, Fort Benning, GA
07 Nov 2011 FMC Yellow Clinic MARTINEZ, HONEY M Martin ACH, Fort Benning, GA
Immunization not carried out because of patient refusal (Z28.21)

13 Nov 2019 Occupational Health FBGA CARR, VANESSA Martin ACH, Fort Benning, GA
Joint pain, localized in the shoulder (719.41)

05 Feb 2008 Physical Therapy JAMES, KRYSTAL K Martin ACH, Fort Benning, GA
31 Jan 2008 Physical Therapy HUMPHRIES, SHAWN E Martin ACH, Fort Benning, GA
Laboratory Studies (V72.60)

21 Jan 2009 FMC Red Clinic JOYCE, MARK T. Martin ACH, Fort Benning, GA
31 Jan 2008 Internal Med Benn VAUGHN, VEETA M Martin ACH, Fort Benning, GA
Left upper quadrant pain (R10.12)
2019
Medical Record
2019

Low back pain (M54.5)

04 Sep 2019 Physical Therapy MCCAMBRIDGE, ERIN K Martin ACH, Fort Benning, GA
THOMAS
15 Mar 2019 After Hours Clinic(Fam Med Cl) CAMPBELL, AVRIL M Martin ACH, Fort Benning, GA
LUMBAGO (724.2)
22 Oct 2009 FMC Yellow Clinic ZAGORSKI, KIM J Martin ACH, Fort Benning, GA
MAJOR DEPRESSION, RECURRENT IN PARTIAL REMISSION (296.35)

27 Apr 2009 Multi-D Behavioral Health STREETER, MICHAEL E Martin ACH, Fort Benning, GA
MAJOR DEPRESSION, SINGLE EPISODE (296.20)

MAJOR DEPRESSION, SINGLE EPISODE MODERATE (296.22)

27 Mar 2009 Multi-D Behavioral Health STREETER, MICHAEL E Martin ACH, Fort Benning, GA
Major depressive disorder, single episode, moderate (F32.1)

Male erectile disorder (F52.21)

29 Jul 2019 AMH M02A Strong Team CAREY, PATRICK M Martin ACH, Fort Benning, GA
16 Jul 2018 AMH M02A Strong Team GRANJA VASQUEZ, JOCHEN Martin ACH, Fort Benning, GA
A
MALE ERECTILE DISORDER (302.72)

MARITAL PROBLEM (V61.10)

MCKENZIE POSTERIOR DERANGEMENT SYNDROME (722.90)

01 May 2012 Physical Therapy HOUSER, JEREMY D Martin ACH, Fort Benning, GA
29 Mar 2012 Physical Therapy HOUSER, JEREMY D Martin ACH, Fort Benning, GA
MESENTERIC PANNICULITIS (567.82)

2019
Medical Record
2019
04 Jun 2013 Surgery MCGUIGAN, REBECCA M Martin ACH, Fort Benning, GA
MIGRAINE HEADACHE (346.90)

11 Oct 2007 CTMC Ambulatory Primary EASON, LINDA F Martin ACH, Fort Benning, GA
Clinic
MULTIPLE BLISTERS (919.2)

25 Feb 2010 FMC Yellow Clinic HOLTZCLAW, KAREN Martin ACH, Fort Benning, GA
ROMA
Nausea with vomiting (787.01)

13 Oct 2009 CTMC Ambulatory Primary SNODDY, ROBERT O Martin ACH, Fort Benning, GA
Clinic
Need For Vaccination MMR (V06.4)

20 Feb 2015 FMC Specialty Clinic THOMAS, ROBERT L. Martin ACH, Fort Benning, GA
Need For Vaccination Poliomyelitis (V04.0)

11 Jul 2012 OST Clinic ROWE, JOHN D Reynolds Army Community
Hospital Ft. Sill, OK
Need For Vaccination Typhoid (V03.1)

Need For Vaccination Yellow Fever (V04.4)

NONORGANIC SLEEP APNEA OBSTRUCTIVE (327.23)

07 Feb 2012 Internal Med Sleep Clinic CARTER, KEVIN A Martin ACH, Fort Benning, GA
07 Feb 2012 Internal Med Sleep Clinic CARTER, KEVIN A Martin ACH, Fort Benning, GA
27 Jan 2012 Internal Med Sleep Clinic CARTER, KEVIN A Martin ACH, Fort Benning, GA
NONORGANIC SLEEP DISORDERS (307.40)

15 Dec 2011 Internal Med Sleep Clinic CARTER, KEVIN A Martin ACH, Fort Benning, GA
Observation For Suspected Condition (V71.9)

26 Aug 2014 ER WILLIAMS, DANISE N Martin ACH, Fort Benning, GA
15 May 2014 ER GREEN, TARA R Martin ACH, Fort Benning, GA
02 Nov 2013 ER BROWN, REGINA S Martin ACH, Fort Benning, GA
30 May 2013 ER WILLIAMS, DANISE N Martin ACH, Fort Benning, GA
30 Mar 2013 ER WILLIAMS, DANISE N Martin ACH, Fort Benning, GA
26 Sep 2010 ER RANDALL, WILLIAM L Martin ACH, Fort Benning, GA
17 Sep 2010 ER RANDALL, WILLIAM L Martin ACH, Fort Benning, GA
21 Aug 2009 ER REEDY, GARY W Martin ACH, Fort Benning, GA
2019
Medical Record
2019
Other Physical Therapy (V57.1)

05 Feb 2008 Physical Therapy JAMES, KRYSTAL K Martin ACH, Fort Benning, GA
OTITIS EXTERNA (380.10)

07 Nov 2014 AMH M02A Strong Team STARBUCK, AARON K Martin ACH, Fort Benning, GA
OTITIS MEDIA (382.9)

04 Nov 2014 AMH M02A Strong Team JONES, RACHEL M Martin ACH, Fort Benning, GA
OVERWEIGHT (278.02)
PANCREATITIS (577.9)
04 Oct 2010 FMC Yellow Clinic MISTRETTA, PATRICIA W Martin ACH, Fort Benning, GA
Patient Counseling Medical Management Five To Eight Patients (V65.49)

Patient Counseling: (V65.40)

14 Jan 2015 Community Health MELENDEZ, ELY J Martin ACH, Fort Benning, GA
Patient Education - Dietary (V65.3)

24 Feb 2010 Nutrition WICKER-ARMOLT, Martin ACH, Fort Benning, GA
JENNIFER C
14 Jan 2009 Nutrition WICKER-ARMOLT, Martin ACH, Fort Benning, GA
JENNIFER C
Pinguecula, bilateral (H11.153)

Presbyopia (H52.4)
PROBLEM CONCERNING BEHAVIOR OF CHILD (V61.20)

13 Nov 2013 FMC Specialty Clinic COX-BEVLEY, SHARON B Martin ACH, Fort Benning, GA
REFRACTIVE ERROR - HYPERMETROPIA (367.0)

10 Feb 2011 Optometry COSTALES, CESAR A Martin ACH, Fort Benning, GA
26 Apr 2010 Optometry RAMIREZ, HABY I Martin ACH, Fort Benning, GA
01 Apr 2009 Optometry STOWE, JENNIFER S Martin ACH, Fort Benning, GA
Regular astigmatism, bilateral (H52.223)
2019
Medical Record
2019

RHINITIS (472.0)
03 Apr 2009 FMC Red Clinic ZAGORSKI, KIM J Martin ACH, Fort Benning, GA
ROUTINE HISTORY AND PHYSICAL (V70.0)

Sclerosing mesenteritis (K65.4)

31 May 2016 Surgery SALADYGA, ANNE T Martin ACH, Fort Benning, GA
Snoring (786.09)
15 Dec 2011 Internal Med Sleep Clinic CARTER, KEVIN A Martin ACH, Fort Benning, GA
SPRAIN LUMBAR (847.2)

TEMPOROMANDIBULAR JOINT-PAIN DYSFUNCTION SYNDROME (524.60)

09 Jan 2015 Otorhinolaryngology ANDREWS, JAMIE NATHAN Martin ACH, Fort Benning, GA
Testicular hypofunction (E29.1)

04 Sep 2019 AMH M02A Strong Team AGUILAR, MICHAEL Martin ACH, Fort Benning, GA
THOMAS
THOMAS
THOMAS
TESTICULAR NEOPLASM (239.5)

Clinic
TRICHOMONIASIS URETHRITIS (131.02)

20 Oct 2014 After Hours Clinic(Fam Med Cl) ROBERTSON, ROSEMARY T Martin ACH, Fort Benning, GA
Tuberculin PPD Nonspec Reaction Without Active Tuberculosis (795.51)

14 Jan 2015 Community Health MELENDEZ, ELY J Martin ACH, Fort Benning, GA
TUBERCULOSIS LATENT (795.51)

29 Jan 2015 Community Health POLLITT, STEPHEN P Martin ACH, Fort Benning, GA
15 Jan 2015 Community Health POLLITT, STEPHEN P Martin ACH, Fort Benning, GA
2019
Medical Record
2019
UPPER RESPIRATORY INFECTION (465.9)

Urinary frequency increased (788.41)

Vaccines Prophylactic Need (V05.9)

Vaccines Prophylactic Need Against Bacterial Diseases (V03.89)

Vaccines Prophylactic Need Against DTP (V06.1)

Vaccines Prophylactic Need Against Td (V06.5)

20 Feb 2015 FMC Specialty Clinic THOMAS, ROBERT L. Martin ACH, Fort Benning, GA
Vaccines Prophylactic Need Against Viral Diseases (V04.89)

Vasectomy status (Z98.52)

05 Jul 2016 FMC Specialty Clinic VEGA, JULIAN T Martin ACH, Fort Benning, GA
VIRAL SYNDROME (079.99)

26 Mar 2012 ER SCHMIDT, MELISSA KAY Martin ACH, Fort Benning, GA
23 Jan 2012 ER SCHMIDT, MELISSA KAY Martin ACH, Fort Benning, GA
Visit for: administrative purpose (V68.9)

23 Mar 2015 AMH M02A Strong Team PYLE, SAMANTHA L Martin ACH, Fort Benning, GA
19 Mar 2015 AMH M02A Strong Team PYLE, SAMANTHA L Martin ACH, Fort Benning, GA
19 Nov 2014 AMH M02A Strong Team LANIER, JEFFREY B Martin ACH, Fort Benning, GA
28 Jun 2013 AMH P01B Bears TO, PHUONG N Martin ACH, Fort Benning, GA
16 Nov 2012 SRP Primary Care Clinic CARTER, AMANDA T JB San Antonio Military
BAMC Treatment Facility, TX 78205
03 Sep 2012 Multi-D Behavioral Health CYRA, MICHAEL S Martin ACH, Fort Benning, GA
Clinic
Visit for: follow-up exam (V67.9)

10 Apr 2008 CTMC Ambulatory Primary LOYD, CLIFTON D Martin ACH, Fort Benning, GA
2019
Medical Record
2019
Clinic
Visit for: issue repeat prescription for medication (V68.1)

18 Mar 2015 Community Health MELENDEZ, ELY J Martin ACH, Fort Benning, GA
18 Feb 2015 Community Health MELENDEZ, ELY J Martin ACH, Fort Benning, GA
Visit for: military services physical (V70.5)

20 Mar 2012 FMC Specialty Clinic CALDWELL, JACQUELINE K Martin ACH, Fort Benning, GA
20 May 2010 FMC Specialty Clinic HOLTZCLAW, KAREN Martin ACH, Fort Benning, GA
ROMA
22 Apr 2010 FMC Yellow Clinic AVERA, CYNTHIA D Martin ACH, Fort Benning, GA
26 Jan 2009 FMC Yellow Clinic HIGDON, MARK L Martin ACH, Fort Benning, GA
Visit for: military services physical accession (V70.5)

09 Jul 2012 OST Optometry ROSA, JUAN L Reynolds Army Community
Visit for: occupational health / fitness exam (V70.5)

27 Nov 2012 Occupational Health FBGA POLLITT, STEPHEN P Martin ACH, Fort Benning, GA
21 Jan 2009 FMC Red Clinic CANNON, DAPHNE A Martin ACH, Fort Benning, GA
Visit for: preoperative exam (V72.84)

16 May 2008 Surgery MCGUIGAN, REBECCA M Martin ACH, Fort Benning, GA
Visit for: refer patient without exam or treatment (V68.81)

07 Jun 2007 TMC Ambulatory LANE, HENDERSON M 20th Medical Group
Visit for: respiratory exam (V72.85)

Visit for: screening exam (V82.9)

20 May 2010 FMC Specialty Clinic HOLTZCLAW, KAREN Martin ACH, Fort Benning, GA
ROMA
09 Jan 2008 Internal Med Benn HOLST, KATHLEEN C Martin ACH, Fort Benning, GA
Visit for: screening exam cardiovascular disorders (V81.2)

27 Nov 2012 Cardiology (EKG) CHATMAN, BERNIECE H Martin ACH, Fort Benning, GA
Visit for: screening exam pulmonary tuberculosis (V74.1)

20 Mar 2015 FMC Specialty Clinic THOMAS, ROBERT L. Martin ACH, Fort Benning, GA
12 Jan 2015 AMH M02A Strong Team STARBUCK, AARON K Martin ACH, Fort Benning, GA
Visit for: sterilization (V25.2)

18 Oct 2010 FMC Specialty Clinic LEE, RACHEL R Martin ACH, Fort Benning, GA
2019
Medical Record
2019
Visit for: vasectomy status (V26.52)

15 Nov 2010 FMC Specialty Clinic ADAMS, JOSHUA A Martin ACH, Fort Benning, GA
X-Ray (V72.5)
03 Nov 2010 FMC Yellow Clinic MISTRETTA, PATRICIA W Martin ACH, Fort Benning, GA
18 Oct 2010 FMC Yellow Clinic MISTRETTA, PATRICIA W Martin ACH, Fort Benning, GA
***** End of Diagnosis History *****
2019
Medical Record
2019
Medications
Active Medications
Rx # Drug Status Quantity Fill Refills

Date Left
M10517086 testosterone, 10 mg/0.5 gram per actuation (2 Active 1 29 2 of 3
%), GEL MD PMP, TRANSDERM Nov
APPLY 4 PUMPS TO FRONT AND INNER 2019
THIGH EVERY MORNING *WASH
HANDS AFTER USE*
M37612138 sumatriptan succinate, 50 MG, TABLET, Active 18 29 1 of 1

ORAL Nov
TAKE ONE TABLET BY MOUTH AT 2019
ONSET OF HEADACHE MAY REPEAT IN
2 HOURS AS NEEDED FOR HEADACHE
NO MORE THAN 4 TABLETS PER DAY
6522733 FLUCELVAX QUAD 2019-2020 (flu vaccine Active 0.5 08 NR

quad 2019-2020(4 years and older)cell Nov
derived/PF), 60MCG/.5ML, SYRINGE, 2019
INTRAMUSC, SEQIRUS, INC., .5 ml
SYRINGE
M10516354 sildenafil citrate, 100 MG, TABLET, ORAL Active 18 16 Oct 2 of 3

TAKE ONE TABLET BY MOUTH 1 HOUR 2019
BEFORE SEXUAL INTERCOURSE NO
MORE THAN 1 A DAY
M37612142 hydrochlorothiazide, 12.5 MG, CAPSULE, Active 60 12 1 of 1

ORAL Aug
TAKE ONE CAPSULE BY MOUTH DAILY 2019
M37612136 lidocaine, 5 %, ADH. PATCH, TOPICAL Active 1 12 10 of

APPLY 1 PATCH EVERY DAY (12 HOURS Aug 10
ON, 12 HOURS OFF) 2019
101009 LIDOCAINE (lidocaine), 5 %, OINT. (G), Active 141.76 28 Oct 0 of 3

TOPICAL, HI-TECH/AKORN C, 35.44 g 2016
TUBE
101009 LIDOCAINE (lidocaine), 5 %, OINT. (G), Active 141.76 28 Sep 1 of 3

TOPICAL, HI-TECH/AKORN C, 35.44 g 2016
TUBE
101009 LIDOCAINE (lidocaine), 5 %, OINT. (G), Active 141.76 18 Jul 3 of 3
2019
Medical Record
2019
TOPICAL, IGI LABS, INC./, 35.44 g TUBE 2016
939424 TRIAZOLAM (triazolam), 0.25 MG, Active 2 03 NR

TABLET, ORAL, GREENSTONE LLC., 10 May
ea. BOTTLE 2009
Cancelled Medications

Date Left
M268156 Dexmethylphenidate Hydrochloride 20mg Cancelled 90 30 NR
Extended release capsule, Oral May
TAKE ONE CAPSULE IN THE MORNING 2013
Discontinued Medications

Date Left
M10503346 sildenafil citrate, 100 MG, TABLET, ORAL Discontinued 18 14 0 of 3
TAKE ONE TABLET BY MOUTH 1 HOUR May
BEFORE SEXUAL INTERCOURSE NO 2019
MORE THAN 1 A DAY
M10501564 sildenafil citrate, 100 MG, TABLET, ORAL Discontinued 6 07 Sep NR

MORE THAN 1 A DAY
M36739314 ibuprofen, 800 MG, TABLET, ORAL Discontinued 30 16 Sep NR

TAKE ONE TABLET THREE TIMES 2016
DAILY WITH FOOD
M36176959 isoniazid, 300 MG, TABLET, ORAL Discontinued 30 15 Jan 8 of 8

TAKE ONE TABLET BY MOUTH EVERY 2015
DAY
M10325804 Testosterone 1%, Gel/Jelly, Transdermal, Discontinued 2 02 5 of 5

1.25g Nov
USE 1 PUMP IN EACH ARM EVERY DAY 2011
M34099173 Omeprazole 20mg, Extended release capsule, Discontinued 28 12 Dec NR

Oral 2008
TAKE 1 CAP PO BID FOR 14 DAYS #28
RF0
Pantoprazole Sodium 40mg, Reconstituted Discontinued UNK NR

solution, Injection
2019
Medical Record
2019
Expired Medications

Date Left
M37525002 levofloxacin, 500 MG, TABLET, ORAL Expired 10 14 Apr NR
DAY FOR 10 DAYS.
M416885 HYDROCODONE BIT/ACETAMINOPHEN, Expired 18 14 Apr NR

5MG-325MG, TABLET, ORAL 2019
TAKE ONE TABLET BY MOUTH EVERY
4 TO 6 HOURS AS NEEDED FOR PAIN
M37525003 naproxen, 500 MG, TABLET, ORAL Expired 30 14 Apr NR

TAKE ONE TABLET BY MOUTH TWICE 2019
A DAY WITH FOOD
NC30281148 lidocaine, 5 %, ADH. PATCH, TOPICAL Expired 1 15 Mar NR

APPLY 1 PATCH EVERY DAY (12 HOURS 2019
ON, 12 HOURS OFF)
M37429366 acetaminophen, 325 MG, TABLET, ORAL Expired 24 16 Dec NR

TAKE TWO TABLETS BY MOUTH 2018
EVERY SIX HOURS AS NEEDED FOR
FEVER -- NOT TO EXCEED 9 TABLETS
PER DAY
M37429365 ibuprofen, 600 MG, TABLET, ORAL Expired 30 16 Dec NR

DAILY BY MOUTH WITH FOOD
M37429367 Cyclobenzaprine 10mg Tablet, Oral Expired 10 16 Dec NR

EIGHT HOURS
M37346313 Pill Splitter, Device, Miscellaneous Expired 1 07 Sep NR

PLACE 1 TABLET IN DEVICE AND 2018
CLOSE LID TO CUT TABLET IN HALF AS
NEEDED
M37346287 Atorvastatin 10 mg oral tablet Expired 90 07 Sep 3 of 3

TAKE ONE TABLET BY MOUTH AT 2018
BEDTIME
M37039902 ondansetron, 8 MG, TAB RAPDIS, ORAL Expired 10 28 NR

TAKE ONE TABLET UNDER TONGUE Aug
EVERY SIX HOURS AS NEEDED FOR 2017
NAUSEA
M36796408 ibuprofen, 800 MG, TABLET, ORAL Expired 30 22 NR
2019
Medical Record
2019
TAKE ONE TABLET THREE TIMES Nov

DAILY WITH FOOD 2016
M36796407 Trimethoprim 160mg + Sulfamethoxazole Expired 20 22 NR

800mg, (Septra DS), Tablet, Oral Nov
TAKE ONE TABLET TWICE A DAY 2016
UNTIL FINISHED
M36739315 benzonatate, 100 MG, CAPSULE, ORAL Expired 21 16 Sep NR

TAKE ONE CAPSULE BY MOUTH THREE 2016
TIMES A DAY FOR COUGH (SWALLOW
WHOLE)
M36739312 Azithromycin 250mg, Tablet, Oral, Z-Pak Expired 1 16 Sep NR

TAKE 2 TABLETS AT ONCE ON DAY 1, 2016
THEN TAKE 1 TABLET EVERY DAY ON
DAYS 2-5.
M36739313 Pseudoephedrine Hydrochloride 60mg + Expired 1 16 Sep NR

Guaifenesin 600mg, Tablet, Oral 2016
TAKE ONE TABLET TWICE DAILY
M346632 oxycodone HCl/acetaminophen, 5 MG- Expired 1 30 Jun NR

325MG, TABLET, ORAL 2016
TAKE ONE TABLET NOW AS DIRECTED
FOR PROCEDURE
M10455943 diazepam, 5 MG, TABLET, ORAL Expired 2 29 Jun NR

TAKE ONE TABLET BY MOUTH THIRTY 2016
MINUTES PRIOR TO PROCEDURE AND
TAKE ANOTHER AT PROCEDURE TIME
M346306 oxycodone HCl/acetaminophen, 5 MG- Expired 10 29 Jun NR

4 TO 6 HOURS AS NEEDED
I30030264 Iopamidol 76%, Injection, Intravenous Expired 1 21 Apr NR

USE AS DIRECTED FOR CONTRAST 2016
MEDIA
M36580011 Azithromycin 250mg, Tablet, Oral, Z-Pak Expired 1 23 Mar NR

DAYS 2-5.
M36580013 fexofenadine HCl, 180 MG, TABLET, ORAL Expired 15 23 Mar NR

DAY FOR NASAL SYMPTOMS
M36580012 guaifenesin, 100 MG/5ML, LIQUID, ORAL Expired 1 23 Mar NR

TAKE 2 TEASPOONFULS BY MOUTH 2016
EVERY FOUR HOURS AS NEEDED FOR
COUGH (MAX: 6 DOSES PER DAY)
2019
Medical Record
2019
M36580014 Clotrimazole 1%, Cream, Topical Expired 1 23 Mar NR

APPLY TO AFFECTED AREAS TWICE A 2016
DAY TO THREE TIMES A DAY FOR 2
WEEKS
M10443919 tramadol HCl, 50 MG, TABLET, ORAL Expired 30 05 Jan NR

TAKE 1 TO 2 TABLETS BY MOUTH 2016
EVERY 4-6 HOURS AS NEEDED FOR
PAIN **NOT TO EXCEED 8 TABLETS PER
DAY**
M36501776 Triamterene 37.5mg + Hydrochlorothiazide Expired 90 05 Jan NR

25mg, (Maxzide-25), Tablet, Oral 2016
TAKE 1 TABLET BY MOUTH EVERY
DAY FOR HTN
M10443921 sildenafil citrate, 100 MG, TABLET, ORAL Expired 15 05 Jan NR

MORE THAN 1 A DAY
M36445351 acetaminophen, 325 MG, TABLET, ORAL Expired 24 30 Oct NR

TAKE 2 TABLETS BY MOUTH EVERY 2015
SIX HOURS AS NEEDED -- NOT TO
EXCEED 9 TABLETS PER DAY
M36445349 Pseudoephedrine Hydrochloride 60mg + Expired 1 30 Oct NR

M36445350 Azithromycin 250mg, Tablet, Oral, Z-Pak Expired 1 30 Oct NR

DAYS 2-5.
M36242045 isoniazid, 300 MG, TABLET, ORAL Expired 30 20 Mar NR

TAKE ONE TABLET EVERY DAY 2015
M36242047 pyridoxine HCl (vitamin B6), 50 MG, Expired 30 20 Mar NR

TABLET, ORAL 2015
TAKE ONE TABLET EVERY DAY
M36176957 pyridoxine HCl (vitamin B6), 50 MG, Expired 30 15 Jan 8 of 8

TABLET, ORAL 2015
TAKE ONE TABLET EVERY DAY
M36170274 naproxen, 500 MG, TABLET, ORAL Expired 60 09 Jan 1 of 1

TAKE ONE TABLET TWICE A DAY WITH 2015
FOOD
M36115705 amoxicillin, 500 MG, CAPSULE, ORAL Expired 30 04 NR

TAKE ONE CAPSULE THREE TIMES A Nov
DAY FOR TEN DAYS 2014
2019
Medical Record
2019
NC30066244 metronidazole, 250 MG, TABLET, ORAL Expired 21 20 Oct NR

TAKE ONE TABLET BY MOUTH THREE 2014
TIMES A DAY FOR 7 DAYS.
M36056100 ondansetron, 4 MG, TAB RAPDIS, ORAL Expired 10 26 NR

MELT 1 TABLET UNDER TONGUE Aug
EVERY 6 TO 8 HOURS AS NEEDED FOR 2014
NAUSEA OR VOMITING
M36056099 acetaminophen, 325 MG, TABLET, ORAL Expired 24 26 NR

TAKE 2 TABLETS BY MOUTH EVERY Aug
SIX HOURS AS NEEDED -- NOT TO 2014
M36056098 Esomeprazole Magnesium Trihydrate 40mg, Expired 15 26 NR

Capsule, Oral Aug
TAKE ONE CAPSULE BY MOUTH EVERY 2014
DAY
M35971822 metaxalone, 800 MG, TABLET, ORAL Expired 12 15 NR

TAKE ONE TABLET THREE TIMES May
EVERY DAY 2014
M35971821 naproxen, 500 MG, TABLET, ORAL Expired 60 15 NR

TAKE ONE TABLET TWICE A DAY WITH May
FOOD 2014
M10403382 HYDROCODONE BIT/ACETAMINOPHEN, Expired 9 15 NR

5MG-325MG, TABLET, ORAL May
EVERY DAY AS NEEDED
M35859438 oseltamivir phosphate, 75 MG, CAPSULE, Expired 1 13 Jan NR

ORAL 2014
TAKE ONE CAPSULE TWICE EVERY
DAY FOR 5 DAYS
M10394711 HYDROCODONE BIT/ACETAMINOPHEN, Expired 18 13 Jan NR

TAKE ONE TABLET EVERY 4 TO 6
HOURS AS NEEDED FOR PAIN
M10389605 CODEINE PHOS/ACETAMINOPHEN, 30- Expired 20 02 NR

300MG, TABLET, ORAL Nov
TAKE ONE BY MOUTH EVERY FOUR 2013
HOURS AS NEEDED FOR PAIN
M35796806 AMOXICILLIN TRI/POTASSIUM CLAV, Expired 20 02 NR

875-125 MG, TABLET, ORAL Nov
TAKE ONE BY MOUTH TWICE A DAY 2013
FOR TEN DAYS
2019
Medical Record
2019
TAKE ONE TABLET THREE TIMES Nov

DAILY WITH FOOD 2013
M35685585 doxycycline hyclate, 100 MG, CAPSULE, Expired 60 28 Jun NR

ORAL 2013
TAKE ONE CAPSULE BY MOUTH EVERY
DAY STARTING 2 DAYS PRIOR TO
TRAVEL UNTIL 2 WEEKS AFTER
RETURN
M35673220 Iopamidol 61%, Solution, Injection Expired 1 14 Jun NR

MEDIA
M35602650 Clarithromycin 500mg Extended release tablet, Expired 28 31 Mar NR

Oral 2013
TAKE TWO TABLETS BY MOUTH
EVERY DAY FOR FOURTEEN DAYS
M35602651 Esomeprazole Magnesium Trihydrate 40mg, Expired 15 31 Mar NR

Capsule, Oral 2013
DAY
M10372435 HYDROCODONE BIT/ACETAMINOPHEN, Expired 10 31 Mar NR

SIX HOURS AS NEEDED FOR PAIN
M35602652 amoxicillin, 500 MG, CAPSULE, ORAL Expired 56 31 Mar NR

TAKE TWO CAPSULES BY MOUTH 2013
TWICE A DAY FOR FOURTEEN DAYS
M10338443 sildenafil citrate, 100 MG, TABLET, ORAL Expired 6 09 Jan 8 of 11

MORE THAN 1 A DAY
M35466445 Iopamidol 61%, Solution, Injection Expired 1 08 NR

USE AS DIRECTED FOR CONTRAST Nov
MEDIA 2012
M10359322 HYDROCODONE BIT/ACETAMINOPHEN, Expired 30 31 Oct NR

5 MG-500MG, TABLET, ORAL 2012
TAKE ONE TABLET TWICE EVERY DAY
AS NEEDED FOR ABDOMINAL OR BACK
PAIN
M35331157 aspirin, 325 MG, TABLET DR, ORAL Expired 90 04 Oct 3 of 3

TAKE ONE TABLET DAILY 2012
M35420674 celecoxib, 100 MG, CAPSULE, ORAL Expired 60 19 Sep NR

TAKE 1 CAPSULE BY MOUTH TWICE A 2012
DAY WITH FOOD FOR 30 DAYS
2019
Medical Record
2019
M10338444 Testosterone 1%, Gel/Jelly, Transdermal, Expired 2 23 Jul 3 of 5

1.25g 2012
USE 1 PUMP IN EACH ARM EVERY DAY
M35105972 Triamterene 37.5mg + Hydrochlorothiazide Expired 90 16 Jun 0 of 1

25mg, (Maxzide-25), Tablet, Oral 2012
DAY
M35331158 ranitidine HCl, 150 MG, TABLET, ORAL Expired 60 16 Jun 5 of 5

TAKE ONE TABLET BY MOUTH TWICE 2012
A DAY
M35284073 sucralfate, 1 gram, TABLET, ORAL Expired 120 28 Apr NR

TAKE ONE TABLET FOUR TIMES A DAY 2012
BEFORE MEALS AND AT BEDTIME
M35284074 Esomeprazole Magnesium Trihydrate 40mg, Expired 30 28 Apr NR

Capsule, Oral 2012
DAY
M35249294 pseudoephedrine HCl, 30 MG, TABLET, Expired 1 27 Mar NR

ORAL 2012
USE PER PACKAGE DIRECTIONS
M35249295 ibuprofen, 800 MG, TABLET, ORAL Expired 30 27 Mar NR

DAILY WITH FOOD
M35249296 Antipyrine + Glycerin + Benzocaine, Solution, Expired 1 27 Mar NR

Otic 2012
PLACE TWO DROPS IN EACH EAR
EVERY FOUR HOURS
M35248926 cyclobenzaprine HCl, 5 MG, TABLET, ORAL Expired 35 26 Mar NR

TAKE ONE TABLET BY MOUTH THREE 2012
TIMES A DAY AND TAKE TWO TABLETS
AT BEDTIME
M35248924 celecoxib, 100 MG, CAPSULE, ORAL Expired 60 26 Mar NR

TAKE ONE CAPSULE BY MOUTH TWICE 2012
A DAY
M10334432 eszopiclone, 3 MG, TABLET, ORAL Expired 14 08 Feb NR

NIGHT
M35181357 ibuprofen, 800 MG, TABLET, ORAL Expired 30 23 Jan NR

DAILY WITH FOOD
M35181356 Ondansetron Hydrochloride 8mg, (Zofran), Expired 30 23 Jan NR
2019
Medical Record
2019
Tablet, Oral 2012

SIX HOURS AS NEEDED FOR NAUSEA
AND VOMITING
M35181358 diphenhydramine HCl, 25 MG, CAPSULE, Expired 30 23 Jan NR

ORAL 2012
TAKE ONE CAPSULE THREE TIMES
DAILY
M35181355 Antipyrine + Glycerin + Benzocaine, Solution, Expired 1 23 Jan NR

Otic 2012
INSTILL 2 DROPS TO EACH EAR THREE
TIMES A DAY FOR 5 DAYS
M35181359 Pseudoephedrine Hydrochloride 60mg + Expired 36 23 Jan NR

M35181354 acetaminophen, 325 MG, TABLET, ORAL Expired 24 23 Jan NR

TAKE 2 TABLETS BY MOUTH EVERY 2012
SIX HOURS AS NEEDED -- NOT TO

TAKE 1 TO 2 TABLETS BY MOUTH
EVERY 4-6 HOURS AS NEEDED FOR
PAIN
M35084848 naproxen, 500 MG, TABLET, ORAL Expired 30 13 Oct NR

TAKE ONE TABLET TWICE A DAY WITH 2011
FOOD
M35084847 cyclobenzaprine HCl, 10 MG, TABLET, Expired 30 13 Oct NR

ORAL 2011
TAKE ONE TABLET THREE TIMES
DAILY AS NEEDED FOR MUSCLE
SPASMS
M10303513 vardenafil HCl, 20 MG, TABLET, ORAL Expired 6 13 Sep 7 of 11

TAKE 1 TABLET 60 MINUTES PRIOR TO 2011
INTERCOURSE; NO MORE THAN 1 PER
DAY
M10303512 Testosterone 1%, Gel/Jelly, Transdermal, Expired 2 24 Feb 2 of 2

Pump 2011
1 PUMP EACH UPPER ARM / BODY
DAILY #1 RF5
M34846741 Fexofenadine Hydrochloride 60mg + Expired 10 09 Feb NR

Pseudoephedrine Hydrochloride 120mg, 2011
Extended release tablet, Oral
T1 TAB PO Q12H
2019
Medical Record
2019

T1 TAB PO Q6H PP
D8012065 Iohexol 300mg/mL, Solution, Injection Expired 1 29 Sep NR

PROFILING PURPOSES ONLY - FOR USE 2010
IN RADIOLOGY CLINIC
UC3007763 PROPOXYPHENE/ACETAMINOPHEN, Expired 5 27 Sep NR

100-650 MG, TABLET, ORAL 2010
T1 TAB OP Q6H PFP
UC3007764 PROPOXYPHENE/ACETAMINOPHEN, Expired 5 27 Sep NR

100-650 MG, TABLET, ORAL 2010
T1 TAB OP Q6H PFP
UC6229002 acetaminophen, 325 MG, TABLET, ORAL Expired 24 27 Sep NR

T 1-2 TABS PO Q4-6H 2010
M10290452 CODEINE PHOS/ACETAMINOPHEN, 30- Expired 8 26 Sep NR

TAKE ONE TAB Q4-6H PRN FOR PAIN
M34708523 Omeprazole 20mg, Extended release capsule, Expired 15 18 Sep 11 of

Oral 2010 11
CD
M34708524 Trimethoprim 160mg + Sulfamethoxazole Expired 20 18 Sep NR

800mg, (Septra DS), Tablet, Oral 2010
T1 TAB PO BID UNTIL FINISHED
M202246 Dexmethylphenidate Hydrochloride 10mg Expired 90 29 Jan NR

Extended release capsule, Oral 2010
T1 CAP PO QD
M10247612 CODEINE PHOS/ACETAMINOPHEN, 30- Expired 10 04 NR

300MG, TABLET, ORAL May
TAKE 1-2 TABS Q4-6H FOR SEVERE PAIN 2009

TAKE 1 TAB Q 6-8 HOURS May
2009
M34238081 Chlorhexidine Gluconate 1.2mg/mL, Liquid, Expired 1 04 NR
Mouth or throat May
SWISH IN MOUTH FOR ONE MINUTE 2009
MORNING AND HS
M34238080 Potassium Clavulanate 125mg + Amoxicillin Expired 20 04 NR

Trihydrate 500mg, (Augmentin), Tablet, Oral May
T1 TAB BID F10D 2009
M34208495 Pseudoephedrine Hydrochloride 60mg + Expired 36 03 Apr NR

2019
Medical Record
2019
T1 TAB PO BID
M34208496 loratadine, 10 MG, TABLET, ORAL Expired 90 03 Apr NR

TD #90 RF0 2009
M34201226 Fluoxetine Hydrochloride 20mg, (Prozac), Expired 30 27 Mar 6 of 6

Capsule, Oral 2009
CD
M10244668 clonazepam, 0.5 MG, TABLET, ORAL Expired 45 27 Mar 1 of 1

T.5 TAB PO QAM AND T1 TAB PO QHS 2009
PRN
I30020069 Iopamidol 61%, Solution, Injection Expired 1 27 Mar NR

MEDIA
M34191965 hyoscyamine sulfate, 0.125 MG, TAB SUBL, Expired 60 18 Mar 2 of 2

SUBLINGUAL 2009
T1 TAB PO Q8H
M34131395 Hydrocortisone + Neomycin Sulfate + Expired 1 20 Jan NR

Polymyxin B Sulfate, Suspension, Otic 2009
PUT 2 DROPS IN EAR(S) Q6H
M10238710 CODEINE PHOS/ACETAMINOPHEN, 30- Expired 10 20 Jan NR

T1 TAB PO Q6H
M34131396 Maalox/Donnatal/Lidocaine Solution 3:2:1 Expired 240 20 Jan NR

Oral 2009
T 30 CC PO TID
M34121890 clarithromycin, 500 MG, TABLET, ORAL Expired 28 15 Jan NR

T1 BID F14 #28 RF0 2009
M34121891 amoxicillin, 500 MG, CAPSULE, ORAL Expired 56 15 Jan NR

T2 CAPS BID F14 2009
M34121893 Omeprazole 20mg, Extended release capsule, Expired 28 15 Jan NR

Oral 2009
T1 CAP PO BID F14
M34091625 Esomeprazole Magnesium Trihydrate 40mg, Expired 90 03 Dec NR

Capsule, Oral 2008
CHS
M34085907 Esomeprazole Magnesium Trihydrate 20mg, Expired 30 26 NR

Capsule, Oral Nov
CD 2008
M34085908 Ondansetron Hydrochloride 8mg, (Zofran), Expired 10 26 NR

Tablet, Oral Nov
T1 TAB PO Q8H PRN FOR NAUSEA #10 2008
2019
Medical Record
2019
RF0
I30019330 Iopamidol 61%, Solution, Injection Expired 1 26 NR

USE AS DIRECTED FOR CONTRAST Nov
MEDIA 2008
M34062741 tramadol HCl, 50 MG, TABLET, ORAL Expired 20 02 NR

TAKE 1 TAB PO Q 4-6 H PRN FOR PAIN Nov
2008
M172574 Oxycodone Hydrochloride + Acetaminophen, Expired 40 19 NR
Tablet, Oral May
T1-2 TABS Q4-6H PP 2008
M33902393 docusate sodium, 100 MG, CAPSULE, ORAL Expired 60 19 NR

T1 CAP BID May
2008
M33875673 tramadol HCl, 50 MG, TABLET, ORAL Expired 60 21 Apr NR
T 1-2 TABS PO QID PRN FOR PAIN 2008
D30055374 metoclopramide HCl, 10 MG, TABLET, Expired 15 20 Mar NR

ORAL 2008
T1 TAB PO TID #15 RF0
D30055372 tramadol HCl, 50 MG, TABLET, ORAL Expired 30 20 Mar NR

T1-2 TABS PO Q6H PP #30 RF0 2008
M169633 Oxycodone Hydrochloride + Acetaminophen, Expired 15 15 Mar NR

Tablet, Oral 2008
T 1-2 TABS Q4-6H PP #15
I30018301 Gadopentetate Dimeglumine 496.01mg/mL, Expired 1 11 Mar NR

Solution, Injection 2008
U UD FOR CONTRAST MEDIA
M33832196 dicyclomine HCl, 20 MG, TABLET, ORAL Expired 40 09 Mar NR

T1 TAB PO Q6H PRN F ABDOMINAL 2008
PAIN
M10214678 Codeine Phosphate + Guaifenesin, Syrup, Oral Expired 1 07 Mar NR

TAKE 1-2 TSP Q4-6H PRN F COUGH 2008
M33830318 ibuprofen, 800 MG, TABLET, ORAL Expired 30 07 Mar NR

T1 TAB PO TID WF 2008
M33830319 acetaminophen, 325 MG, TABLET, ORAL Expired 24 07 Mar NR

TAKE 1 TO 2 TABLETS Q4-6H NOT TO 2008
M33788234 methocarbamol, 500 MG, TABLET, ORAL Expired 40 26 Jan 5 of 5

T2 TAB QID #40 RF5 2008
M33788233 ibuprofen, 800 MG, TABLET, ORAL Expired 30 26 Jan NR

TT WF #30 2008
2019
Medical Record
2019
M33771876 Cephalexin 250mg Capsule, Oral Expired 40 09 Jan NR

T1 CAP Q6H OR QID F10D 2008
D30031871 meloxicam, 7.5 MG, TABLET, ORAL Expired 30 16 Oct 1 of 1

T1 TAB PO BID F 7 DAYS THEN 1 TAB PO 2007
QD
D30031602 acetaminophen, 325 MG, TABLET, ORAL Expired 24 11 Oct NR

T1-2 TABS PO Q4-6H PRN **MAX OF 12 2007
TABS PER DAY**
I30017443 Metoclopramide 1mg/mL Syrup, Oral Expired 1 14 Sep NR

10MG IV GIVEN IN ER 2007
I30017444 Acetaminophen 650mg, Suppository, Rectal Expired 1 14 Sep NR

650MG PR X1 IN ER 2007
I30017441 Albuterol Sulfate 0.83mg/mL + Ipratropium Expired 1 14 Sep NR

Bromide 0.5mg/3mL, Solution, Inhalation 2007
NEB TX IN ER X1
I30017442 Ceftriaxone Sodium 20mg/mL + Dextrose, Expired 1 14 Sep NR

Iso-osmotic, Solution, Intravenous, 50mL 2007
1GM IV IN ER
M33664684 Pseudoephedrine Hydrochloride 120mg + Expired 20 11 Sep NR

Guaifenesin 600mg, Extended release tablet, 2007
Oral
TBD
M33664683 Azithromycin 250mg, (Zithromax Z-Pak), Expired 1 11 Sep NR

Tablet, Oral 2007
TAKE 2 TABLETS AT ONCE ON DAY 1,
THEN TAKE 1 TABLET DAILY ON DAYS
2-5.
M33664685 Albuterol 90mcg Aerosol powder, Inhalation Expired 1 11 Sep NR

INHALE 2 PUFFS PRN QID #1 RF0 2007
UC6102345 ibuprofen, 800 MG, TABLET, ORAL Expired 15 08 Jul NR

T1 TAB PO TID PFP 2007
TL39748 desloratadine, 5 MG, TABLET, ORAL Expired 180 05 Dec NR

T1 TAB BID FOR ALLERGY 2005
TL15239 bismuth subsalicylate, 262 MG, TAB CHEW, Expired 30 10 Dec NR

ORAL 2004
CHEW 1 TAB PO QH UNTIL RELIEF
**MAX 8 TAB PER DAY** #24 RF0
Cefazolin Sodium 1g, Reconstituted solution, Expired UNK NR

Injection
2019
Medical Record
2019
Cefazolin Sodium 1g, Reconstituted solution, Expired UNK NR

Injection
***** End of Medications *****
2019
Medical Record
2019
Procedures
Ophthalmological New Patient Start Comprehensive Care on 10 Feb 2011

Date Performed: 10 Feb 2011 Date Reported: 10 Feb 2011
Verified: Yes CPT: 92004
Source: Unknown Source of Info Status: Active
Comment:
Determination Of Refractive State on 10 Feb 2011

Comment:
Spectacles Services Fitting Monofocals (Not For Aphakia) on 10 Feb 2011

Comment:
Ophthalmological New Patient Start Comprehensive Care on 05 May 2010

Date Performed: 05 May 2010 Date Reported: 05 May 2010
Comment:
Determination Of Refractive State on 05 May 2010

Comment:
Spectacles Services Fitting Monofocals (Not For Aphakia) on 05 May 2010

Comment:
2019
Medical Record
2019
Medical Nutrition Therapy Group (2 or More Individual(s)) on 25 Feb 2010

Comment:
Psychiatric Therapy Individual Approximately 45 Minutes on 03 Jun 2009

Date Performed: 03 Jun 2009 Date Reported: 03 Jun 2009
Comment:
Psychiatric Therapy Individual Approximately 45 Minutes on 07 May 2009

Comment:
Psychiatric Diagnostic Evaluation Review of Records and Reports on 27 Apr

2009
Date Performed: 27 Apr 2009 Date Reported: 27 Apr 2009
Comment:
Psych Ther Indiv Approx 30 Min W/ Medical Evaluation & Management on

27 Apr 2009
Comment:
Psychiatric Therapy Individual Approximately 30 Minutes on 08 Apr 2009

Comment:
Ophthalmological New Patient Start Comprehensive Care on 01 Apr 2009

2019
Medical Record
2019
Comment:
Determination Of Refractive State on 01 Apr 2009

Comment:
Spectacles Services Fitting Monofocals (Not For Aphakia) on 01 Apr 2009

Comment:
Psychiatric Diagnostic Evaluation Comprehensive Examination on 27 Mar

2009
Date Performed: 27 Mar 2009 Date Reported: 27 Mar 2009
Comment:
Psychiatric Diagnostic Evaluation Review of Records and Reports on 27 Mar

2009
Comment:
Psychiatric Diagnostic Evaluation Comprehensive Examination on 11 Mar

2009
Comment:
Psychiatric Diagnostic Evaluation Review of Records and Reports on 11 Mar

2009
Comment:
2019
Medical Record
2019
Psychiatric Therapy Preparation of Psychiatric Status Report on 11 Mar 2009

Comment:
Medical Nutrition Therapy Group (2 or More Individual(s)) on 14 Jan 2009

Date Performed: 14 Jan 2009 Date Reported: 14 Jan 2009
Comment:
Postoperative Visit, Without Charge on 22 May 2008

Comment:
Patient Counseling Medical Management Individual Patient

Date Performed: Unknown Date Reported: 11 Sep 2019
Comment:
Physical Therapy: ___ Session Segments, 15 Minutes Each

Comment:
Physical Therapy Service Evaluation Moderate Complexity

Comment:
***** End of Procedures *****
2019
Medical Record
2019
Family History
Family medical history on 08 Aug 2019

Date Onset: 09 Aug 2019 Date Reported: 08 Aug 2019
Source: Clinical Evidence Relationship: General FHx
Status: Active
Comment: ~Update at Wellness Visit or Annually~MOTHER/FATHER: HTN~MOTHER/FATHER:
DM~No 1st Degree Relative: CAD~No 1st Degree Relative: Cancer~No 1st Degree Relative:
Alcohol or Substance Abuse
No family history of supplemental HPI [use for free text] on 08 Aug 2019
Date Onset: 09 Aug 2019 Date Reported: 08 Aug 2019
Status: Active
Comment: LBP Red Flag - Age NOT greater than 70 years
No family history [use for free text] on 25 Jan 2018

Date Onset: 25 Jan 2018 Date Reported: 25 Jan 2018
Status: Active
Comment: No family history of glaucoma; no other eye disease
Family history of test conclusions [Use for free text] on 01 Jun 2016
Date Onset: 01 Jun 2016 Date Reported: 01 Jun 2016
Status: Active
Comment: A written list of medications was given to the patient
Daughter's history of test conclusions [Use for free text] on 01 Jun 2016
Date Onset: 01 Jun 2016 Date Reported: 01 Jun 2016
Source: Clinical Evidence Relationship: Daughter
Status: Active
Comment: The patient was educated on the importance of managing medication information
No family history of bleeding problems on 09 Jan 2015

Status: Active
Comment:
2019
Medical Record
2019
No family history of cancer on 09 Jan 2015

Status: Active
Comment:
No family history of congenital deafness on 09 Jan 2015

Status: Active
Comment:
Family history of nonorganic sleep apnea on 25 Jan 2012

Status: Active
Comment:
Family history of heart disease on 25 May 2010

Date Onset: 25 May 2010 Date Reported: 25 May 2010
Status: Active
Comment:
No angina pectoris on 25 May 2010

Status: Active
Comment:
Family history of cancer on 25 May 2010

Status: Active
Comment: breast cancer on moms side.
Family history [use for free text] on 25 May 2010

Status: Active
Comment: DIABETES patients father has type 1
2019
Medical Record
2019
No family history of mental illness (not intellectual disabilities) on 13 Mar

2009
Date Onset: 13 Mar 2009 Date Reported: 13 Mar 2009
Status: Active
Comment:
No family history of alcoholism on 13 Mar 2009

Date Onset: 13 Mar 2009 Date Reported: 13 Mar 2009
Status: Active
Comment:
No malignant neoplasm of large intestine on 05 Nov 2008

Date Onset: 05 Nov 2008 Date Reported: 05 Nov 2008
Status: Active
Comment:
Arteriosclerotic cardiovascular disease (ASCVD) on 09 Jan 2008

Source: Patient Relationship: General FHx
Status: Active
Comment: MI age 50
Type 2 diabetes mellitus on 09 Jan 2008

Source: Patient Relationship: General FHx
Status: Active
Comment:
***** End of Family History *****
2019
Medical Record
2019
Resulted Labs
Follicle Stimulating Hormone+Luteinizing Hormone on 23 Aug 2019

Collection Date: 23 Aug 2019 Site/Specimen: SERUM
Ordering Clinician: AGUILAR,
MICHAEL
THOMAS
Comment:
Chem
Name Value Units Range Abnormal
Follitropin 5.6 mIU/mL
Interpretation:
REFERENCE RANGES:
ADULT FEMALE FOLLICULAR: 3-20 mIU/mL
PEAK: 9-26 mIU/mL
LUTEAL: 1-12 mIU/mL
POST MENOPAUSAL: 18-153 mIU/mL
ADULT MALE: 1-12 mIU/mL
Lutropin 8.0 mIU/mL
Interpretation:
REFERENCE RANGES:
ADULT FEMALE FOLLICULAR: 2-15 mIU/mL
PEAK: 22-105 mIU/mL
LUTEAL: 0.6-19 mIU/mL
POST MENOPAUSAL: 16-24 mIU/mL
ADULT MALE: 2-12 mIU/mL
Prostate Specific Ag on 12 Aug 2019

MICHAEL
THOMAS
Comment:
Chem
Prostate Specific Ag 0.85 ng/mL (0.00-4.00)
Hemogram+Differential Auto on 12 Aug 2019

Collection Date: 12 Aug 2019 Site/Specimen: BLOOD
MICHAEL
THOMAS
2019
Medical Record
2019
Comment:
Chem
Hematocrit 41.5 % (42-52) Lower Than
Normal
WBC 6.7 x10(3)/mcL (4.9-10.0)
RBC 4.98 x10(6) (4.7-6.1)
Hemoglobin 14.4 g/dL (14.0-18.0)
MCV 83.3 fL (80-96)
MCH 29.0 pg (27-31)
MCHC 34.8 g/dL (32.0-36.0)
RDW CV 13.5 % (11.5-14.5)
MPV 10.0 fL (6.8-10)
Platelets 269 x10(3)/mcL (150-450)
ABS Neutrophils 3.3 x10(3)/mcL (1.4-6.5)
Neutrophils 49.1 % (30-70)
ABS Lymphocytes 2.7 x10(3)/mcL (1.0-4.0)
Lymphocytes 40.6 % (20-40) Higher Than
Normal
ABS Monocytes 0.4 x10(3)/mcL (0.0-1.0)
Monocytes 6.6 % (0-10)
ABS Eosinophils 0.2 x10(3)/mcL (0.0-0.5)
Eosinophils 2.5 % (0-5)
ABS Basophils 0.1 x10(3)/mcL (0.0-0.2)
Basophils 1.2 % (0-2)
Testosterone Free+Total on 06 Sep 2018

Collection Date: 06 Sep 2018 Site/Specimen: SERUM
Ordering Clinician: GRANJAVASQUE
Z, JOCHEN A
Comment:
Chem
Testosterone 250 ng/dL 264-916 Lower Than
Normal
Interpretation:
Adult male reference interval is based on a population of
healthy nonobese males (BMI <30) between 19 and 39 years old.
Travison, et.al. JCEM 2017,102;1161-1173. PMID: 28324103.
Testosterone Free 6.6 pg/mL 6.8-21.5 Lower Than

Normal
Hemoglobin A1c Panel on 18 Jul 2018

Collection Date: 18 Jul 2018 Site/Specimen: BLOOD
Z, JOCHEN A
Comment:
Chem
2019
Medical Record
2019

Hemoglobin A1c 5.4 % (4.0-5.6)
Interpretation:
PRE-DIABETIC: 5.7-6.4
DIABETIC: >OR= 6.5%
ADA TARGET: <7.0%
ACTION SUGGESTED: >7.0%
Estimated Average Glucose 108 mg/dL
Interpretation:
The Estimated Average Glucose (EAG) is an estimated average of the glucose
level for the past 2-3 months. It is a calculation based on the Hemoglobin
A1C result and expressed in mg/dL.
Testosterone Free+Total on 18 Jul 2018

Collection Date: 18 Jul 2018 Site/Specimen: SERUM
Z, JOCHEN A
Comment:
Chem
Normal
Interpretation:
Adult male reference interval is based on a population of
healthy nonobese males (BMI <30) between 19 and 39 years old.
Travison, et.al. JCEM 2017,102;1161-1173. PMID: 28324103.

Normal
Comprehensive Metabolic Panel on 18 Jul 2018

Collection Date: 18 Jul 2018 Site/Specimen: PLASMA
Z, JOCHEN A
Comment:
Chem
Chloride 102 mmol/L (98-107)
Albumin 3.8 g/dL (3.4-5.0)
Bilirubin 0.3 mg/dL (0.2-1.3)
Calcium 9.9 mg/dL (8.4-12.2)
Creatinine 0.9 mg/dL (0.66-1.25)
Glucose 87 mg/dL (74-106)
Interpretation:
2019
Medical Record
2019
Refer to current ADA guidelines for diagnosis of impaired glucose metabolism

and diabetes.
Alkaline Phosphatase 96 U/L (38-126)

Potassium 3.8 mmol/L (3.6-5.2)
Protein 7.5 g/dL (6.4-8.2)
Sodium 143 mmol/L (136-145)
Aspartate 19 U/L (0-40)
Aminotransferase
Urea Nitrogen 8 mg/dL (7-18)
Carbon Dioxide 28 mmol/L (21-32)
Anion Gap 13 mmol/L (8-16)
Alanine Aminotransferase 28 U/L (0-41)
GFR Non-Black 96 mL/min
Interpretation:
>=90 mL/min/1.73m2 = Normal
60 -89 mL/min/1.73m2 = Mildly decreased GFR
30-59 mL/min/1.73m2 = Moderately decreased GFR
15-29 mL/min/1.73m2 = Severely decreased GFR
< 15 mL/min/1.73m2 = Kidney failure
This is an estimated glomerular filtration rate (eGFR) only. The value has
been derived from the Chronic Kidney Disease - Epidemiology (CKD-Epi)
Collaboration Equation. The calculation automatically takes patient sex into
account, but CHCS cannot automatically adjust the formula for African
American (AA) patients, therefore two GFR results are reported -- GFR-NON AA
and GFR-AA. As with all estimations, results may not be valid for certain
sub-groups including: pediatric patients (0-17 years old), severely
hypoalbuminemic patients, patients not in steady state (including acute renal
failure), dialysis patients, and patients with atypical body habitus. Results
will not be reported on patients under 18 years of age.
Some pharmacological therapeutics are dosed based on older versions of the

eGFR. Where deemed necessary, refer to Pharmacy for assistance or more
information.
GFR Black 111 mL/min
Lipids on 18 Jul 2018

Z, JOCHEN A
Comment:
Chem
Triglyceride 246 mg/dL (0-199) Higher Than
Normal
Cholesterol 205 mg/dL (0-199) Higher Than
Normal
HDL Cholesterol 47 mg/dL (40-60)
LDL Cholesterol 109 mg/dL (0-129)
2019
Medical Record
2019
Urinalysis on 16 Nov 2017

Collection Date: 16 Nov 2017 Site/Specimen: URINE
Ordering Clinician: WILLIAMS,
LILLIAN W.
Comment: Pre-employment SG exam. thanx, L. Cain, RN
Chem
Urobilinogen NEGATIVE EU/dL (NEGATIVE)
Color YELLOW
Appearance CLEAR (CLEAR)
Specific Gravity 1.021 (1.005-1.035)
Bilirubin NEGATIVE (NEGATIVE)
Glucose NEGATIVE mg/dL (NEGATIVE)
Protein NEGATIVE mg/dL (NEGATIVE)
pH 6.0 (5.0-7.5)
Nitrite NEGATIVE (NEGATIVE)
Leukocyte Esterase NEGATIVE (NEGATIVE)
Ketones NEGATIVE mg/dL (NEGATIVE)
Blood NEGATIVE (NEGATIVE)
RBC <1 /HPF (0-2)
Mucus RARE (0-OCC)
WBC 1 /HPF (0-5)
Mumps Virus Ab on 16 Nov 2017

Collection Date: 16 Nov 2017 Site/Specimen: SERUM
LILLIAN W.
Comment:
Chem
Mumps Virus Ab POSITIVE
Interpretation:
INTERPRETATION:
NEGATIVE = NOT IMMUNE
POSITIVE = IMMUNE
INDETERMINATE = BETWEEN THE CUTOFF FOR IMMUNITY
Rubeola Virus Ab on 16 Nov 2017

LILLIAN W.
Comment:
Chem
Rubeola Virus Ab POSITIVE
2019
Medical Record
2019
Interpretation:
INTERPRETATION:
POSITIVE = IMMUNE
Varicella Virus Ab on 16 Nov 2017

LILLIAN W.
Comment: Job-related baeline. thanx, L. Cain, RN
Chem
Varicella Zoster Virus Ab POSITIVE
Interpretation:
NORMAL=NEGATIVE FOR IGG ANTIBODIES
POSITIVE=POSITIVE FOR IGG ANTIBODIES
INCONCLUSIVE=PLEASE RESUBMIT NEW SPECIMEN WITHIN 2 WEEKS FOR FURTHER
TESTING.
Hepatitis B Virus Surface Ab on 16 Nov 2017

LILLIAN W.
Comment: Job-related baeline. thanx, L. Cain, RN
Chem
Hepatitis B Virus Surface POSITIVE
Ab
Interpretation:
NORMAL REFERENCE RANGE WITH HEPATITIS B VACCINE (FULL SERIES): POSITIVE.
NORMAL REFERENCE RANGE WITHOUT HEPATITIS B VACCINE: NEGATIVE.
Rubella Virus Ab on 16 Nov 2017

LILLIAN W.
Comment:
Chem
Rubella Virus Ab POSITIVE
Interpretation:
2019
Medical Record
2019
INTERPRETATION:
POSITIVE = IMMUNE
INDETERMINATE = BETWEEN CUT-OFF FOR IMMUNITY
Basic Metabolic Panel on 16 Nov 2017

Collection Date: 16 Nov 2017 Site/Specimen: PLASMA
LILLIAN W.
Comment:
Chem
Interpretation:
and diabetes.

Calcium 9.1 mg/dL (8.4-12.2)
Interpretation:

information.
2019
Medical Record
2019
Lipids on 16 Nov 2017

LILLIAN W.
Comment:
Chem
Triglyceride 92 mg/dL (0-199)
Cholesterol 179 mg/dL (0-199)
Hemogram+Differential Auto on 16 Nov 2017

Collection Date: 16 Nov 2017 Site/Specimen: BLOOD
LILLIAN W.
Comment: Pre-employment SG exam. thanx, L. Cain, RN
Chem
Hematocrit 44.0 % (42-52)
WBC 6.8 x10(3)/mcL (4.9-10.0)
RBC 5.37 x10(6) (4.7-6.1)
MCV 82.1 fL (80-96)
MPV 9.2 fL (6.8-10)
MCH 28.5 pg (27-31)
MCHC 34.8 % (32-36)
RDW CV 13.4 % (11.5-14.5)
Platelets 288 x10(3)/mcL (150-450)
Lymphocytes 37.7 % (20-40)

Ordering Clinician: VANDERSPURT,
CECILY
KENNEDY
Comment:
Chem
2019
Medical Record
2019
MCV 83.8 fL (80-96)

WBC 7.2 x10(3)/mcL (4.9-10.0)
RBC 5.41 x10(6) (4.7-6.1)
MCH 28.9 pg (27-31)
MCHC 34.5 % (32-36)
RDW CV 13.4 % (11.5-14.5)
MPV 9.1 fL (6.8-10)
Platelets 251 x10(3)/mcL (150-450)
Neutrophils 87.2 % (30-70) Higher Than
Normal
ABS Lymphocytes 0.7 x10(3)/mcL (1.0-4.0) Lower Than
Normal
Lymphocytes 9.0 % (20-40) Lower Than
Normal
CBC W/Diff Manual on 28 Aug 2017

CECILY
KENNEDY
Comment:
Chem
Platelet Estimate ADEQUATE
Neutrophils Segmented 85 % (30-70)
Lymphocytes % 10 % (20-40) Lower Than
Normal
Eosinophils % 1 % (0-5)
Monocytes % 4 % (0-10)
RBC Morphology NORMAL
(NC/NC)
Lipase on 28 Aug 2017

Collection Date: 28 Aug 2017 Site/Specimen: PLASMA
CECILY
KENNEDY
Comment:
Chem
Triacylglycerol Lipase 19 U/L (13-60)
2019
Medical Record
2019
Comprehensive Metabolic Panel on 28 Aug 2017

CECILY
KENNEDY
Comment:
Chem
Glucose 131 mg/dL (74-106) Higher Than
Normal
Interpretation:
and diabetes.
Albumin 4.2 g/dL (3.4-5.0)

Calcium 8.4 mg/dL (8.4-12.2)
Protein 7.7 g/dL (6.4-8.2)
Aminotransferase
Interpretation:

2019
Medical Record
2019
information.

Ordering Clinician: TAMBE, MOSES
A
Comment:
Chem
Urobilinogen 2.0 mg/dL (NEGATIVE) Higher Than
Normal
Color YELLOW
pH 6.0 (5.0-7.5)
RBC 1 /HPF (0-2)
Mucus RARE (0-OCC)
WBC 1 /HPF (0-5)
Semen Analysis Post Vasectomy on 19 Sep 2016

Collection Date: 19 Sep 2016 Site/Specimen: Seminal Fluid
Ordering Clinician: CAREY, PATRICK
M
Comment:
Order # 160912-02537
Filler # 160919 MI 4605
Status Final
Type Microbiology
Origin DoD
MTF/Facility Martin ACH, Fort Benning, GA
Ordering Provider CAREY, PATRICK M
Priority ROUTINE
DATE ORDERED 12 Sep 2016 1109
DATE_RESULTED 19 Sep 2016 1410
COLLECT_SAMPLE SEMINAL FLUID
BACTERIOLOGY RESULT NO SPERMATOZOA SEEN.
Results Final report
2019
Medical Record
2019
TISSUE EXAM on 30 Jun 2016

Collection Date: 30 Jun 2016 Site/Specimen: A: right vas B: left vas
Ordering Clinician: VEGA, JULIAN T
Comment:
Order # 160708-02828
Status Certify
Type Anatomic Pathology
Origin DoD
POC Enc E258485
Enc Fac Martin ACH, Fort Benning, GA
Procedure TISSUE EXAM
Provider VEGA, JULIAN T
Ordered Date 08 Jul 2016 1111
Priority ROUTINE
Specimen TISSUE
Resulted Date 14 Jul 2016 1549.1-0400
Col 30Jun16@1010 TISSUE(TISSUE)
Hcp VEGA,JULIAN T Req Loc: FMC SPEC
Performing Lab ANATOMICAL PATHOLOGY
160708 S 2069
TISSUE E C JDP14Jul16@1549
CoPath Report
Patient WAITERS,TOMMIE ALAJANDRO Specimen #: S16-
2069
Accessioned 07/08/16
Pathologist Jeffrey D. Prichard, CPT, MC
SPECIMEN A: right vas B: left vas
CLINICAL DIAGNOSIS AND 45 yo male present for vasectomy
HISTORY
PRE-OPERATIVE DIAGNOSIS vasectomy
POST-OPERATIVE DIAGNOSIS Operative Findings: vasectomy
Post-operative Diagnosis: vasectomy
GROSS DESCRIPTION Received as two parts labeled A and B and each part labeled
"Waiters,
Tommie 20/1757."
Part A - Labeled "Right vas" - A specimen consisting of a single
tan
cylindrical core of tissue measuring 0.7 cm in length by
approximately 0.1
cm in diameter and submitted intact entirely in cassette A1.
Part B - Labeled "Left vas" - A specimen consisting of a single tan
approximately 0.5
cm in diameter and submitted intact entirely in cassette B1.
FINAL DIAGNOSIS
A. VAS, RIGHT, VASECTOMY -- UNREMARKABLE VAS DEFERENS, COMPLETE LUMEN
IDENTIFIED.
B. VAS, RIGHT, VASECTOMY -- UNREMARKABLE VAS DEFERENS WITH
SURROUNDING SMALL CALIBER VESSELS,
COMPLETE LUMEN IDENTIFIED.
2019
Medical Record
2019
jdp/07/14/16 ** Report Electronically Signed **

Jeffrey D. Prichard, CPT, MC
CPT Codes 12345 ; 88302 ; 88302 Level II surgical pathology, gross and
microscopic
evaluation
12345 ; 88302 ; 88302 Level II surgical pathology, gross and
microscopic
evaluation
SNOMED CODES
1. M00100; P1100; T79200; T79210
2. M00100; P1100; T79200; T79210
Lipase on 21 Apr 2016

Collection Date: 21 Apr 2016 Site/Specimen: PLASMA
Ordering Clinician: LESTER, JOSEPH
L
Comment:
Chem
Comprehensive Metabolic Panel on 21 Apr 2016

L
Comment:
Chem
Chloride 99.9 mmol/L (98-107)
Albumin 3.9 g/dL (3.4-5.0)
Calcium 9.4 mg/dL (8.4-12.2)
Normal
Interpretation:
and diabetes.

Protein 7.2 g/dL (6.4-8.2)
Aminotransferase
Urea Nitrogen 10.6 mg/dL (7-18)
Anion Gap 10.0 mmol/L (10-20)
2019
Medical Record
2019
Interpretation:
Anion Gap calculation is (NA+K)-(Cl+CO2)

Interpretation:

information.
Hemogram+Differential Auto on 21 Apr 2016

Collection Date: 21 Apr 2016 Site/Specimen: BLOOD
L
Comment:
Chem
WBC 9.3 x10(3)/mcL (4.9-10.0)
RBC 5.20 x10(6) (4.7-6.1)
MCV 82.2 fL (80-96)
MCH 28.1 pg (27-31)
MCHC 34.2 % (32-36)
RDW CV 13.4 % (11.5-14.5)
MPV 9.3 fL (6.8-10)
Platelets 250 x10(3)/mcL (150-450)
Normal
2019
Medical Record
2019

ABS Eosinophils 0.4 x10(3)/mcL (0-.5)
Urinalysis on 21 Apr 2016

Collection Date: 21 Apr 2016 Site/Specimen: URINE
L
Comment: abd pain
Chem
Urobilinogen 4.0 mg/dL (NEGATIVE) Higher Than
Normal
Color YELLOW
pH 6.0 (5.0-7.5)
RBC <1 /HPF (0-2)
Mucus RARE (0-OCC)
WBC <1 /HPF (0-5)
Lipids on 07 Jan 2016

Collection Date: 07 Jan 2016 Site/Specimen: PLASMA
Ordering Clinician: MCCOMB,
CLARA E
Comment: reordered
Chem
Normal
LDL Cholesterol 152 mg/dL (0-129) Higher Than
Normal
Testosterone Free+Total on 07 Jan 2016

Collection Date: 07 Jan 2016 Site/Specimen: SERUM
2019
Medical Record
2019
CLARA E
Comment:
Chem
Normal
Normal
Comment 18 COMMENT
Hemoglobin A1c Panel on 07 Jan 2016

Collection Date: 07 Jan 2016 Site/Specimen: BLOOD
CLARA E
Comment:
Chem
Interpretation:
DIABETIC: >OR= 6.5%
ADA TARGET: <7.0%
Interpretation:
Test performed at
Martin Army Community Hospital
7950 Martin Loop
Fort Benning, GA 31905
Prostate Specific Ag on 07 Jan 2016

CLARA E
Comment:
Chem
Prostate Specific Ag 1.10 ng/mL (0.00-4.00)
Comprehensive Metabolic Panel on 07 Jan 2016

CLARA E
Comment:
2019
Medical Record
2019
Chem
Albumin 4.1 g/dL (3.4-5.0)
Calcium 9.2 mg/dL (8.4-12.2)
Protein 7.7 g/dL (6.4-8.2)
Interpretation:
and diabetes.

Aminotransferase
Urea Nitrogen 10.5 mg/dL (7-18)
Interpretation:

Interpretation:

information.
2019
Medical Record
2019
Mumps Virus Ab on 22 Dec 2015

Collection Date: 22 Dec 2015 Site/Specimen: SERUM
Ordering Clinician: TRIMUEL,
SHARITA K
Comment:
Chem
Interpretation:
INTERPRETATION:
POSITIVE = IMMUNE
Rubeola Virus Ab on 22 Dec 2015

SHARITA K
Comment:
Chem
Interpretation:
INTERPRETATION:
POSITIVE = IMMUNE
Varicella Virus Ab on 22 Dec 2015

SHARITA K
Comment:
Chem
Interpretation:
TESTING.
2019
Medical Record
2019
Hepatitis B Virus Surface Ab on 22 Dec 2015

SHARITA K
Comment:
Chem
Ab
Interpretation:
Rubella Virus Ab on 22 Dec 2015

SHARITA K
Comment:
Chem
Interpretation:
INTERPRETATION:
POSITIVE = IMMUNE
Bile Acids Total on 14 Jan 2015

Ordering Clinician: MELENDEZ, ELY
Comment: ?? ppd
Chem
Bile Acids 6.0 mcmol/L 3.8-20.9
Hemogram+Differential Auto on 14 Jan 2015

Comment: ?? ppd
Chem
2019
Medical Record
2019
WBC 8.3 x10(3)/mcL (4.9-10.0)

RBC 5.67 x10(6) (4.7-6.1)
MCV 82.5 fL (80-96)
MCH 27.1 pg (27-31)
MCHC 32.9 % (32-36)
RDW CV 13.1 % (11.5-14.5)
MPV 9.4 fL (6.8-10)
Platelets 279 x10(3)/mcL (150-450)
Hepatic Function Panel on 14 Jan 2015

Comment: ?? ppd
Chem
Aminotransferase
Albumin 4.3 g/dL (3.4-5.0)
Bilirubin Direct <0.2 mg/dL (0.0-0.3)
Protein 7.6 g/dL (6.4-8.2)
Urinalysis on 14 Jan 2015

Collection Date: 14 Jan 2015 Site/Specimen: URINE
Comment: ?? ppd
Chem
Color YELLOW
Urobilinogen NEGATIVE mg/dL
pH 7.0 (5.0-7.5)
2019
Medical Record
2019

RBC <1 /HPF (0-2)
Mucus RARE (0-OCC)
WBC <1 /HPF (0-5)
Urine Culture on 04 Nov 2014

Collection Date: 04 Nov 2014 Site/Specimen: Urine
Ordering Clinician: JONES, RACHEL
M
Comment:
Order # 141104-05281
Filler # 141104 MI 3216
Status Final
Type Microbiology
Origin DoD
Ordering Provider JONES, RACHEL M
Priority ROUTINE
DATE ORDERED 04 Nov 2014 1430
DATE_RESULTED 07 Nov 2014 0955
COLLECT_SAMPLE URINE CC
BACTERIOLOGY RESULT NO GROWTH IN 24 HOURS.
NO GROWTH IN 48 HOURS.
Chlamydia+Gonococcus DNA Probe on 04 Nov 2014

M
Comment:
Chem
Neisseria gonorrhoeae DNA NEGATIVE
Interpretation:
REFERENCE RANGE: NEGATIVE
The performance of endocervical, vaginal, male urethral swabs and male urines
has not been evaluated in adolescents less than 14 years of age. The
recommended testing in patients less than 14 years of age is Chlamydia/GC
culture. Female urines are not a FDA approved sample type and were validated
by Martin Army Microbiology Department.
Test Method:
Hologic Panther
2019
Medical Record
2019
Chlamydia sp. DNA NEGATIVE
Interpretation:
REFERENCE RANGE: NEGATIVE
The performance of endocervical, vaginal, male urethral swabs and male urine
specimens has not been evaluated in adolescents less than 14 years of age.
The recommended testing for patients less than 14 years of age is
Chlamydia/GC culture. Female urine specimens are not a FDA approved sample
type and were validated by Martin Army Microbiology Department.
Test Method:
Hologic Panther

M
Comment:
Chem
Urobilinogen 12.0 EU/dL (0.0-3.0) Higher Than
Normal
Color AMBER
pH 6.5 (5.0-7.5)
Leukocyte Esterase 25 (NEGATIVE)
RBC 11-30 /HPF (0-2)
Bacteria 2+ (MOD) /HPF (NONE)
Calcium Oxalate Crystals OCCASIONAL (NONE)
Mucus FEW (0-OCC)
Epithelial Cells Squamous 0-2 /HPF (FEW)
WBC 0-2 /HPF (0-5)
Influenza A+B Virus Ag Rapid on 04 Nov 2014

Collection Date: 04 Nov 2014 Site/Specimen: NASOPHARYNGEAL SWAB
M
Comment:
Chem
Influenza Virus A Ag NEGATIVE FOR
2019
Medical Record
2019
FLU A PROTEIN
ANTIGEN
Influenza Virus B Ag NEGATIVE FOR
FLU B PROTEIN
ANTIGEN
Streptococcus pyogenes Ag on 04 Nov 2014

Collection Date: 04 Nov 2014 Site/Specimen: PHARYNX
M
Comment:
Chem
Streptococcus pyogenes Ag NEGATIVE (NEGATIVE)
Throat Culture on 04 Nov 2014

Collection Date: 04 Nov 2014 Site/Specimen: Pharynx
M
Comment:
Order # 141104-02389
Filler # 141104 MI 3156
Status Final
Type Microbiology
Origin DoD
Ordering Provider JONES, RACHEL M
Priority ROUTINE
DATE ORDERED 0
COLLECT_SAMPLE PHARYNX
BACTERIOLOGY RESULT NORMAL THROAT FLORA / NO GROUP (A) BETA
STREPTOCOCCUS ISOLATED.

Ordering Clinician: MISTRETTA,
PATRICIA W
Comment:
Chem
2019
Medical Record
2019
Amylase on 26 Aug 2014

PATRICIA W
Comment:
Chem
Amylase 106 U/L (25-115)
Interpretation:
Test performed at
7950 Martin Loop
Fort Benning, Georgia 31905
(706)544-2221
Helicobacter pylori Ab on 26 Aug 2014

PATRICIA W
Comment:
Chem
Helicobacter pylori Ab Positive for
Helicobacter
Pylori
Interpretation:
Reference Range: Negative for Helicobacter pylori
This method has not been established for patients under 18 years of age.
Cardiac Enzymes Panel on 26 Aug 2014

PATRICIA W
Comment:
Chem
Creatine Kinase 143 U/L (55-170)
Creatine Kinase MB 0.51 ng/mL (0.00-2.37)
Interpretation:
Test performed at
7950 Martin Loop
2019
Medical Record
2019
(706)544-2221
Troponin I Cardiac <0.012 ng/mL (0.0-0.034)
Interpretation:
1. Serial sampling is recommended to detect the temporal rise and fall of
cTnI levels characteristic of AMI.
2. The Joint European Society of Cardiology/American College of Cardiology
(ESC/ACC) and the National Academy of Clinical Biochemistry Standards of
Laboratory Practices (NACB) recommends that the diagnosis of AMI includes
the presence of clinical history indicative of Acute Coronary Syndrome (ACS)
and a maximum concentration of cardiac troponin exceeding the 99th percentile
(0.034 ng/mL for this assay) of a normal reference population on a least one
occasion during the first 24 hours.
The AMI diagnostic cutoff for this assay is 0.120 ng/mL.
Test performed at
7950 Martin Loop
(706)544-2221
Comprehensive Metabolic Panel on 26 Aug 2014

PATRICIA W
Comment:
Chem
Albumin 4.3 g/dL (3.4-5.0)
Interpretation:
Total bilirubin by this method is not intended for neonatal samples.
Biases of up to +/- 10% have been observed.
Test performed at
7950 Martin Loop
(706)544-2221
Calcium 10.4 mg/dL (8.4-12.2)

Interpretation:
and diabetes.
2019
Medical Record
2019

Protein 7.5 g/dL (6.4-8.2)
Aminotransferase
Interpretation:

Interpretation:

information.
GFR Black 95 mL/min

PATRICIA W
Comment:
Chem
WBC 8.4 x10(3)/mcL (4.9-10.0)
RBC 5.30 x10(6) (4.7-6.1)
2019
Medical Record
2019
MCV 84.7 fL (80-96)

MCH 28.9 pg (27-31)
MCHC 34.2 % (32-36)
RDW CV 13.2 % (11.5-14.5)
MPV 9.5 fL (6.8-10)
Platelets 246 x10(3)/mcL (150-450)
Normal
Lipase on 31 May 2013

Collection Date: 31 May 2013 Site/Specimen: PLASMA
Ordering Clinician: ADLER, JEFFREY
BRIAN
Comment:
Chem
Comprehensive Metabolic Panel on 31 May 2013

BRIAN
Comment:
Chem
Albumin 4.0 g/dL (3.4-5.0)
Interpretation:
Test performed at
7950 Martin Loop
(706)544-2221
Calcium 9.3 mg/dL (8.4-12.2)

2019
Medical Record
2019
Interpretation:
and diabetes.

Protein 7.4 g/dL (6.4-8.2)
Aminotransferase
Interpretation:
Urinalysis on 31 May 2013

Collection Date: 31 May 2013 Site/Specimen: URINE
BRIAN
Comment:
Chem
Color YELLOW
Appearance HAZY (CLEAR)
Urobilinogen <2.0 EU/dL (0.0-3.0)
pH 6.5 (5.0-7.5)
RBC <1 /HPF (0-2)
Amorphous Sediment RARE (0)
Mucus RARE (0-OCC)
WBC 1 /HPF (0-5)
Hemogram+Differential Auto on 31 May 2013

Collection Date: 31 May 2013 Site/Specimen: BLOOD
BRIAN
Comment:
2019
Medical Record
2019
Chem
MCV 84.8 fL (80-96)
WBC 7.8 x10(3)/mcL (4.9-10.0)
RBC 5.05 x10(6) (4.7-6.1)
MCH 29.0 pg (27-31)
MCHC 34.3 % (32-36)
RDW CV 13.4 % (11.5-14.5)
MPV 9.2 fL (6.8-10)
Platelets 226 x10(3)/mcL (150-450)
Normal
Occult Blood on 07 Feb 2013

Collection Date: 07 Feb 2013 Site/Specimen: FECES
Ordering Clinician: ZAGORSKI, KIM
JOSEPH
Comment:
Chem
Occult Blood NEGATIVE

JOSEPH
Comment:
Chem

JOSEPH
Comment:
Chem
2019
Medical Record
2019


JOSEPH
Comment:
Chem
WBC 8.4 x10(3)/mcL (4.9-10.0)
RBC 5.35 x10(6) (4.7-6.1)
MCV 85.5 fL (80-96)
MCH 29.7 pg (27-31)
MCHC 34.7 % (32-36)
RDW CV 13.3 % (11.5-14.5)
MPV 9.7 fL (6.8-10)
Platelets 231 x10(3)/mcL (150-450)
ABS Lymphocytes 4.2 x10(3)/mcL (1.0-4.0) Higher Than
Normal
Normal
Lipase on 29 Jan 2013

JOSEPH
Comment:
Chem
Amylase on 29 Jan 2013

JOSEPH
Comment:
Chem
2019
Medical Record
2019

Amylase 94 U/L (25-115)
Interpretation:
Test performed at
7950 Martin Loop
(706)544-2221

JOSEPH
Comment:
Chem
Albumin 4.3 g/dL (3.4-5.0)
Interpretation:
Test performed at
7950 Martin Loop
(706)544-2221
Calcium 9.4 mg/dL (8.4-12.2)

Normal
Interpretation:
and diabetes.

Protein 7.9 g/dL (6.4-8.2)
Aminotransferase
2019
Medical Record
2019
Interpretation:

Ordering Clinician: POLLITT,
STEPHEN P
Comment: Pre-placement physical exam. Thanx, L. Cain, RN
Chem
Color YELLOW
Protein TRACE mg/dL (NEGATIVE)
pH 5.5 (5.0-7.5)
RBC <1 /HPF (0-2)
Mucus RARE (0-OCC)
WBC 1 /HPF (0-5)
Hepatitis B Virus Surface Ab on 20 Nov 2012

STEPHEN P
Comment:
Chem
Ab
Interpretation:
MMR Panel on 20 Nov 2012

STEPHEN P
Comment:
Chem
2019
Medical Record
2019

Interpretation:
INTERPRETATION:
POSITIVE = IMMUNE
Interpretation:
INTERPRETATION:
POSITIVE = IMMUNE
Interpretation:
INTERPRETATION:
POSITIVE = IMMUNE
Varicella Virus Ab on 20 Nov 2012

STEPHEN P
Comment:
Chem
Interpretation:
TESTING.

STEPHEN P
Comment:
Chem
2019
Medical Record
2019
Interpretation:
and diabetes.

Interpretation:
Calcium 9.4 mg/dL (8.4-12.2)

STEPHEN P
Comment:
Chem
Normal
Normal

STEPHEN P
Comment: Pre-placement physical exam. Thanx, L. Cain, RN
Chem
WBC 7.0 x10(3)/mcL (4.9-10.0)
RBC 5.16 x10(6) (4.7-6.1)
MCV 86.8 fL (80-96)
MCH 29.7 pg (27-31)
MCHC 34.2 % (32-36)
RDW CV 13.1 % (11.5-14.5)
MPV 8.9 fL (6.8-10)
Platelets 271 x10(3)/mcL (150-450)
2019
Medical Record
2019

Normal
Comprehensive Metabolic Panel on 19 Nov 2012

Ordering Clinician: CLAY, EMILY C
Comment:
Chem
Interpretation:
and diabetes.
Albumin 4.2 g/dL (3.4-5.0)

Interpretation:
Test performed at
7950 Martin Loop
(706)544-2221
Calcium 9.5 mg/dL (8.4-12.2)

Protein 8.1 g/dL (6.4-8.2)
Aminotransferase
Interpretation:
2019
Medical Record
2019

Comment:
Chem
WBC 6.9 x10(3)/mcL (4.9-10.0)
RBC 5.20 x10(6) (4.7-6.1)
MCV 85.8 fL (80-96)
MCH 29.6 pg (27-31)
MCHC 34.5 % (32-36)
RDW CV 13.1 % (11.5-14.5)
MPV 8.9 fL (6.8-10)
Platelets 283 x10(3)/mcL (150-450)
Normal
Hemoglobin A1c Panel on 19 Nov 2012

Comment:
Chem
Interpretation:
DIABETIC: >OR= 6.5%
ADA TARGET: <7.0%
Interpretation:
Test performed at
7950 Martin Loop
2019
Medical Record
2019
Lipase on 19 Nov 2012

Comment:
Chem
Helicobacter pylori on 19 Nov 2012

Collection Date: 19 Nov 2012 Site/Specimen: Serum
Comment:
Order # 121109-01816
Filler # 121119 MI 7829
Status Final
Type Microbiology
Origin DoD
Ordering Provider CLAY, EMILY C
Priority ROUTINE
COLLECT_SAMPLE BLOOD
BACTERIOLOGY RESULT POSITIVE FOR HELICOBACTER PYLORI.
Urea Nitrogen on 02 Nov 2012

Comment: for cct scan
Chem
Creatinine on 02 Nov 2012

Comment: for cct scan
Chem
2019
Medical Record
2019
Urinalysis on 31 Oct 2012

Collection Date: 31 Oct 2012 Site/Specimen: URINE
Comment:
Chem
Color YELLOW
pH 5.5 (5.0-7.5)
RBC <1 /HPF (0-2)
Mucus RARE (0-OCC)
WBC <1 /HPF (0-5)
Urine Culture on 31 Oct 2012

Collection Date: 31 Oct 2012 Site/Specimen: Urine
Comment:
Order # 121031-05237
Filler # 121031 MI 6253
Status Final
Type Microbiology
Origin DoD
Ordering Provider CLAY, EMILY C
Priority ROUTINE
DATE ORDERED 31 Oct 2012 1501
COLLECT_SAMPLE URINE/CC
BACTERIOLOGY RESULT NO GROWTH IN 24 HOURS.
<10,000 COL/ML CONSISTENT WITH SKIN
CONTAMINATION
ABO Group+Rh Type on 06 Jul 2012

Ordering Clinician: PEARSON,
MAROLYN J
Comment:
2019
Medical Record
2019
Chem
ABO Group+Rh Type AB POS
Interpretation:
Results performed on the Tango Blood Bank analyzer.
Accession Screening and Immunization Program Ab Panel on 06 Jul 2012

Collection Date: 06 Jul 2012 Site/Specimen: SERUM
Ordering Clinician: PEARSON,
MAROLYN J
Comment:
Chem
Varicella Zoster Virus Ab POS
IgG
Hepatitis A Virus Ab POS
Hepatitis B Virus Surface POS
Ab
Interpretation:
PANEL TEST RESULT INFORMATION:
POS: Indicates a Positive result. Immune Status
NEG: Indicates a Negative result. Non-Immune Status
EQUIV: Indicates an equivocal result. Repeat test
REAC: Indicates a Positive result. Immune Status
NR: Indicates a Negative result. Non-Immune Status
Rubella Virus Ab POS

Rubeola Virus Ab POS
Coagulation Panel (PT+APTT+INR) on 16 Jun 2012

Collection Date: 16 Jun 2012 Site/Specimen: PLASMA
Ordering Clinician: SCHMIDT,
MELISSA KAY
Comment:
Chem
Protime 13.2 Sec (10.7-13.9)
Interpretation:
Test performed at
APTT 33 Sec (22-35)
Interpretation:
Test performed at
2019
Medical Record
2019

7950 Martin Loop
INR 1.07 (2-3) Lower Than

Normal
Interpretation:
THERAPEUTIC RANGE: 2.0 - 3.0
(INR is applicable only to those patients who have been stabilized for
several weeks on oral anticoagulants. It is not useful for preoperative
screening or monitoring hemostatic abnormalities.)
Hepatic Function Panel on 16 Jun 2012

MELISSA KAY
Comment:
Chem
Albumin 3.8 g/dL (3.4-5.0)
Interpretation:
Test performed at
7950 Martin Loop
(706)544-2221
Bilirubin Direct 0.00 mg/dL (0.0-0.3)
Interpretation:
Test performed at
7950 Martin Loop
(706)544-2221

Aminotransferase
Protein 7.3 g/dL (6.4-8.2)
2019
Medical Record
2019
Troponin I Cardiac on 16 Jun 2012

MELISSA KAY
Comment:
Chem
Troponin I Cardiac <0.012 ng/mL (0.0-0.034)
Interpretation:
1. Serial sampling is recommended to detect the temporal rise and fall of
cTnI levels characteristic of AMI.
2. The Joint European Society of Cardiology/American College of Cardiology
(ESC/ACC) and the National Academy of Clinical Biochemistry Standards of
Laboratory Practices (NACB) recommends that the diagnosis of AMI includes
the presence of clinical history indicative of Acute Coronary Syndrome (ACS)
and a maximum concentration of cardiac troponin exceeding the 99th percentile
(0.034 ng/mL for this assay) of a normal reference population on a least one
occasion during the first 24 hours.
The AMI diagnostic cutoff for this assay is 0.120 ng/mL.
Test performed at
7950 Martin Loop
(706)544-2221
Creatine Kinase on 16 Jun 2012

MELISSA KAY
Comment:
Chem
Creatine Kinase 70 U/L (55-170)
Basic Metabolic Panel on 16 Jun 2012

MELISSA KAY
Comment:
Chem
Interpretation:
2019
Medical Record
2019

and diabetes.

Interpretation:
Calcium 9.0 mg/dL (8.4-12.2)
Creatine Kinase MB on 16 Jun 2012

MELISSA KAY
Comment:
Chem
Creatine Kinase MB 0.43 ng/mL (0.00-2.37)
Interpretation:
Test performed at
7950 Martin Loop
(706)544-2221
Hemogram+Differential Auto on 16 Jun 2012

Collection Date: 16 Jun 2012 Site/Specimen: BLOOD
MELISSA KAY
Comment:
Chem
WBC 8.4 x10(3)/mcL (4.9-10.0)
RBC 5.10 x10(6) (4.7-6.1)
MCV 83.4 fL (80-96)
MCH 28.6 pg (27-31)
MCHC 34.3 % (32-36)
RDW CV 14.0 % (11.5-14.5)
MPV 8.9 fL (6.8-10)
Platelets 236 x10(3)/mcL (150-450)
2019
Medical Record
2019

ABS Lymphocytes 4.9 x10(3)/mcL (1.0-4.0) Higher Than
Normal
Normal
Hemogram+Differential Auto on 28 Apr 2012

Collection Date: 28 Apr 2012 Site/Specimen: BLOOD
Ordering Clinician: CROUCH,
ROBERT JOSEPH
Comment:
Chem
WBC 4.9 x10(3)/mcL (4.9-10.0)
RBC 5.22 x10(6) (4.7-6.1)
MCV 85.1 fL (80-96)
MCH 29.3 pg (27-31)
MCHC 34.4 % (32-36)
RDW CV 13.0 % (11.5-14.5)
MPV 8.9 fL (6.8-10)
Platelets 190 x10(3)/mcL (150-450)
Normal
Monocytes 10.3 % (0-10) Higher Than
Normal
Lipase on 28 Apr 2012

ROBERT JOSEPH
Comment:
Chem
2019
Medical Record
2019
Comprehensive Metabolic Panel on 28 Apr 2012

ROBERT JOSEPH
Comment:
Chem
Albumin 3.9 g/dL (3.4-5.0)
Interpretation:
Test performed at
7950 Martin Loop
(706)544-2221
Calcium 8.7 mg/dL (8.4-12.2)

Interpretation:
and diabetes.

Protein 7.7 g/dL (6.4-8.2)
Aminotransferase
Interpretation:
Urinalysis on 28 Apr 2012

Collection Date: 28 Apr 2012 Site/Specimen: URINE
ROBERT JOSEPH
2019
Medical Record
2019
Comment:
Chem
Urobilinogen 2.0 EU/dL (0.0-3.0)
Color YELLOW
Protein 30 mg/dL (NEGATIVE)
pH 6.5 (5.0-7.5)
RBC 2 /HPF (0-2)
Mucus MARKED (0-OCC)
WBC 1 /HPF (0-5)
Glucose Fasting on 19 Apr 2012

Ordering Clinician: CALDWELL,
JACQUELINE K
Comment:
Chem
Glucose Fasting 85 mg/dL (74-106)
Prostate Specific Ag on 28 Mar 2012

Collection Date: 28 Mar 2012 Site/Specimen: SERUM
JACQUELINE K
Comment:
Chem
Prostate Specific Ag 1.01 ng/mL (0-4.0)
Interpretation:
Test performed at
7960 Martin Loop
(706)544-2221
Comprehensive Metabolic Panel on 28 Mar 2012

Collection Date: 28 Mar 2012 Site/Specimen: PLASMA
2019
Medical Record
2019
JACQUELINE K
Comment:
Chem
Albumin 4.2 g/dL (3.4-5.0)
Interpretation:
Test performed at
7950 Martin Loop
(706)544-2221
Calcium 8.9 mg/dL (8.4-12.2)

Normal
Interpretation:
and diabetes.

Protein 7.4 g/dL (6.4-8.2)
Aminotransferase
Interpretation:
Lipids on 28 Mar 2012

JACQUELINE K
Comment:
Chem
Triglyceride 185 mg/dL (0-149) Higher Than
Normal
2019
Medical Record
2019
Normal
Glucose Fasting on 28 Mar 2012

JACQUELINE K
Comment:
Chem
Glucose Fasting 132 mg/dL (74-106) Higher Than
Normal
Testosterone on 02 Nov 2011

JOSEPH
Comment:
Chem
Testosterone 153.5 ng/dL 241-827 Lower Than
Normal
Prostate Specific Ag on 02 Nov 2011

JOSEPH
Comment:
Chem
Prostate Specific Ag 1.02 ng/mL (0-4.0)
Interpretation:
Test performed at
7960 Martin Loop
(706)544-2221
Potassium on 02 Nov 2011

JOSEPH
Comment:
2019
Medical Record
2019
Chem

JOSEPH
Comment:
Chem
Normal
Normal
Hemoglobin A1c Panel on 02 Nov 2011

JOSEPH
Comment:
Chem
Interpretation:
DIABETIC: >OR= 6.5%
ADA TARGET: <7.0%
Interpretation:
Test performed at
7950 Martin Loop
Testosterone on 09 Feb 2011

Collection Date: 09 Feb 2011 Site/Specimen: SERUM
JOSEPH
Comment:
Chem
2019
Medical Record
2019

Testosterone 207.4 ng/dL 241-827 Lower Than
Normal
Hemogram+Differential Auto on 04 Oct 2010

Collection Date: 04 Oct 2010 Site/Specimen: BLOOD
PATRICIA W
Comment:
Chem
WBC 5.0 x10(3)/mcL (4.9-10.0)
RBC 5.11 x10(6) (4.7-6.1)
MCV 85.2 fL (80-96)
MCH 30.4 pg (27-31)
MCHC 35.6 % (32-36)
RDW CV 12.8 % (11.5-14.5)
MPV 8.4 fL (6.8-10)
Platelets 237 x10(3)/mcL (150-450)
Magnesium on 04 Oct 2010

Collection Date: 04 Oct 2010 Site/Specimen: PLASMA
PATRICIA W
Comment:
Chem
Magnesium 1.9 mg/dL (1.8-2.4)
Lipase on 04 Oct 2010

PATRICIA W
Comment:
Chem
2019
Medical Record
2019
Triacylglycerol Lipase 123.0 U/L (73-393)
Interpretation:
Test performed at
7950 Martin Loop
(706)544-1221
Amylase on 04 Oct 2010

PATRICIA W
Comment:
Chem
Amylase 61 U/L (25-115)
Interpretation:
Test performed at
7950 Martin Loop
(706)544-2221
Comprehensive Metabolic Panel on 04 Oct 2010

PATRICIA W
Comment:
Chem
Albumin 3.4 g/dL (3.4-5.0)
Calcium 9.0 mg/dL (8.5-10.1)
Interpretation:
and diabetes.

Protein 7.6 g/dL (6.4-8.2)
Sodium 135 mmol/L (136-145) Lower Than
Normal
2019
Medical Record
2019

Aminotransferase
Anion Gap 6.1 mmol/L (10-20) Lower Than
Normal
Interpretation:
Lipids on 04 Oct 2010

PATRICIA W
Comment:
Chem
Normal
Normal
Lipase on 28 Sep 2010

Collection Date: 28 Sep 2010 Site/Specimen: PLASMA
Ordering Clinician: KEIGER,
CHRISTINA M
Comment:
Chem
Triacylglycerol Lipase 89.0 U/L (1-65) Higher Than
Normal

CHRISTINA M
Comment:
Chem
Triacylglycerol Lipase 101.0 U/L (1-65) Higher Than
Normal
2019
Medical Record
2019
Amylase on 28 Sep 2010

CHRISTINA M
Comment:
Chem
Amylase 69 U/L (15-115)
Chem 7 on 28 Sep 2010

CHRISTINA M
Comment:
Chem
Interpretation:
ADA Guidelines January 2007:
1. Symptoms of diabetes and a casual plasma glucose>= 200 mg/dL.
Casual is defined as any time of day without regard to time since last
meal. The classic symptoms of diabetes include polyuria, poly dipsia,
and unexplained weight loss.
OR
2. FPG>=126 mg/dL. Fasting is defined as no caloric intake for at least 8
hours.
OR
3. 2-hour plasma glucose >= 200 mg/dL during an OGTT. The Test should
be performed as described by the World Health Organization, using a
glucose load containing the equivalent of 75-g anhydrous glucose
dissolved in water.
Urea Nitrogen 11.0 mg/mL (7-22)
Interpretation:
New normal range as of 5/18/2010

Carbon Dioxide 28.0 mmol/L (20-30)
Liver Panel on 28 Sep 2010

2019
Medical Record
2019

CHRISTINA M
Comment:
Chem
Alkaline Phosphatase 88.0 U/L (33-113)
Aminotransferase
Lactate Dehydrogenase 166 U/L (125-286)
Interpretation:
NOTE: Critical High Value of 1430 U/L adapted 05/04/2010 approved by the
MSEC.

Gamma-Glutamyl 23.0 U/L (5-61)
Transferase
Alanine Aminotransferase 43.0 U/L (5-49)
Interpretation:
NOTE: Critical high value of 245 U/L for males and 190 U/L for females
added 5/4/2010 by recommendation from MSEC.

CHRISTINA M
Comment:
Chem
Triacylglycerol Lipase NOT DONE U/L (1-65)

CHRISTINA M
Comment:
Chem
Amylase NOT DONE U/L (15-115)
Chem 7 on 28 Sep 2010

CHRISTINA M
Comment:
Chem
2019
Medical Record
2019

Glucose NOT DONE mg/dL (70-110)
Interpretation:
OR
hours.
OR
dissolved in water.
Urea Nitrogen NOT DONE mg/mL (7-22)
Interpretation:
New normal range as of 5/18/2010
Sodium NOT DONE mmol/L (135-145)

Potassium NOT DONE mmol/L (3.2-4.7)
Chloride NOT DONE mmol/L (99-111)
Carbon Dioxide NOT DONE mmol/L (20-30)
Creatinine NOT DONE mg/dL (0.8-1.4)
Liver Panel on 28 Sep 2010

CHRISTINA M
Comment:
Chem
Gamma-Glutamyl NOT DONE U/L (5-61)
Transferase
Alkaline Phosphatase NOT DONE U/L (33-113)
Aspartate NOT DONE U/L (10-38)
Aminotransferase
Lactate Dehydrogenase NOT DONE U/L (125-286)
Interpretation:
NOTE: Critical High Value of 1430 U/L adapted 05/04/2010 approved by the
MSEC.
Bilirubin NOT DONE mg/dL (0.1-1.1)

Alanine Aminotransferase NOT DONE U/L (5-49)
2019
Medical Record
2019
Interpretation:
NOTE: Critical high value of 245 U/L for males and 190 U/L for females
added 5/4/2010 by recommendation from MSEC.
Hemolysis on 28 Sep 2010

CHRISTINA M
Comment:
Chem
Hemolysis GROSS (NONE)
HEMOLYSIS
VISIBLE
Interpretation:
The presence of hemolysis may falsely elevate results for the following
analytes: Potassium, Lactate Dehydrogenase, Ferritin, Iron, CSF Protein, and
Total Bilirubin.
The presence of hemolysis may falsely lower results for the following
analytes: CSF Glucose.
CBC on 28 Sep 2010

Collection Date: 28 Sep 2010 Site/Specimen: BLOOD
CHRISTINA M
Comment:
Chem
MCH 29.5 pg (27-34)
WBC 7.03 x10(3)/mcL (4.5-11.5)
RBC 5.3 x10(6)/mcL (4.6-6.0)
Hemoglobin 15.7 g/dL (14-18)
MCV 82.3 fL (80-100)
MCHC 35.8 g/dL (32.0-36.0)
Platelets 269.0 x10(3)/mcL (150-450)
MPV 11.5 fL (9.0-13.0)
RDW SD 39.6 fL (37-55)
2019
Medical Record
2019
Urinalysis on 18 Sep 2010

Collection Date: 18 Sep 2010 Site/Specimen: URINE
Ordering Clinician: RANDALL,
WILLIAM LEWIS
Comment:
Chem
Color YELLOW
pH 5.5 (5.0-7.5)
Mucus RARE (0-OCC)
WBC <1 /HPF (0-5)

WILLIAM LEWIS
Comment:
Chem
Triacylglycerol Lipase 170.0 U/L (73-393)
Interpretation:
Test performed at
7950 Martin Loop
(706)544-1221

WILLIAM LEWIS
Comment:
Chem
Amylase 68 U/L (25-115)
2019
Medical Record
2019
Interpretation:
Test performed at
7950 Martin Loop
(706)544-2221
Comprehensive Metabolic Panel on 18 Sep 2010

WILLIAM LEWIS
Comment:
Chem
Albumin 3.3 g/dL (3.4-5.0) Lower Than
Normal
Calcium 8.8 mg/dL (8.5-10.1)
Normal
Interpretation:
and diabetes.

Potassium 3.3 mmol/L (3.6-5.2) Lower Than
Normal
Protein 7.1 g/dL (6.4-8.2)
Aminotransferase
Normal
Interpretation:
Hemogram+Differential Auto on 18 Sep 2010

WILLIAM LEWIS
Comment:
2019
Medical Record
2019
Chem
Normal
WBC 7.3 x10(3)/mcL (4.9-10.0)
RBC 4.83 x10(6) (4.7-6.1)
MCV 86.3 fL (80-96)
MCH 30.5 pg (27-31)
MCHC 35.3 % (32-36)
RDW CV 12.9 % (11.5-14.5)
MPV 8.4 fL (6.8-10)
Platelets 251 x10(3)/mcL (150-450)

Ordering Clinician: HOLTZCLAW,
KAREN ROMA
Comment:
Chem
WBC 5.3 x10(3)/mcL (4.9-10.0)
RBC 5.02 x10(6) (4.7-6.1)
MCV 83.7 fL (80-96)
MCH 30.1 pg (27-31)
MCHC 35.9 % (32-36)
RDW CV 13.0 % (11.5-14.5)
MPV 9.2 fL (6.8-10)
Platelets 256 x10(3)/mcL (150-450)
2019
Medical Record
2019
Comprehensive Metabolic Panel on 20 May 2010

KAREN ROMA
Comment:
Chem
Normal
Calcium 8.6 mg/dL (8.5-10.1)
Interpretation:
and diabetes.

Protein 7.3 g/dL (6.4-8.2)
Aminotransferase
Interpretation:
Lipids on 20 May 2010

KAREN ROMA
Comment:
Chem
Normal
LDL Cholesterol 146.8 mg/dL (0-129) Higher Than
Normal
2019
Medical Record
2019
Magnesium on 21 Aug 2009

Ordering Clinician: REEDY, GARY W
Comment:
Chem
Magnesium 1.9 mg/dL (1.8-2.4)
Hepatic Function Panel on 21 Aug 2009

Comment:
Chem
Normal
Bilirubin Direct 0.07 mg/dL (0.0-0.3)
Alanine Aminotransferase 69 U/L (30-65) Higher Than
Normal
Aspartate 45 U/L (15-37) Higher Than
Aminotransferase Normal
Protein 7.1 g/dL (6.4-8.2)

Comment:
Chem
Troponin I Cardiac on 21 Aug 2009

Comment:
Chem
Troponin I Cardiac <0.04 ng/mL
Interpretation:
The reference range for normal is < or = to 0.05 ng/mL. The cut off for
myocardial infarction (AMI) is 0.6 ng/mL
2019
Medical Record
2019
Phosphorus on 21 Aug 2009

Comment:
Chem
Phosphate 3.9 mg/dL (2.5-4.9)
Creatine Kinase on 21 Aug 2009

Comment:
Chem
Creatine Kinase 1990 U/L (35-233) Higher Than
Normal
Basic Metabolic Panel on 21 Aug 2009

Comment:
Chem
Interpretation:
and diabetes.

Normal
Interpretation:
Calcium 8.8 mg/dL (8.5-10.1)
Creatine Kinase MB on 21 Aug 2009

2019
Medical Record
2019
Comment:
Chem
Creatine Kinase MB <0.50 ng/mL (0.0-3.6)
Protime+INR+APTT on 21 Aug 2009

Comment:
Chem
Protime 10.0 Sec (9.5-11.5)
APTT 26 Sec (25-34)
INR 0.98 (2-3) Lower Than
Normal
Interpretation:
THERAPEUTIC RANGE: 2.0 - 3.0
(INR is applicable only to those patients who have been stabilized for
several weeks on oral anticoagulants. It is not useful for preoperative
screening or monitoring hemostatic abnormalities.)

Comment:
Chem
WBC 7.4 x10(3)/mcL (4.9-10.0)
RBC 5.01 x10(6) (4.7-6.1)
MCV 84.2 fL (80-96)
MCH 29.0 pg (27-31)
MCHC 34.5 % (32-36)
RDW CV 13.0 % (11.5-14.5)
MPV 9.7 fL (6.8-10)
Platelets 241 x10(3)/mcL (150-450)
2019
Medical Record
2019
Urinalysis on 21 Aug 2009

Collection Date: 21 Aug 2009 Site/Specimen: URINE
Comment:
Chem
Color YELLOW
pH 5.5 (5.0-7.5)
WBC 1 /HPF (0-5)
Mucus SLIGHT (0-OCC)
Urea Nitrogen on 18 Mar 2009

Ordering Clinician: SISK, CHAD
MICHAEL
Comment:
Chem
Creatinine on 18 Mar 2009

Ordering Clinician: SISK, CHAD
MICHAEL
Comment:
Chem

JOSEPH
Comment:
Chem
2019
Medical Record
2019

Albumin 3.7 g/dL (3.4-5.0)
Calcium 9.0 mg/dL (8.5-10.1)
Interpretation:
and diabetes.

Protein 7.9 g/dL (6.4-8.2)
Aminotransferase
Normal
Interpretation:

JOSEPH
Comment:
Chem

JOSEPH
Comment:
Chem
WBC 5.4 x10(3)/mcL (4.9-10.0)
RBC 5.47 x10(6) (4.7-6.1)
2019
Medical Record
2019
MCV 84.1 fL (80-96)

MCH 28.9 pg (27-31)
MCHC 34.3 % (32-36)
RDW CV 12.8 % (11.5-14.5)
MPV 9.9 fL (6.8-10)
Platelets 222 x10(3)/mcL (150-450)
Monocytes 11.8 % (0-10) Higher Than
Normal
TISSUE EXAM on 03 Dec 2008

Collection Date: 03 Dec 2008 Site/Specimen: TISSUE
Ordering Clinician: MCGUIGAN,
REBECCA
MARIER
Comment:
Order # 081204-03937
Status Certify
Origin DoD
POC Enc E258485
Provider MCGUIGAN, REBECCA MARIER
Ordered Date 04 Dec 2008 1301
Priority ROUTINE
Specimen TISSUE
Resulted Date 09 Dec 2008 1230.1-0500

Ordering Clinician: TRICKEY, DAVID
N
Comment:
Chem
2019
Medical Record
2019

N
Comment:
Chem
Albumin 3.6 g/dL (3.4-5.0)
Calcium 8.9 mg/dL (8.5-10.1)
Interpretation:
and diabetes.

Protein 7.4 g/dL (6.4-8.2)
Aminotransferase
Normal
Interpretation:

N
Comment:
Chem
WBC 10.9 x10(3)/mcL (4.9-10.0) Higher Than
Normal
RBC 5.08 x10(6) (4.7-6.1)
MCV 84.0 fL (80-96)
MCH 29.2 pg (27-31)
MCHC 34.8 % (32-36)
RDW CV 12.8 % (11.5-14.5)
2019
Medical Record
2019
MPV 9.7 fL (6.8-10)

Platelets 247 x10(3)/mcL (150-450)
ABS Neutrophils 8.8 x10(3)/mcL (1.4-6.5) Higher Than
Normal
Normal
Normal

N
Comment:
Chem
Urobilinogen 2.0 EU/dL (0.0-3.0)
Color YELLOW
pH 5.5 (5.0-7.5)
RBC <1 /HPF (0-2)
Mucus RARE (0-OCC)
Urea Nitrogen on 13 Nov 2008

REBECCA
MARIER
Comment:
Chem
2019
Medical Record
2019
Creatinine on 13 Nov 2008

REBECCA
MARIER
Comment:
Chem

Ordering Clinician: CASS, DAVID A.
Comment:
Chem

Comment:
Chem
Albumin 3.5 g/dL (3.4-5.0)
Bilirubin 0.3 mg/dL (0.4-1.4) Lower Than
Normal
Calcium 8.7 mg/dL (8.5-10.1)
Interpretation:
and diabetes.

Protein 7.2 g/dL (6.4-8.2)
Aminotransferase
Normal
Interpretation:
2019
Medical Record
2019
Helicobacter pylori on 13 Nov 2008

Collection Date: 13 Nov 2008 Site/Specimen: Serum
Comment:
Order # 081113-00027
Filler # 081113 MI 32063
Status Final
Type Microbiology
Origin DoD
Ordering Provider CASS, DAVID A.
Priority ASAP
COLLECT_SAMPLE BLOOD
BACTERIOLOGY RESULT NEGATIVE FOR HELICOBACTER PYLORI.

Ordering Clinician: KAPLAN, JOSEPH
Comment:
Chem
Amylase on 08 Nov 2008

Comment:
Chem
Amylase 54 U/L (25-115)

Comment:
Chem
2019
Medical Record
2019
Normal
Bilirubin 0.3 mg/dL (0.4-1.4) Lower Than
Normal
Calcium 7.2 mg/dL (8.5-10.1) Lower Than
Normal
Chloride 111 mmol/L (100-108) Higher Than
Normal
Interpretation:
and diabetes.

Potassium 3.5 mmol/L (3.6-5.2) Lower Than
Normal
Protein 5.9 g/dL (6.4-8.2) Lower Than
Normal
Aminotransferase
Normal
Interpretation:

Comment:
Chem
WBC 7.5 x10(3)/mcL (4.9-10.0)
RBC 5.08 x10(6) (4.7-6.1)
MCV 83.8 fL (80-96)
MCH 29.5 pg (27-31)
MCHC 35.2 % (32-36)
RDW CV 13.2 % (11.5-14.5)
MPV 9.9 fL (6.8-10)
Platelets 243 x10(3)/mcL (150-450)
2019
Medical Record
2019


Comment: abd pqain
Chem
WBC 1 /HPF (0-5)
Color YELLOW
Appearance HAZY (CLEAR)
Urobilinogen 4.0 EU/dL (0.0-3.0) Higher Than
Normal
pH 6.0 (5.0-7.5)
RBC 1 /HPF (0-2)
Calcium Oxalate Crystals FEW (NONE)
Mucus MODERATE (0-OCC)
Epithelial Cells Squamous <1 /HPF (0-5)

Comment:
Chem
Normal
WBC 6.9 x10(3)/mcL (4.9-10.0)
RBC 4.94 x10(6) (4.7-6.1)
MCV 84.0 fL (80-96)
MCH 29.2 pg (27-31)
MCHC 34.7 % (32-36)
RDW CV 13.1 % (11.5-14.5)
MPV 9.6 fL (6.8-10)
Platelets 250 x10(3)/mcL (150-450)
2019
Medical Record
2019


Comment:
Chem
Interpretation:
and diabetes.

Creatinine 1.4 mg/dL (0.6-1.3) Higher Than
Normal
Normal
Interpretation:
Calcium 8.9 mg/dL (8.5-10.1)

Comment:
Chem
Color YELLOW
2019
Medical Record
2019
pH 6.5 (5.0-7.5)
RBC <1 /HPF (0-2)
Amorphous Sediment RARE (0)
Mucus RARE (0-OCC)
WBC 1 /HPF (0-5)
TISSUE EXAM on 19 May 2008

Collection Date: 19 May 2008 Site/Specimen: TISSUE
REBECCA
MARIER
Comment:
Order # 080520-02615
Status Amended
Origin DoD
POC Enc E258485
Provider MCGUIGAN, REBECCA MARIER
Ordered Date 20 May 2008 1106
Priority ROUTINE
Specimen TISSUE
Resulted Date 22 May 2008 1702.1-0400
Basic Metabolic Panel on 16 May 2008

REBECCA
MARIER
Comment:
Chem
Interpretation:
and diabetes.

2019
Medical Record
2019

Interpretation:
Calcium 8.8 mg/dL (8.5-10.1)

REBECCA
MARIER
Comment:
Chem
WBC 4.9 x10(3)/mcL (4.9-10.0)
RBC 5.18 x10(6) (4.7-6.1)
MCV 84.1 fL (80-96)
MCH 27.6 pg (27-31)
MCHC 32.8 % (32-36)
RDW CV 13.8 % (11.5-14.5)
MPV 9.6 fL (6.8-10)
Platelets 287 x10(3)/mcL (150-450)
Urinalysis on 09 Mar 2008

Collection Date: 09 Mar 2008 Site/Specimen: URINE
Ordering Clinician: RITCHIE, BETTY
BROWN
Comment:
Chem
Color YELLOW
2019
Medical Record
2019

pH 7.0 (5.0-7.5)
RBC <1 /HPF (0-2)
Mucus RARE (0-OCC)
Epithelial Cells Squamous <1 /HPF (0-5)
Hemogram+Differential Auto on 09 Mar 2008

Collection Date: 09 Mar 2008 Site/Specimen: BLOOD
BROWN
Comment:
Chem
WBC 4.4 x10(3)/mcL (4.9-10.0) Lower Than
Normal
RBC 5.28 x10(6) (4.7-6.1)
MCV 82.7 fL (80-96)
MCH 29.4 pg (27-31)
MCHC 35.5 % (32-36)
RDW CV 12.7 % (11.5-14.5)
MPV 9.2 fL (6.8-10)
Platelets 220 x10(3)/mcL (150-450)
Lipase on 09 Mar 2008

BROWN
Comment:
Chem
2019
Medical Record
2019
Amylase on 09 Mar 2008

BROWN
Comment:
Chem
Amylase 56 U/L (25-115)
Comprehensive Metabolic Panel on 09 Mar 2008

BROWN
Comment:
Chem
Albumin 3.4 g/dL (3.4-5.0)
Calcium 8.8 mg/dL (8.5-10.1)
Interpretation:
and diabetes.

Protein 7.2 g/dL (6.4-8.2)
Aminotransferase
Carbon Dioxide 33 mmol/L (21-32) Higher Than
Normal
Normal
Interpretation:

Ordering Clinician: HOLST,
KATHLEEN C
2019
Medical Record
2019
Comment:
Chem
Protein 7.4 g/dL (6.4-8.2)
Albumin 3.5 g/dL (3.4-5.0)
Calcium 9.1 mg/dL (8.5-10.1)
Interpretation:
and diabetes.

Aminotransferase
Normal
Normal
Interpretation:

KATHLEEN C
Comment:
Chem

KATHLEEN C
Comment:
Chem
2019
Medical Record
2019

Normal
WBC 5.4 x10(3)/mcL (4.9-10.0)
RBC 4.97 x10(6) (4.7-6.1)
MCV 83.7 fL (80-96)
MCH 29.6 pg (27-31)
MCHC 35.3 % (32-36)
RDW CV 13.3 % (11.5-14.5)
MPV 9.2 fL (6.8-10)
Platelets 248 x10(3)/mcL (150-450)
Wound Culture on 09 Jan 2008

Collection Date: 09 Jan 2008 Site/Specimen: Wound
KATHLEEN C
Comment:
Order # 080109-05334
Filler # 080109 MI 663
Status Final
Type Microbiology
Origin DoD
Ordering Provider HOLST, KATHLEEN C
Priority ROUTINE
DATE ORDERED 09 Jan 2008 1617
DATE_RESULTED 12 Jan 2008 1407
COLLECT_SAMPLE SWAB
Staphylococcus aureus
Hemogram+Differential Auto on 11 Sep 2007

Comment: CHEST PN
Chem
2019
Medical Record
2019
WBC 9.6 x10(3)/mcL (4.9-10.0)

RBC 5.23 x10(6) (4.7-6.1)
MCV 84.8 fL (80-96)
MCH 29.3 pg (27-31)
MCHC 34.6 % (32-36)
RDW CV 13.0 % (11.5-14.5)
MPV 9.5 fL (6.8-10)
Platelets 238 x10(3)/mcL (150-450)
ABS Neutrophils 8.6 x10(3)/mcL (1.4-6.5) Higher Than
Normal
Normal
ABS Lymphocytes 0.5 x10(3)/mcL (1.0-4.0) Lower Than
Normal
Normal
CBC W/Diff Manual on 11 Sep 2007

J
Comment:
Chem
Neutrophils Segmented 89 % (30-70)
Lymphocytes % 6 % (20-40) Lower Than
Normal
Eosinophils % 1 % (0-5)
Basophils % 1 % (0-2)
Platelet Estimate ADEQUATE
Monocytes % 3 % (0-10)
RBC Morphology NORMAL
(NC/NC)
Basic Metabolic Panel on 11 Sep 2007

Comment: CHEST PN
Chem
Interpretation:
2019
Medical Record
2019

and diabetes.
Urea Nitrogen 5 mg/dL (7-18) Lower Than

Normal
Chloride 99 mmol/L (100-108) Lower Than
Normal
Normal
Normal
Interpretation:
Calcium 8.5 mg/dL (8.5-10.1)
Chem 7 on 08 Jul 2007

Ordering Clinician: PETERSON,
JAMES L
Comment:
Chem
Glucose 126.0 mg/dL (70-110) Higher Than
Normal
Interpretation:
OR
hours.
OR
dissolved in water.
Urea Nitrogen 9.0 mg/dL (7.1-19.5)

Potassium NOT DONE mmol/L (3.2-4.7)
Carbon Dioxide 28.0 mmol/L (20-30)
2019
Medical Record
2019
Hemolysis on 08 Jul 2007

JAMES L
Comment:
Chem
Hemolysis MODERATE (NONE)
HEMOLYSIS
VISIBLE
Interpretation:
The presence of hemolysis may falsely elevate results for the following
analytes: Potassium, Lactate Dehydrogenase, Iron, CSF Protein, and Total
Bilirubin.
The presence of hemolysis may falsely lower results for the following
analytes: CSF Glucose.
CBC on 08 Jul 2007

JAMES L
Comment:
Chem
MCHC 36.4 g/dL (32.0-36.0) Higher Than
Normal
WBC 5.72 x10(3)/mcL (4.5-11.5)
RBC 5.4 x10(6)/mcL (4.6-6.0)
Hemoglobin 16.0 g/dL (14-18)
MCV 81.3 fL (80-100)
MCH 29.6 pg (27-34)
Platelets 240.0 x10(3)/mcL (150-450)
Normal
MPV 11.1 fL (9.0-13.0)
RDW SD 38.1 fL (37-55)
Glucose-6-Phosphate Dehydrogenase Quant on 05 Nov 2004

2019
Medical Record
2019
Ordering Clinician: FTDIX,

PROVIDER
Comment: SRC 6204
Chem
Glucose-6-Phosphate 13.9 U/g Hgb 7-20.5
Dehydrogenase
Interpretation:
All persons below our lower limit of 7 are considered "Deficient".
Values greater than the upper limit of our reference range are considered
"Normal" in accordance with guidance from the Tietz Textbook on Clinical
Chemistry, which states that values greater than the upper limit of the
reference range are encountered in any condition associated with younger than
normal RBC's (as in hemolytic anemias not due to G6PD deficiency), but are of
no clinical significance.
TEST PERFORMED IN BAMC REFERENCE LABORATORY.

Specimen: 3-5 mL whole blood (EDTA tube,Lavender top - do not use twist-off
caps). Do not freeze G6PD samples. Refrigerated samples are good for only 7
days; ship ASAP after collection. Excessive leukocytes or platelets, which
are high in G6PD, may interfere in the assay. Reticulocytes have higher G6PD
levels than mature erythrocytes, so samples should not be collected after a
severe hemolytic crisis.
G6PD reported value is a calculation based on G6PD and hemoglobin values.
Glucose-6-Phosphate Dehydrogenase on 05 Nov 2004

Ordering Clinician: BYRNES,
MICHAEL J
Comment:
Chem
Glucose-6-Phosphate 13.9 U/g Hgb 7-20.5
Dehydrogenase
Interpretation:
All persons below our lower limit of 7 are considered "Deficient".
Values greater than the upper limit of our reference range are considered
"Normal" in accordance with guidance from the Tietz Textbook on Clinical
Chemistry, which states that values greater than the upper limit of the
reference range are encountered in any condition associated with younger than
normal RBC's (as in hemolytic anemias not due to G6PD deficiency), but are of
no clinical significance.
TEST PERFORMED IN BAMC REFERENCE LABORATORY.

Specimen: 3-5 mL whole blood (EDTA-tube,Lavender top - do not use twist-off
caps). Do not freeze G6PD samples. Refrigerated samples are good for only 7
2019
Medical Record
2019
days; ship ASAP after collection. Excessive leukocytes or platelets, which

are high in G6PD, may interfere in the assay. Reticulocytes have higher G6PD
levels than mature erthrocytes, so samples should not be collected after a
severe hemolytic crisis.
G6PD reported value is a calculation based on G6PD and hemoglobin values.
Glucose-6-Phosphate Dehydrogenase on 06 May 2003

Ordering Clinician: LARGOZA,
NONATO A
Comment: draw all pending labs, even those from April
Chem
Glucose-6-Phosphate NORMAL NORMAL
Dehydrogenase
Sickle Cell Screen on 06 May 2003

NONATO A
Chem
Sickle Cell Screen NEGATIVE
Rapid Plasma Reagin on 06 May 2003

Collection Date: 06 May 2003 Site/Specimen: SERUM
NONATO A
Chem
Reagin Ab NONREAC NR
Physical Panel on 06 May 2003

NONATO A
Comment:
Chem
Cholesterol 187 mg/dL 200
Interpretation:
2019
Medical Record
2019
Desirable: <200 MG/DL

Borderline High: 200-239 MG/DL
High: >/= 240 MG/DL
Triglyceride 110.0 mg/dL 0-150

HDL Cholesterol 45.0 mg/dL 29-67
LDL Cholesterol 120 mg/dL 1-130
Interpretation:
Age: 2-19yrs
<110 MG/DL = Desirable
110-129 M/DL = Borderline High
>/= 130 MG/DL = High
Age >/= 20yrs:

<130 MG/DL = Desirable
130-159 MG/DL = Borderline High
>/= 160 MG/DL = High
Note: LDL result of 0 MG/DL indicates an invalid result due to triglyceride

result > 400 MG/DL.
VLDL Cholesterol 22 mg/dL 5-56

Cholesterol/HDL 4.16 ratio 0-5
Cholesterol
Interpretation:
RISK FEMALE RATIO MALE RATIO
---- ------------ ----------
1/2 AVERAGE 3.27 3.43
1X AVERAGE 4.44 4.97
2X AVERAGE 7.05 9.55
3X AVERAGE 11.04 23.39
Glucose 89 mg/dL 70-110
Urinalysis Macroscopic on 06 May 2003

Collection Date: 06 May 2003 Site/Specimen: URINE
NONATO A
Comment:
Chem
Blood NEG mg/dL NEG
pH 6.5
Interpretation:
NORMAL RANGE: 5-8
Glucose NEG mg/dL NEG

Ketones NEG mg/dL NEG
Protein NEG mg/dL NEG-TRACE
2019
Medical Record
2019
Bilirubin NEG mg/dL NEG

Nitrite NEG mg/dL NEG
Specific Gravity 1.015 1.003-1.03
Interpretation:
NORMAL FLUID INTAKE: 1.016 - 1.022
RANGE: 1.001 - 1.035
Color YELLOW
Appearance CLEAR
Urobilinogen 0.2 EU/dL 0.2-1
WBC NEG
CBC on 06 May 2003

NONATO A
Comment:
Chem
Platelets 263 x10(3) 130-400
WBC 5.3 x10(3)/mcL 4.8-10.8
RBC 5.42 x10(6)/mcL 4.15-5.71
Hemoglobin 15.6 g/dL 14.0-18.0
Hematocrit 47.0 % 42-52
MCV 86.7 fL 80-94
MCH 28.8 pg 27-33.0
MCHC 33.2 g/dL 33-37
RDW CV 13.1 % 11.5-14.5
MPV 8.1 fL 7.4-10.4
Lymphocytes 36.9 % 18.0-46.0
Monocytes 5.4 % 5.0-12
Neutrophils 53.9 % 42.2-75.2
ABS Lymphocytes 2.0 x10(3)/mcL 1.0-3.2
ABS Monocytes 0.3 x10(3)/mcL 0.3-0.8
ABS Neutrophils 2.8 x10(3)/mcL 1.4-6.4
ABS Eosinophils 0.2 x10(3)/mcL 0.1-0.5
ABS Basophils 0.0 x10(3)/mcL 0.0-0.2
Basophils 0.3 % 0.-3.4
Eosinophils 3.5 % 0.7-6.8
***** End of Resulted Labs *****
2019
Medical Record
2019
Radiology
Chest PA And Lateral Upright Series Report on 11 Dec 2017
Procedure: Chest PA And Lateral Upright Series Report

Order Comment: NO BRIEF COMMENT
47 y/o M needs follow up annual screening as occupational requirement for latent
Reason for Order: TB.
Exam #: 17120611
Exam Date/Time: 11 Dec 2017 11:14:00
Transcription
Date/Time: 11 Dec 2017 13:00:00
Provider: CAREY, PATRICK M
Requesting Location: AMHM02ASTRONG TEAM MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Result Code: SEE RADIOLOGIST'S REPORT
Interpreted By: VAHJEN, GLEN A
Approved By: VAHJEN, GLEN A
Approved Date: 11 Dec 2017 12:57:00
Report Text
2 views of the chest were performed. Comparison is made prior studies, most recently 12/23/2016. No infiltrate
or pleural effusion was identified. The heart size is within normal limits. The upper mediastinal and hilar
structures show no evidence of lymph node enlargement. The bony structures are intact.
IMPRESSION: Negative study as described above.

Reason for Order: TB.
Exam #: 16131542
Transcription
Date/Time: 23 Dec 2016 13:41:00
Status: COMPLETE
Interpreted By: TALLEY-WILLIS, SANDRA K
Approved By: TALLEY-WILLIS, SANDRA K
2019
Medical Record
2019
Report Text
Chest, PA and lateral:
INDICATION: Annual screening as occupational requirement for latent TB
COMPARISON: 9/16/2016
CHEST: PA and left lateral views of the chest show satisfactory inflation of the lungs with no evidence of active
inflammatory disease. The cardiac silhouette appears normal with no evidence of chamber enlargement. The
mediastinum, great vessels, pleurae, diaphragm, and bony thorax are unremarkable.
CONCLUSION: Negative chest.
Duplex Visceral Vessels Limited Report on 21 Nov 2016
Procedure: Duplex Visceral Vessels Limited Report

Reason for Order: pain, swelling, concerned for torsion
Exam #: 16120873
Exam Date/Time: 21 Nov 2016 21:16:00
Transcription Date/Time: 22 Nov 2016 08:27:00
Provider: TAMBE, MOSES A
Requesting Location: EMERGENCY ROOM MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Interpreted By: ROHENA, QUINQUILLA IVAN RAF
Approved By: ROHENA, QUINQUILLA IVAN RAF
Approved Date: 22 Nov 2016 08:28:00
Report Text
Please see composite testicular ultrasound report dated the same date.
ckb
Ultrasound Testicular Report on 21 Nov 2016
Procedure: Ultrasound Testicular Report

Reason for Order: pain, swelling, concerned for torsion
Exam #: 16120870
2019
Medical Record
2019

Status: COMPLETE
Interpreted By: DIDOMENICO, PAUL BARTOLOMEO
Approved By: DIDOMENICO, PAUL BARTOLOMEO
Report Text
Radiology Report Patient Name: TOMMIE WAITERS Accession Number: 0048-16120870 Patient ID Number:
1068397665 [Approved Date]: 11/21/2016 11:09 PM Date of Birth: 08/18/1970 Approving Physician:
DiDomenico MD, Paul Institution: BMACH Code: REASON FOR STUDY PROVIDED: pain, swelling,
concerned for torsion PROCEDURE: TESTICULAR US PERSONAL DATA - PRIVACY OF ACT 1974 1
TECHNIQUE: Grayscale and Doppler sonogram of the testicles was obtained. COMPARISON: None available
FINDINGS: The right testicle measures 3.7 x 1.9 x 3 cm and the left measures 3.5 x 1.9 x 2.7 cm. The epididymis
appears normal bilaterally. Normal vascular flow is confirmed within both testes. There is no intratesticular
lesion with the exception of scattered small calcifications which are nonspecific. There is a small right
epididymal head cyst. There is no significant hydrocele bilaterally. Small cyst also noted in the right epididymis
tail. The right inferior epididymis is somewhat hyperemic as noted on images 92 and 94. The left epididymis
appears normal. No evidence of varicocele. IMPRESSION: Mildly hyperemic right epididymis, consistent with
epididymitis. No evidence of testicular torsion. DiDomenico MD, Paul
Chest PA And Lateral Upright Series Report on 16 Sep 2016

Order Comment: Bed 2
Reason for Order: Cough
Exam #: 16096177
Exam Date/Time: 16 Sep 2016 19:49:00
Transcription Date/Time: 17 Sep 2016 10:28:00
Status: COMPLETE
Approved Date: 17 Sep 2016 10:24:00
Report Text
Chest, Two Views:
History: Cough
Comparison: 4/21/2016
Findings: Frontal and lateral views. The heart and lungs are within normal limits. No acute infiltrate or active
disease is seen. The bony structures and soft tissues are intact.
Impression: Normal study.
2019
Medical Record
2019
CT Abdomen/Pelvis With Contrast Report on 21 Apr 2016
Procedure: CT Abdomen/Pelvis With Contrast Report

Reason for Order: epigastric/luq pain
Exam #: 16040758
Exam Date/Time: 21 Apr 2016 01:25:00
Transcription Date/Time: 21 Apr 2016 09:00:00
Provider: LESTER, JOSEPH L
Status: COMPLETE
Interpreted By: BORUCHOV, SCOTT
Approved By: BORUCHOV, SCOTT
Approved Date: 21 Apr 2016 09:17:00
Report Text
Patient Name: TOMMIE A WAITERS
Accession Number: 0048-16040758
Patient ID: 1068397665
Approval Date: 4/21/2016
Approval Time: 3:02 AM ET
Approving Physician: Boruchov, Scott D
PROCEDURE: CT of the abdomen and pelvis with contrast
HISTORY: Abdominal pain
TECHNIQUE: Axial images were obtained from the lung bases through the pubic symphysis after oral and
intravenous contrast administration.
FINDINGS: The lung bases are unremarkable. The liver, spleen, pancreas, gallbladder, kidneys and adrenal
glands are normal. There are prominent lymph nodes seen within the root of the mesentery with mild
inflammation in the root of the mesentery. Findings may represent mesenteric panniculitis. Otherwise there is no
mesenteric, retroperitoneal or pelvic lymphadenopathy. There is no abdominal or pelvic ascites. The bowel is
normal without evidence of obstruction or inflammation. There is no abscess or fluid collection. The urinary
bladder and pelvic structures are unremarkable.
IMPRESSION: Mild inflammation in the root of the mesentery. Findings may represent mesenteric panniculitis.
Otherwise unremarkable CT of the abdomen and pelvis.
2019
Medical Record
2019
Chest PA And Lateral Upright Series Report on 21 Apr 2016

Reason for Order: abdominal pain
Exam #: 16040759
Exam Date/Time: 21 Apr 2016 01:25:00
Transcription Date/Time: 21 Apr 2016 08:31:00
Status: COMPLETE
Interpreted By: MCINTIRE, CHRISTOPHER LEON
Approved By: MCINTIRE, CHRISTOPHER LEON
Approved Date: 21 Apr 2016 08:28:00
Report Text
PA and lateral views of the chest 4/21/2016
FINDINGS: Heart size within normal limits. Lungs are clear.
CONCLUSION: No acute abnormality, unchanged since 12/30/2015

Reason for Order: 45 y/o male with positive PPD with induration of 15mm. Please provide
Exam #: 15108615
Transcription Date/Time: 30 Dec 2015 16:08:00
Requesting Location: FMC SPECIALTY CLINIC MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Report Text
Chest, Two Views:
HISTORY: +PPD with induration at 15 mm.
2019
Medical Record
2019
Findings: Frontal and lateral views. The heart and lungs are within normal limits. No acute infiltrate or active
disease is seen. The bony structures and soft tissues are intact.
Chest PA And Lateral Upright Series Report on 09 Jan 2015

Reason for Order: 44 y/o male with history of 2mm positive ppd on 17 NOV in need of chest x-ray
Exam #: 14098124
Exam Date/Time: 09 Jan 2015 08:48:00
Transcription Date/Time: 09 Jan 2015 13:56:00
Provider: STARBUCK, AARON K
Status: COMPLETE
Interpreted By: MCINTIRE, CHRISTOPHER L
Approved By: MCINTIRE, CHRISTOPHER L
Approved Date: 09 Jan 2015 12:50:00
Report Text
PA and lateral views of the chest 1/9/2015
FINDINGS: Heart size within normal limits. Lungs are clear. Specifically no findings to suggest active
tuberculosis identified.
CONCLUSION: No acute abnormality
CT Neck Without Contrast Report on 02 Nov 2013
Procedure: CT Neck Without Contrast Report

PT W/ FB IN THROAT, PT STATES UNABLE TO KEEP WATER DOWN & STATES
Reason for Order: IS AFFECTING
Exam #: 13087865
Transcription
Date/Time: 04 Nov 2013 08:31:00
Provider: DEDINSKY, MARK J
Requesting
Location: EMERGENCY ROOM MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Interpreted By: NEELY, PHILIP
2019
Medical Record
2019
Approved By: NEELY, PHILIP

Report Text
Final Report
PROCEDURE: CT NECK WITHOUT CONTRAST
TECHNIQUE: Computerized tomography of the soft tissue neck was performed without contrast material. This
study is performed without intravascular contrast material and its sensitivity for pathology, including neoplasms,
inflammation, abscess, free fluid, thrombosis, and arterial dissection, is reduced compared with a contrast
enhanced study. CPT 70490
HISTORY: Foreign body in throat
COMPARISONS: None.
TECHNICAL QUALITY: Satisfactory.
FINDINGS:
Paranasal sinuses and mastoids: Scattered mild inflammatory mucosal changes.
Nasopharynx: Within normal limits. Oral cavity and oropharynx: Within normal limits with no peritonsillar
abscess or retropharyngeal soft tissue thickening. Epiglottis and vallecula: Within normal limits. Larynx and
pyriform sinuses: Within normal limits. Thyroid gland: Within normal limits. Lymph nodes: Within normal
limits. Salivary glands: Within normal limits.
Upper thorax: No significant abnormality.
Bony structures: No significant abnormality.
Other: No radiodense foreign body identified
IMPRESSION:
1. No evidence of foreign body. 2. Mild sinusitis.
ws:DR-INTELERAD
Electronically Signed By Philip Neely, M.D. on 2013-11-02 03:08 CTZ Dictated Nov 02, 2013 03:08 Philip
Neely Transcribed
amc dt: 11-4-13 @ 0835 EST
Soft Tissue Neck Series Report on 02 Nov 2013
Procedure: Soft Tissue Neck Series Report

Reason for Order: r/o fb throat
Exam #: 13087861
2019
Medical Record
2019

Provider: DEDINSKY, MARK J
Status: COMPLETE
Interpreted By: SHEPHERD, PIERRE N
Approved By: SHEPHERD, PIERRE N
Report Text
COMPARISON: None
FINDINGS: A soft tissue neck series fails to reveal a retained radiopaque foreign body. The bones and soft
tissues are otherwise unremarkable.
IMPRESSION: No retained radiopaque foreign body is identified.
CT Abdomen/Pelvis With Contrast Report on 17 Jun 2013

follow up mesenteric panniculitis seen on CT scan in 11/2012. f/u in 6 months was
Reason for Order: recommended.
Exam #: 13045782
Exam Date/Time: 17 Jun 2013 08:03:00
Transcription
Date/Time: 17 Jun 2013 09:46:00
Provider: MCGUIGAN, REBECCA MARIER
Requesting Location: SURGERY MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Interpreted By: ALMONTE, ILDEFONSO G D
Approved By: ALMONTE, ILDEFONSO G D
Approved Date: 17 Jun 2013 09:34:00
Report Text
CT abdomen and pelvis with contrast:
HISTORY: 43-year-old male for follow-up of possible mesenteric panniculitis.
Oval contrast was given prior to the study. Spiral axial slices were obtained through the abdomen and pelvis after
the intravenous injection of 99 cc Isovue-370. Exam compared to 11/28/2012 study.
This is still a suggestion of mesenteric haziness above the umbilicus with several mesenteric lymph nodes almost
similar to the prior study. The haziness is not confined to the central portion without any mass effect of
surrounding structures. No discrete mass is identified. There is also no increased vascularity within or
surrounding the area.
2019
Medical Record
2019
Within normal bowel gas pattern is within normal noted. No obstruction is seen. No bowel inflammatory process
is noted. No fluid in the cul-de-sac is seen.
The visualized heart is within normal. Bowel chronic scarring or platelike atelectasis right lung base again seen
the no discrete lung mass notch is seen. No falx is noted. Normal enhancement of the liver, gallbladder,
pancreas, adrenals, kidneys and spleen. No obvious mass is identified. No calcified gallbladder stone is noted.
No urinary tract stone or obstructive uropathy is seen. Normal enhancement of the abdominal aorta and pelvic
branches is noted. The bones are intact.
IMPRESSION: 1. Persistent area of mesenteric fat haziness which is nonspecific panniculitis, exact nature or
cause is not known. This should be correlated with the clinical findings if the patient has signs or symptoms and
with the laboratory findings. A follow-up study in 6 months to monitor stability may be done. 2. The rest is
within normal.
Acute Abdomen Series Report on 30 May 2013
Procedure: Acute Abdomen Series Report

Reason for Order: Abd Pain
Exam #: 13044655
Exam Date/Time: 30 May 2013 20:23:00
Transcription Date/Time: 30 May 2013 21:04:00
Provider: ADLER, JEFFREY BRIAN
Status: COMPLETE
Interpreted By: KOCHER, BRADLEY L
Approved By: KOCHER, BRADLEY L
Approved Date: 30 May 2013 20:52:00
Report Text
ACUTE ABDOMINAL SERIES:
FINDINGS: The frontal view of the chest shows no acute infiltrate or subdiaphragmatic free air. The heart is
normal.
The supine and upright views of the abdomen show a nonspecific bowel gas pattern with a few air filled loops of
small bowel centrally. There is stool and gas noted throughout the colon and rectum. There is no abnormal
calcification, soft tissue mass or acute osseous abnormality.
IMPRESSION: Nonspecific bowel gas pattern with a few air filled loops of small bowel present centrally. If
there are clinical symptoms suggestive of obstruction, further evaluation with a contrast-enhanced abdominal CT
could be considered.
CT Renal With IVP Report on 28 Nov 2012
Procedure: CT Renal With IVP Report
2019
Medical Record
2019
Order
Comment: NO BRIEF COMMENT
Reason for 42 yr old male w/ 5 weeks of LUQ abd pain adn flank pain. Ct abd w/out evid of pain source.
Order: Labs essentially normal. Please do CT IVP to further eval. THANKS.
Exam #: 12097140
Exam
Date/Time: 28 Nov 2012 07:59:00
Transcription
Date/Time: 28 Nov 2012 09:24:00
Provider: CLAY, EMILY C
Requesting
Location: AMHM02DYELLOW TEAM MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Report Text
TECHNIQUE: CT/IVP using standard MACH protocol
FINDINGS: The lung bases are clear except for bibasilar atelectasis. There is linear scarring versus atelectasis at
the right lung base.
Precontrast images are unremarkable except for a punctate calcification within the right pelvis. The kidneys are
symmetric in size and contour and demonstrate normal enhancement and excretion of contrast into the ureters.
Delayed images demonstrate normal appearing ureters without ureteral filling defect or external compression.
The left ureter is completely opacified appears normal in appearance. The distal most aspect of the right ureter is
not well visualized likely secondary peristalsis. The bladder is normal in appearance without evidence of filling
defect.
The liver, spleen, pancreas and adrenal glands are unremarkable. The visualized portions of the large and small
bowel and stomach are unremarkable on this noncontrast evaluation. The major branches of the abdominal aorta
and hepatic and portal venous systems appear unremarkable.
Incidental note of mild haziness of the mesenteric fat with multiple subcentimeter mesenteric lymph nodes.
The osseous structures and peripheral soft tissues are unremarkable.
IMPRESSION: 1. No evidence of obstructive uropathy or renal collecting system filling defect. The distal most
aspect of the right ureter is not well visualized likely secondary peristalsis. 2. Mesenteric panniculitis which is a
nonspecific finding but can be seen in infectious or inflammatory processes and also has an association with
lymphoma. Clinical and laboratory correlation is recommended as well as a six-month follow-up abdomen pelvis
CT to evaluate for interval change.
CT Abdomen/Pelvis With Contrast Report on 08 Nov 2012

Order
2019
Medical Record
2019
42 yr old AD obese male w/ 2 weeks of dull LUQ and L flank pain. No hematuria, no
Reason for constipation per patient. UA clear. AAS normal. No h/o kidney stones. Please eval w/ CT
Order: abd/pelvis w/ contrast to
Exam #: 12091812
Exam
Date/Time: 08 Nov 2012 08:12:00
Transcription
Date/Time: 08 Nov 2012 09:34:00
Requesting
Status: COMPLETE
Interpreted By: FARRA, SAMIR
Approved By: FARRA, SAMIR
Report Text
CAT scan the abdomen and pelvis with IV and oral contrast:
History of hematuria. There is small pleural base nodule seen in the posterior gutter at the level of the left hilum
probably related to scarring.
The liver and spleen appeared unremarkable. Normal appearing gallbladder and normal in the glands and
kidneys. Normal appearing abdominal aorta. No retroperitoneal lymphadenopathy. No delayed films were
obtained to evaluate the intrarenal collecting system , ureters and urinary bladder with intraluminal contrast. This
can be performed with CT IVP.
Acute Abdomen Series Report on 31 Oct 2012
Procedure: Acute Abdomen Series Report

Order
Reason for 42 yr old AD obese male w/ 2 weeks of dull LUQ and L flank pain. No hematuria, no
Order: constipation per patient. No h/o kidney stones. Please eval w/ AAS. THANKS>
Exam #: 12091630
Exam
Date/Time: 31 Oct 2012 15:33:00
Transcription
Date/Time: 31 Oct 2012 17:49:00
Requesting
Status: COMPLETE
Interpreted By: PARK, MICHAEL HUGH
Approved By: PARK, MICHAEL HUGH
Approved Date: 31 Oct 2012 17:45:00
2019
Medical Record
2019
Report Text
FINDINGS: The frontal view of the chest shows no acute infiltrate or subdiaphragmatic free air. The heart is
normal.
The supine and upright views of the abdomen show a normal bowel gas pattern. No abnormal calcification,
definable soft tissue mass or any other significant finding is seen.
IMPRESSION: Nonobstructed bowel gas pattern.
Left Hip Series Report on 19 Sep 2012
Procedure: Left Hip Series Report

42 Y/O MALE AD SOLDIER WITH LEFT LATERAL HIP PAIN AT THE GREATER
Reason for Order: TROCHANTER.
Exam #: 12079198
Transcription
Date/Time: 19 Sep 2012 11:55:00
Provider: ZAGORSKI, KIM JOSEPH
Requesting
Location: AMH FP YELLOW TEAM MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Interpreted By: LEWIS, WILLIAM
Approved By: LEWIS, WILLIAM
Report Text
Exam: Routine views of the left hip without priors.
Clinical indication: Pain
FINDINGS:
No fracture-dislocation or definite stress related changes. No degenerative change. No soft tissue abnormality
IMPRESSION: Negative exam.
Chest PA And Lateral Upright Series Report on 16 Jun 2012

Reason for Order: chest pain
2019
Medical Record
2019
Exam #: 12051764
Exam Date/Time: 16 Jun 2012 11:27:00
Transcription Date/Time: 16 Jun 2012 11:36:00
Provider: SCHMIDT, MELISSA KAY
Status: COMPLETE
Approved Date: 16 Jun 2012 10:42:00
Report Text
PA and lateral views of the chest. Comparison made with 21 August 2009
CLINICAL INDICATION: Chest pain
FINDINGS:
Clear lungs without consolidation, effusion or pneumothorax. No hilar enlargement or cardiomegaly. Midline
trachea. Osseous structures appear normal.
IMPRESSION: No evidence of acute cardiopulmonary disease.
Ultrasound Abdomen (3 Studies) Report on 29 Oct 2010
Procedure: Ultrasound Abdomen (3 Studies) Report

Order
40 yo AD soldier with epigastric/LUQ pain x 2 weeks with nausea- CT scan 27 Sept at Ft
Reason for Jackson showed pancreatitis- lipase/amylase slightly elevated last week- normal today- pt still
Order: with pain- pleae
Exam #: 10085295
Exam
Date/Time: 29 Oct 2010 08:21:00
Transcription
Date/Time: 29 Oct 2010 10:30:00
Provider: MISTRETTA, PATRICIA W
Requesting
Location: FMC YELLOW CLINIC MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Report Text
2019
Medical Record
2019
Abdomen ultrasound:
The body of the pancreas measures within normal limits. The head and detail of the pancreas could not be
visualized due to overlying gas. The left lobe liver appears homogeneous. The right lobe liver also appears
homogeneous and reveal no mass lesion. There is mild diffuse increase in the resistive liver suspicious of low-
grade of diffuse fatty infiltrate. The liver span is 13 cm. The common bile duct measures 4.2 mm in diameter.
This is within normal limits. The gallbladder appears unremarkable. The right kidney measures 10.2 cm in length
and 4.4 cm in AP diameter. The left kidney appears unremarkable as well and measures 11.3 x 4.9 cm. The
spleen is not enlarged.
IMPRESSION:
Probably Mild diffuse fatty infiltrated in the liver otherwise negative study.
CT Abdomen/Pelvis With Contrast Report on 28 Sep 2010

Order Comment: MD REQUIRES ABDOMEN ONLY
Reason for Order: 40yo M c/o worsening LUQ pain; elevated lipase
Exam #: 10053201
Transcription
Date/Time: 28 Sep 2010 22:08:00
Provider: KEIGER, CHRISTINA M
MACH IMMEDIATE CARE CLINIC MONCRIEF ARMY COMMUNITY
Requesting Location: HOSP
Status: COMPLETE
Result Code: SEE REPORT
Interpreted By: HARSHANY, MARK LAWRENCE
Approved By: HARSHANY, MARK LAWRENCE
Report Text
CHCS 10053201
CT as the abdomen and pelvis was performed after oral and IV contrast
History: Left upper quadrant pain
FINDINGS: No mass, lymphadenopathy, free gas, fat stranding or abnormal fluid collection is visualized. The
pancreatic head appears full. Trace peripancreatic head fat stranding is suggested. No gross fluid collections or
frank pancreatic gland edema.
Splenule noted. Multifocal regions of hepatic low density, compatible with hepatic steatosis. The remainder of
the exam is unremarkable for age.
IMPRESSION: 1. Findings suggestive of acute pancreatitis.
2019
Medical Record
2019
Abdomen With Supine And Upright Series Report on 27 Sep 2010
Procedure: Abdomen With Supine And Upright Series Report

Reason for Order: c/o left sided abdominal pain x 10 days
Exam #: 10052956
Transcription
Date/Time: 28 Sep 2010 07:09:00
MACH IMMEDIATE CARE CLINIC MONCRIEF ARMY COMMUNITY
Requesting Location: HOSP
Status: COMPLETE
Report Text
CHCS 10052956
The KUB film of the abdomen shows the renal outlines to be of normal size, shape and position. The psoas,
properitoneal and pelvic soft tissue outlines appear normal. No organomegaly or masses are seen within the
abdomen. The overall intestinal gas pattern is normal. The visualized bony structures of the lumbosacral spine
and pelvis are within normal limits. No calcifications are seen along the urinary tracts or in the region of the
gallbladder and pancreas.
IMPRESSION: Negative study
CT Abdomen/Pelvis Without Contrast Report on 17 Sep 2010
Procedure: CT Abdomen/Pelvis Without Contrast Report

Order Comment: BED 9
Reason for Order: ABDOMINAL PAIN
Exam #: 10080091
Provider: RANDALL, WILLIAM LEWIS
Status: COMPLETE
Interpreted By: PATTEN, STEPHEN R
Approved By: PATTEN, STEPHEN R
Report Text
CT abdomen and pelvis without contrast:
INDICATION: Abdominal pain. TECHNIQUE: 2.5 mm contiguous axial images were obtained through the
abdomen post without intravenous contrast. COMPARISON: 3/30/2009, 11/26/2008, 392008.
2019
Medical Record
2019
FINDINGS: Again seen is mild stranding of the mesentery in the left upper quadrant and midabdomen with
scattered nonenlarged lymph nodes. This area of misty mesentery is unchanged over the multiple previous
examinations. There is no free air or free fluid in the abdomen. Mixed is not visualized however there is no
periappendiceal or pericecal inflammation. The remainder of the bowel is otherwise unremarkable there is no
evidence of acute diverticulitis. Solid organs are grossly unremarkable although examination is limited without
intravenous contrast. Scarring or atelectasis is noted in the right lung base.
IMPRESSION: 1. Stable appearance of misty mesentery without marked change.
Initial interpretation provided by NightHawk radiology services by Dr. Swope on September 18, 2010 at 0135
hours.
Chest PA And Lateral Upright Series Report on 21 Aug 2009

Reason for Order: L. sided CP
Exam #: 09076673
Exam Date/Time: 21 Aug 2009 01:37:00
Transcription Date/Time: 21 Aug 2009 08:23:00
Provider: REEDY, GARY W
Status: COMPLETE
Interpreted By: JOHNSON, CHRISTOPHER SHANE
Approved By: JOHNSON, CHRISTOPHER SHANE
Approved Date: 21 Aug 2009 08:01:00
Report Text
CHEST PA/LAT:
COMPARISON: 9/11/2007.
FINDINGS: PA and lateral chest radiographs demonstrate no evidence of effusion, atelectasis or focal
consolidative opacity. The cardiomediastinal silhouette is unremarkable. Osseous structures and soft tissues are
normal.
CT Abdomen/Pelvis With Contrast Report on 30 Mar 2009

38 YO MALE WITH RECURRENT PERI-UMBILICAL PAIN AND H/O
Reason for Order: MESENTERIC ADENITIS
Exam #: 09029145
2019
Medical Record
2019
Exam Date/Time: 30 Mar 2009 15:15:00

Transcription
Date/Time: 30 Mar 2009 16:36:00
Provider: SISK, CHAD MICHAEL
Requesting Location: GASTROENTEROLOGY CLINIC MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Interpreted By: WYCHE, LENNON D JR
Approved By: WYCHE, LENNON D JR
Approved Date: 30 Mar 2009 16:19:00
Report Text
CT abdomen and pelvis with contrast
HISTORY: 38 yo male with recurrent periumbilical pain and history of mesenteric adenitis.
Contiguous axial images through the chest and abdomen at 3 and 5 mm intervals respectively, were obtained
after IV injection of Ultravist 370. Oral contrast had already been given. No infiltrates are seen in the lower lung
fields. Heart size is normal, liver, spleen, pancreas, adrenals, gallbladder, kidneys, inferior vena cava and aorta
are within normal limits. A few scattered lymph nodes in the mesentery, none of which measure up to 1.2 cm.
Compared to earlier CT scan dated 3/9/2008, these lymph nodes are less numerous and smaller and there is no
overall increase radiodensity to the mesentery at that time. Today's study is more similar in appearance to
11/26/2008 the scan on the lymph nodes are smaller less numerous than previous study from March 2008. There
is no bowel obstruction. The gallbladder is negative for stones. No obstructive changes of the stomach. Gas and
stool and contrast seen in colon. Could not identify the appendix but no pericecal masses are identified. No
obstructive changes of the small bowel or colon.
CONCLUSION: 1. Stable appearance since 11/26/2008 CT scan showing scattered mesenteric lymph nodes but
none are greater than 1.2 cm and they are unchanged in appearance since last study of 11/26/2008. 2. No
increase density of the mesentery seen at this time. 3. No small bowel or colonic obstruction. 4. No renal mass or
renal obstruction. 5. Could not identify the appendix but no pericecal masses are seen. 6. No gallstones or
pancreatitis identified.
CT Abdomen With Contrast Report on 26 Nov 2008
Procedure: CT Abdomen With Contrast Report

Reason for Order: epigastric pain, had MRI today, recommended CT with IV contrast for
Exam #: 08103243
Provider: TRICKEY, DAVID N
Status: COMPLETE
Interpreted By: DECKER, CARL WILLIAM
Approved By: DECKER, CARL WILLIAM
2019
Medical Record
2019
Report Text
CT OF THE ABDOMEN WITH CONTRAST
PROCEDURE: Patient was prepared with 3 doses oral contrast. Following the intravenous administration of 100
cc iodinated contrast material helically acquired axial imaging of the abdomen was performed.
FINDINGS: Overall the nodal burden in the mesentery is diminished compared with 3/08. The appearance of a
Misty mesentery is also nearly completely resolved. The visualized liver, gallbladder, spleen, pancreas, adrenal
glands and kidneys are unremarkable. Incidental note is made of a small splenule.
IMPRESSION: Near-complete resolution of mesenteric adenitis and infiltration of mesenteric fat. Would
recommend follow-up scan in one year to insure continued stability or sooner if clinically indicated.
MRI Abdomen With And Without Contrast Report on 25 Nov 2008
Procedure: MRI Abdomen With And Without Contrast Report

hx of abnormal appearing mesentery ? mesenteric sclerosis vs lymphoma - request f/u
Reason for Order: MRI
Exam #: 08095993
Transcription
Date/Time: 25 Nov 2008 17:05:00
Requesting Location: SURGERY MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Report Text
CAT scan of the the abdomen without and with IV contrast:
The study is compared to the previous exams. In the area of the previously described increased attenuation of the
mesentery and the lymph node enlargement on the CAT scan there is no suspicious enhancement on today's
MRI exam. There is residual prominence of the mesentery lymph nodes. A CT imaging without and with IV
contrast would be helpful to be compared to the previous CAT scan dated 3/9/2008. The liver, and kidneys reveal
no gross mass lesion.
MRI Abdomen Without Contrast Report on 17 Mar 2008
Procedure: MRI Abdomen Without Contrast Report

2019
Medical Record
2019
Reason for Order: Radiologist recommended to repeat sequences-suboptimal study secondary to

Exam #: 08022237
Transcription Date/Time: 18 Mar 2008 12:39:00
Provider: KAPLAN, JOSEPH
Status: COMPLETE
Interpreted By: HADLEY, JOHNATHAN
Approved By: HADLEY, JOHNATHAN
Report Text
MRI of the abdomen
HISTORY: Abnormal CT examination demonstrating increased density within the mesentery and small lymph
nodes along the mesenteric root.
TECHNIQUE: Axial T2-weighted fat-suppressed and nonsuppressed breath-hold imaging of the abdomen was
performed as well as coronal FIESTA. Correlation is made with contrast-enhanced examination of 11 March
2008.
FINDINGS: There is a subtle decrease in the overall fatty signal within the mesentery in the area of interest.
However, this does not appear to represent edema based on the fat-suppressed sequences. There is poor overall
fat saturation as well as chemical shift artifact.
IMPRESSION: 1. Very subtle decreased fatty signal along the root of mesentery. Given the faint mild
enhancement of this region of the abdomen on postcontrast imaging, the previous differential considerations of
mesenteric sclerosis, underlying infection, or less likely neoplasia remain. The subtle halo of normal appearing
fat surrounding the veins of the mesentery on CT would favor mesenteric sclerosis. A short interval follow-up
with contrast-enhanced CT in 3 months could be obtained. Definitive diagnosis would require open surgical
biopsy.
MRI Abdomen With And Without Contrast Report on 11 Mar 2008
Procedure: MRI Abdomen With And Without Contrast Report

Reason for Order: ordered per dr hadley
Exam #: 08020307
Status: COMPLETE
2019
Medical Record
2019
Report Text
MRI of the abdomen with and without contrast
HISTORY: Abnormal CT examination demonstrating mesenteric stranding.
FINDINGS: Multiplanar, multisequence imaging of the abdomen was performed. There is considerable
respiratory motion artifact present on the study. This significantly degrades image quality.
In the area of interest along the root of the mesentery there is demonstration of numerous small lymph nodes
measure 5-6 mm in short axis dimension. There is suggestion of subtle enhancement within the mesenteric fat
on dynamic postcontrast imaging. No definite precontrast correlate is seen for the area of signal abnormality
noted on postcontrast imaging. This is likely secondary to image degradation from respiratory motion. The
visualized portions of the kidney, spleen, liver, and aorta are normal in appearance.
IMPRESSION: 1. The examination is suboptimal secondary to respiratory motion artifact. Repeat imaging
should be performed.
(Coronal sequences, FIESTA, and respiratory gating should be used on repeat exam to minimize motion.)
CT Abdomen/Pelvis Without Contrast Report on 09 Mar 2008
Procedure: CT Abdomen/Pelvis Without Contrast Report

Reason for Order: acute onset lower abdominal pain
Exam #: 08019772
Provider: RITCHIE, BETTY BROWN
Status: COMPLETE
Report Text
RENAL STONE CT
TECHNIQUE: 2.5 mm thick helical imaging was performed from the dome of the diaphragm through the
symphysis pubis.
FINDINGS:
CT of the abdomen: The unopacified solid viscera are unremarkable. There is no free fluid or free air seen within
the abdomen. There is no hydronephrosis or nephrolithiasis. The kidneys are unremarkable. Incidental note is
made mildly increased groundglass attenuation along the mesentery extending into the left lower quadrant. There
are several small lymph nodes associated with this finding. The largest of these measures approximately 7 mm
long axis.
2019
Medical Record
2019
CT of the pelvis: The appendix is normal in appearance. The bladder is well-distended and otherwise
unremarkable. No distal ureteral stones are seen. No free fluid or free air is present within the pelvis. Visualized
loops of large and small bowel are normal in appearance.
IMPRESSION: 1. No evidence of nephrolithiasis, hydroureter, or bladder calculus. 2. Subtly increased was

attenuation in the mesenteric fat as described above. Finding is nonspecific particularly on a noncontrast
examination. Mesenteric sclerosis is in the differential for a "misty mesentery." Other disease processes such as
lymphoma are also in the differential. MRI with contrast is recommended. 3. Results were called to Dr. Kaplan
at 1614 hours and read back of critical results was performed.
Right Shoulder Series Report on 28 Jan 2008
Procedure: Right Shoulder Series Report

Reason for Order: s/p mvc, has pain in shoulder
Exam #: 08007350
Status: COMPLETE
Report Text
Right shoulder, multiple views
FINDINGS: A small bone density projects inferior to the acromion which is not clearly corticated. There is a
concave deformity in the posterior humeral head seen on the axillary views only. This may represent an old
Hill-Sachs injury. Otherwise no fracture seen. No significant degenerative changes.
IMPRESSION: Possible fracture involving the inferior surface of acromion. Also possible old Hill-Sachs lesion.
C-Spine Series Report on 25 Jan 2008
Procedure: C-Spine Series Report

Reason for Order: MVC
Exam #: 08006960
2019
Medical Record
2019

Status: COMPLETE
Report Text
Cervical spine in collar shows cervical straightening with no fracture or subluxation. Intervertebral disc spaces
are well maintained. The prevertebral soft tissues are unremarkable. The atlantoaxial joint spaces are symmetric.
IMPRESSION: Unremarkable cervical spine in collar
L-Spine (5 Views) With Obliques Series Report on 15 Oct 2007
Procedure: L-Spine (5 Views) With Obliques Series Report

Reason for Order: chronic LBP with radicular complaints s/p MVA 1 year ago. R/O bony changes
Exam #: 07084609
Exam Date/Time: 15 Oct 2007 07:53:00
Transcription
Date/Time: 15 Oct 2007 10:40:00
Provider: VAILLANT, GEORGE R
CTMC AMBULATORY PRIMARY CLINIC COMBINED TROOP MEDICAL
Requesting Location: DIV
Status: COMPLETE
Report Text
LUMBAR SPINE, FOUR VIEWS:
FINDINGS: AP, lateral, obliques and spot lateral views. The vertebral alignment is normal. The bodies and
disc spaces are intact. No compression deformity, spondylolysis or spondylolisthesis is seen. The sacro-iliac
joints are normal.
IMPRESSION: Normal study.
Chest PA And Lateral Upright Series Report on 11 Sep 2007

Order Comment: CHEST PN
Reason for Order: CHEST PN
Exam #: 07074344
2019
Medical Record
2019

Status: COMPLETE
Report Text
PA AND LATERAL CHEST:
COMPARISON: None.
FINDINGS: The trachea is midline, and the cardiac silhouette is within normal limits for size. The lungs are
clear without evidence of focal consolidation, effusion, or pneumothorax.
***** End of Radiology *****
2019
Medical Record
2019
Immunizations
Vaccine Series VISVersion Date Manufacturer Lot No. Dose/Site Exemption Administered By
Influenza, Inj., 1 8/7/2015 14 SmithKline 29F3B .5 None HUDSON,
quad., preservative Nov mL/Righ JAMISHA A
free 2017 t Arm
IPPD 0 28 Sanofi Pasteur EXEMPT .1 Pos Test THOMAS,
Dec mL/Righ ROBERT L.
2015 t Arm
IPPD 0 20 Sanofi Pasteur C4513BB .1 None THOMAS,
Mar mL/Left ROBERT L.
2015 Arm
MMR 2 04/20/12 20 Merck k005175 .5 None THOMAS,
Feb mL/Left ROBERT L.
2015 Arm
Tdap 1 05/19/13 20 Sanofi Pasteur 9544Y .5 None THOMAS,
Feb mL/Righ ROBERT L.
2015 t Arm
Influenza Split 0 28 CSL / None TRANSCRIBE
(Injectable) Oct Biotherapies, D
2012 Inc.
Influenza, 1 28 Unknown UNK / None TRANSCRIBE
unspecified Oct D
formulation 2012
Influenza Split 1 12 Novartis UNK / None TRANSCRIBE
(Injectable) Sep Pharmaceutical D
2011 Corp.
Influenza Split 0 12 Novartis / None TRANSCRIBE
(Injectable) Oct Pharmaceutical D
2010 Corp.
Influenza, Split 1 12 Novartis 111784P1 / None TRANSCRIBE
(incl. purified Oct Pharmaceutical D
surface antigen) 2010 Corp.
Novel influenza- 1 29 Unknown UNK / None TRANSCRIBE
H1N1-09 Jan D
2010
Influenza, Split 1 13 Sanofi Pasteur UT3172AA / None TRANSCRIBE
(incl. purified Nov D
surface antigen) 2009
Influenza, Live, 1 18 MedImmune, 500552P / None TRANSCRIBE
Intranasal Oct Inc. D
2008
Hep B - Adult 3 14 Merck 1054U / None TRANSCRIBE
Dec D
2007
Influenza, Split 1 14 SmithKline UNK / None TRANSCRIBE
(incl. purified Dec D
IPPD 1 04 Aventis Behring C2212AA / None TRANSCRIBE
Dec L.L.C D
2005
Hep B - Adult 2 08 SmithKline AHBVB005A / None TRANSCRIBE
Nov A D
2005
Influenza, Split 1 22 Other U1771AA / None TRANSCRIBE
(incl. purified Oct D
Hep A (Adult) 2 08 Merck 0112P / None TRANSCRIBE
Jul D
2005
Hep B - Adult 1 08 SmithKline AHBVB005A / None TRANSCRIBE
Jul A D
2005
Varicella 1 04 NONE / Not TRANSCRIBE
2019
Medical Record
2019
Jan Suscep D
2005
Vaccinia (Smallpox) 1 30 Unknown UNK / None TRANSCRIBE
Nov D
2004
Influenza, Split 1 05 Aventis Behring UNK / None TRANSCRIBE
(incl. purified Nov L.L.C D
IPPD 1 05 Aventis Behring C1601AA / None TRANSCRIBE
Nov L.L.C D
2004
Meningococcal 1 05 Aventis Behring UB269AA / None TRANSCRIBE
MPSV4 Nov L.L.C D
2004
Hep A (Adult) 1 20 Merck 0872N / None TRANSCRIBE
Jul D
2004
IPV 1 20 Sanofi Pasteur X0316 / None TRANSCRIBE
Jul D
2004
MMR 1 20 Merck 0391N / None TRANSCRIBE
Jul D
2004
Td (adult), adsorbed 1 20 Sanofi Pasteur U1014AA / None TRANSCRIBE
Jul D
2004
Typhoid, ViCPs 1 20 Sanofi Pasteur X0481 / None TRANSCRIBE
Jul D
2004
***** End of Immunizations *****
2019
Medical Record
2019
Previous Encounters
13 Nov 2019 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by CARR,
VANESSA
Immunization not carried out because of patient

Encounter ID: BENN-19805852 Primary Dx:
refusal
Patient: WAITERS, TOMMIE Date: 13 Nov 2019 1542 EST Appt Type: FTR
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: OCCUPATIONAL HEALTH FBGA Provider: CARR,VANESSA
BENNING
Patient Status: Outpatient Clinic Phone: 544-2273
Reason for Appointment: Written by YOUNG,BARBARA R @ 13 Nov 2019 1542 EST

FLU IMMUNIZATION CIV
Screening Last Updated by CARR,VANESSA @ 13 Nov 2019 1622 EST
Allergen information verified by CARR, VANESSA @ 13 Nov 2019 1622 EST

Reason(s) For Visit (Chief Complaint): Vaccination Not Carried Out Due To Patient Refusal Influenza (New): FLU VACCINE;
Vitals Written by CARR,VANESSA @ 13 Nov 2019 1622 EST

Tobacco Use: No; Alcohol Use: No; Pain Scale: 0/10 Pain Free
S/O Note Written by CARR,VANESSA @ 13 Nov 2019 1623 EST

Therapy
• No immunization administration; employee provided medical documentation from Publix Pharmacy or Flucelvax Quadrivalent
Influenza vaccine given on 8 NOV 2019; Seqirus.
A/P Written by CARR,VANESSA @ 13 Nov 2019 1623 EST

1. Immunization not carried out because of patient refusal
Disposition Written by CARR,VANESSA @ 13 Nov 2019 1623 EST

Disposition: Released w/o Limitations
Follow up: as needed in the OCCUPATIONAL HEALTH FBGA clinic.
Discussed: Diagnosis with Patient who indicated understanding.
Signed By CARR,VANESSA @ 13 Nov 2019 1624 EST
-------------------------------------------------------------------------------------
CHANGE HISTORY
The following Screening Note Was Overwritten by CARR,VANESSA @ 13 Nov 2019 1622 EST:
2019
Medical Record
2019
11 Sep 2019 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by CARR,
VANESSA
EXAM, FORMAL OCCUPATIONAL

HEALTH PROGRAM INCLUDING
HEARING CONSERVATION
Encounter ID: BENN-19625086 Primary Dx: PROGRAM, PERIODIC FOR
CONTINUED SURVEILLANCE FOR
OCCUPATIONAL WORKPLACE
EXPOSURE
Patient: WAITERS, TOMMIE Date: 11 Sep 2019 0925 EDT Appt Type: FTR
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: OCCUPATIONAL HEALTH FBGA Provider: CARR,VANESSA
BENNING
Autocites Refreshed by NESMITH,KAREN A @ 11 Sep 2019 0930 EDT

Problems Family History Allergies
• Male erectile disorder F52.21 • No family history of supplemental HPI No Known Allergies
• MESENTERIC PANNICULITIS [use for free text] (General FHx)
• Patient Counseling: • Family medical history (General FHx)
• BURSITIS TROCHANTERIC • No family history [use for free text]
• Visit for: military services physical (General FHx)
accession • Family history of test conclusions [Use
• Counseling About Travel for free text] (General FHx)
• GASTRITIS • Daughter's history of test conclusions
• HYPERGLYCEMIA [Use for free text] (Daughter)
• MCKENZIE POSTERIOR • No family history of bleeding problems
DERANGEMENT SYNDROME (General FHx)
• Patient Counseling Medical • No family history of congenital deafness
Management Five To Eight Patients (General FHx)
• NONORGANIC SLEEP APNEA • No family history of cancer (General
OBSTRUCTIVE FHx)
• NONORGANIC SLEEP DISORDERS • Family history of nonorganic sleep apnea
• HYPERLIPIDEMIA (General FHx)
• OVERWEIGHT • Family history of heart disease
• HYPERTENSION (SYSTEMIC) • No family history of angina pectoris
• HYPOGONADISM • Family history of cancer
• ASTIGMATISM • Family history [use for free text]
• MALE ERECTILE DISORDER • No family history of mental illness (not
• Snoring intellectual disabilities)
• Visit for: vasectomy status • No family history of alcoholism
• Abdominal pain in the left upper belly • No family history of malignant neoplasm
(LUQ) of large intestine
• LUMBAGO • Maternal history of arteriosclerotic
• MAJOR DEPRESSION, RECURRENT cardiovascular disease (ASCVD)
IN PARTIAL REMISSION (Mother)
• ADJUSTMENT DISORDER WITH • Paternal history of type 2 diabetes
DEPRESSED MOOD mellitus (Father)
• REFRACTIVE ERROR -
HYPERMETROPIA
• GENERALIZED ANXIETY DISORDER
• MAJOR DEPRESSION, SINGLE
EPISODE MODERATE
• Abdominal pain around the belly button
(periumbilical)
• ASSESS PATIENT CONDITION WORK-
RELATED OCCUPATIONAL
DISEASE
• ANXIETY DISORDER NOS
EPISODE
2019
Medical Record
2019
• Blood Pressure Isolated Elevated

• Visit for: military services physical
• Visit for: occupational health / fitness
exam
• Body Mass Index
• Patient Education - Dietary
• GASTRITIS DUE TO H. PYLORI
• HELICOBACTER PYLORI (H. PYLORI)
INFECTION
• Visit for: preoperative exam
• Visit for: follow-up exam
• TESTICULAR NEOPLASM
• Abdominal pain
• Other Physical Therapy
• Joint pain, localized in the shoulder
• CERVICALGIA
• Visit for: screening exam
• FOLLICULITIS
• MIGRAINE HEADACHE
• BACKACHE
Active Medications
Active Medications Status Sig Refills Left Last Filled
testosterone, 10 mg/0.5 gram per actuation (2 %), Active APPLY 4 PUMPS TO FRONT 3 of 3 23 Aug 2019
GEL MD PMP, TRANSDERM AND INNER THIGH EVERY
MORNING *WASH HANDS
AFTER USE* #1 RF3
hydrochlorothiazide, 12.5 MG, CAPSULE, ORAL Active TAKE ONE CAPSULE BY 1 of 1 12 Aug 2019
MOUTH EVERY DAY #60 RF1
sumatriptan succinate, 50 MG, TABLET, ORAL Active TAKE ONE TABLET BY MOUTH 1 of 1 12 Aug 2019
AT ONSET OF HEADACHE MAY
REPEAT IN 2 HOURS AS
NEEDED FOR HEADACHE NO
MORE THAN 4 TABLETS PER
DAY #18 RF1
lidocaine, 5 %, ADH. PATCH, TOPICAL Active APPLY 1 PATCH EVERY DAY 10 of 10 12 Aug 2019
(12 HOURS ON, 12 HOURS
OFF) #1 RF10
sildenafil citrate, 100 MG, TABLET, ORAL Active TAKE ONE TABLET BY MOUTH 3 of 3 08 Aug 2019
1 HOUR BEFORE SEXUAL
INTERCOURSE NO MORE
THAN 1 A DAY #18 RF3
LIDOCAINE (lidocaine), 5 %, OINT. (G), TOPICAL, Active 0 of 3 28 Oct 2016
HI-TECH/AKORN C, 35.44 g TUBE
LIDOCAINE (lidocaine), 5 %, OINT. (G), TOPICAL, Active 1 of 3 28 Sep 2016
LIDOCAINE (lidocaine), 5 %, OINT. (G), TOPICAL, Active 3 of 3 18 Jul 2016
IGI LABS, INC./, 35.44 g TUBE
TRIAZOLAM (triazolam), 0.25 MG, TABLET, Active NR 03 May 2009
ORAL, GREENSTONE LLC., 10 ea. BOTTLE
Reason for Appointment: Written by NESMITH,KAREN A @ 11 Sep 2019 0925 EDT

MSS DOM
Screening Last Updated by NESMITH,KAREN A @ 11 Sep 2019 0928 EDT

Reason(s) For Visit (Chief Complaint): ARMED FORCES MEDICAL EXAM HEARING CONSERVATION PROGRAM PERIODIC
(New): ANNUAL MSS DOM;
Vitals Written by NESMITH,KAREN A @ 11 Sep 2019 0926 EDT

BP: 124/79 Right Arm, Adult Cuff; HR: 88; Tobacco Use: No; Alcohol Use: No; Pain Scale: 5/10 Moderate; Pain Scale Comments:
BAKC AND LEFT SHOULDER
Vitals Written by NESMITH,KAREN A @ 11 Sep 2019 0927 EDT
Pain Scale: 5/10 Moderate; Pain Scale Comments: BACK AND LEFT SHOULDER
Questionnaire Autocites Refreshed by NESMITH,KAREN A @ 11 Sep 2019 0930 EDT

Questionnaires
2019
Medical Record
2019
Learning Needs Assessment Version: 2 Completed On: 11 Sep 2019

1. What is your Primary Language?Cual es su lenguaje primario? : English
2. Do you require a interpreter to speak with your health care provider?¿Usted necesita un intérprete para comunicarse con su
proveedor de cuidado médico?: No
3. Indicate the highest schooling completed:: College
4. What aspects of your health or your child's health would you like more information on?:
_______________________________________________________________
5. Do you have any learning barriers?: None
6. How do you best learn? Please indicate all that apply:: One-on-One Instruction; Reading material; Videos; Demonstration
7. Overall, do you feel motivated to learn more about your health and wellness?: Sometimes
8. Do you have any spiritual, cultural or social practices we should consider in planning your health care? It the answer is yes,
please list:: None
9. THIS SECTION APPLIES ONLY TO THE PATIENT (NOT PARENTS or GUARDIAN):Do you have an Advance Medical
Directive?: No (If no, would you like information? Yes No)
10. How would you describe your current state of health?]: Fair
11. Everyone experiences stress. How well are you managing your current level of stress?: Poorly
12. Do you have any problems performing your normal activities of daily living?: No
13. Do you have nutritional concerns that have not been addressed? ( If yes, remember to discuss this with your healthcare team
today!): Yes
S/O Note Written by CARR,VANESSA @ 12 Sep 2019 1045 EDT

Reason for Visit
Visit for: occupational health/fitness exam Annual MSS.
History of present illness
The Patient is a 49 year old male.
Reporting for Annual Job Related Medical Surveillance Screening IAW AR 40-5. Job related hazards include but are not limited to
airborne, contact and droplet infections, bending, stooping, lifting, reaching, pushing, and pulling. Provided printed materials on
work station ergonomics, prevention of eye strain related to VDT use, posture, and body mechanics. Counseled regarding Personal
Protective Equipment (PPE) and health protocols which includes but is not limited to the consistent practice of good hand hygiene,
sneeze and cough protocols, good body mechanics, work station ergonomics, annual monitoring for TB exposure and obtaining
immunizations such as influenza and a one time TDaP. TDaP and Influenza are current. Denies constitutional symptoms of or
exposures to patients with known active TB. Counseled regarding BBP exposures and given written material for the steps to take in
the event of an exposure. Encouraged to contact Occupational Health in the event of work related health/safety concerns, injuries
or illness. Employee verbalized understanding and has no additional questions or concerns at this time.
Past medical history reviewed with worker by verbal history and questionnaire(s), by questionnaire learning needs assessment,
TB questionnaire, and Columbia-Suicide Severity Rating Scale Questionnaire completed. Patient answered NO to all questions in
Step 1 and Step 3. Hard copy questionnaire place in CEMR, and medication list reviewed with patient, patient reports that he
currently takes HCTZ, and no other medications.
Past medical/surgical history
Reported:
No active problems reported include HTN, back and left shoulder pain.
Recent Events: Recent events no significant illness, injury, or surgery reported within the last 12 months, and employee denies
any BBP, other hazardous exposures, or work related injuries since the last work related physical assessment.
Physical findings
Vital Signs:
° Current vital signs reviewed.
General Appearance:
• General appearance: alert, appears well, with normal gait and stance. PLAN: Repeat Medical Surveillance Screening
annually.
Skin:
• Skin: integrity of hands is intact, free of cuts and rashes.
Tests
Laboratory Studies:
Audiometry:
Audiometry Communicates appropriately by spoken word, and responds appropriately in normal voice tones to verbal
commands. No hazardous noise exposures identified for this job.
General:
Tests Record of immunity by titer to communicable disease in place for MMR, Varicella, and Hep B.
A/P Written by NESMITH,KAREN A @ 11 Sep 2019 0930 EDT

1. EXAM, FORMAL OCCUPATIONAL HEALTH PROGRAM INCLUDING HEARING CONSERVATION PROGRAM, PERIODIC
FOR CONTINUED SURVEILLANCE FOR OCCUPATIONAL WORKPLACE EXPOSURE
Procedure(s): - Patient Counseling Medical Management Individual Patient
2. Encounter for screening for respiratory tuberculosis
Plan/Comment(s): - MEDCOM FORM 831 COMPLETE WITH NO SIGN OF S/S OF TB DOCUMENTED
Disposition Written by CARR,VANESSA @ 12 Sep 2019 1046 EDT
2019
Medical Record
2019

Signed By CARR,VANESSA (BSN, RN, COHN-S, CMSRN, Occupational Health Nurse) @ 12 Sep 2019 1046 EDT
-------------------------------------------------------------------------------------
CHANGE HISTORY
The following Screening Note Was Overwritten by NESMITH,KAREN A @ 11 Sep 2019 0926 EDT:
2019
Medical Record
2019
04 Sep 2019 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by AGUILAR,
MICHAEL THOMAS
Encounter ID: BENN-19605699 Primary Dx: Testicular hypofunction
Patient: WAITERS, TOMMIE Date: 04 Sep 2019 1229 EDT Appt Type: T-CON*
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02ASTRONG TEAM Provider: AGUILAR,MICHAEL THOMAS
BENNING
Patient Status: Outpatient Clinic Phone: 762-408-2560/2559 Call Back Phone: (706) 326-4585
Reason for Telephone Consult: Written by AGUILAR,MICHAEL THOMAS @ 04 Sep 2019 1229 EDT
F/u on lab tests
Lab Result Cited by AGUILAR,MICHAEL THOMAS @ 04 Sep 2019 1229 EDT

Follicle Stimulating Hormone+Luteinizing Site/Specimen 23 Aug 2019 1431 Units Ref Range
Hormone
Follitropin SERUM 5.6 mIU/mL
Lutropin SERUM 8.0 mIU/mL
A/P Written by AGUILAR,MICHAEL THOMAS @ 04 Sep 2019 1234 EDT

1. Testicular hypofunction E29.1
Plan/Comment(s): - Est pt - chronic problem - LH/FSH came back in nml range suggesting secondary hypogonadism. Will
screen for pituitary dysfunction with PRL + TSH with repeat CBC + PSA + Testosterone lvl to monitor
therapeutic response.
Laboratory(ies): - Lab Test: PROLACTIN; Collection Priority: Routine
- Lab Test: TSH, SENSITIVE; Collection Priority: Routine
- Lab Test: HEMOGRAM AUTO+COMP AUTO DIFF; Collection Priority: Routine
Disposition Written by AGUILAR,MICHAEL THOMAS @ 04 Sep 2019 1230 EDT
Signed By AGUILAR,MICHAEL THOMAS (DO, CPT, Staff Family Medicine Physician, Martin Army Community Hospital) @ 04
Sep 2019 1234 EDT
2019
Medical Record
2019
04 Sep 2019 at Martin ACH, Fort Benning, GA, Physical Therapy by MCCAMBRIDGE,
ERIN K
Encounter ID: BENN-19603996 Primary Dx: Low back pain
Patient: WAITERS, TOMMIE Date: 04 Sep 2019 0855 EDT Appt Type: SPEC
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: PHYSICAL THERAPY Provider: MCCAMBRIDGE,ERIN K.
BENNING
Autocites Refreshed by MCCAMBRIDGE,ERIN K @ 04 Sep 2019 0903 EDT

Allergies
No Known Allergies
Active Medications
testosterone, 10 mg/0.5 gram per actuation (2 %), Active APPLY 4 PUMPS TO FRONT 3 of 3 23 Aug 2019
GEL MD PMP, TRANSDERM AND INNER THIGH EVERY
MORNING *WASH HANDS
AFTER USE* #1 RF3
hydrochlorothiazide, 12.5 MG, CAPSULE, ORAL Active TAKE ONE CAPSULE BY 1 of 1 12 Aug 2019
sumatriptan succinate, 50 MG, TABLET, ORAL Active TAKE ONE TABLET BY MOUTH 1 of 1 12 Aug 2019
AT ONSET OF HEADACHE MAY
REPEAT IN 2 HOURS AS
NEEDED FOR HEADACHE NO
MORE THAN 4 TABLETS PER
DAY #18 RF1
lidocaine, 5 %, ADH. PATCH, TOPICAL Active APPLY 1 PATCH EVERY DAY 10 of 10 12 Aug 2019
(12 HOURS ON, 12 HOURS
OFF) #1 RF10
sildenafil citrate, 100 MG, TABLET, ORAL Active TAKE ONE TABLET BY MOUTH 3 of 3 08 Aug 2019
1 HOUR BEFORE SEXUAL
INTERCOURSE NO MORE
THAN 1 A DAY #18 RF3
Atorvastatin 10 mg oral tablet Active TAKE ONE TABLET BY MOUTH 3 of 3 07 Sep 2018
AT BEDTIME #90 RF3
LIDOCAINE (lidocaine), 5 %, OINT. (G), TOPICAL, Active 0 of 3 28 Oct 2016
LIDOCAINE (lidocaine), 5 %, OINT. (G), TOPICAL, Active 1 of 3 28 Sep 2016
LIDOCAINE (lidocaine), 5 %, OINT. (G), TOPICAL, Active 3 of 3 18 Jul 2016
IGI LABS, INC./, 35.44 g TUBE
TRIAZOLAM (triazolam), 0.25 MG, TABLET, Active NR 03 May 2009
Reason for Appointment:

Low back pain
Appointment Comments:
mon
Note Written by MCCAMBRIDGE,ERIN K @ 04 Sep 2019 0956 EDT

Lumbar Spine Physical Therapy Evaluation
Subjective
Patient was confirmed with correct full name and date of birth.
Pt verbally consented to today’s examination and treatment.
Date of Evaluation: Click here to enter a date.
Military Status: Retired
MOS/Occupation: CNA - GI clinic at BMACH
MRAT: N/A
2019
Medical Record
2019
History
Chief Complaint: low back pain
History/MOI: 49 y/o male with low back pain since 2008. He injured his back in a vehicle accident in Iraq. He denies
any recent injury or trauma to the back. He reports his pain has been getting progressively worse. He has been
through therapy in the past (2009ish). His pain is primarily in the low back but will have occasional pain into BLE that
will last for a couple days and then go away.
Patient Goals/Motivation: to reduce pain
Pain location: across low back

Pain presence: ☒constant ☐intermittent
VAS Score: 6/10
Numbness/tingling: ☒No ☐Yes:
Aggravating Factors: prolonged walking/sitting/standing
Mitigating Factors: changing position, pain medicine, pain patches
FABQ: 19+11=30
Functional Disability Score: Oswestry: 32%
Past Medical/Surgical History:

Medical: Reported medical history
HTN
Low back pain
H pylori
Hypogonadism
Common Migraine
ED.
Surgical / Procedural: Surgical / procedural history
Appendectomy - 1991
Cyst removal left wrist - 2001 2002.
Medications: See active medication list in ALTHA
Medication reconciliation: Not indicated, no medications prescribed, no medications changed
Imaging: See citation in ALTHA
Often bothered by feeling down, depressed or hopeless? ☒No ☐Yes:

Often bothered by little interest or pleasure in doing thing? ☒No ☐Yes:
Columbia Suicide Severity Rating Scale: N/A
Tobacco: ☒No ☐Yes:

-Requested assistance with cessation: ☒No ☐Yes:
Red Flags:
-Systemic: No fevers, chills, and no reported weight change; no reported infections
-Head: No headache
-Cardiovascular: No chest pain or discomfort
-Pulmonary: No shortness of breath, no changes in cough or sputum
-Gastrointestinal: Normal appetite; No dysphagia, no nausea, no vomiting, no fecal incontinence
-Genitourinary: No urinary loss of control, no urinary retention
-Endocrine: No excessive sweating
-Neurological: No dizziness, no tingling, no numbness; no reported dizziness or vertigo
Examination
Affect: no apparent distress
Observation: No acute signs/symptoms of infection/DVT. No bruising, edema or swelling noted.
Posture: Sitting: Poor; Standing: Poor
Correction of Posture: Same
Neurological
Motor Deficit: BLE myotomes 5/5
Sensory Deficit: Dermatomes (LE): WNL to crude touch (B)
2019
Medical Record
2019
Reflexes: Patellar tendon (2+) bilat, Achilles tendon (2+) bilat

Dural Signs: (-) B Slump, (-) B SLR
Functional Assessment
Squat: ½ squat with pain
Movement Loss:
Lumbar Spine:
Direction Movement Loss Pain
Flexion Fingertips to mid-thigh pain during movement
Extension Major pain during movement
Right Lateral Side glide Moderate pain during movement
Left Lateral Side Glide Moderate pain during movement
Special Tests
(+) (B) Patrick’s/FABER
(-) (B) SLR
(+) (B) Prone Knee Flexion/Ely’s
Palpation
TTP
Repeated Movements
Movement Symptoms During Testing Symptoms After Testing
Extension in lying Increase No Worse
Repeated Extension in Increase No Worse
Lying
Repeated Extension in Increase No Worse
Lying with wedge support
Extension in standing Increase No Worse
Repeated extension in Increase No Worse
standing
Instructed for HEP: repeated lumbar extension in lying with support under abdomen or in standing 10x every 2-3
hours. Educated pt on use of lumbar roll and posture corrections throughout the day. Educated pt to stop if loss of
ROM or peripheralization of symptoms, pt stated understanding
TREATMENT
1. Physical Therapy Evaluation (97162)
2. Therapeutic Exercise (97110): Patient instructed on and performed exercises listed above x 15 minutes.
3. Patient educated on assessment, treatment options, risk, plan of care, benefits/goals of skilled PT
intervention, prognosis, and importance of long-term self-management of condition.
4. Response to treatment: Pt tolerated evaluation and treatment without complaint.
5. Learning needs were assessed. No Barriers to education noted.
6. The patient expressed and demonstrated understanding of all instruction and has agreed to present POC.
Provisional Classification: Derangement or other

ASSESSMENT
Pt is a 49 y/o male who presents with chronic low back pain. His symptoms are consistent with lumbar derangement
or other to include chronic pain. The pt will benefit from a trial of in clinic therapy for MDT, strengthening, stretching,
manual therapy and modalities as needed for pain relief.
Prognosis: Good if compliant with therapy
GOALS made in conjunction with patient at initial evaluation.

Short-term goal(s): 3-4 weeks
1. Pt will report 25% improvement in symptoms with daily and functional activities.
2. Pt will be independence HEP
Long-term goal(s): 6-8 weeks
2019
Medical Record
2019
1. Pt will report 50% improvement in symptoms with daily and functional activities.
2. Pt will be independent in long-term management of their condition.
PLAN
The pt will be seen 2x weeks and follow up in 4 weeks.
MARTIN ARMY PHYICAL THERAPY CLINIC

Daily Exercise/Procedure Flowsheet
Patient: Waiter, Tommie (20/1757)
DOB:18Aug1970
Diagnosis: LBP Therapist: McCambridge
Special Concerns: Frequency: 2x3 week
Follow-Up: 3-4 weeks
Exercise/Date:
Repeated lumbar extension in
lying on wedge 3x10 (beginning
and end of tx)
Bridge with TB around knees
Clamshells
Prone swimmer -> bird dog
TrA activation with:

-pelvic tilt 20x
-march 20x
-heel slide (heel contact with
mat) 20x
-knee extension 20x
-arm lift/march 20x
Ice PRN
Time in Clinic
Pain Scale pre/post _/10
Provider Initials
DATE Treatment Notes / Adverse Reactions / Complaints

Goals:
2019
Medical Record
2019
A/P Written by MCCAMBRIDGE,ERIN K @ 04 Sep 2019 0946 EDT

1. Low back pain M54.5
Procedure(s): - (97162) Physical Therapy Service Evaluation Moderate Complexity
- (97110) Physical Therapy: ___ Session Segments, 15 Minutes Each
Disposition Written by MCCAMBRIDGE,ERIN K @ 04 Sep 2019 0949 EDT

Follow up: in the PHYSICAL THERAPY clinic.
Discussed: Diagnosis, Medication(s)/Treatment(s), Alternatives, Potential Side Effects with Patient who indicated understanding.
Note Written by HOPKINS,TARA L @ 04 Sep 2019 0846 EDT

Consult Order
Referring Provider: AGUILAR,MICHAEL THOMAS
Date of Request: 09 Aug 2019
Priority: Routine
Provisional Diagnosis:
Low back pain
Reason for Request:
48 y/o AAM, obese, HTN with chronic low back pain. Please evaluate and provide stretching strengthening regimen +/- dry needling.
Thank you.
Signed By MCCAMBRIDGE,ERIN K (PHYSICAL THERAPIST, BMACH, Ft. Benning, GA) @ 04 Sep 2019 0956 EDT
2019
Medical Record
2019
20 Aug 2019 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by AGUILAR,
MICHAEL THOMAS
Encounter ID: BENN-19567760 Primary Dx: Testicular hypofunction
Patient: WAITERS, TOMMIE Date: 20 Aug 2019 1645 EDT Appt Type: T-CON*
ALAJANDRO
BENNING
Patient Status: Outpatient Call Back Phone: (706)-326-4585
AutoCites Refreshed by AGUILAR,MICHAEL THOMAS @ 20 Aug 2019 1645 EDT

Allergies
•No Known Allergies
Reason for Telephone Consult:Written by AGUILAR,MICHAEL THOMAS @ 20 Aug 2019 1645 EDT
Review lab results
Note Written by AGUILAR,MICHAEL THOMAS @ 20 Aug 2019 1711 EDT

relayhealth physician reply
Mr. Waiters,
I wanted to follow up with you after coming to see us in clinic.
How are you handling the new blood pressure medication? What types of blood pressure numbers are you seeing? Please make a
follow up appointment with us to monitor your blood pressure if you haven't already.
In regards to the testosterone replacement, I reviewed the labs and your blood counts, prostate blood test, and testosterone are all
consistent with safe use of testosterone replacement therapy. We no longer have the androgel and now have the pump solution. It is
applied to the front and inner thighs every morning. I placed the order for the testosterone in the pharmacy and you can pick it up at
your convenience. I did not that we are missing one blood test which could change our evaluation of why you have low testosterone.
I have placed the order in for that blood test. Once I get the results I will update you on that. We will repeat the testosterone level in
the morning, 1 month after starting therapy to ensure that it is working appropriately.
Prior to starting a new medicine, I just want to review. There are some known side effects with testosterone. The most common
being skin irritation at the site of administration. If this happens we can change the route that we deliver the medication. There is a
theoretical risk of increasing prostate volume and therefore increasing prostate cancer risk with this therapy and is something that
we will monitor for. There is risk that this medication can also cause blood clots in the leg or lung, though that is usually only seen in
men who have prior blood clot or a person in their immediate family with blood clot issues. Lastly, we also don't know the effects of
this medication on the heart and there are some studies that suggest it could increase risk of heart attack. These are all the same
risks as you were taking when you were on Androgel previously and are not unique to this medication.
Please let me know what questions you have,
Dr. M. Aguilar
Lab Result Cited by AGUILAR,MICHAEL THOMAS @ 20 Aug 2019 1646 EDT
Prostate Specific Ag Site/Specimen 12 Aug 2019 1528 Units Ref Rng
Prostate Specific Ag SERUM 0.85 ng/mL (0.00-4.00)

Hemogram+Differential Auto Site/Specimen 12 Aug 2019 1528 Units Ref Rng
WBC BLOOD 6.7 x10(3)/mcL (4.9-10.0)
RBC BLOOD 4.98 x10(6) (4.7-6.1)
Hemoglobin BLOOD 14.4 g/dL (14.0-18.0)
Hematocrit BLOOD 41.5 (L) % (42-52)
MCV BLOOD 83.3 fL (80-96)
MCH BLOOD 29.0 pg (27-31)
MCHC BLOOD 34.8 g/dL (32.0-36.0)
RDW CV BLOOD 13.5 % (11.5-14.5)
MPV BLOOD 10.0 fL (6.8-10)
Platelets BLOOD 269 x10(3)/mcL (150-450)
2019
Medical Record
2019
ABS Neutrophils BLOOD 3.3 x10(3)/mcL (1.4-6.5)

Neutrophils BLOOD 49.1 % (30-70)
ABS Lymphocytes BLOOD 2.7 x10(3)/mcL (1.0-4.0)
Lymphocytes BLOOD 40.6 (H) % (20-40)
ABS Monocytes BLOOD 0.4 x10(3)/mcL (0.0-1.0)
Monocytes BLOOD 6.6 % (0-10)
ABS Eosinophils BLOOD 0.2 x10(3)/mcL (0.0-0.5)
Eosinophils BLOOD 2.5 % (0-5)
ABS Basophils BLOOD 0.1 x10(3)/mcL (0.0-0.2)
Basophils BLOOD 1.2 % (0-2)

Testosterone Free+Total Site/Specimen 06 Sep 2018 1010 Units Ref Rng
Testosterone SERUM 250 (L) ng/dL 264-916
Testosterone Free SERUM 6.6 (L) pg/mL 6.8-21.5

Testosterone Free+Total Site/Specimen 18 Jul 2018 1501 Units Ref Rng
Testosterone SERUM 233 (L) ng/dL 264-916
Testosterone Free SERUM 6.1 (L) pg/mL 6.8-21.5
A/P Written by AGUILAR,MICHAEL THOMAS @ 20 Aug 2019 1713 EDT

1. Testicular hypofunction E29.1: Will obtain LH/FSH to determine primary vs secondary hypogonadims and evaluate accordingly.
Goal supplementation is 400-700ng/dL and will target this. Will repeat testosterone level in 1mo w/ PSA.
Medication(s): -TESTOSTERONE 10 MG/0.5GM TDRM GLPM [60] [PENDING PDTS] - APPLY 4 PUMPS TO FRONT
AND INNER THIGH EVERY MORNING *WASH HANDS AFTER USE* #1 RF3
Comment: Initiating therapy for male hypogonadism
Laboratory(ies): -LH/FSH PANEL (Routine); TESTOSTERONE,FREE AND TOTAL (Routine) Start Date: 09/17/2019;
PROSTATE SPECIFIC AG (Routine) Start Date: 09/17/2019
Disposition Last Updated by AGUILAR,MICHAEL THOMAS @ 20 Aug 2019 1645 EDT
Signed By AGUILAR, MICHAEL THOMAS (DO, CPT, Staff Family Medicine Physician, Martin Army Community Hospital) @ 20
Aug 2019 1713
2019
Medical Record
2019
08 Aug 2019 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by AGUILAR,
MICHAEL THOMAS
Patient: WAITERS, TOMMIE Date: 08 Aug 2019 1530 EDT Appt Type: FTR
ALAJANDRO
BENNING
Patient Status: Outpatient
AutoCites Refreshed by AGUILAR,MICHAEL THOMAS @ 08 Aug 2019 1614 EDT

Allergies

AGUILAR/BACK PAIN & HEADACHES/706.326.4585
jmi
Vitals
Vitals Written by GHOLSON,RACHEL J @ 08 Aug 2019 1534 EDT
BP: 148/86, HR: 92, RR: 20, T: 97.6 °F, HT: 66 in, WT: 250.2 lbs, BMI: 40.38, BSA: 2.2 square meters,
Tobacco Use: No, Alcohol Use: No
Allergen information verified by GHOLSON,RACHEL J @ 08 Aug 2019 1534 EDT
S/O Note Written by AGUILAR,MICHAEL THOMAS @ 09 Aug 2019 0724 EDT

<<Note accomplished in TSWF-CORE>>
PH: 706.326.4585
Mr. Waiters is a 48 y/o AAM with HTN, Hypogonadism, Migraine who presents to FMC to reinstute care.
Back pain
-states that the pain is getting worse and worse
-Endorses onset > 10yrs prior
-has to sleep with pillows under his back and in certain medications for some relief
-has been taking advil and tylenol with mild relief. has also tried motrin PRN with similar results.
-dull , constant pain at 7-8/10 without OTC meds , at 4-5/10 with meds
-has tried injections and lidocaine patches as well. States that injections seemed to help the most; has recieved injections at FM
clinic in the past. Last injection was 2 months ago at the night clinic.
-denies any other associated symptoms
-denies any radiation, numbness, tingling, weakness
-aggravating factors include prolonged sitting
-location of the pain is localized to lumbar region without radiation.
ROS negative for bladder/bowel changes, fever, sweats, or chills
HA
-sharp frontal pain
-has tried imitrex in the past (injection) that would last days
-currently taking BC powders for relief , provides about 2 hours of relief
-4-5/10 pain typical
-denies nausea/vomiting
-endorses blurry vision during HA
-denies halos, auras, and spots in field of vision
-sumatriptan 50mg
2019
Medical Record
2019
Low testosterone
-patient endorses remote history of being diagnosed with low testosterone
-states that he previously was taking testosterone replacement topical
-failed to refill prescription, now requesting refill as his last testosterone level was low
Hypertension
-patient has previously discussed his high blood pressure with providers and decided to attempt trial of diet/exercise/lifestyle
management for control
-despite this, patient continues to endorse home blood pressure readings of systolic >140 and BP at visit today is 148/84.
-patient states that he is interested in starting blood pressure medication at this time.
.
Headache.
Blurry vision.
LBP Red Flag - NO Recent significant trauma.

LBP Red Flag - NO Mild trauma at age > 50 years.
LBP Red Flag - NO Unexplained weight loss.
LBP Red Flag - NO Recent infection.
LBP Red Flag - NO Unexplained fever.
LBP Red Flag - NO Immunosuppression.
LBP Red Flag - NO Previous or current cancer.
LBP Red Flag - NO Intravenous drug use.
LBP Red Flag - NO Osteoporosis.
LBP Red Flag - NO Chronic corticosteroid use.
LBP Red Flag - Age NOT greater than 70 years.
LBP Red Flag - NO Focal neurological deficit.
LBP Red Flag - ABLE to control bladder or bowels.
LBP Red Flag - NO Saddle anesthesia.
LBP Red Flag - Duration greater than 6 weeks.
Current medication
Including OTC meds, vitamins, herbals, etc.
SILDENAFIL (VIAGRA) 100MG ORAL TABLET-TAKE ONE TABLET BY MOUTH 1 HOUR BEFORE SEXUAL INTERCOURSE NO
MORE THAN 1 A DAY
Hydrochlorothiazide 12.5mg 1tb po daily
Sumatriptan 50mg 1tb po at onset of headache, may repeat in 2hr
Ibuprofen OTC PRN back pain
Lidoderm TDSY apply to affected area, 12hrs/24hr period
Acetaminophen OTC PRN back pain.

Reported:
HTN
Low back pain
H pylori
Hypogonadism
Common Migraine
ED.
Appendectomy - 1991
Cyst remonal left wrist - 2001 2002.
Personal history
Social history reviewed Married
5 children
Nurse tech- GI clinic at BMACH.
Alcohol: Not using alcohol AUDIT-C Date: 07/16/2018 Score: 0.
History
706-326-4585- CONTACT NUMBER
JC Screening Date: 08 August 2019 Date Due: 6 August 2020.

English - Patients Preferred Language (written or spoken)
2019
Medical Record
2019
Verbal, Written - Preferred method of learning

No - Do you have any Learning Disability, Language Barrier, hearing/vision deficit?
NO - Advanced Directive Completed?
No - Do you have cultural or religious beliefs may affect your care?
No - Are you enrolled in EFMP?
Never - (SILS) How often do you need to have someone help you when you read instructions, pamphlets, or other written
material from your doctor or pharmacy?
Clinical Key Patient Education Handouts: https://www.clinicalkey.com
.
Annual Questions Date: 8/8/19.
Date last updated: 07/16/2018
Administered health literacy deficit assessment:
[ x ] REALM-SF Reading Assessment - Number of words pronounced correctly: 7
Menopause
Antibiotics
Exercise
Jaundice
Rectal
Anemia
Behavior
.
Family history
Family medical history
Update at Wellness Visit or Annually
MOTHER/FATHER: HTN
MOTHER/FATHER: DM
No 1st Degree Relative: CAD
No 1st Degree Relative: Cancer
No 1st Degree Relative: Alcohol or Substance Abuse.
Review of systems
Systemic: No fever and no chills.
Otolaryngeal: No hearing loss and no tinnitus.
Gastrointestinal: No nausea, no vomiting, and no abdominal pain.
Neurological: No dizziness, no vertigo, and no fainting.
Physical findings
Vital Signs:
• Temperature: Reviewed. • RR: Reviewed. • PR: Reviewed. • Blood pressure: Reviewed.
General Appearance:
° Well developed. ° Well nourished. ° In no acute distress.
Neck:
Appearance: ° Of the neck was normal.
Eyes:
General/bilateral:
Pupils: ° PERRL.
External: ° Conjunctiva exhibited no abnormalities.
Sclera: ° Normal.
Ears:
General/bilateral:
Outer Ear: ° Normal.
Hearing: ° No hearing abnormalities.
Nose:
General/bilateral:
External Deformities: ° No external nose deformities.
Oral Cavity:
Lips: ° Showed no abnormalities.
Lungs:
° Respiration rhythm and depth was normal. ° Exaggerated use of accessory muscles for inspiration was not observed.
° Clear to auscultation. ° No wheezing was heard. ° No rhonchi were heard. ° No rales/crackles were heard.
Cardiovascular:
Heart Rate And Rhythm: ° Normal.
Heart Sounds: ° Normal S1 and S2. ° No S3 heard. ° No gallop was heard. ° No pericardial friction rub heard.
Murmurs: ° No murmurs were heard.
Edema: ° Not present.
Capillary Refill Test: ° A capillary refill test was normal.
Abdomen:
Visual Inspection: ° Abdomen was not distended.
Auscultation: ° Bowel sounds were not diminished or absent.
Palpation: ° Abdominal non-tender. ° No mass was palpated in the abdomen.
2019
Medical Record
2019
Liver: ° Normal to palpation.

Spleen: ° Normal to palpation.
Musculoskeletal System:
General/bilateral: • Musculoskeletal system: decreased ROM in rotation and flexion of the lumbar spine.
Lumbar / Lumbosacral Spine:
General/bilateral: ° A straight-leg raising test of the right leg was negative. ° A straight-leg raising test of the left leg was
negative.
Functional Exam:
General/bilateral: • Mobility was limited.
Other:
General/bilateral: • Muscle tenderness bilat SI joints.
Neurological:
° Oriented to time, place, and person.
Cranial Nerves: ° Normal.
Sensation: ° No sensory exam abnormalities were noted. ° No decreased response to tactile stimulation of the lower (L3)
aspect of the right thigh. ° No decreased response to tactile stimulation of the lower (L3) aspect of the left thigh. ° No
decreased response to tactile stimulation on the knee and medial leg (L4) on the right only. ° No decreased response to
tactile stimulation on the knee and medial leg (L4) on the left only. ° Tactile stimulation showed no decreased sensory
response on the right lateral leg and dorsum of the foot (L5). ° Tactile stimulation showed no decreased sensory
response on the left lateral leg and dorsum of the foot (L5). ° Tactile stimulation showed no reduced sensory response on
the sole of the right foot and on the right posterior leg. ° Tactile stimulation showed no reduced sensory response on the
sole of the left foot and on the left posterior leg (S1).
Strength: Value
Strength of flexion of the right hip was normal 5 out of 5
Strength of flexion of the left hip was normal 5 out of 5
Strength of adduction of the right hip was normal 5 out of 5
Strength of adduction of the left hip was normal 5 out of 5
Strength of extension of the right knee was normal 5 out of 5
Strength of extension of the left knee was normal 5 out of 5
Dorsiflexion strength of the right ankle was normal 5 out of 5
Dorsiflexion strength of the left ankle was normal 5 out of 5
Plantar flexion strength of the right ankle was normal 5 out of 5
Plantar flexion strength of the left ankle was normal 5 out of 5
Eversion strength of the right ankle was normal 5 out of 5
Eversion strength of the left ankle was normal 5 out of 5
° Motor strength was normal. ° No lower extremity weakness was observed.
Coordination / Cerebellum: ° No coordination/cerebellum abnormalities were noted.
Balance: ° Normal.
Gait And Stance: ° Normal.
Reflexes: ° Deep tendon reflexes were normal.
Reflexes: Value
Normal right knee jerk reflex 2
Normal left knee jerk reflex 2
Normal right ankle jerk reflex 2
Normal left ankle jerk reflex 2
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Skin:
° Showed no ecchymosis. ° Temperature was normal.
Practice Management
Preventive medicine services
1. Tetanus Vaccine: 2-20-2015 Tdap
2. Influenza vaccine: out of stock
3. Pneumococcal Vaccine: @65
4. Shingrix Vaccine: @50
5. Colonoscopy: @50
6. Asthma: No
7. Diabetes: No.
A/P Last updated by AGUILAR,MICHAEL THOMAS @ 09 Aug 2019 1118 EDT

1. Low back pain M54.5: Est pt - chronic problem - controlled - 48 y/o AAM with chronic LBP. No redflags on exam. Will optimize
supportive care measures and refer to PT. F/u in 4-6wks for continued symptoms.
Medication(s): -LIDOCAINE 5 % TOP PATCH [EA] - APPLY 1 PATCH EVERY DAY (12 HOURS ON, 12 HOURS OFF)
#1 RF10 Start Date: 08/09/2019 Order Date: 08/09/2019 11:12
Consult(s): -Referred To: PHYSICAL THERAPY CONSULT (Routine) Specialty: Clinic: REFERRAL
2019
Medical Record
2019
MANAGEMENT CLINIC Provisional Diagnosis: Low back pain Order Date: 08/09/2019 11:13
2. Chronic migraine without aura, not intractable, without status migrainosus G43.709: Chronic problem - uncontrolled - hx of
common migraine that was well controlled on Sumatriptan subQ. He thought they were getting better and failed to f/u and now is
having recurrence of typical symptoms. Neuro exam intact and non-focal. Discussed going back on Sumatriptan and pt requested
PO version as opposed to subq. Will reinitate therapy at 50mg and encouraged f/u in 4-6wks.
Medication(s): -SUMAtriptan 50 MG ORAL TAB - TAKE ONE TABLET EVERY TWO HOURS AS NEEDED FOR
HEADACHE NO MORE THAN 4 TABLETS PER DAY #18 RF1 Start Date: 08/09/2019 Order Date:
08/09/2019 11:15
3. Essential (primary) hypertension I10: chronic problem - uncontrolled - Elevated blood pressure in clinic > 140/90 with
concordinant report on home BP monitoring. Will initate therapy on HCTz and ask pt to f/u in 3-5 wks for medication monitoring.
Medication(s): -hydroCHLOROthiazide 12.5 MG ORAL CAP - TAKE ONE TABLET BY MOUTH EVERY DAY #60 RF1
Start Date: 08/09/2019 Order Date: 08/09/2019 11:16
4. Testicular hypofunction E29.1: Acute complaint - Pt endorses primary hypogonadism treated with androgel in the past. Has two
confirmatory low testosterone AM levels on lab review.
Laboratory(ies): -HEMOGRAM AUTO+COMP AUTO DIFF (Routine) Start Date: 08/09/2019 Order Date: 08/09/2019
11:18; PROSTATE SPECIFIC AG (Routine) Start Date: 08/09/2019 Order Date: 08/09/2019 11:18
Disposition Written by AGUILAR,MICHAEL THOMAS @ 09 Aug 2019 1119 EDT

Released w/o Limitations
Follow up: with PCM and/or in the AMHM02ASTRONG TEAM clinic.
Administrative Options: Consultation requested
Note Written by AGUILAR,MICHAEL THOMAS @ 09 Aug 2019 1119 EDT

** Pt seen and evaluated on 8 Aug 2019, note signed on 9 Aug 2019 **
Signed By AGUILAR, MICHAEL THOMAS (DO, CPT, Staff Family Medicine Physician, Martin Army Community Hospital) @ 09
Aug 2019 1119
_________________________________________________________________________________________________________
CHANGE HISTORY
The following A/P Note Was Overwritten by AGUILAR,MICHAEL THOMAS @ 09 Aug 2019 0731 EDT:
The A/P section was last updated by AGUILAR,MICHAEL THOMAS @ 09 Aug 2019 0731 EDT - see above.Previous Version of A/P section was entered/updated by
MCGAHEE,JONATHAN T @ 08 Aug 2019 1625 EDT.
1. Low back pain: -patient has chronic history of LBP without radiation or red flag symptoms
-has tried multiple OTC treatments, lidocaine patches, and steroid injections in the past which provide moderate relief
-consider referral to pain management
2. Chronic migraine without aura, not intractable, without status migrainosus: -patient states that migraine is beginning to occur more frequently
-OTC meds are not providing adequate relief
-patient states that he had substantial relief with imitrex injection in the past. Is interested in renewing this treatment regimen at this time
3. Essential (primary) hypertension: -patient endorses home blood pressure readings with systolic >140 on a regular basis
-given hypertensive readings recorded at today's exam and previous exams, despite patient incorportating increased physical activity and changes to diet, consider beginning
low dose HCTZ at this viist.
4. Testicular hypofunction
The following S/O Note Was Overwritten by AGUILAR,MICHAEL THOMAS @ 09 Aug 2019 0723 EDT:
S/O Note Written by MCGAHEE,JONATHAN TAYLOR @ 08 Aug 2019 1535 EDT
CC: back pain and migraine
Back pain
-states that the pain is getting worse and worse
-has to sleep with pillows under his back and in certain medications for some relief
-has been taking advil and tylenol with mild relief. has also tried motrin PRN with similar results.
-dull , constant pain at 7-8/10 without OTC meds , at 4-5/10 with meds
-has tried injections and lidocaine patches as well. States that injections seemed to help the most; has recieved injections at FM clinic in the past. Last injection was 2 months
ago at the night clinic.
-denies any other associated symptoms
-denies any radiation, numbness, tingling, weakness
-aggravating factors include prolonged sitting
-location of the pain is localized to lumbar region without radiation.
ROS negative for bladder/bowel changes, fever, sweats, or chills
HA
-sharp frontal pain
-has tried imitrex in the past (injection) that would last days
-currently taking BC powders for relief , provides about 2 hours of relief
-4-5/10 pain typical
-denies nausea/vomiting
-endorses blurry vision during HA
-denies halos, auras, and spots in field of vision
Low testosterone
-patient endorses remote history of being diagnosed with low testosterone
-states that he previously was taking testosterone replacement topical
-failed to refill prescription, now requesting refill as his last testosterone level was low
Hypertension
2019
Medical Record
2019
-patient has previously discussed his high blood pressure with providers and decided to attempt trial of diet/exercise/lifestyle management for control
-despite this, patient continues to endorse home blood pressure readings of systolic >140 and BP at visit today is 148/84.
-patient states that he is interested in starting blood pressure medication at this time.
.
Headache.
Blurry vision.
Current medication
SILDENAFIL (VIAGRA) 100MG ORAL TABLET-TAKE ONE TABLET BY MOUTH 1 HOUR BEFORE SEXUAL INTERCOURSE NO MORE THAN 1 A DAY .
Reported:
HTN
Low back pain
H pylori.
Appendectomy - 1991
Personal history
5 children
History

Never - (SILS) How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?
.
Menopause
Antibiotics
Exercise
Jaundice
Rectal
Anemia
Behavior
.
Family history
MOTHER/FATHER: HTN
MOTHER/FATHER: DM
Review of systems
Otolaryngeal: No hearing loss and no tinnitus.
Gastrointestinal: No nausea, no vomiting, and no abdominal pain.
Neurological: No dizziness, no vertigo, and no fainting.
Physical findings
Vital Signs:
General Appearance:
Eyes:
General/bilateral:
Pupils: ° PERRL.
Sclera: ° Normal.
Lungs:
° Respiration rhythm and depth was normal. ° Clear to auscultation. ° No wheezing was heard. ° No rhonchi were heard. ° No rales/crackles were heard.
Cardiovascular:
Abdomen:
Palpation: ° Abdominal non-tender. ° No mass was palpated in the abdomen.
General/bilateral: • Musculoskeletal system: decreased ROM in rotation and flexion of the lumbar spine.
Neurological:
Sensation: ° No sensory exam abnormalities were noted.
2019
Medical Record
2019
Motor: ° Strength was normal.

Balance: ° Normal.
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Practice Management
5. Colonoscopy: @50
6. Asthma: No
7. Diabetes: No.
The following S/O Note Was Overwritten by MCGAHEE,JONATHAN T @ 08 Aug 2019 1547 EDT:
S/O Note Written by GHOLSON,RACHEL JEWELL @ 08 Aug 2019 1528 EDT
Current medication
SILDENAFIL (VIAGRA) 100MG ORAL TABLET-TAKE ONE TABLET BY MOUTH 1 HOUR BEFORE SEXUAL INTERCOURSE NO MORE THAN 1 A DAY .
Reported:
HTN
Low back pain
H pylori.
Appendectomy - 1991
Personal history
5 children
History

Never - (SILS) How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?
.
Menopause
Antibiotics
Exercise
Jaundice
Rectal
Anemia
Behavior
.
Family history
MOTHER/FATHER: HTN
MOTHER/FATHER: DM
Practice Management
5. Colonoscopy: @50
6. Asthma: No
7. Diabetes: No.
2019
Medical Record
2019
29 Jul 2019 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by CAREY,
PATRICK M
Encounter ID: BENN-19497985 Primary Dx: Male erectile disorder
Patient: WAITERS, TOMMIE Date: 29 Jul 2019 0811 EDT Appt Type: T-CON*
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02ASTRONG TEAM Provider: CAREY,PATRICK M
BENNING
AutoCites Refreshed by CAREY,PATRICK M @ 02 Aug 2019 1606 EDT

Allergies
Labs
No Labs Found.
Rads
No Rads Found.
Vitals
No Vitals Found.
Reason for Telephone Consult:Written by AVERA,CYNTHIA D @ 29 Jul 2019 0811 EDT

medication refill
Note Written by AVERA,CYNTHIA D @ 29 Jul 2019 0813 EDT
Message Details
From Mr. Tommie Waiters
To Cynthia Avera
Provider Dr. Patrick Carey DO
Patient Tommie Waiters
Sent Date Jul 27, 2019 1:49 PM
Subject Prescription - Renewal Request
-----Selected Medications-----
Viagra
Oral Tablet 100 MG
Message -------Comment-------
--------Contact Information--------
Home Phone: (706) 326-4585
Mobile Phone: (706) 326-4585
Work Phone: (706) 326-4585
2019
Medical Record
2019
View/Print Last Updated Oct 10, 2018
Waiters, Tommie -- DOB Aug 18, 1970
Note Written by GUNN,TRAVIS B @ 05 Aug 2019 0749 EDT

message sent through relay health.travis
A/P Last Updated by CAREY,PATRICK M @ 02 Aug 2019 1622 EDT
1. Male erectile disorder F52.21:
Will refil at same.
Please notifiy patient/parent and let them know the requested medications have been renewed. Thank you.
Medication(s): -SILDENAFIL (VIAGRA) 100MG ORAL TABLET--P - TAKE ONE TABLET BY MOUTH 1 HOUR
BEFORE SEXUAL INTERCOURSE NO MORE THAN 1 A DAY #18 RF3 Start Date: 08/02/2019 Order
Date: 08/02/2019 16:11
Disposition Last Updated by GUNN,TRAVIS B @ 05 Aug 2019 0751 EDT

Follow up: as needed with PCM.
Signed By CAREY, PATRICK M (LTC, MC, DO, CAQSM, Primary Care Sports Medicine Physician) @ 05 Aug 2019 0916
_________________________________________________________________________________________________________
CHANGE HISTORY
The following Disposition Note Was Overwritten by GUNN,TRAVIS B @ 05 Aug 2019 0751 EDT:
The Disposition section was last updated by GUNN,TRAVIS B @ 05 Aug 2019 0751 EDT - see above.Previous Version of Disposition section was entered/updated by
CAREY,PATRICK M @ 02 Aug 2019 1622 EDT.
2019
Medical Record
2019
14 Apr 2019 at Martin ACH, Fort Benning, GA, ER by WRIGHT, GISELE L
Encounter for observation for other

Encounter ID: BENN-19219867 Primary Dx: suspected diseases and conditions ruled
out
Patient: WAITERS, TOMMIE Date: 14 Apr 2019 0407 EDT Appt Type: EROOM
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: EMERGENCY ROOM Provider: WRIGHT,GISELE L
BENNING
A/P Written by WRIGHT,GISELE L @ 14 Apr 2019 0515 EDT

1. Encounter for observation for other suspected diseases and conditions ruled out: THIS DOCUMENTATION IS TO VERIFY
THAT THE PATIENT WAS SEEN IN THE EMERGENCY DEPARTMENT AND THIS NOTE IS SIGNED FOR ADMINISTRATIVE
PURPOSES ONLY. PATIENT'S ENCOUNTER DOCUMENTATION SCANNED INTO ESSENTRIS SECTION NUMBER SIX AND
ARTIFACTS AND IMAGES IN THE PATIENT ED MEDICAL RECORD.
Disposition Written by WRIGHT,GISELE L @ 14 Apr 2019 0515 EDT

Signed By WRIGHT, GISELE L (MSA, EMERGENCY ROOM, MACH, FT BENNING, GA) @ 14 Apr 2019 0515
2019
Medical Record
2019
28 Mar 2019 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by FOSTER,
KAROLYNNE L
Encounter for administrative examinations,

unspecified
Patient: WAITERS, TOMMIE Date: 28 Mar 2019 0806 EDT Appt Type: FTR
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: OCCUPATIONAL HEALTH FBGA Provider: FOSTER,KAROLYNNE L
BENNING
AutoCites Refreshed by GRAY,MARION T @ 28 Mar 2019 1345 EDT

Allergies
Reason for Appointment:Written by YOUNG,BARBARA R @ 28 Mar 2019 0806 EDT

FIT TESTING CIV
Screening Written by FOSTER,KAROLYNNE L @ 29 Mar 2019 1321 EDT

Reason For Appointment: Notes Entered by: YOUNG,BARBARA R 28 Mar 2019 0806
------------------------------
FIT TESTING CIV
Reason(s) For Visit (Chief Complaint): Visit for: occupational health / fitness exam (Follow-Up) : RFT/CIV;
Vitals
Vitals Written by GRAY,MARION T @ 28 Mar 2019 1341 EDT
BP: 129/86, HR: 81, HT: 66 in, WT: 233 lbs, BMI: 37.61, BSA: 2.134 square meters, Tobacco Use: No
Questionnaire AutoCites Refreshed by GRAY,MARION T @ 28 Mar 2019 1345 EDT

Questionnaires
RESPIRATOR QUESTIONNAIRE FBN GA OH Version: 1 Completed On: 28 Mar 2019

The Selected Provider is FOSTER, KAROLYNNE L in the Occupational Health FBGA clinic.
1. CAN YOU READ (If not, an impartial individual must read the questionnaire to the employee).: Yes
2. Age of worker on the day of this interview. : 48
3. Sex: Male
4. Height in inches: 66
5. Weight (in pounds): 233
6. Job Title: See comment section;
7. A PHONE NUMBER WITH AREA CODE WHERE YOU CAN BE REACHED BY HEALTH CARE PROFESSIONAL
REVIEWING THIS QUESTIONNAIRE: See Comments;
8. THE BEST TIME TO REACH YOU AT THIS NUMBER: Anytime;
9. HAS YOUR EMPLOYER TOLD YOU HOW TO CONTACT THE HEALTH CARE PROFESSIONAL WHO WILL REVIEW THIS
QUESTIONNAIRE: YES;
10. CHECK THE TYPE OF RESPIRATOR THAT WILL BE USED (more than one can be selected): N, R, P, Disposable
Respirator ( Filter-mask, Non-cartridge type only);
11. HAVE YOU WORN A RESPIRATOR?: No;
12. DO YOU CURRENTLY SMOKE TOBACCO OR HAVE YOU SMOKED TOBACCO IN THE LAST MONTH?: No
13. HAVE YOU EVER HAD ANY OF THE FOLLOWING CONDITIONS (Seizures, Diabetes, Allergic reaction that interferes
with your breathing, Claustrophobia, Trouble smelling odors, Elevated cholesterol)?: NO to all conditions;
14. EVER HAVE ANY OF THE FOLLOWING PULMONARY OR LUNG PROBLEMS (Asbestosis, Asthma, Chronic bronchitis,
Emphysema, Pneumonia, Tuberculosis, Silicosis, Pneumothorax , Lung cancer, Broken ribs, Chest injuries or surgeries,
Any other lung problem)?: Tuberculosis;NO to all pulmonary or lung problems;
15. DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING SYMPTOMS OF PULMONARY OR LUNG ILLNESS (Shortness
of breath, SOB walking fast up incline, SOB walking at ordinary pace on level ground with others, SOB walking at your
own pace on level ground, SOB washing and dressing, SOB that interferes with job, Cough that produces phlegm,
Coughing that wake you early in morning, Coughing occurring mostly while lying down, Coughing up blood in the last
month, Wheezing, Wheezing that interferes with job, Chest pain when breathing deeply, Any other symptoms that you
think may be related to lung problems)?: NO to all symptoms of pulmonary and lung illnesses;
16. HAVE YOU EVER HAD ANY OF THE FOLLOWING CARDIOVASCULAR OR HEART PROBLEMS (Heart attack, Stroke,
2019
Medical Record
2019
Angina, Heart failure, Swelling in legs or feet not caused by walking, Heart arrhythmia, High blood pressure, Any other
heart problem you've been told about)?: High blood pressure;
17. HAVE YOU EVER HAD ANY OF THE FOLLOWING CARDIOVASCULAR OR HEART SYMPTOMS ( Frequent pain or
tightness in your chest, Pain or tightness in your chest during physical activity, Pain or tightness in your chest that
interferes with your job, Heart skipping or missing a beat, Heartburn or indigestion or any other symptoms that you think
may be related to heart or circulation problems)?: NO to all cardiovascular or heart symptoms;
18. DO YOU CURRENTLY TAKE ANY MEDICATIONS FOR ANY OF THE FOLLOWING PROBLEMS (Breathing or lung
problems, Heart trouble, Blood pressure, Seizures)?: Does NOT take any medications for listed conditions;
19. IF YOU'VE USED A RESPIRATOR, HAVE YOU EVER HAD ANY OF THE FOLLOWING PROBLEMS, (Eye irritation, Skin
allergies or rashes, Anxiety, General weakness or fatigue, Any other problem that interferes with your use of a respirator):
NEVER used a respirator;
20. HAVE YOU EVER LOST VISION IN EITHER EYE (Temporarily or Permanently)?: No
21. DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING VISION PROBLEMS (Wear contact lenses, Wear glasses, Color
blind, Any other eye or vision problem): Wear glasses;
22. HAVE YOU EVER HAD AN INJURY TO YOUR EARS, INCLUDING A BROKEN EARDRUM: No
23. DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING HEARING PROBLEMS (Difficulty hearing, Wear a hearing aide,
Any other hearing or ear problem): Any other hearing or ear problem;
24. HAVE YOU EVER HAD A BACK INJURY: No
25. DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING MUSCULOSKELETAL PROBLEMS (Weakness in arms, hands,
legs, or feet, Back pain, Difficulty fully moving your arms and legs, Pain or stiffness when you lean forward or backward at
the waist, Difficulty fully moving your head up or down, Difficulty fully moving your head side to side, Difficultly bending at
your knees, Difficultly squatting to the ground, Climbing a flight of stairs or ladder carrrying more than 25 pounds, Any
other muscle or skeletal problem that interferes with using a respirator): Back pain;
26. WOULD YOU LIKE TO TALK TO A HEALTH CARE PROFESSIONAL WHO WILL REVIEW THIS QUESTIONNAIRE ABOUT
YOUR ANSWERS TO THIS QUESTIONNAIRE: No
27. VERIFICATION/CONSENT STATEMENT:I verify that the above information is true and complete to the best of my knowledge.
I hereby give permission for a physical examination (if needed) to determine my suitability for respirator use. I understand that this
examination is designed to satisfy regulatory requirements and should not be considered to be a routine medical examination. I
agree to "self report" changes in my medical condition that may affect my ability to work safely to my supervisor.STATEMENT
SIGNED BY EMPLOYEE: Yes
28. REVIEWED BY: KAROLYNNE FOSTER, RN;
S/O Note Written by GRAY,MARION T @ 28 Mar 2019 1342 EDT

He reported: Encounter Background Information: Completed DA 4700(MED) OP 459 and OSHA Mandatory Respirator Medical
Questionnaire; reviewed with worker. Fit testing completed and tolerated well. Cleared for N-95 use; Respirator Used Card
dispensed and counseled to complete fit testing protocol annually. Mask size XX-Large.
A/P Written by FOSTER,KAROLYNNE L @ 29 Mar 2019 1321 EDT

1. Encounter for administrative examinations, unspecified
Procedure(s): -Spirometry x 1
-Patient Counseling Medical Management Individual Patient x 1
Disposition Written by FOSTER,KAROLYNNE L @ 29 Mar 2019 1321 EDT

Follow up: as needed .
Signed By FOSTER, KAROLYNNE L (REGISTERED NURSE) @ 29 Mar 2019 1321
2019
Medical Record
2019
15 Mar 2019 at Martin ACH, Fort Benning, GA, After Hours Clinic(Fam Med Cl) by
CAMPBELL, AVRIL M
Patient: WAITERS, TOMMIE Date: 15 Mar 2019 1743 EDT Appt Type: 24HR
ALAJANDRO
Treatment Facility: CBMH NORTH Clinic: AFTER HOURS CLINIC(FAM Provider: CAMPBELL,AVRIL
COLUMBUS-BENNING MED CL)
AutoCites Refreshed by CAMPBELL,AVRIL M @ 15 Mar 2019 1807 EDT

Allergies
Reason for Appointment:Written by THOMAS,ORLANDRA D @ 15 Mar 2019 1743 EDT

CAREY/BACK PAIN/X 2 WKS GETTING WORST
Screening Written by BOWLING,ELSIE L @ 15 Mar 2019 1757 EDT

Reason For Appointment: Notes Entered by: THOMAS,ORLANDRA D 15 Mar 2019 1743
------------------------------
CAREY/BACK PAIN/X 2 WKS GETTING WORST
Allergen information verified by BOWLING, ELSIE L @ 15 Mar 2019 1757 EDT
Vitals
Vitals Written by BOWLING,ELSIE L @ 15 Mar 2019 1754 EDT
BP: 153/99, HR: 79, RR: 16, T: 98.1 °F, HT: 66 in, WT: 249 lbs, BMI: 40.19, BSA: 2.195 square meters
S/O Note Written by CAMPBELL,AVRIL @ 15 Mar 2019 2228 EDT

Chief complaint
The Chief Complaint is: Back Pain.

48 y/o male presents to After Hours Clinic with c/o lower back pain x 2 months. He reports he woke up this morning and the pain
was worse than he experienced over the last few months which prompted him to come in to be evaluated. He denies recent
reinjury just reports he feels pain is related to prior injury in 2006 due to Hum V rear-ending him in Iraq. He describes the pain as a
constant throbbing pain with intermittent sharp stabbing pains ''almost like someone is sticking me with a needle''. He has been
taking Motrin 800mg and Aleve with minimal relief of his discomfort- for about an hour and then pain will flare up again. Deneis
numbness, bowel / bladder changes, or radiation of pain down his legs. Hx of X-Rays to his back about 4 or 5 years ago. Hx of
PT- 2013 without relief of his prior pain. NKDA
.
Pain Severity 7 / 10.

LBP Red Flag - NO Recent infection.
LBP Red Flag - NO Unexplained fever.
LBP Red Flag - NO Immunosuppression.
LBP Red Flag - NO Intravenous drug use.
LBP Red Flag - NO Osteoporosis.
LBP Red Flag - NO Focal neurological deficit.
LBP Red Flag - NO Saddle anesthesia.
LBP Red Flag - NO Recent significant trauma.
LBP Red Flag - NO Mild trauma at age > 50 years.
LBP Red Flag - NO Previous or current cancer.
LBP Red Flag - NO Chronic corticosteroid use.
LBP Red Flag - Age NOT greater than 70 years.
LBP Red Flag - ABLE to control bladder or bowels.
LBP Red Flag - Duration NOT greater than 6 weeks.
2019
Medical Record
2019
LBP Red Flag - NO Unexplained weight loss.

Patient was identified using full name plus any suffix and DOB.
Patient advised to wait 15 minutes for observation: Patient stated understanding (x) [ ] Patient declined [ ] Patient waited and
assessed by:
Outcome of Patient:
[ x ] Released to Self Care
[ ] Released with Attendant/Caregiver
[ ] Returned to Provider
[ ] Transferred to Emergency Department
[ ] Admitted to:
....
Patient education given and patient verbalizes understanding.
Current medication
Motrin and Tylenol as needed.

sildenfil 100 mg as needed
.
Reported:
HTN
Low back pain
H pylori.
Appendectomy - 1991
Personal history
5 children
History ANNUAL QUESTIONS
Preferred language (written or spoken): [x ] English [ ] Other:
Preferred method of learning? [ ] Verbal [ x] Written [ x ] Visual [ ] Other (Specify):
Learning disability, language barrier, hearing/vision deficit? [ ] Yes [ x ] No (Specify):
(SILS) How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your
doctor or pharmacy?
[x ] Never [ ] Rarely [ ] Sometimes [ ] Often [ ] Always
Advance directives completed? [ ] Yes [x ] No
Is a copy of the Advance directive in the record? [ ] Yes [x ] No
Do you have any cultural or religious beliefs that may affect your care? [ ] Yes [ x ] No
Are you enrolled in EFMP? [ ] Yes [x ] No
Contact preference: 706-326-4585
PCM: Dr.Carey
.............
Menopause
Antibiotics
Exercise
Jaundice
Rectal
Anemia
Behavior
[ ] Other:
Health literacy response care plan:

[ ] Referral to special needs care coordinator
[ ] Other:
.............
Family history
HTN- both parents
DM- both parents
Cancer - om.
Review of systems
2019
Medical Record
2019

Genitourinary: No urinary loss of control.
Musculoskeletal: Back pain and muscle aches.
Neurological: No dizziness, no lightheadedness, no motor disturbances, and no gait abnormality. Sensory disturbances tingling
across lower back.
Physical findings
Vital Signs:
General Appearance:
° Well-appearing. ° Well developed. ° Well nourished. ° In no acute distress.
General/bilateral: • Lumbosacral spine exhibited tenderness on palpation across lower back. • Lumbosacral spine did not
demonstrate full range of motion limited in all direction. • Lumbosacral spine pain was elicited by motion in all
direction. ° Lumbosacral spine exhibited no muscle spasms. ° Lumbosacral spine motion was normal. ° A straight-
leg raising test of the right leg was negative. ° A straight-leg raising test of the left leg was negative.
Functional Exam:
General/bilateral: • Mobility was limited in all direction.
Other:
General/bilateral: • Muscle tenderness lower back and bilateral paraspinal muscles.
Neurological:
Sensation: ° No sensory exam abnormalities were noted. ° No decreased response to tactile stimulation of the upper (L2)
aspect of the right thigh. ° No decreased response to tactile stimulation of the upper (L2) aspect of the left thigh. ° No
decreased response to tactile stimulation of the lower (L3) aspect of the right thigh. ° No decreased response to tactile
stimulation of the lower (L3) aspect of the left thigh. ° No decreased response to tactile stimulation on the knee and
medial leg (L4) on the right only. ° No decreased response to tactile stimulation on the knee and medial leg (L4) on the
left only. ° Tactile stimulation showed no decreased sensory response on the right lateral leg and dorsum of the foot (L5).
° Tactile stimulation showed no decreased sensory response on the left lateral leg and dorsum of the foot (L5).
Strength: Value
Strength of flexion of the right hip was normal 5 out of 5
Strength of flexion of the left hip was normal 5 out of 5
Strength of extension of the right knee was normal 5 out of 5
Strength of extension of the left knee was normal 5 out of 5
Dorsiflexion strength of the right ankle was normal 5 out of 5
Dorsiflexion strength of the left ankle was normal 5 out of 5
Plantar flexion strength of the right ankle was normal 5 out of 5
Plantar flexion strength of the left ankle was normal 5 out of 5
Eversion strength of the right ankle was normal 5 out of 5
Eversion strength of the left ankle was normal 5 out of 5
Motor (Strength): ° No lower extremity weakness was observed.
Reflexes: Value
Normal right knee jerk reflex 2
Normal left knee jerk reflex 2
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Test conclusions
KETOROLAC
S: Written order verified from provider to administer Ketorolac.

Pain Assessment:
Reported Pain Level: __7/ 10
Location of Pain: [ x ] lower back
O: Current allergy status shows no contraindications.

Procedure: Ketorolac IM for pain relief.
Drug Given: Ketorolac (Toradol)
Manufacturer: Hospira
Lot #: 86-125-DK
Exp. Date: 1Feb2020
Dose Given: 60mg
Route: [ x ] IM Injection site [ ] R [ ] L Deltoid [ ] R [ x ] L Gluteal [ ] IV piggy back
Medication Verified by: Demetrius Lewis, LPN
Given by: E. Bowling, LPN
Time administered: 6.22 pm
2019
Medical Record
2019
A/P: Patient tolerated medication without adverse reactions.

1. Pain reassessment s/p of administration of Ketorolac @ ___ hrs.
2. Reported Pain Level: ___ / 10
3. Location of Pain:
4. Provider notified of pain response to injection.
....
Practice Management
Lipids - Lipids Site/Specimen 16 Nov 2017 1303
Cholesterol PLASMA 179
HDL Cholesterol PLASMA 48
LDL Cholesterol PLASMA 113
Triglyceride PLASMA 92
10-yr CVD Risk Assessment - Calculator used -

Diabetes Screening -
Aspirin Prophylaxis -
HIV Screen -
Hep C screening: Date:
Colorectal Cancer Screening - @55
[ ] Colonoscopy [ ] FOB x 3 [ ] Flex Sig [ ] CT Colonography
[ ] FIT-DNA
Tetanus (Td/Tdap) - FEB 2015

Influenza Vaccine - Nov 2017
Zoster Vaccine -
Pneumococcal Vaccine - PPSV23: PCV13:
HPV Vaccine -
Men:
Aortic Aneurysm Screen (if ever a smoker) -
..............
Patient BMI >= 30. Date: 07/16/2018.
A/P Last updated by CAMPBELL,AVRIL M @ 15 Mar 2019 2311 EDT

1. Low back pain M54.5: Chronic back pain with recent flare; On exam, limited ROM, normal sensation and strength. Give
Toradol 60 MG x 1 now; No Ibuprofen for 12 hours after Toradol. Also instructed to use heat/ice for 20 minutes couple times/day,
then Gentle ROM. Add Lidoderm Patches. f/u with PCM in 1 wk if no improvement. Go to ER for worsening pain, altered sensation
and motor difficulties.
Procedure(s): -(96372) Physician Supervised Injection Intramuscular x 1 ADDITIONAL PROVIDER(S):
BOWLING,ELSIE L - Verfied by full name and date of birth . Advised to wait 15 mintus prior to waiting
leaving. Patient stated understaniding.
Medication(s): -KETOROLAC 30 MG/ML IM VIAL [2ML] - GIVE 60 MG INTRAMUSCULARLY FOR 1 DOSE NOW #1
RF0 Ordered By: CAMPBELL,AVRIL M Ordering Provider: CAMPBELL, AVRIL
-LIDOCAINE 5 % TOP PATCH [EA] - APPLY 1 PATCH EVERY DAY (12 HOURS ON, 12 HOURS OFF)
#1 RF0 Ordered By: CAMPBELL,AVRIL M Ordering Provider: CAMPBELL, AVRIL
2. Essential (primary) hypertension I10: Elevated BP today. Pt states he is not taking any BP meds. D/w Pt goal BP <140/90 and
that elevated BP can lead to increase in MI/CVA. Could be elevated secondary to back pain. Instructed f/u with PCM to discuss BP
elevation.
Disposition Last updated by CAMPBELL,AVRIL M @ 15 Mar 2019 2311 EDT

Follow up: 1 week(s) with PCM or sooner if there are problems.
Signed By CAMPBELL, AVRIL M (Physician, NCMH FORT BENNING GA) @ 15 Mar 2019 2311
_________________________________________________________________________________________________________
CHANGE HISTORY
The following Disposition Note Was Overwritten by CAMPBELL,AVRIL M @ 15 Mar 2019 2311 EDT:
2019
Medical Record
2019
The Disposition section was last updated by CAMPBELL,AVRIL M @ 15 Mar 2019 2311 EDT - see above.Previous Version of Disposition section was entered/updated by
CAMPBELL,AVRIL M @ 15 Mar 2019 2254 EDT.
The following A/P Note Was Overwritten by CAMPBELL,AVRIL M @ 15 Mar 2019 2311 EDT:
The A/P section was last updated by CAMPBELL,AVRIL M @ 15 Mar 2019 2311 EDT - see above.Previous Version of A/P section was entered/updated by CAMPBELL,AVRIL
M @ 15 Mar 2019 2251 EDT.
1. Low back pain M54.5: Chronic back pain with recent flare; On exam, limited ROM, normal sensation and strength. Give
Toradol 60 MG x 1 now; No Ibuprofen for 12 hours after Toradol. Also instructed to use heat/ice for 20 minutes couple times/day, then Gentle ROM. Add Lidoderm Patches. f/u
with PCM in 1 wk if no improvement. Go to ER for worsening pain, altered sensation and motor difficulties.
Procedure(s): -(96372) Physician Supervised Injection Intramuscular x 1 ADDITIONAL PROVIDER(S): BOWLING,ELSIE L - Verfied by full name and
date of birth . Advised to wait 15 mintus prior to waiting leaving. Patient stated understaniding.
Medication(s): -KETOROLAC 30 MG/ML IM VIAL [2ML] - GIVE 60 MG INTRAMUSCULARLY FOR 1 DOSE NOW #1 RF0 Ordered By:
CAMPBELL,AVRIL M Ordering Provider: CAMPBELL, AVRIL
-LIDOCAINE 5 % TOP PATCH [EA] - APPLY 1 PATCH EVERY DAY (12 HOURS ON, 12 HOURS OFF) #1 RF0 Ordered By:
The following Signature(s) No Longer Applies because this Encounter Was Opened for Amendment by CAMPBELL,AVRIL M @ 15 Mar 2019 2300 EDT:
Signed CAMPBELL, AVRIL (Physician, NCMH FORT BENNING GA) @ 15 Mar 2019 2256
The following A/P Note Was Overwritten by CAMPBELL,AVRIL M @ 15 Mar 2019 2251 EDT:
The A/P section was last updated by CAMPBELL,AVRIL M @ 15 Mar 2019 2251 EDT - see above.Previous Version of A/P section was entered/updated by BOWLING,ELSIE L
@ 15 Mar 2019 1825 EDT.
1. Low back pain M54.5: Toradol 60 MG x 1 now
Procedure(s): -(96372) Physician Supervised Injection Intramuscular x 1 ADDITIONAL PROVIDER(S): BOWLING,ELSIE L - Verfied by full name and
date of birth . Advised to wait 15 mintus prior to waiting leaving. Patient stated understaniding.
The following S/O Note Was Overwritten by CAMPBELL,AVRIL M @ 15 Mar 2019 2244 EDT:
S/O Note Written by BOWLING,ELSIE L @ 15 Mar 2019 1912 EDT
Chief complaint

48 y/o male presents to After Hours Clinic with c/o lower back pain x 2 months. He reports he woke up this morning and the pain was worse than he experienced over the last
few months which prompted him to come in to be evaluated. He denies recent reinjury just reports he feels pain is related to prior injury in 2006 due to Hum V rear-ending him
in Iraq. He describes the pain as a constant throbbing pain with intermittent sharp stabbing pains ''almost like someone is sticking me with a needle''. He has been taking
Motrin 800mg and Aleve with minimal relief of his discomfort- for about an hour and then pain will flare up again. Deneis numbness, bowel / bladder changes, or radiation of
pain down his legs. Hx of X-Rays to his back about 4 or 5 years ago. Hx of PT- 2013 without relief of his prior pain. NKDA

Patient advised to wait 15 minutes for observation: Patient stated understanding (x) [ ] Patient declined [ ] Patient waited and assessed by:
Outcome of Patient:
[ ] Admitted to:
....
Current medication

.
Reported:
HTN
Low back pain
H pylori.
Appendectomy - 1991
Personal history
5 children
(SILS) How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?
PCM: Dr.Carey
.............
2019
Medical Record
2019

Menopause
Antibiotics
Exercise
Jaundice
Rectal
Anemia
Behavior
[ ] Other:

[ ] Other:
.............
Family history
HTN- both parents
DM- both parents
Cancer - om.
Test conclusions
KETOROLAC
S: Written order verified from provider to administer Ketorolac.

Pain Assessment:
Reported Pain Level: __7/ 10
Location of Pain: [ x ] lower back
O: Current allergy status shows no contraindications.

Procedure: Ketorolac IM for pain relief.
Drug Given: Ketorolac (Toradol)
Manufacturer: Hospira
Lot #: 86-125-DK
Exp. Date: 1Feb2020
Dose Given: 60mg
Route: [ x ] IM Injection site [ ] R [ ] L Deltoid [ ] R [ x ] L Gluteal [ ] IV piggy back
Medication Verified by: Demetrius Lewis, LPN
Given by: E. Bowling, LPN
Time administered: 6.22 pm
A/P: Patient tolerated medication without adverse reactions.

1. Pain reassessment s/p of administration of Ketorolac @ ___ hrs.
2. Reported Pain Level: ___ / 10
3. Location of Pain:
4. Provider notified of pain response to injection.
....
Practice Management

HIV Screen -
[ ] FIT-DNA

Zoster Vaccine -
HPV Vaccine -
Men:
..............
Patient BMI >= 30. Date: 07/16/2018.
The following A/P Note Was Overwritten by BOWLING,ELSIE L @ 15 Mar 2019 1825 EDT:
The A/P section was last updated by BOWLING,ELSIE L @ 15 Mar 2019 1825 EDT - see above.Previous Version of A/P section was entered/updated by CAMPBELL,AVRIL M
@ 15 Mar 2019 1820 EDT.
1. Low back pain M54.5: Toradol 60 MG x 1 now
Procedure(s): -(96372) Physician Supervised Injection Intramuscular x 1
The following S/O Note Was Overwritten by CAMPBELL,AVRIL M @ 15 Mar 2019 1816 EDT:
S/O Note Written by BOWLING,ELSIE L @ 15 Mar 2019 1757 EDT
2019
Medical Record
2019
Chief complaint

48 y/o male presents to After Hours Clinic with c/o lower back pain x 2 months. He reports he woke up this morning and the pain was worse than it has ever been in a few
months which prompted him to come in to be evalutaed. He denies recent reinjury just reports he feels pain is related to prior injury in 2006 due to Hum V rear-ending him in
Iraq. He describes the pain as a constant throbbing pain with intermittent sharp stabbing pain ''almost like someone is sticking me with a needle''. He has been taking Motrin
800mg and Aleve with minimal relief of his discomfort for about an hour and then pain with flare up again. Deneis numbness, or bowel or bladder changes or radiation of pain
down his legs. Hx of X-Rays to his back about 4 or 5 years. Hx of PT 2013 without relief of his prior pain. NKDA

Current medication

.
Reported:
HTN
Low back pain
H pylori.
Appendectomy - 1991
Personal history
5 children
PCM: Dr.Carey
.............
Menopause
Antibiotics
Exercise
Jaundice
Rectal
Anemia
Behavior
[ ] Other:

[ ] Other:
.............
Family history
HTN- both parents
DM- both parents
Cancer - om.
Practice Management

HIV Screen -
[ ] FIT-DNA

Zoster Vaccine -
2019
Medical Record
2019

HPV Vaccine -
Men:
..............
Patient BMI >= 30. Date: 07/16/2018.
2019
Medical Record
2019
16 Dec 2018 at Martin ACH, Fort Benning, GA, ER by MYRICK, ANGELA M

out
Patient: WAITERS, TOMMIE Date: 16 Dec 2018 1500 EST Appt Type: EROOM
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: EMERGENCY ROOM Provider: MYRICK,ANGELA MONICHE
BENNING
A/P Written by MYRICK,ANGELA M @ 16 Dec 2018 1818 EST

1. Encounter for observation for other suspected diseases and conditions ruled out Z03.89: This documentation is to verify
that the patient was seen in the Emergency Department and this note is signed for administrative purposes only. Patient's encounter
documentation scanned into the Essentris section number six and artifacts and images in the patient ED Medical Record.
Disposition Written by MYRICK,ANGELA M @ 16 Dec 2018 1818 EST

Signed By MYRICK, ANGELA M (MSA, BMACH Emergency Department) @ 16 Dec 2018 1818
2019
Medical Record
2019
30 Sep 2018 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by AVERA,
CYNTHIA D
Encounter ID: BENN-18707515 Primary Dx: Encounter for issue of repeat prescription
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02ASTRONG TEAM Provider: AVERA,CYNTHIA D
BENNING
AutoCites Refreshed by CAREY,PATRICK M @ 03 Oct 2018 1001 EDT

Allergies
Labs
No Labs Found.
Rads
No Rads Found.
Vitals
No Vitals Found.
Reason for Telephone Consult:Written by AVERA,CYNTHIA D @ 30 Sep 2018 2306 EDT

medication request
S/O Note Written by CAREY,PATRICK M @ 12 Oct 2018 2227 EDT

Subjective
No need to send me back the t-con , you can sign. Thanks.Cindy please relay the following in relay health. Mr. Waiters, I have
ordered the Viagra for maximum allowed which is 18 pills over a 3 month period. With 3 refills. Prior to prescribing testosterone gel,
I would like to further evaluate potential causes of low testosterone. Please come in to have labs drawn. I would also like to
schedule an appointment with me in November to discuss the lab results and treatment plan.Thank you.-Dr. Carey
Note Written by AVERA,CYNTHIA D @ 30 Sep 2018 2308 EDT
Message Details
From Mr. Tommie Waiters
To Cynthia Avera
Provider Dr. Patrick Carey DO
Patient Tommie Waiters
Sent Date Sep 28, 2018 1:57 PM
Subject Medication Refill
Sir, I am writing to request a prescription refill for Viagra. The last
prescription was for only six pills. I would if possible like to get a 30 day
Message supply. I would also like to get a refill for Andro Gell 1.6....
Thanks
2019
Medical Record
2019
Tommie Waiters
706-326-4585
View/Print Never Updated
Waiters, Tommie -- DOB Aug 18, 1970
Note Written by PETERSON,BERNICE @ 11 Oct 2018 1042 EDT

LM for patient to call back to schedule appointment.
Note Written by PETERSON,BERNICE @ 12 Oct 2018 1209 EDT
LM for patient to call back for appointment.
A/P Last Updated by CAREY,PATRICK M @ 12 Oct 2018 2226 EDT
1. Encounter for issue of repeat prescription Z76.0
2. Male erectile disorder F52.21: Viagra reordered.
I don't see the medical record. He had a complete evaluation for testicular hypofunction. Would also consider evaluating pituitary
checking prolactin, iron saturation and consider imaging of the pituitary. Unless this was already done off post.
Testicular hypofunction may be due to obesity or other cause. We should complete the evaluation for hypogonadism prior to
Providing testosterone.
Please let him know to come in to get additional labs done. You will probably have to send a letter based on recent difficulty in
contacting him via phone. Thanks.
Medication(s): -SILDENAFIL (VIAGRA) 100MG ORAL TABLET--P - TAKE ONE TABLET BY MOUTH 1 HOUR
BEFORE SEXUAL INTERCOURSE NO MORE THAN 1 A DAY #18 RF3 Start Date: 10/12/2018 Order
Date: 10/12/2018 22:25
Laboratory(ies): -PROLACTIN (Routine) Start Date: 10/06/2018 Order Date: 10/06/2018 20:27; IRON PANEL (Routine)
Start Date: 10/06/2018 Order Date: 10/06/2018 20:28; FERRITIN (Routine) Start Date: 10/06/2018
Order Date: 10/06/2018 20:28; HEMOGRAM AUTO+COMP AUTO DIFF (Routine) Start Date:
10/06/2018 Order Date: 10/06/2018 20:29; LH/FSH PANEL (Routine) Start Date: 10/06/2018 Order
Date: 10/06/2018 20:30
3. Testicular hypofunction E29.1
Disposition Last Updated by AVERA,CYNTHIA D @ 16 Oct 2018 0822 EDT
Note Written by AVERA,CYNTHIA D @ 16 Oct 2018 0819 EDT

Pt notified per Relay Health as requested.
Signed By AVERA, CYNTHIA D (Registered Nurse) @ 16 Oct 2018 0822
2019
Medical Record
2019
15 Aug 2018 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by GRANJA
VASQUEZ, JOCHEN A
Encounter for examination and observation

for unspecified reason
Patient: WAITERS, TOMMIE Date: 15 Aug 2018 1447 EDT Appt Type: T-CON*
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02ASTRONG TEAM Provider: GRANJAVASQUEZ,JOCHEN
BENNING A
Reason for Telephone Consult:Written by TERRY,LEIGH C @ 15 Aug 2018 1447 EDT

Carey / lab results / 706 326 4585
Telephone Consult Comments: Written by TERRY,LEIGH C @ 15 Aug 2018 1447 EDT
TEST RESULTS
What is a good contact number and time to call you back?: 706 326 4585 anytime
What provider ordered the Test? Carey
What test results are you requesting?: blood work
When was test done?: about 3 weeks ago
Where was test done? MACH
Do you have a Relay Health Account?: no
** Pt notified of 72hr response time**
S/O Note Written by GRANJAVASQUEZ,JOCHEN A @ 05 Sep 2018 1436 EDT

Subjective
Reviewed labs with patient. Elevated trigycerides in non-fasting lipid panel. Recommended diet and exercise and will also add
moderate dose statin, atorvastatin 10mg, Pt does not meet criteria for high dose stating with ASCVD 10yr risk of 5.2%. However,
patient interested in optimizing risk reduction which include BP control and moderate dose statin. Testosterone was low but result
suboptimal as lab was drawn outside standard time of 0800-1000. Will repeat lab.
Lab Result Cited by GUNN,TRAVIS B @ 15 Aug 2018 1530 EDT

Lipids Site/Specimen 18 Jul 2018 1501
Cholesterol PLASMA 205 (H)
Triglyceride PLASMA 246 (H)

Comprehensive Metabolic Panel Site/Specimen 18 Jul 2018 1501
Albumin PLASMA 3.8
Bilirubin PLASMA 0.3
Calcium PLASMA 9.9
Chloride PLASMA 102
Creatinine PLASMA 0.9
Glucose PLASMA 87 
Alkaline Phosphatase PLASMA 96
Potassium PLASMA 3.8
Protein PLASMA 7.5
Sodium PLASMA 143
Aspartate Aminotransferase PLASMA 19
Urea Nitrogen PLASMA 8
2019
Medical Record
2019
Carbon Dioxide PLASMA 28

Anion Gap PLASMA 13
Alanine Aminotransferase PLASMA 28
GFR Non-Black PLASMA 96 
GFR Black PLASMA 111

Testosterone Free+Total Site/Specimen 18 Jul 2018 1501
Testosterone SERUM 233 (L) 
Testosterone Free SERUM 6.1 (L)

Hemoglobin A1c Panel Site/Specimen 18 Jul 2018 1504
Hemoglobin A1c BLOOD 5.4 
Estimated Average Glucose BLOOD 108 
A/P Written by GRANJA-VASQUEZ,JOCHEN A @ 05 Sep 2018 1434 EDT

1. Encounter for examination and observation for unspecified reason
Medication(s): -ATORVASTATIN 10 MG ORAL TAB - TAKE ONE TABLET BY MOUTH AT BEDTIME #90 RF3 Start
Date: 09/05/2018 Order Date: 09/05/2018 14:33 Ordered By: GRANJA-VASQUEZ,JOCHEN A Ordering
Provider: GRANJAVASQUEZ, JOCHEN A
Laboratory(ies): -TESTOSTERONE,FREE AND TOTAL (Routine) Start Date: 09/05/2018 Order Date: 09/05/2018 14:18
Ordered By: GRANJA-VASQUEZ,JOCHEN A Ordering Provider: GRANJAVASQUEZ, JOCHEN A
Disposition Last updated by GRANJA-VASQUEZ,JOCHEN A @ 05 Sep 2018 1439 EDT

Follow up: as needed with PCM and/or in the AMHM02ASTRONG TEAM clinic.
Note Written by GRANJA-VASQUEZ,JOCHEN A @ 05 Sep 2018 1434 EDT

Additional A/P Information:
Discontinued ATORVASTATIN 20 MG ORAL TAB - TAKE ONE TABLET BY MOUTH AT BEDTIME
Signed By GRANJA-VASQUEZ, JOCHEN A (Physician) @ 05 Sep 2018 1439

_________________________________________________________________________________________________________
CHANGE HISTORY
The following Disposition Note Was Overwritten by GRANJA-VASQUEZ,JOCHEN A @ 05 Sep 2018 1417 EDT:
The Disposition section was last updated by GRANJA-VASQUEZ,JOCHEN A @ 05 Sep 2018 1417 EDT - see above.Previous Version of Disposition section was
entered/updated by GUNN,TRAVIS B @ 05 Sep 2018 1341 EDT.
2019
Medical Record
2019
16 Jul 2018 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by GRANJA
VASQUEZ, JOCHEN A
Encounter for general adult medical

examination without abnormal findings
Patient: WAITERS, TOMMIE Date: 16 Jul 2018 1440 EDT Appt Type: FTR
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02ASTRONG TEAM Provider: GRANJAVASQUEZ,JOCHEN
BENNING A

CAREY/PT NEEDS RX REFILLS MUST BE SEEN(AS PER PT)/706-326-4583
CLM
Screening Written by JONES,JESSICA @ 16 Jul 2018 1455 EDT

Reason For Appointment: CAREY/PT NEEDS RX REFILLS MUST BE SEEN(AS PER PT)/706-326-4583
Allergen information verified by JONES, JESSICA @ 16 Jul 2018 1455 EDT
Vitals
Vitals Written by JONES,JESSICA @ 16 Jul 2018 1451 EDT
Tobacco Use: No, Alcohol Use: No,
Pain Scale: 3/10 Mild, Pain Scale Comments: lower back pai
S/O Note Written by GRANJAVASQUEZ,JOCHEN A @ 23 Jul 2018 0651 EDT

Chief complaint
The Chief Complaint is: Medication refill.
Patient seen on 16JUL18. Late 23JUL18.
47 year old male presents to clinic for sildenafil refill. No further concerns at this time.
Physician note: 47yoM presents for annual physical and request sildenafil refill. He denies significant changes to his health. He
denies taking testosterone any longer. He endorsed feeling unmotivated in the past and low energy. He says this has been going on
for some years. However, he says his family gives him purpose/motivation. He denied being depressed. He has not had a physical
exam with labs since getting out of the military.
Not thinking about suicide.
PHQ-2 Depression Screen Negative. Score: 1.
Patient IS NOT currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid.
Patient reports that they are compliant with medications.
Patient has NOT received other care since their last visit with this clinic.
GAD-2 Screen Negative. Score: 1.
Current medication
sildenfil 100 mg as needed.

Reported:
HTN
Low back pain
H pylori.
2019
Medical Record
2019
Appendectomy - 1991
Personal history
5 children
(SILS) How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your
doctor or pharmacy?
PCM: Dr.Carey
.............
Menopause
Antibiotics
Exercise
Jaundice
Rectal
Anemia
Behavior
[ ] Other:

[ ] Other:
.............
Family history
HTN- both parents
DM- both parents
Cancer - om.
Review of systems
Systemic: No fever, no chills, and no recent weight loss.
Head: No headache.
Otolaryngeal: No earache, no nasal discharge, no nasal passage blockage (stuffiness), and no sore throat.
Cardiovascular: No chest pain or discomfort.
Pulmonary: No dyspnea and no cough.
Gastrointestinal: No nausea, no vomiting, no abdominal pain, no bright red blood per rectum, no diarrhea, and no constipation.
Genitourinary: No change in urinary frequency and no feelings of urinary urgency. No dysuria.
Musculoskeletal: No back pain.
Neurological: No lightheadedness.
The patient HAS NOT traveled outside of the country in the past 90 days.
Physical findings
Vital Signs:
General Appearance:
Head:
Injuries: ° No evidence of a head injury.
Appearance: ° Head normocephalic.
Neck:
Palpation: ° No tenderness of the neck.
Thyroid: ° Showed no abnormalities.
Eyes:
General/bilateral:
External: ° Eyelids showed no abnormalities.
2019
Medical Record
2019
Lymph Nodes:
° Cervical lymph nodes were not enlarged. ° Submandibular lymph nodes were not enlarged. ° Supraclavicular lymph nodes
were not enlarged.
Lungs:
Cardiovascular:
Heart Sounds: ° Normal S1 and S2. ° No gallop was heard. ° No click was heard. ° No pericardial friction rub heard.
Back:
° No costovertebral angle tenderness.
Abdomen:
Palpation: ° Abdomen was soft. ° No abdominal guarding. ° Abdominal non-tender. ° No mass was palpated in the abdomen.
Functional Exam:
General/bilateral: ° Mobility was not limited.
Neurological:
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Test conclusions
Medication list was updated at the beginning of the visit.
Practice Management

HIV Screen -
[ ] FIT-DNA

Zoster Vaccine -
HPV Vaccine -
Men:
..............
Patient BMI >= 30. Date: 07/16/2018.
Lab Result Cited by GRANJA VASQUEZ,JOCHEN A @ 23 Jul 2018 0625 EDT

Hemoglobin A1c Panel Site/Specimen 18 Jul 2018 1504 Units Ref Rng
Hemoglobin A1c BLOOD 5.4 % (4.0-5.6)
Estimated Average Glucose BLOOD 108 mg/dL
Comprehensive Metabolic Panel Site/Specimen 18 Jul 2018 1501 Units Ref Rng
Albumin PLASMA 3.8 g/dL (3.4-5.0)
2019
Medical Record
2019
Bilirubin PLASMA 0.3 mg/dL (0.2-1.3)

Calcium PLASMA 9.9 mg/dL (8.4-12.2)
Chloride PLASMA 102 mmol/L (98-107)
Creatinine PLASMA 0.9 mg/dL (0.66-1.25)
Glucose PLASMA 87 mg/dL (74-106)
Alkaline Phosphatase PLASMA 96 U/L (38-126)
Potassium PLASMA 3.8 mmol/L (3.6-5.2)
Protein PLASMA 7.5 g/dL (6.4-8.2)
Sodium PLASMA 143 mmol/L (136-145)
Aspartate Aminotransferase PLASMA 19 U/L (0-40)
Urea Nitrogen PLASMA 8 mg/dL (7-18)
Carbon Dioxide PLASMA 28 mmol/L (21-32)
Anion Gap PLASMA 13 mmol/L (8-16)
Alanine Aminotransferase PLASMA 28 U/L (0-41)
GFR Non-Black PLASMA 96 mL/min
GFR Black PLASMA 111 mL/min
Lipids Site/Specimen 18 Jul 2018 1501 Units Ref Rng

Cholesterol PLASMA 205 (H) mg/dL (0-199)
HDL Cholesterol PLASMA 47 mg/dL (40-60)
LDL Cholesterol PLASMA 109 mg/dL (0-129)
Triglyceride PLASMA 246 (H) mg/dL (0-199)
A/P Written by GRANJA VASQUEZ,JOCHEN A @ 23 Jul 2018 0656 EDT

1. Encounter for general adult medical examination without abnormal findings: Pt is a 47 y/o AAM with PMHx of HTN, obesity,
ED who presents to clinic for annual physical exam. VS WNL and exam unremarkable. Patient has been managing his BP with diet
and exercise however he previously was on maxazide. Patient had a 24hr BP monitor order placed in 2016 but results of study not
found in AHLTA. As pt has not had routine screening labs, will order A1C, Lipid panel, and CMP. Testosterone for evaluation of Low
-T. PHQ-2 and GAD screening negative. BH counseling offered to patient due to previously indentified depression but was declined.
Patient denies SI/HI
-Will review labs with patient

- Continue diet and exercise. Will discuss 24hr BP monitor with patient.
- Sildenfil refilled.
Dr. Sloan was available for precepting.
Medication(s): -PILL SPLITTER--MISC DEVI - PLACE 1 TABLET IN DEVICE AND CLOSE LID TO CUT TABLET IN
HALF AS NEEDED #1 RF0 Start Date: 07/23/2018 Order Date: 07/23/2018 06:34
-SILDENAFIL (VIAGRA) 100MG ORAL TABLET--P - TAKE ONE TABLET 1 HOUR BEFORE SEXUAL
INTERCOURSE NO MORE THAN 1 A DAY #6 RF0 Start Date: 07/23/2018 Order Date: 07/23/2018
06:35
Laboratory(ies): -COMPREHENSIVE METABOLIC PANEL (Routine); HGB A1C POCT (Routine); LIPIDS (Routine);
TESTOSTERONE,FREE AND TOTAL (Routine)
2. Male erectile disorder
Disposition Written by GRANJA VASQUEZ,JOCHEN A @ 23 Jul 2018 0657 EDT

Follow up: as needed in 12 month(s) with PCM and/or in the AMHM02ASTRONG TEAM clinic or sooner if there are problems.
Signed By GRANJA VASQUEZ, JOCHEN A (Physician) @ 23 Jul 2018 0657

_________________________________________________________________________________________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by GRANJA VASQUEZ,JOCHEN A @ 23 Jul 2018 0628 EDT:
S/O Note Written by JONES,JESSICA @ 16 Jul 2018 1500 EDT
Chief complaint
The Chief Complaint is: Medication refill.
47 year old male presents to clinic for sildenafil refill. No further concerns at this time.
Not thinking about suicide.
PHQ-2 Depression Screen Negative. Score: 1.
2019
Medical Record
2019
GAD-2 Screen Negative. Score: 1.
Current medication
sildenfil 100 mg as needed.

Reported:
HTN
Low back pain
H pylori.
Appendectomy - 1991
Personal history
5 children
Nurse tech.
PCM: Dr.Carey
.............
Menopause
Antibiotics
Exercise
Jaundice
Rectal
Anemia
Behavior
[ ] Other:

[ ] Other:
.............
Family history
HTN- both parents
DM- both parents
Cancer - om.
Review of systems
Test conclusions
Practice Management

HIV Screen -
[ ] FIT-DNA

Zoster Vaccine -
HPV Vaccine -
Men:
..............
2019
Medical Record
2019
Patient BMI >= 30. Date: 07/16/2018.
2019
Medical Record
2019
03 Jul 2018 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by CAREY,
PATRICK M
Encounter ID: BENN-18478279 Primary Dx: Encounter for issue of repeat prescription
ALAJANDRO
BENNING
AutoCites Refreshed by CAREY,PATRICK M @ 03 Jul 2018 1652 EDT

Allergies
No Allergies Found.
Labs
No Labs Found.
Rads
No Rads Found.
Vitals
No Vitals Found.
Reason for Telephone Consult:Written by YOUNG,IVORY M @ 03 Jul 2018 1541 EDT

CAREY/ RX REFILL
Telephone Consult Comments: Written by YOUNG,IVORY M @ 03 Jul 2018 1541 EDT
MEDICATION
What is a good contact number and time to call you back?:706-326-4585

Medication needed?:SILDENAFIL (VIAGRA) 100MG ORAL
Amount of medication currently available:10
Do you want your Meds Refilled at MACH Pharmacy?:MACH
What Provider prescribed this medication in past?:ZAGORSKI
Do you have a Relay Health Account?:No
**Pt notified of 72hr response time**
S/O Note Written by CAREY,PATRICK M @ 05 Jul 2018 0955 EDT

Subjective
chart reviewed including labs, meds and medical conditions.Review of records indicates he had prior low T and had two scripts for
viagra in last 2 years.It appears he is no longer using the testosterone gel given no scripts in several years. I think it is a good idea
to have him make an apt to discuss his health rather than refil the script over the phone.called pt no answer,. no message left on
voice mail. please contact the patient and relay above. Thanks.
S/O Note Written by CAREY,PATRICK M @ 11 Jul 2018 1223 EDT

Subjective
please send him a letter:We have attempted to contact you regarding your request for medication refill. After reviewing your medical
record it appears we have not seen you in our clinic to complete follow up and managament of some previous medical issues.
Please make a follow up appointment so we can futher discuss. Very Respectfully,-Dr. Carey.
Note Written by GROTHAUSE,TINA J @ 10 Jul 2018 0945 EDT

attemtped to contact patient.. left voice mail for patient to call and schedule appointment with provider.
attemtepd again to contact patient.. left voice mail for patient to please call to schedule appointment.
attemtped a 3rd time to contact patient.. left another voice mail stating patient needs to schedule appointment to get refills. Stated to
call CAO to schedule that appointment
Mailed instructions to patient to please call to schedule appointment
A/P Last Updated by CAREY,PATRICK M @ 03 Jul 2018 1658 EDT
1. Encounter for issue of repeat prescription Z76.0: Viagra script Mar 2012 and Jan 2016. Initial script was written for a tcon.
2019
Medical Record
2019
Disposition Last Updated by GROTHAUSE,TINA J @ 11 Jul 2018 1546 EDT
Signed By CAREY, PATRICK M (MAJ, MC, DO, CAQSM, RMSK, Family/Sports Medicine Physician) @ 12 Jul 2018 2006
2019
Medical Record
2019
23 Apr 2018 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by WILLIAMS,
LILLIAN W
Encounter for pre-employment

examination
Patient: WAITERS, TOMMIE Date: 23 Apr 2018 1030 EDT Appt Type: FTR
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: OCCUPATIONAL HEALTH FBGA Provider: WILLIAMS,LILLIAN W.
BENNING
AutoCites Refreshed by WILLIAMS,LILLIAN W @ 23 Apr 2018 1519 EDT

Problems Allergies
•MESENTERIC PANNICULITIS No Allergies Found.
•Patient Counseling:
•BURSITIS TROCHANTERIC
•Visit for: military services physical
accession
•Counseling About Travel
•GASTRITIS
•HYPERGLYCEMIA
•MCKENZIE POSTERIOR
DERANGEMENT SYNDROME
•Patient Counseling Medical Management
Five To Eight Patients
•NONORGANIC SLEEP APNEA
OBSTRUCTIVE
•NONORGANIC SLEEP DISORDERS
•HYPERLIPIDEMIA
•OVERWEIGHT
•HYPERTENSION (SYSTEMIC)
•HYPOGONADISM
•ASTIGMATISM
•MALE ERECTILE DISORDER
•Snoring
•Visit for: vasectomy status
•Abdominal pain in the left upper belly
(LUQ)
•LUMBAGO
•MAJOR DEPRESSION, RECURRENT
IN PARTIAL REMISSION
•ADJUSTMENT DISORDER WITH
DEPRESSED MOOD
•REFRACTIVE ERROR -
HYPERMETROPIA
•GENERALIZED ANXIETY DISORDER
•MAJOR DEPRESSION SINGLE
EPISODE MODERATE
•Abdominal pain around the belly button
(periumbilical)
•ASSESS PATIENT CONDITION WORK-
DISEASE
•ANXIETY DISORDER NOS
•MAJOR DEPRESSION, SINGLE
EPISODE
•Blood Pressure Isolated Elevated
•Visit for: occupational health / fitness
exam
•Body Mass Index
•Patient Education - Dietary
•GASTRITIS DUE TO H. PYLORI
2019
Medical Record
2019
•HELICOBACTER PYLORI (H. PYLORI)

INFECTION
•Visit for: preoperative exam
•Visit for: follow-up exam
•TESTICULAR NEOPLASM
•Abdominal pain
•Other Physical Therapy
•Joint pain, localized in the shoulder
•CERVICALGIA
•Visit for: screening exam
•FOLLICULITIS
•MIGRAINE HEADACHE
•BACKACHE
Other PMHs Social History Procedures

No Other PMHs Found. No Social History Found. •Spectacles Services Fitting Monofocals
(Not For Aphakia) (10 Feb 2011)
•Determination Of Refractive State (10 Feb
2011)
•Ophthalmological New Patient Start
Comprehensive Care (10 Feb 2011)
•Spectacles Services Fitting Monofocals
(Not For Aphakia) (05 May 2010)
•Determination Of Refractive State (05
May 2010)
Comprehensive Care (05 May 2010)
•Medical Nutrition Therapy Group (2 or
More Individual(s)) (25 Feb 2010)
•Psychiatric Therapy Individual
Approximately 45 Minutes (03 Jun
2009)
Approximately 45 Minutes (07 May
2009)
•Psychiatric Diagnostic Evaluation Review
of Records and Reports (27 Apr 2009)
•Psych Ther Indiv Approx 30 Min W/
Medical Evaluation & Management (27
Apr 2009)
Approximately 30 Minutes (08 Apr
2009)
(Not For Aphakia) (01 Apr 2009)
•Determination Of Refractive State (01 Apr
2009)
Comprehensive Care (01 Apr 2009)
of Records and Reports (27 Mar 2009)
•Psychiatric Diagnostic Evaluation
Comprehensive Examination (27 Mar
2009)
•Psychiatric Therapy Preparation of
Psychiatric Status Report (11 Mar
2009)
2009)
More Individual(s)) (14 Jan 2009)
•Postoperative Visit, Without Charge (22
May 2008)
•Modalities Ultrasound (05 Feb 2008)
•Physical Therapy: ___ Session
2019
Medical Record
2019
Segments, 15 Minutes Each (05 Feb

2008)
•Physical Therapy Service Evaluation (31
Jan 2008)
Segments, 15 Minutes Each (31 Jan
2008)
•Incision And Drainage Of Skin Abscess
(09 Jan 2008)
•INJECTION, KETOROLAC
TROMETHAMINE, PER 15 MG (11 Oct
2007)
•Physician Supervised Injection
Intramuscular (11 Oct 2007)
Intravenous (08 Jul 2007)
TROMETHAMINE, PER 15 MG (08 Jul
2007)
•INFUSION, NORMAL SALINE
SOLUTION , 1000 CC (08 Jul 2007)
•Parenteral Fluids IV Infusion For
Hydration (08 Jul 2007)
•ECG 12-Lead (08 Jul 2007)
Jun 2007)
•Assisted Exercises For ROM (07 Jun
2007)
Active Medications
LIDOCAINE (LIDOCAINE), 5 %, OINT. (G), Active 0 of 3 28 Oct 2016
TOPICAL, HI-TECH/AKORN C, 35.44 g TUBE
LIDOCAINE (LIDOCAINE), 5 %, OINT. (G), Active 1 of 3 28 Sep 2016
LIDOCAINE (LIDOCAINE), 5 %, OINT. (G), Active 3 of 3 18 Jul 2016
TOPICAL, IGI LABS, INC./, 35.44 g TUBE
TRIAZOLAM (TRIAZOLAM), 0.25 MG, TABLET, Active NR 03 May 2009

PRE-EMPLOYMENT PHYS PART 2 NURSING ASST
BRY
Vitals
Vitals Written by CLAYTON,MARNIE D @ 23 Apr 2018 1037 EDT
BP: 120/82 Left Arm, HR: 75, HT: 66 in, WT: 247.4 lbs, BMI: 39.93, BSA: 2.189 square meters, Tobacco Use: No,
Alcohol Use: No,
Pain Scale: 0 Pain Free
S/O Note Written by WILLIAMS,LILLIAN W. @ 23 Apr 2018 1519 EDT

<<Note accomplished in TSWF-CORE>>This is a 47 y/o male presenting today for a pre-employment physical exam.
.
Review of systems
Head: No headache.
2019
Medical Record
2019
Physical findings
General:
• Physical examination Normal physical exam.
Vital Signs:
General Appearance:
Head:
Neck:
Eyes:
General/bilateral:
Pupils: ° PERRL. ° Size of the pupil was normal.
External: ° Eyelids showed no abnormalities. ° Conjunctiva exhibited no abnormalities.
Sclera: ° Normal.
Ears:
General/bilateral:
Nose:
General/bilateral:
Discharge: ° No nasal discharge seen.
Cavity: ° Nasal septum normal. ° Nasal mucosa normal. ° Nasal turbinate not erythematous. ° Nasal turbinate not
swollen.
Sinus Tenderness: ° No sinus tenderness.
Oral Cavity:
Buccal Mucosa: ° Examination showed no abnormalities.
Pharynx:
Oropharynx: ° Normal. ° Tonsils showed no abnormalities.
Lymph Nodes:
were not enlarged.
Lungs:
Cardiovascular:
Back:
° No costovertebral angle tenderness.
Abdomen:
Functional Exam:
Other:
General/bilateral: ° No muscle tenderness.
Neurological:
° Oriented to time, place, and person. ° Judgement was not impaired.
Motor (Strength): ° Strength of the upper extremities was normal. ° No lower extremity weakness was observed.
Coordination / Cerebellum: ° No impairment of finger-to-nose movement was seen. ° No impairment of heel-to-shin movement
was seen.
Balance: ° Normal. ° Romberg's sign was absent.
Psychiatric:
2019
Medical Record
2019
Mood: ° Euthymic.
Affect: ° Normal.
Skin:
° Showed no ecchymosis. ° Temperature was normal. ° No skin lesions.
Nails:
° Normal.
Lab Result Cited by CLAYTON,MARNIE D @ 23 Apr 2018 1038 EDT

Urinalysis Site/Specimen 16 Nov 2017 1304 <o>
Color URINE YELLOW
Appearance URINE CLEAR
Specific Gravity URINE 1.021
Urobilinogen URINE NEGATIVE
Bilirubin URINE NEGATIVE
Glucose URINE NEGATIVE
Protein URINE NEGATIVE
pH URINE 6.0
Nitrite URINE NEGATIVE
Leukocyte Esterase URINE NEGATIVE
Ketones URINE NEGATIVE
Blood URINE NEGATIVE
RBC URINE <1
Mucus URINE RARE
WBC URINE 1

Rubeola Virus Ab Site/Specimen 16 Nov 2017 1303
Rubeola Virus Ab SERUM POSITIVE 
Varicella Virus Ab Site/Specimen 16 Nov 2017 1303

Varicella Zoster Virus Ab SERUM POSITIVE <o>
Mumps Virus Ab Site/Specimen 16 Nov 2017 1303

Mumps Virus Ab SERUM POSITIVE 
Hepatitis B Virus Surface Ab Site/Specimen 16 Nov 2017 1303

Hepatitis B Virus Surface Ab SERUM POSITIVE <o>
Rubella Virus Ab Site/Specimen 16 Nov 2017 1303

Rubella Virus Ab SERUM POSITIVE 
A/P Written by WILLIAMS,LILLIAN W @ 23 Apr 2018 1522 EDT

1. Encounter for pre-employment examination Z02.1: Normal physical exam.
Disposition Written by WILLIAMS,LILLIAN W @ 23 Apr 2018 1523 EDT

Signed By WILLIAMS, LILLIAN W (NP-C, Martin Army Community Hospital) @ 23 Apr 2018 1523
2019
Medical Record
2019
20 Apr 2018 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by MITCHELL,
CHARLENE M

PROGRAM, ESTABLISH BASELINE
PRIOR TO OCCUPATIONAL
WORKPLACE EXPOSURE
Patient: WAITERS, TOMMIE Date: 20 Apr 2018 1100 EDT Appt Type: FTR
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: OCCUPATIONAL HEALTH FBGA Provider: MITCHELL,CHARLENE M
BENNING
AutoCites Refreshed by MITCHELL,CHARLENE M @ 20 Apr 2018 1646 EDT

Problems Allergies
accession
•GASTRITIS
•HYPERGLYCEMIA
OBSTRUCTIVE
•HYPERLIPIDEMIA
•OVERWEIGHT
•HYPOGONADISM
•ASTIGMATISM
•Snoring
(LUQ)
•LUMBAGO
DEPRESSED MOOD
HYPERMETROPIA
EPISODE MODERATE
(periumbilical)
DISEASE
EPISODE
2019
Medical Record
2019

exam
•Body Mass Index
INFECTION
•Abdominal pain
•CERVICALGIA
•FOLLICULITIS
•BACKACHE
Procedures
2011)
May 2010)
2009)
2009)
Apr 2009)
2009)
2009)
2009)
2009)
2009)
2019
Medical Record
2019

May 2008)
2008)
Jan 2008)
2008)
(09 Jan 2008)
2007)
2007)
•ECG 12-Lead (08 Jul 2007)
Jun 2007)
2007)
Active Medications

PRE-EMPLOYMENT PHYS PART 1 NURSING ASST
BRY
Screening Written by CLAYTON,MARNIE D @ 20 Apr 2018 1052 EDT

Reason For Appointment: PRE-EMPLOYMENT PHYS PART 1 NURSING ASST
Allergen information verified by CLAYTON, MARNIE D @ 20 Apr 2018 1052 EDT

Reason(s) For Visit (Chief Complaint): ARMED FORCES MEDICAL EXAM HEARING CONSERVATION PROGRAM
ESTABLISH BASELINE (New) : PART I PHYSICAL- NURSE ASST;
Vitals
Vitals Written by CLAYTON,MARNIE D @ 20 Apr 2018 1504 EDT
BP: 154/79 Left Arm, HR: 87, HT: 66 in, WT: 247 lbs, BMI: 39.87, BSA: 2.188 square meters, Tobacco Use: No,
Alcohol Use: No, Pain Scale: 0 Pain Free
Questionnaire AutoCites Refreshed by MITCHELL,CHARLENE M @ 20 Apr 2018 1646 EDT

Questionnaires
Learning Needs Assessment Version: 2 Completed On: 20 Apr 2018
2019
Medical Record
2019
The Selected Provider is MITCHELL, CHARLENE M in the Occupational Health FBGA clinic.
2. Do you require a interpreter to speak with your health care provider??Usted necesita un int?rprete para comunicarse con su
proveedor de cuidado m?dico?: No
_______________________________________________________________
5. Do you have any learning barriers?: None;
6. How do you best learn? Please indicate all that apply:: Reading material;Demonstration;Group instructions;
7. Overall, do you feel motivated to learn more about your health and wellness?: Always;
please list:: Spiritual
10. How would you describe your current state of health?]: Good
11. Everyone experiences stress. How well are you managing your current level of stress?: Excellent
today!): Yes
S/O Note Written by CLAYTON,MARNIE D @ 20 Apr 2018 1521 EDT

Reason for Visit
Visit for: occupational health/fitness exam CIV PART I PHYSICAL.
He reported: Past medical history reviewed with worker by verbal history and questionnaire(s). PMH reviewed by
questionnaire learning needs assessment, TB questionnaire, and Columbia-Suicide Severity Rating Scale Questionnaire completed.
Patient answered NO to all questions in Step 1 and Step 3. Hard copy questionnaire place in CEMR and medication list reviewed
with patient Patient states that he currently does not take any medications.
Reported:
Active problems Noted- past medical/surgical history (see DD2807-1). Pt reports:
hx bronchitis in 2007
Seasonal allergies
wears glasses
H. pylori infection- 2011
Broken left shoulder blade- 1997
sp left wrist cyst removal in 2001 and 2002 ; appendectomy 1991
Pt reports positive IPPD in 2012 with 9 months INH treatment. CXR- wnl DEC 2017.
Recent Events: No recent events No reported significant illness, injury, or surgery within the last 12 months.
Physical findings
Vital Signs:
General Appearance:
° Well-appearing and offering no complaints at this time.
Eyes:
General/bilateral:
Visual Assessment: • Distance binocular acuity w/ current Rx: 20/ 20. • Binocular with current Rx: 20/ 30. ° Near vision
was normal. ° A color vision exam was normal 6/6.
Right Eye:
Visual Assessment: • Distance right acuity with current Rx: 20/ 20. • Near vision right eye with current Rx: 20/ 30.
Left Eye:
Visual Assessment: • Distance left acuity with current Rx: 20/ 20. • Near vision left eye with current Rx: 20/ 30.
Skin:
• Skin: integrity of hands is intact, free of cuts and rashes.
Tests
Laboratory Studies:
Audiometry:
Audiometry Communicates appropriately by spoken word, and responds appropriately in nomal voice tones to verbal
commands. No hazardous noise exposures identified for this job.
General:
Tests Record of immunity by titer to communicable disease in place for MMR, Hep B, and Varicella. Tdap and Flu vaccine up
to date.
2019
Medical Record
2019





Rad Result Cited by CLAYTON,MARNIE D @ 20 Apr 2018 1508 EDT
WAITERS, TOMMIE ALAJANDRO 20/1757 DoD ID: 1068397665 47yo 18 Aug 1970 M
********** CHEST PA/LAT **********
POC Enc: #E258485 POC Fac: Martin ACH, Fort Benning, GA
Status: Complete
Procedure: CHEST PA/LAT

Order Date: 08-Dec-2017 11:38:00
Reason for Order:
TB.
Exam #: 17120611
Exam Date/Time: 11-Dec-2017 11:14:00
Transcription Date/Time: 11-Dec-2017 13:00:00
Requesting Location:
AMHM02ASTRONG TEAM MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Approved Date: 11-Dec-2017 12:57:00
Report Text:
2 views of the chest were performed. Comparison is made prior studies, most
recently 12/23/2016. No infiltrate or pleural effusion was identified. The heart
size is within normal limits. The upper mediastinal and hilar structures show no
evidence of lymph node enlargement. The bony structures are intact.
A/P Last Updated by CLAYTON,MARNIE D @ 20 Apr 2018 1053 EDT

1. EXAM, FORMAL OCCUPATIONAL HEALTH PROGRAM INCLUDING HEARING CONSERVATION PROGRAM, ESTABLISH
BASELINE PRIOR TO OCCUPATIONAL WORKPLACE EXPOSURE DOD0214
Procedure(s): -(99173) Screening Test Of Visual Acuity, Quantitative, Bilateral x 1
Disposition Last updated by MITCHELL,CHARLENE M @ 20 Apr 2018 1647 EDT
2019
Medical Record
2019

Follow up: in the OCCUPATIONAL HEALTH FBGA clinic. - Comments: Return for part II physical.
Signed By MITCHELL, CHARLENE M (Registered Nurse, Martin ACH, Fort Benning, GA) @ 20 Apr 2018 1647
_________________________________________________________________________________________________________
CHANGE HISTORY
The following Disposition Note Was Overwritten by MITCHELL,CHARLENE M @ 20 Apr 2018 1647 EDT:
The Disposition section was last updated by MITCHELL,CHARLENE M @ 20 Apr 2018 1647 EDT - see above.Previous Version of Disposition section was entered/updated by
CLAYTON,MARNIE D @ 20 Apr 2018 1053 EDT.
Follow up: in the OCCUPATIONAL HEALTH FBGA clinic. - Comments: Return for part II physical.
2019
Medical Record
2019
25 Jan 2018 at Martin ACH, Fort Benning, GA, Optometry by MELLING, SCOTT R
Encounter for examination of eyes and

vision with abnormal findings
Patient: WAITERS, TOMMIE Date: 25 Jan 2018 0815 EST Appt Type: SPEC
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: OPTOMETRY Provider: MELLING,SCOTT R
BENNING

ree7063264585
jlp
S/O Note Written by MELLING,SCOTT R @ 25 Jan 2018 0930 EST

Reason for Visit
Visit for: Noticing more up close; also feels a little pressure on his eyes; feels like he's squeezing his eyes to see
.
He reported: Past medical history reviewed -- confirmed meds/allergies; no pain; LEE: a few years.
Reported:
Past medical history -- no chronic illnesses.
Surgical / Procedural: No surgical / procedural history of previous eye surgery.
Physical Trauma: Trauma to the eye -- JP4 fuel splashed in both eyes (2005); no problems since.
Diagnoses:
No glaucoma
No amblyopia
No strabismus.
Hypertension -- approx 2 yrs.
Hyperlipidemia -- approx 6 yrs.
No thyroid disorder
No diabetes mellitus
Family history
Family medical history mom, dad: diabetes and HBP
No family history of glaucoma; no other eye disease.
Physical findings
Eyes:
General/bilateral:
Visual Assessment: • Autorefraction was used: OD +025-050x038, OS +050-075x117
.
. • A phoropter was used (SUBJECTIVE):
OD +025-050x040
OS +050-075x115
.
. • Cycloplegic drops used ----Patient educated on signs, symptoms, and precautions with dilation; instilled 1%
tropicamide 1gtt OU x 2 (1-2 min inbetween drops) @ 840. ° Lensometry pupillary distance was unspecified --
(measured by PD ruler): 69. ° A trial frame was not used Px prefers add of +175.
Intraocular Pressure: ° Normal NCT IOP 15/16 @ 800.
Extraocular Movements: ° Eye vergence was normal ---NPC (in cm): 8. ° A cover-uncover test was normal. ° An
alternate cover test was normal.
Pupils: ° PERRL. ° No Marcus Gunn pupil was seen.
External: • Conjunctiva exhibited abnormalities -- pingueculas OU. ° Eye showed no abnormalities. ° Eyelids showed no
abnormalities.
Sclera: ° Normal.
Cornea: • Assessed -- arcus OU.
Anterior Chamber: ° Exhibited no abnormalities -- 4 x 4 OU.
Uveal Tract: ° Normal.
Lens: ° Normal.
Vitreous: ° Normal.
Retina: • Fundoscopic exam through dilated pupils was performed ----No holes, tears or retinal detachments in either eye
(BIO and 20D). ° Normal. ° Macula was normal ---clear, flat OU. ° Retinal vessels were normal --within normal OU.
2019
Medical Record
2019
Visual Field: ° A visual fields exam by confrontation was normal.

Right Eye:
Visual Assessment: • Distance right acuity without Rx: 20/ 20-2. • Near vision right eye manifest: 20/ 20 w/add.
• Distance right manifest acuity: 20/ 15.
Extraocular Movements: ° Right eye motility was normal.
Optic Disc: • Cup ratio .4/.4.
Left Eye:
Visual Assessment: • Distance left acuity without Rx: 20/ 20-2. • Near vision left eye manifest: 20/ 20 w/add. • Distance
left acuity with manifest: 20/ 15-.
Extraocular Movements: ° Motility was normal.
Optic Disc: • Cup ratio .3/.4v.
A/P Last Updated by MELLING,SCOTT R @ 25 Jan 2018 0933 EST

1. Encounter for examination of eyes and vision with abnormal findings:
-- Rx subj w/add; also a SV near Rx using the subj plus the add
-- No hypertensive retinopathy noted; cont to work to manage BP well
Procedure(s): -Ophthalmological New Patient Start Comprehensive Care x 1 ADDITIONAL PROVIDER(S):

CURTIS,ALISON JANE
-Determination Of Refractive State x 1
-Spectacles Services Fitting Monofocals (Not For Aphakia) x 1 ADDITIONAL PROVIDER(S):
HOWARD,TROY L
2. Hypermetropia, bilateral
3. Regular astigmatism, bilateral
4. Presbyopia
5. Pinguecula, bilateral: Pt educ: avoid things that would dry the eyes; use sunprotection outdoors
6. Arcus senilis, bilateral
Disposition Last Updated by MELLING,SCOTT R @ 25 Jan 2018 0934 EST

Follow up: 18 month(s) or sooner if there are problems.
Signed By MELLING, SCOTT R (OD, MEd, FAAO, Chief, Optometry Services) @ 25 Jan 2018 0934
Note Written by HOWARD,TROY L @ 25 Jan 2018 1131 EST

(Added after encounter was signed.)
2019
Medical Record
2019
2019
Medical Record
2019
18 Jan 2018 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by CAIN, LOIS
R
Encounter for other administrative

examinations
Patient: WAITERS, TOMMIE Date: 18 Jan 2018 1408 EST Appt Type: FTR
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: OCCUPATIONAL HEALTH FBGA Provider: CAIN,LOIS R
BENNING
AutoCites Refreshed by CAIN,LOIS R @ 18 Jan 2018 1544 EST

Allergies
No Allergies Found.
Active Medications
Reason for Appointment:Written by YOUNG,BARBARA R @ 18 Jan 2018 1408 EST

CIV INPROC GUARD
Screening Written by CAIN,LOIS R @ 18 Jan 2018 1544 EST

Reason For Appointment: Notes Entered by: YOUNG,BARBARA R 18 Jan 2018 1408
------------------------------
CIV INPROC GUARD
Reason(s) For Visit (Chief Complaint): visit for: occupational health / fitness exam (New) : New Employee Inprocessing;
Vitals
Vitals Written by ROBERSON,PATRICIA A @ 18 Jan 2018 1415 EST
BP: 134/80 Left Arm, Adult Cuff, HR: 78, HT: 66 in, WT: 232 lbs, SpO2: 99%, BMI: 37.44,
BSA: 2.13 square meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 0 Pain Free
Questionnaire AutoCites Refreshed by CAIN,LOIS R @ 18 Jan 2018 1544 EST

Questionnaires
S/O Note Written by CAIN,LOIS R @ 18 Jan 2018 1545 EST

He reported: General overall feeling well; alert, oriented.
Ear symptoms: Communicates appropriately by spoken word in normal voice tones.
Musculoskeletal symptoms: States he is able to bend, lift, stoop and pick up to 40+ pounds.
Allergic/immunologic symptoms .ASA causes hives. Denies latex sensitivity.
Seen today for New Employee Inprocessing.

Allergies
An allergy Aspirin causes Hives.
Vaccinations
T dap current from Feb 2015. Flu vaccine current from Nov 2017.
Reported:
2019
Medical Record
2019
Past medical history Excessive weight gain over past year, denial of any significant medical history, no recent change in
medical history, no active problems, and no prior serious illness.
Recent Events: No recent events.
Surgical / Procedural: No surgical / procedural history reported over past year.
Medications: No medication history reported.
Tests: A PPD was not performed Denies travel out of the country in past year. Denies current symptoms of active TB or
known exposure to TB patient. Does not work / volunteer in high risk area. IPPD not required: low risk.
Personal history
Behavioral: No tobacco use.
Physical findings
Eyes:
General/bilateral:
Visual Assessment: • Vision assessed without correction for pre-placement physical exam and not repeated today.
Objective
Reviewed job duties, hazardous exposures and use of appropriate personal protective equipment (PPE)~.
Tests
Record of immunity to communicable disease in place for MMR, varicella and hepatitis-B.
Laboratory Studies:
Audiometry:
Audiometry provided IAW current Hearing Conservation program; 2215 at pre-placement exam. Repeat in one year. ~
Fitted, issued and instructed in use of blue Quattros HPD and carrying case. Demonstrated back correct technique.
A/P Written by CAIN,LOIS R @ 18 Jan 2018 1552 EST

1. Encounter for other administrative examinations
Procedure(s): -Ear Protector Attenuation Measurements x 1
Disposition Written by CAIN,LOIS R @ 18 Jan 2018 1553 EST

Follow up: 12 month(s) in the OCCUPATIONAL HEALTH FBGA clinic or sooner if there are problems.
Discussed: Diagnosis, Medication(s)/Treatment(s) with Patient who indicated understanding.
Signed By CAIN, LOIS R (RN, COHN-S, Occupational Health Service) @ 18 Jan 2018 1553
2019
Medical Record
2019
11 Dec 2017 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by CAREY,
PATRICK M
Encounter for screening for respiratory

tuberculosis
Patient: WAITERS, TOMMIE Date: 11 Dec 2017 1157 EST Appt Type: T-CON*
ALAJANDRO
BENNING
AutoCites Refreshed by CAREY,PATRICK M @ 11 Dec 2017 1744 EST

Allergies
No Allergies Found.
Labs
No Labs Found.
Rads
********** CHEST PA/LAT **********

Status: Complete

Order Date: 08-Dec-2017 11:38:00
Reason for Order:
TB.
Exam #: 17120611
Exam Date/Time: 11-Dec-2017 11:14:00
Transcription Date/Time: 11-Dec-2017 13:00:00
AMHM02ASTRONG TEAM MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Approved Date: 11-Dec-2017 12:57:00
Report Text:
2 views of the chest were performed. Comparison is made prior studies, most
recently 12/23/2016. No infiltrate or pleural effusion was identified. The heart
size is within normal limits. The upper mediastinal and hilar structures show no
evidence of lymph node enlargement. The bony structures are intact.
Vitals
No Vitals Found.
Reason for Telephone Consult:Written by DUNOVANT,GLORIA A @ 11 Dec 2017 1157 EST

FORM
Telephone Consult Comments: Written by DUNOVANT,GLORIA A @ 11 Dec 2017 1157 EST
Please complete form for pts. Copy in mailbox /contact no. 706-326-4585
2019
Medical Record
2019
S/O Note Written by CAREY,PATRICK M @ 11 Dec 2017 1745 EST

Subjective
Please note the chest x-ray showed no active pulmonary disease. Form completed and signed. Please let him know he can pick it
up at the front desk. Thank you
Note Written by DUNOVANT,GLORIA A @ 13 Dec 2017 1125 EST

Attempts to contact pts. on 12 December 2017 I spoke to pts.on 13 December to pick-
up forms.
A/P Last Updated by CAREY,PATRICK M @ 11 Dec 2017 1745 EST
1. Encounter for screening for respiratory tuberculosis Z11.1
Disposition Last Updated by CAREY,PATRICK M @ 11 Dec 2017 1745 EST
Signed By CAREY, PATRICK M (MAJ, MC, DO, CAQSM, RMSK, Family/Sports Medicine Physician) @ 14 Dec 2017 0744
2019
Medical Record
2019
11 Dec 2017 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by GILL,
CATHERINE ANN
Patient: WAITERS, TOMMIE Date: 11 Dec 2017 0940 EST Appt Type: FTR
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02ASTRONG TEAM Provider: GILL,CATHERINE ANNE
BENNING

Carey/Chest xray for TB for work purpose/706-326-4585
Appointment Comments: Written by GRIFFIN,STEPHANIE D @ 08 Dec 2017 1541 EST
HEDIS OVERDUE MAMMO, COLON **** MLC
S/O Note Written by PIERRE,LESLIE D @ 08 Dec 2017 1515 EST

Allergies
Allergies: Current Allergies Reviewed and updated in the AHLTA allergy module.
Current Allergies:NKDA
.
Current medication
VIAGRA 100MG 1 TAB AS NEEDED
ANDROGEL 2 PUMPS DAILY
ASA 81 MG EVERY DAY
ZANTAC 150MG 2 TIMES DAILY (TAKES AS NEEDED )

MAXZIDE 37.5MG-25MG EVERY DAY
Tramodol 1 tab by mouth by mouth every day as needed

Updated 6/1/2016
.
Reported:
Recent Events: Medication compliance.
HTN
DEPRESSION
OVERWEIGHT
MALE ERECTILE DISORDER
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
GANGLION RIGHT WRIST
ABD LAPROSCOPY 2012
.
Personal history
Social history reviewed Social History:
Household Occupants: 4
Next of Kin: Kadidia Waiter (wife) 404-421-3064
Children: 3.
Behavioral: No tobacco use in the last 10 years.
Alcohol: Not using alcohol AUDIT-C Date: 11/04/2014.
History Additional JC/AAACH/HIS:
Annual Screen date: 61/2016 retake 6/1/2017
Preferred method of learning is Verbal, Written, Visual, Hands On.
No - Do you have a learning disability, language barrier, hearing/vision deficit?
No - Advanced Directives Completed?
No - Is a copy of the Advanced Directives in the record?
No - Do you have any cultural or religious beliefs that may affect your care?
2019
Medical Record
2019

Yes - Are you registered for Relay Health/Secure Messaging?
No - Do you use a Personal Health Record (PHR)?
What is your preferred language for discussing your health care? ENGLISH
CONTACT INFO: 706-326-4585 PCM Dr Carey.
Family history
CA- mother- bresat
mother - MI age 55 yrs
father- DM.
.
Practice Management
Lipid Screening - 26 aug 2014
Diabetes Screening - 26 aug 2014
Aspirin Prophylaxis - taking aspirin 81
HIV Screen - no records
Colonoscopy - n/a
Tetanus (Td/Tdap) - due

Influenza Vaccine - due
Zoster Vaccine - n/a
Pneumococcal Vaccine - n/a
.
Patient does NOT exercise for at least 30 minutes a day.
Patient
's BMI >= 30. Screening Date:11/04/2014.
Patient Did Not Show for Appointment

Encounter Cancelled by GILL,CATHERINE ANNE @ 11 Dec 2017 1458 EST
2019
Medical Record
2019
PATRICK M

examinations
ALAJANDRO
BENNING

Allergies
No Allergies Found.
Labs
No Labs Found.
Rads
No Rads Found.
Vitals
No Vitals Found.
Reason for Telephone Consult:Written by CRISCO,ANTHONY T @ 06 Dec 2017 0823 EST

General questions for the doctor:CAREY
Telephone Consult Comments: Written by CRISCO,ANTHONY T @ 06 Dec 2017 0823 EST
General questions for the doctor
PT's phone number:706-326-4585

Reason:PT REQUEST X-RAY REFERRAL DUE TO TB. PATIENT HAS BEEN GETTING CHEST X-RAY FOR THE LAST 8YEAR.
PLEASE CALL FOR MORE INFORMATION
Urgency: Routine
** Pt notified of 72hr respone time**

Subjective
please let him know chest radiograph was ordered. He can come anytime the radiology department is open and get the x-rays. I
will call him when I get the results.

Subjective
called pt no answer. no specific identification on voicemail. no message left.
Note Written by DUNOVANT,GLORIA A @ 11 Dec 2017 1201 EST

Attempts to contact pts.,no answer @ this times.Patient went to x-ray on 11 December
2017.
1. Encounter for other administrative examinations Z02.89: 47 y/o M needs follow up annual screening as occupational
requirement for latent
TB.
Radiology(ies): -CHEST PA/LAT (Routine) Start Date: 12/08/2017 Order Date: 12/08/2017 11:38 Impression: 47 y/o M
needs follow up annual screening as occupational requirement for latent TB.
2019
Medical Record
2019
2019
Medical Record
2019
27 Nov 2017 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by WILLIAMS,
LILLIAN W
Encounter for pre-employment

examination
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: OCCUPATIONAL HEALTH FBGA Provider: WILLIAMS,LILLIAN W.
BENNING
AutoCites Refreshed by WILLIAMS,LILLIAN W @ 27 Nov 2017 1105 EST

Problems Allergies
accession
•GASTRITIS
•HYPERGLYCEMIA
OBSTRUCTIVE
•HYPERLIPIDEMIA
•OVERWEIGHT
•HYPOGONADISM
•ASTIGMATISM
•Snoring
(LUQ)
•LUMBAGO
DEPRESSED MOOD
HYPERMETROPIA
EPISODE MODERATE
(periumbilical)
DISEASE
EPISODE
exam
•Body Mass Index
2019
Medical Record
2019

INFECTION
•Abdominal pain
•CERVICALGIA
•FOLLICULITIS
•BACKACHE
Other PMHs Social History Procedures

No Other PMHs Found. No Social History Found. •Spectacles Services Fitting Monofocals
2011)
May 2010)
2009)
2009)
Apr 2009)
2009)
2009)
2009)
2009)
2009)
May 2008)
2019
Medical Record
2019

2008)
Jan 2008)
2008)
(09 Jan 2008)
2007)
2007)
•ECG 12-Lead (08 Jul 2007)
Jun 2007)
2007)
Active Medications

PRE-EMPLOYMENT PHYS PART 2 NEW GUARD
BRY
Vitals
Vitals Written by ROBERSON,PATRICIA A @ 27 Nov 2017 1028 EST
BP: 137/75 Left Arm, Adult Cuff, HR: 78, HT: 66 in, WT: 232 lbs, BMI: 37.44, BSA: 2.13 square meters, Tobacco
Use: No, Alcohol Use: No,
S/O Note Written by WILLIAMS,LILLIAN W. @ 27 Nov 2017 1106 EST

<<Note accomplished in TSWF-CORE>> This is a 47 y/o male presenting today gor a pre-employment physical exam.
.
Review of systems
Head: No headache.
2019
Medical Record
2019
History of HTN.
Physical findings
General:
• Physical examination
Normal physical exam.

Vital Signs:
General Appearance:
° Normal. ° Well developed. ° Well nourished. ° In no acute distress.
Head:
Neck:
Ears:
General/bilateral:
Nose:
General/bilateral:
Discharge: ° No nasal discharge seen.
swollen.
Oral Cavity:
Pharynx:
Lymph Nodes:
were not enlarged.
Lungs:
Cardiovascular:
Abdomen:
Functional Exam:
Other:
General/bilateral: ° No muscle tenderness.
Neurological:
° Oriented to time, place, and person. ° Judgement was not impaired.
Coordination / Cerebellum: ° No impairment of finger-to-nose movement was seen. ° No impairment of heel-to-shin movement
was seen.
Balance: ° Normal. ° Romberg's sign was absent.
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Skin:
2019
Medical Record
2019

Nails:
° Normal.
Lab Result Cited by YOUNG,BARBARA R @ 27 Nov 2017 0955 EST

Color URINE YELLOW
Urobilinogen URINE NEGATIVE
Protein URINE NEGATIVE
pH URINE 6.0
RBC URINE <1
Mucus URINE RARE
WBC URINE 1





Lipids Site/Specimen 16 Nov 2017 1303

Basic Metabolic Panel Site/Specimen 16 Nov 2017 1303

Sodium PLASMA 140
Chloride PLASMA 99
Anion Gap PLASMA 13
Calcium PLASMA 9.1
GFR Non-Black PLASMA 97 
GFR Black PLASMA 113
Hemogram+Differential Auto Site/Specimen 16 Nov 2017 1303 <o>

WBC BLOOD 6.8
RBC BLOOD 5.37
Hemoglobin BLOOD 15.3
Hematocrit BLOOD 44.0
MCV BLOOD 82.1
MCH BLOOD 28.5
MCHC BLOOD 34.8
RDW CV BLOOD 13.4
MPV BLOOD 9.2
2019
Medical Record
2019
Platelets BLOOD 288

ABS Neutrophils BLOOD 3.4
Neutrophils BLOOD 49.4
ABS Lymphocytes BLOOD 2.6
Lymphocytes BLOOD 37.7
ABS Monocytes BLOOD 0.6
Monocytes BLOOD 8.3
ABS Eosinophils BLOOD 0.2
Eosinophils BLOOD 3.5
ABS Basophils BLOOD 0.1
Basophils BLOOD 1.1
A/P Written by WILLIAMS,LILLIAN W @ 27 Nov 2017 1108 EST

1. Encounter for pre-employment examination Z02.1: Normal physical exam.
Disposition Written by WILLIAMS,LILLIAN W @ 27 Nov 2017 1108 EST

Signed By WILLIAMS, LILLIAN W (NP-C, Martin Army Community Hospital) @ 27 Nov 2017 1108
2019
Medical Record
2019
16 Nov 2017 at Martin ACH, Fort Benning, GA, Cardiology Clinic by WADZINSKI,
WILLIAM J
Encounter for screening for cardiovascular

disorders
Patient: WAITERS, TOMMIE Date: 16 Nov 2017 1408 EST Appt Type: PROC
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: CARDIOLOGY CLINIC Provider: WADZINSKI,WILLIAM J
BENNING
AutoCites Refreshed by WADZINSKI,WILLIAM J @ 16 Nov 2017 1627 EST

Family History Allergies
•family medical history (General FHx) No Allergies Found.
•family history of test conclusions [Use for
free text] (General FHx)
•daughter's history of test conclusions [Use
for free text] (Daughter)
•no family history of congenital deafness
(General FHx)
•no family history of cancer (General FHx)
•no family history of bleeding problems
(General FHx)
•family history of supplemental HPI [use
for free text] (General FHx)
•family history of nonorganic sleep apnea
(General FHx)
•family history of heart disease
•family history of cancer
•no family history of angina pectoris
•family history [use for free text]
•no family history of mental illness (not
retardation)
•no family history of alcoholism
•no family history of malignant neoplasm of
large intestine
•maternal history of arteriosclerotic
cardiovascular disease (ASCVD)
(Mother)
•paternal history of type 2 diabetes mellitus
(Father)
Other PMHs Social History

No Other PMHs Found. No Social History Found.
Reason for Appointment:Written by GRAY,TARSHA R @ 16 Nov 2017 1408 EST

EKG
Note Written by GRAY,TARSHA R @ 16 Nov 2017 1409 EST
2019
Medical Record
2019
A/P Written by WADZINSKI,WILLIAM J @ 16 Nov 2017 1632 EST
2019
Medical Record
2019
1. Encounter for screening for cardiovascular disorders: Electrocardiogram (EKG)Reason for test: Screening
Normal sinus rhythm

PR interval: Normal
QRS duration: Normal
QT/QTc: Normal
P-P interval: Regular
R-R interval: Regular
Axis: Normal
AV Block: NoneConducting System Abnormality: None
Chamber enlargement: None
Prior infarction: None
Ischemia: None
Ectopy: None
Overall impression:
1. Normal EKG
Procedure(s): -ECG Interpretation And Report Only x 1
Disposition Written by WADZINSKI,WILLIAM J @ 16 Nov 2017 1632 EST

Signed By WADZINSKI, WILLIAM J (MD, MAJ, MC USA, Internal Medicine, MACH) @ 16 Nov 2017 1632
2019
Medical Record
2019
16 Nov 2017 at Martin ACH, Fort Benning, GA, Cardiology Clinic by GRAY, TARSHA R
Encounter for screening for cardiovascular

disorders
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: CARDIOLOGY CLINIC Provider: GRAY,TARSHA R
BENNING
AutoCites Refreshed by GRAY,TARSHA R @ 16 Nov 2017 1305 EST

Family History Allergies
•family medical history (General FHx) No Allergies Found.
•family history of test conclusions [Use for
free text] (General FHx)
•daughter's history of test conclusions [Use
for free text] (Daughter)
•no family history of congenital deafness
(General FHx)
•no family history of cancer (General FHx)
•no family history of bleeding problems
(General FHx)
•family history of supplemental HPI [use
for free text] (General FHx)
•family history of nonorganic sleep apnea
(General FHx)
•family history of heart disease
•family history of cancer
•no family history of angina pectoris
•family history [use for free text]
•no family history of mental illness (not
retardation)
•no family history of alcoholism
•no family history of malignant neoplasm of
large intestine
•maternal history of arteriosclerotic
cardiovascular disease (ASCVD)
(Mother)
•paternal history of type 2 diabetes mellitus
(Father)
Active Medications
Reason for Appointment:Written by GRAY,TARSHA R @ 16 Nov 2017 1304 EST

EKG
Questionnaire AutoCites Refreshed by GRAY,TARSHA R @ 16 Nov 2017 1305 EST

Questionnaires
S/O Note Written by GRAY,TARSHA R @ 16 Nov 2017 1305 EST

Chief complaint
2019
Medical Record
2019
The Chief Complaint is: An EKG was performed by Taisha Gray in the Cardiology Dept and results are pending physician
interpretation.
A/P Written by GRAY,TARSHA R @ 16 Nov 2017 1306 EST

1. Encounter for screening for cardiovascular disorders
Procedure(s): -ECG Performance of Tracing Only x 1
Disposition Written by GRAY,TARSHA R @ 16 Nov 2017 1306 EST

Follow up: with PCM.
Signed By GRAY, TARSHA R (EKG Tech, Martin Army Hospital) @ 16 Nov 2017 1306
2019
Medical Record
2019
16 Nov 2017 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by CAIN, LOIS
R

PROGRAM, ESTABLISH BASELINE
PRIOR TO OCCUPATIONAL
WORKPLACE EXPOSURE
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: OCCUPATIONAL HEALTH FBGA Provider: CAIN,LOIS R
BENNING
AutoCites Refreshed by CAIN,LOIS R @ 16 Nov 2017 1239 EST

Allergies
No Allergies Found.
Active Medications

PRE-EMPLOYMENT PHYS PART 1 NEW GUARD
BRY
Screening Written by CAIN,LOIS R @ 16 Nov 2017 1240 EST

Reason For Appointment: PRE-EMPLOYMENT PHYS PART 1 NEW GUARD
Reason(s) For Visit (Chief Complaint): ROUTINE PRE-EMPLOYMENT SCREENING EXAMINATION WITHOUT ABNORMAL
FINDINGS (New) : Pre-placement physical exam - Part 1;
Comments: POSITION APPLIED FOR: Security Guard
Vitals
Vitals Written by NESMITH,KAREN A @ 16 Nov 2017 1142 EST
BP: 132/78 Left Arm, Adult Cuff, HR: 70, HT: 66 in, WT: 232.0 lbs, BMI: 37.44, BSA: 2.13 square meters, Tobacco
Use: No, Alcohol Use: No,
Questionnaire AutoCites Refreshed by CAIN,LOIS R @ 16 Nov 2017 1239 EST

Questionnaires
Learning Needs Assessment Taken On: 16 Nov 2017

The Selected Provider is CAIN, LOIS R in the Occupational Health FBGA clinic.
2. Do you require a interpreter to speak with your health care provider??Usted necesita un int?rprete para comunicarse con su
proveedor de cuidado m?dico?: No
_______________________________________________________________
5. Do you have any learning barriers?: None;
2019
Medical Record
2019
6. How do you best learn? Please indicate all that apply:: One-on-One Instruction;Reading material;
7. Overall, do you feel motivated to learn more about your health and wellness?: Always;
please list:: None
10. How would you describe your current state of health?]: Good
11. Everyone experiences stress. How well are you managing your current level of stress?: Good
today!): Yes
S/O Note Written by CAIN,LOIS R @ 16 Nov 2017 1543 EST

He reported: General overall feeling well; alert, oriented.
Ear symptoms: Communicates appropriately by spoken word in normal voice tones.
Musculoskeletal symptoms: States he is able to bend, lift, stoop and pick up to 40+ pounds. Demonstrates ability to bend,
squat, push, lift without pain or difficulty.
No allergic/immunologic symptoms . Denies latex sensitivity.
Seen today for pre-employment physical exam - Part 1.
Allergies
An allergy ASA causes HIves.
Vaccinations
T dap current from 2015.
Reported:
Past medical history "Aches & Pains", Planned 50 pound weight loss over past 5 months due to diet changes and exercise.
States he had the flu x 2 weeks ago, no active problems, and no prior serious illness.
Recent Events: No recent events.
Surgical / Procedural: Surgical / procedural history Ganglion cyst removed left wrist x 2. appendectomy - age 21.
Medications: No medication history reported at this time.
Tests: A PPD was not performed Denies travel out of the country in past year. Denies current symptoms of active TB or
known exposure to TB patient: low risk.
Personal history
Physical findings
Eyes:
General/bilateral:
Visual Assessment: • Vision assessed without correction. States he has glasses - reads a lot. • Distance binocular acuity
w/o Rx: 20/ 20 Depth: 9/ 9 color vision: 6/ 6 Peripheral vision to 85* left & right. • Binocular w/o Rx: 20/ 20 (
Near ).
Right Eye:
Visual Assessment: • Distance right acuity without Rx: 20/ 20. • Near vision right eye w/o Rx: 20/ 20 NEAR.
Left Eye:
Visual Assessment: • Distance left acuity without Rx: 20/ 25. • Left eye w/o Rx: 20/ 30 NEAR.
Tests
Lab tests & EKG ordered.
Laboratory Studies:
Pulmonary Function Tests:
Pulmonary function tests Complete PFT is filed in candidate's health record, spirometry performed sitting and standing. Mixed
results. States he does not feel he is at full strenght since experiencing the flu. Plan to repeat PFT when he returns for Part2 of
physical exam, pre-bronchodilator, FVC performed: 2.87 L = 85 %, FEV1 performed: 2.24 L = 81 %, and FEV1 (FEV1/FVC): 0.78
= 95%.
Audiometry:
Audiometry provided IAW current Hearing Conservation program; 2215, WNL. Repeat in one year.
.
A/P Written by CAIN,LOIS R @ 16 Nov 2017 1556 EST

1. EXAM, FORMAL OCCUPATIONAL HEALTH PROGRAM INCLUDING HEARING CONSERVATION PROGRAM, ESTABLISH
BASELINE PRIOR TO OCCUPATIONAL WORKPLACE EXPOSURE
Procedure(s): -Screening Test Of Visual Acuity, Quantitative, Bilateral x 1
-Threshold Audiogram (Pure Tone) x 1
Laboratory(ies): -URINALYSIS (Routine): Pre-employment SG exam. thanx, L. Cain, RN Ordered By: CAIN,LOIS R
2019
Medical Record
2019
Ordering Provider: WILLIAMS, LILLIAN W.; HEMOGRAM AUTO+COMP AUTO DIFF (Routine): Pre-
employment SG exam. thanx, L. Cain, RN Ordered By: CAIN,LOIS R Ordering Provider: WILLIAMS,
LILLIAN W.; BASIC METABOLIC PANEL (Routine) Ordered By: CAIN,LOIS R Ordering Provider:
WILLIAMS, LILLIAN W.; LIPIDS (Routine) Ordered By: CAIN,LOIS R Ordering Provider: WILLIAMS,
LILLIAN W.; HEPATITIS B SURFACE AB (Routine): Job-related baeline. thanx, L. Cain, RN Ordered
By: CAIN,LOIS R Ordering Provider: WILLIAMS, LILLIAN W.; VARICELLA VIRUS AB (Routine): Job-
related baeline. thanx, L. Cain, RN Ordered By: CAIN,LOIS R Ordering Provider: WILLIAMS, LILLIAN
W.; RUBELLA VIRUS AB (Routine) Ordered By: CAIN,LOIS R Ordering Provider: WILLIAMS, LILLIAN
W.; RUBEOLA VIRUS AB (Routine) Ordered By: CAIN,LOIS R Ordering Provider: WILLIAMS, LILLIAN
W.; MUMPS VIRUS AB (Routine) Ordered By: CAIN,LOIS R Ordering Provider: WILLIAMS, LILLIAN W.
2. Encounter for screening for respiratory disorder NEC
Procedure(s): -Spirometry Pre-bronchodilator x 1
Disposition Written by CAIN,LOIS R @ 16 Nov 2017 1557 EST

Follow up: 1 week(s) in the OCCUPATIONAL HEALTH FBGA clinic or sooner if there are problems.
Signed By CAIN, LOIS R (RN, COHN-S, Occupational Health Service) @ 16 Nov 2017 1558
2019
Medical Record
2019
14 Nov 2017 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by HUDSON,
JAMISHA A
Encounter ID: BENN-17911662 Primary Dx: Encounter for immunization
Patient: WAITERS, TOMMIE Date: 14 Nov 2017 1346 EST Appt Type: 24HR
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: FMC SPECIALTY CLINIC Provider: HUDSON,JAMISHA A
BENNING
AutoCites Refreshed by HUDSON,JAMISHA A @ 14 Nov 2017 1401 EST

Allergies
No Allergies Found.
Reason for Appointment:Written by GRAHAM,TONYA @ 14 Nov 2017 1346 EST

Flu Injection
Questionnaire AutoCites Refreshed by HUDSON,JAMISHA A @ 14 Nov 2017 1401 EST

Questionnaires
S/O Note Written by HUDSON,JAMISHA A @ 14 Nov 2017 1401 EST

Outcome of Patient:
[ ] Admitted to:
..............
Patient advised to wait 15 minutes for observation: [ ] Patient declined [ ] Patient waited and assessed by:
Test conclusions
GENERAL VACCINE
S: Pt in need of immunization. Immunization history reviewed for immunization status. Allergy status verified during this encounter.
Pt denies pregnancy at this time. Patient denies any recent immunization that would prevent receiving the above immunization(s).
Patient denies fever.
O: Pre-vaccination Assessment:
Current allergy status shows no contraindications for the above immunization(s).

Patient does not appear ill.
No erythema noted prior to the injection, at the injection site(s).
The following immunization(s) given: Flucelvax
Injection site: Right Deltoid

Given by: D. Lewis, LPN
Time Administered: 1358
Dose: 0.5 mL
Route: IM
Lot # 195248
MFR: SEQ
EXP Date: 06/2018
A/P: 1. Post-Vaccination Assessment:
2019
Medical Record
2019
2. No adverse reactions were reported and the patient left the clinic in good condition
3. Follow up: [x ] PRN [ ] In ___ weeks for booster.
4. VIS dated [ x ] given to patient
..............
A/P Written by HUDSON,JAMISHA A @ 14 Nov 2017 1404 EST

1. Encounter for immunization Z23
Procedure(s): -(90471) Immunization Administration One Vaccine x 1 ADDITIONAL PROVIDER(S):
CHRISTENSEN,SCOTT RYAN
-(90674) Viral Flu Vacc Cell Culture Deriv, Antibiotic Free, Quadrivalent, 0.5mL, IM x 1 ADDITIONAL
PROVIDER(S): CHRISTENSEN,SCOTT RYAN
Disposition Written by HUDSON,JAMISHA A @ 14 Nov 2017 1404 EST

Signed By HUDSON, JAMISHA A (LPN, APCC-IronMike) @ 14 Nov 2017 1404
2019
Medical Record
2019
27 Aug 2017 at Martin ACH, Fort Benning, GA, ER by POWELL, STEPHANIE K

out
Patient: WAITERS, TOMMIE Date: 27 Aug 2017 2200 EDT Appt Type: EROOM
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: EMERGENCY ROOM Provider: POWELL,STEPHANIE KAREN
BENNING
A/P Written by POWELL,STEPHANIE K @ 28 Aug 2017 0103 EDT

1. Encounter for observation for other suspected diseases and conditions ruled out: This documentation is to verify that the
patient was seen in the Emergency Department and this note is signed for administrative purposes only. Patient's encounter
documentation scanned into the HAIMS section in AHLTA, note is titled Emergency Department Encounter.
Disposition Written by POWELL,STEPHANIE K @ 28 Aug 2017 0103 EDT

Signed By POWELL, STEPHANIE K (Physician) @ 28 Aug 2017 0104
2019
Medical Record
2019
PATRICK M

unspecified
ALAJANDRO
Treatment Facility: CBMH NORTH Clinic: AMHM02ASTRONG TEAM Provider: CAREY,PATRICK M
COLUMBUS-BENNING
AutoCites Refreshed by PETERSON,BERNICE @ 27 Dec 2016 1358 EST

Allergies
No Allergies Found.
Reason for Telephone Consult:Written by HOLLIS,GEORGE S @ 23 Dec 2016 1336 EST

Dr. Carey, your pt Mr. Tommie A. Waiters left Medical Report for your perusal
Telephone Consult Comments: Written by HOLLIS,GEORGE S @ 23 Dec 2016 1336 EST
Mr. Tommie A. Waiters left Medical Report For Persons Giving Care To Children for your perusal and completion. Patient request
to be contacted when Report has been completed and signed by contacting him @ 706-326-4585. The Report is in your MailBox in
Distribution.
Note Written by PETERSON,BERNICE @ 27 Dec 2016 1358 EST

Paperwork was picked up today by patient.
1. Encounter for administrative examinations, unspecified Z02.9
Note Written by CAREY,PATRICK M @ 27 Dec 2016 1444 EST

negative CXR. for TB screening.
2019
Medical Record
2019
PATRICK M

unspecified
ALAJANDRO
COLUMBUS-BENNING

Allergies
No Allergies Found.
Labs
No Labs Found.
Rads
No Rads Found.
Vitals
No Vitals Found.
Reason for Telephone Consult:Written by SHELDON,KELSEY N @ 22 Dec 2016 1136 EST

Carey/order x ray
Telephone Consult Comments: Written by SHELDON,KELSEY N @ 22 Dec 2016 1136 EST
General questions for the doctor
PT's phone number: 706-326-4585
Reason: Pt states he is due for TB test, and requesting provider order a chest x-ray. Please call when ordered.
Urgency: Routine
** Pt notified of 72hr respone time**

Subjective
Has positive PPD in past. treated with 5-6 months of INH. His occupation requires annual CXR if hx of + PPD. Will order films. He
will bring in forms to complete for work.
A/P Written by CAREY,PATRICK M @ 22 Dec 2016 1627 EST

Radiology(ies): -CHEST PA/LAT (Routine) Impression: 46 y/o M needs follow up annual screening as occupational
requirement for latent TB.
Disposition Written by CAREY,PATRICK M @ 22 Dec 2016 1627 EST
2019
Medical Record
2019
21 Nov 2016 at Martin ACH, Fort Benning, GA, ER by SMITH, TIFFANY S

out
Patient: WAITERS, TOMMIE Date: 21 Nov 2016 1843 EST Appt Type: EROOM
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: EMERGENCY ROOM Provider: SMITH,TIFFANY S
BENNING
A/P Written by SMITH,TIFFANY S @ 22 Nov 2016 0038 EST

documentation scanned into HAIMS section in AHLTA, note is titled Emergency Department Encounter Note
Disposition Written by SMITH,TIFFANY S @ 22 Nov 2016 0038 EST

Signed By SMITH, TIFFANY S (MEDICAL SUPPORT ASSISTANT, BMACH EMERGENCY DEPARTMENT) @ 22 Nov 2016 0038
2019
Medical Record
2019
30 Sep 2016 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by CAREY,
PATRICK M

unspecified
ALAJANDRO
COLUMBUS-BENNING
AutoCites Refreshed by CAREY,PATRICK M @ 30 Sep 2016 1147 EDT

Allergies
No Allergies Found.
Labs
No Labs Found.
Rads
********** CHEST PA/LAT **********

Status: Complete

Event Date: 16-Sep-2016 19:42:00
Order Comment: Bed 2
Reason for Order: Cough
Exam #: 16096177
Exam Date/Time: 16-Sep-2016 19:49:00
Transcription Date/Time: 17-Sep-2016 10:28:00
EMERGENCY ROOM MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Approved Date: 17-Sep-2016 10:24:00
Report Text:
Chest, Two Views:
History: Cough
Findings: Frontal and lateral views. The heart and lungs are within normal
limits. No acute infiltrate or active disease is seen. The bony structures and
soft tissues are intact.
Vitals
No Vitals Found.
Reason for Telephone Consult:Written by CAREY,PATRICK M @ 30 Sep 2016 1144 EDT

lab results
2019
Medical Record
2019
Telephone Consult Comments: Written by CAREY,PATRICK M @ 30 Sep 2016 1144 EDT

informed pt of negative result.
S/O Note Written by CAREY,PATRICK M @ 30 Sep 2016 1148 EDT

Subjective
s/p vasectomy. no sperm seen.
A/P Last Updated by CAREY,PATRICK M @ 30 Sep 2016 1148 EDT

Disposition Last Updated by CAREY,PATRICK M @ 30 Sep 2016 1148 EDT
Signed By CAREY, PATRICK M (MAJ, MC, DO, CAQSM, RMSK, Family/Sports Medicine Physician) @ 30 Sep 2016 1148
2019
Medical Record
2019
16 Sep 2016 at Martin ACH, Fort Benning, GA, ER by BOGARD, MICHAEL A

out
Patient: WAITERS, TOMMIE Date: 16 Sep 2016 1828 EDT Appt Type: EROOM
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: EMERGENCY ROOM Provider: BOGARD,MICHAEL A
BENNING
A/P Written by BOGARD,MICHAEL A @ 16 Sep 2016 2356 EDT

documentation scanned into HAIMS and is titled ER chart.
Disposition Written by BOGARD,MICHAEL A @ 16 Sep 2016 2356 EDT

Signed By BOGARD, MICHAEL A (MSA, BMACH EMERGENCY DEPARTMENT) @ 16 Sep 2016 2356
2019
Medical Record
2019
15 Jul 2016 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by VEGA, JULIAN
T

examinations
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02ASTRONG TEAM Provider: VEGA,JULIAN T
BENNING
AutoCites Refreshed by VEGA,JULIAN T @ 15 Jul 2016 1518 EDT

Allergies
No Allergies Found.
Vitals
No Vitals Found.
Reason for Telephone Consult:Written by VEGA,JULIAN T @ 15 Jul 2016 1518 EDT

lab results
Note Written by GUNN,TRAVIS B @ 15 Jul 2016 1534 EDT

pt active in relay health.message sent regarding lab results.will lcosae t-con
Lab Result Cited by VEGA,JULIAN T @ 15 Jul 2016 1518 EDT
Tissue Exam
Date Collected: 30 Jun 2016 1010
POC Enc: E258485
Enc Fac: Martin ACH, Fort Benning, GA
Clinician: VEGA, JULIAN T
Status: Certify
Procedure: TISSUE EXAM
Order #: 160708-02828
Provider: VEGA, JULIAN T
Ordered Date: 08 Jul 2016 1111
Priority: ROUTINE
Specimen: TISSUE
Resulted Date: 14 Jul 2016 1549.1-0400
Col: 30Jun16@1010 TISSUE(TISSUE)
Hcp: VEGA,JULIAN T Req Loc: FMC SPEC
Performing Lab: ANATOMICAL PATHOLOGY
160708 S 2069
TISSUE E C: JDP14Jul16@1549
CoPath Report
Patient: WAITERS,TOMMIE ALAJANDRO Specimen #: S16-2069
Accessioned: 07/08/16
Pathologist: Jeffrey D. Prichard, CPT, MC
SPECIMEN:
A: right vas B: left vas
CLINICAL DIAGNOSIS AND HISTORY:
45 yo male present for vasectomy
PRE-OPERATIVE DIAGNOSIS:
vasectomy
POST-OPERATIVE DIAGNOSIS:
Operative Findings: vasectomy
Post-operative Diagnosis: vasectomy
GROSS DESCRIPTION:
Received as two parts labeled A and B and each part labeled
"Waiters,
Tommie 20/1757."
Part A - Labeled "Right vas" - A specimen consisting of a single tan
2019
Medical Record
2019
approximately 0.1
cm in diameter and submitted intact entirely in cassette A1.
Part B - Labeled "Left vas" - A specimen consisting of a single tan
approximately 0.5
cm in diameter and submitted intact entirely in cassette B1.
FINAL DIAGNOSIS:
A. VAS, RIGHT, VASECTOMY:
-- UNREMARKABLE VAS DEFERENS, COMPLETE LUMEN
IDENTIFIED.
B. VAS, RIGHT, VASECTOMY:
-- UNREMARKABLE VAS DEFERENS WITH SURROUNDING
SMALL CALIBER VESSELS,
COMPLETE LUMEN IDENTIFIED.
jdp/07/14/16 ** Report Electronically Signed **
Jeffrey D. Prichard, CPT, MC
CPT Codes:
microscopic
evaluation
microscopic
evaluation
SNOMED CODES
1. M00100; P1100; T79200; T79210
2. M00100; P1100; T79200; T79210
A/P Last Updated by VEGA,JULIAN T @ 15 Jul 2016 1519 EDT

1. Encounter for other administrative examinations: Please call the patient and inform him that both vas deferens were identified
on tissue exam. Thank you
Disposition Last Updated by VEGA,JULIAN T @ 15 Jul 2016 1550 EDT

Signed By VEGA, JULIAN T (Captain, Physician DO PGY 3, Licensed Physician, Family Medicine Resident, MACH) @ 15 Jul
2016 1551
_________________________________________________________________________________________________________
CHANGE HISTORY
The following Disposition Note Was Overwritten by GUNN,TRAVIS B @ 15 Jul 2016 1534 EDT:
The Disposition section was last updated by GUNN,TRAVIS B @ 15 Jul 2016 1534 EDT - see above.Previous Version of Disposition section was entered/updated by
VEGA,JULIAN T @ 15 Jul 2016 1518 EDT.
2019
Medical Record
2019
05 Jul 2016 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by VEGA, JULIAN T
Encounter ID: BENN-16595277 Primary Dx: Essential (primary) hypertension
Patient: WAITERS, TOMMIE Date: 05 Jul 2016 0920 EDT Appt Type: PROC
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: FMC SPECIALTY CLINIC Provider: VEGA,JULIAN T
BENNING

Allergies
No Allergies Found.
Vitals
No Vitals Found.

vas pop
bjs
Vitals
Vitals Written by VEGA,JULIAN T @ 05 Jul 2016 1421 EDT
BP: 145/89, HR: 76, RR: 18, T: 98.1 °F, Tobacco Use: No, Alcohol Use: No, Pain Scale: 3/10 Mild
S/O Note Written by VEGA,JULIAN T @ 05 Jul 2016 1421 EDT

Chief complaint
The Chief Complaint is: Vasectomy post op.
Note Written by VEGA,JULIAN T @ 06 Jul 2016 0837 EDT

AHLTA down at the time of the encounter. The encouter was entered on 06July 2016.
SO: The patient's pain is 3/10. He reports being able to walk without discomfort. No acute concerns. Denies fever, chills, swelling,
bruising, bleeding, hematuria. He states that he has not ejaculated since procedure.
vital signs reviewed

PE: penis - normal, scrotum - incision healing normally, no redness, or swelling present.
A/P Written by VEGA,JULIAN T @ 06 Jul 2016 0841 EDT

1. Essential (primary) hypertension: follow up with PCM.
2. Vasectomy status: Pt is healing normally. Orders entered for post vasectomy semenalysis. pending tissue exam of vas
deferens. Pt to continue return to activity, using scrotal support. Tylenol and motrin as needed for pain. pt verbalized agreement.
Disposition Written by VEGA,JULIAN T @ 06 Jul 2016 0841 EDT

Follow up: as needed in 4 week(s) with PCM or sooner if there are problems.
Signed By VEGA, JULIAN T (Captain, Physician DO PGY 3, Licensed Physician, Family Medicine Resident, MACH) @ 06 Jul
2016 0841
2019
Medical Record
2019
30 Jun 2016 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by VEGA, JULIAN T
Encounter ID: BENN-16590210 Primary Dx: Encounter for sterilization
Patient: WAITERS, TOMMIE Date: 30 Jun 2016 1100 EDT Appt Type: PROC
ALAJANDRO
BENNING
AutoCites Refreshed by VEGA,JULIAN T @ 30 Jun 2016 1008 EDT

Allergies
No Allergies Found.
Vitals
No Vitals Found.

vas
bjs
Vitals
Vitals Written by SMITH,AUSTIN M @ 30 Jun 2016 1020 EDT
BP: 127/87, HR: 85, RR: 18, T: 98.8 °F, HT: 66 in, WT: 243 lbs, BMI: 39.22, BSA: 2.173 square meters,
S/O Note Written by VEGA,JULIAN T @ 30 Jun 2016 1032 EDT

Chief complaint
The Chief Complaint is: Vasectomy counseling.
A 45 yr old AAM present today for referral for Vasectomy . Pt already have 5 children ranging from 3wks to 22yrs. Has discussed
with spouse and both are happy with their family and do not desire further children. In stable monogomous relationship. Patient
understands irreversability of procuedre and would not desire further children under any circumstances. Pt has no history of
testicular trauma. No history of STDs.
General overall feeling /health - Very Good.

PHQ-2 Depression Screen Negative.
Procedure Final Time Out:
[ X ] Yes [ ] No Patient was identified using full name plus any suffix and DOB.
[ X ] Yes [ ] No Patient was evaluated and medical record reviewed to include medical history and laboratory findings, if ordered.
[ ] Yes [ ] No [ X ] N/A Radiographs are properly oriented and correct laterality has been visually confirmed (if applicable).
[ ] Yes [ ] No [ X ] N/A Procedure and site/side matches the consent form (if applicable).
[ ] Yes [ ] No [ X ] N/A Patient was involved in the site/side marking (if applicable).
[ X ] Yes [ ] No Final Time Out - Physician paused (if alone) or verbally confirmed with the procedure team that this is the correct
patient, procedure and site/side (if applicable). The patient has been positioned correctly for the procedure. All necessary
equipment and implants are available.
.........
Patient has NOT received other care since their last visit with this clinic. Pt was last seen urology. He will be referred to Gastro.
Allergies
.
Current medication
2019
Medical Record
2019

ASA 81 MG EVERY DAY


Updated 6/1/2016
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Family history
CA- mother- bresat
father- DM.
.
Review of systems
Head: No headache.
Physical findings
Vital Signs:
2019
Medical Record
2019
General Appearance:
Lungs:
Genitalia:
Penis: ° Normal.
Scrotum: ° Normal.
Testes: ° Normal.
Neurological:
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Skin:
Test conclusions
Procedure Counseling: Possible limitations and risks include pain.
Procedure Counseling: Possible limitations and risks include bleeding.
Procedure Counseling: Possible limitations and risks include infection.
Procedure Counseling: Possible limitations and risks include complications from anesthesia.
Procedure Counseling: Possible limitations and risks include partial success requiring repetition of procedure.
Procedure Counseling: Checklist - Verified the signed consent form is in the chart.
Procedure Counseling: Peri-operative risks, benefits, and limitations discussed and understood - patient wished to proceed.
VASECTOMY
An examination of the genitals is normal; both testes normal without tenderness, masses, hydroceles, varicoceles, erythema or
swelling.
Shaft normal, meatus normal without discharge. No inguinal hernia noted. No inguinal lymphadenopathy. Anatomic landmarks were
confirmed
Under sterile conditions, a 1-2 cm wheal was made at median raphe with 1% Lidocaine without Epinephrine was administered to
provide local skin anesthesia. The median raphe was dissected with a sharp hemostat. The needle is then advanced through the
wheal parallel and adjacent to the Left Vas and toward the external inguinal ring. After gentle aspiration, 2-5 cc of 1% Lidocaine
without Epinephrine was injected into the external spermatic fascia.
The Left Vas was maneuvered to the desired location to the opening at the median raphe. The soft tissue is then bluntly dissected
with a fine cured hemostat. The Left Vas was elevated through the incision and exposed under the midline scrotal raphe 1 cm below
the base of the penis. The Vas was hemitransceted and thermal cautery applied to a 1 cm length inside the lumen of the prosthetic
end of the cut vas until blanching occurred. The vas was then completely transected, and the testicular end left open. A section of
the vas was sent to pathology for confirmation. The area was inspected thoroughly and good hemostasis was noted before the vas
was reduced back into the scrotum. The procedure was repeated in the Right Vas. The estimated blood loss was <2 cc. Skin was
dressed with sterile gauze. Tape was applied to keep the bandage on overnight, and scrotal support placed. The patient tolerated
the procedure well.
.........
Practice Management
Colonoscopy - n/a

.
Patient
A/P Last Updated by VEGA,JULIAN T @ 30 Jun 2016 1019 EDT
2019
Medical Record
2019
1. Encounter for sterilization: 45 yo male received vasectomy on the 30Jun2016 . Pt tolerated the procedure well no acute
concerns, minimal bruising and normal healing of the scrotum occurring. The patient was instructed to use scrotal support. Limit
physical activity. Patient given instructions (handout) regarding physical activity. Patient given return precautions. Tissue pathology
pending. Pt informed to use alternative form of contraception until semen analysis completed. Semen analysis ordered for 4 weeks
from today. Will call the patient with results. Pt has narcotics to use over the weekend. Pt to return on 5Jul2016 for follow up
appointment. Pt verbalized agreement.
Procedure(s): -Surgery Vas Deferens Vasectomy x 1

-Dr.-Supervised Specimen Handling / Transfer: Office To Lab x 1
Laboratory(ies): -TISSUE EXAM (Routine); SEMEN POST VASECTOMY (Routine) Start Date: 07/28/2016
Disposition Last Updated by VEGA,JULIAN T @ 30 Jun 2016 1033 EDT

Follow up: as needed in 5 day(s) with PCM or sooner if there are problems.
Signed By VEGA, JULIAN T (Captain, Physician DO PGY 3, Licensed Physician, Family Medicine Resident, MACH) @ 30 Jun
2016 1033
Co-Signed By PARK, JAMES J (Physician) @ 30 Jun 2016 1309
_________________________________________________________________________________________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by VEGA,JULIAN T @ 30 Jun 2016 1032 EDT:
S/O Note Written by SMITH,AUSTIN M @ 30 Jun 2016 1021 EDT
Chief complaint
A 45 yr old AAM present today for referral for Vasectomy . Pt already have 5 children ranging from 3wks to 22yrs. Has discussed with spouse and both are happy with their
family and do not desire further children. In stable monogomous relationship. Patient understands irreversability of procuedre and would not desire further children under any
circumstances. Pt has no history of testicular trauma. No history of STDs.

[ X ] Yes [ ] No Final Time Out - Physician paused (if alone) or verbally confirmed with the procedure team that this is the correct patient, procedure and site/side (if
applicable). The patient has been positioned correctly for the procedure. All necessary equipment and implants are available.
.........
Allergies
.
Current medication
ASA 81 MG EVERY DAY


Updated 6/1/2016
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
2019
Medical Record
2019
ABD LAPROSCOPY 2012

.
Personal history
Children: 3.
Family history
CA- mother- bresat
father- DM.
.
Review of systems
Head: No headache.
Test conclusions
VASECTOMY
An examination of the genitals is normal; both testes normal without tenderness, masses, hydroceles, varicoceles, erythema or swelling.
Shaft normal, meatus normal without discharge. No inguinal hernia noted. No inguinal lymphadenopathy. Anatomic landmarks were confirmed
Under sterile conditions, a 1-2 cm wheal was made at median raphe with 1% Lidocaine without Epinephrine was administered to provide local skin anesthesia. The median
raphe was dissected with a sharp hemostat. The needle is then advanced through the wheal parallel and adjacent to the Left Vas and toward the external inguinal ring. After
gentle aspiration, 2-5 cc of 1% Lidocaine without Epinephrine was injected into the external spermatic fascia.
The Left Vas was maneuvered to the desired location to the opening at the median raphe. The soft tissue is then bluntly dissected with a fine cured hemostat. The Left Vas was
elevated through the incision and exposed under the midline scrotal raphe 1 cm below the base of the penis. The Vas was hemitransceted and thermal cautery applied to a 1
cm length inside the lumen of the prosthetic end of the cut vas until blanching occurred. The vas was then completely transected, and the testicular end left open. A section of
the vas was sent to pathology for confirmation. The area was inspected thoroughly and good hemostasis was noted before the vas was reduced back into the scrotum. The
procedure was repeated in the Right Vas. The estimated blood loss was <2 cc. Skin was dressed with sterile gauze. Tape was applied to keep the bandage on overnight, and
scrotal support placed. The patient tolerated the procedure well.
.........
Practice Management
Colonoscopy - n/a

.
Patient
The following S/O Note Was Overwritten by SMITH,AUSTIN M @ 30 Jun 2016 1022 EDT:
Chief complaint
2019
Medical Record
2019
circumstances. Pt has no history of testicular trauma. No history of STDs.

[ X ] Yes [ ] No Final Time Out - Physician paused (if alone) or verbally confirmed with the procedure team that this is the correct patient, procedure and site/side (if
.........
Allergies
.
Current medication
ASA 81 MG EVERY DAY


Updated 6/1/2016
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Family history
CA- mother- bresat
father- DM.
.
Review of systems
Head: No headache.
2019
Medical Record
2019

Test conclusions
VASECTOMY
An examination of the genitals is normal; both testes normal without tenderness, masses, hydroceles, varicoceles, erythema or swelling.
Shaft normal, meatus normal without discharge. No inguinal hernia noted. No inguinal lymphadenopathy. Anatomic landmarks were confirmed
Under sterile conditions, a 1-2 cm wheal was made at median raphe with 1% Lidocaine without Epinephrine was administered to provide local skin anesthesia. The median
raphe was dissected with a sharp hemostat. The needle is then advanced through the wheal parallel and adjacent to the Left Vas and toward the external inguinal ring. After
gentle aspiration, 2-5 cc of 1% Lidocaine without Epinephrine was injected into the external spermatic fascia.
The Left Vas was maneuvered to the desired location to the opening at the median raphe. The soft tissue is then bluntly dissected with a fine cured hemostat. The Left Vas was
elevated through the incision and exposed under the midline scrotal raphe 1 cm below the base of the penis. The Vas was hemitransceted and thermal cautery applied to a 1
cm length inside the lumen of the prosthetic end of the cut vas until blanching occurred. The vas was then completely transected, and the testicular end left open. A section of
the vas was sent to pathology for confirmation. The area was inspected thoroughly and good hemostasis was noted before the vas was reduced back into the scrotum. The
procedure was repeated in the Right Vas. The estimated blood loss was <2 cc. Skin was dressed with sterile gauze. Tape was applied to keep the bandage on overnight, and
scrotal support placed. The patient tolerated the procedure well.
.........
Practice Management
Colonoscopy - n/a

.
Patient
2019
Medical Record
2019
27 Jun 2016 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by VEGA, JULIAN T
Patient: WAITERS, TOMMIE Date: 27 Jun 2016 0920 EDT Appt Type: PROC
ALAJANDRO
BENNING

Allergies
No Allergies Found.
Vitals
BP: 126/80, HR: 88, RR: 18, T: 98.1 °F, HT: 66 in, WT: 243 lbs, BMI: 39.22, BSA: 2.173 square meters, Tobacco Use: No, Alcohol
Use: No,

vas preop
bjs
Vitals

understands irreversability of procuedre and would not desire further children under any circumstances. Pt has no history of
testicular trauma. No history of STDs.

Allergies
.
Current medication
ASA 81 MG EVERY DAY


Updated 6/1/2016
2019
Medical Record
2019
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Family history
CA- mother- bresat
father- DM.
.
Review of systems
Head: No headache.
Physical findings
Vital Signs:
General Appearance:
Lungs:
Genitalia:
Penis: ° Normal.
Scrotum: ° Normal.
Testes: ° Normal.
2019
Medical Record
2019
Neurological:
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Skin:
Practice Management
Colonoscopy - n/a

.
Patient
A/P Last updated by VEGA,JULIAN T @ 27 Jun 2016 1017 EDT

1. Encounter for sterilization: 45 yo male presents for pre-op vasectomy appointment. He has 6 children and would like to have
permanent sterilization. He understands the risks and benefits of the elective procedure. He signed the consent form. Patient given
preop information packet to review and instructions. Patient given prescription for Valium to use before procedure and pain
medication to use afterward. Patient will follow up Thursday for his appointment. If he has any questions to call clinic. Patient
verbalizes agreement.
Medication(s): -OXYCODONE/APAP 5MG/325MG ORAL TAB--PO 5M - TAKE ONE EVERY 4-6 HOURS AS NEEDED
#10 RF0 Ordered By: SMITH,AUSTIN M Ordering Provider: VEGA, JULIAN T
-DIAZEPAM (VALIUM)--PO 5MG TAB - TAKE ONE TABLET THIRTY MINUTES PRIOR TO
PROCEDURE AND TAKE ANOTHER AT PROCEDURE TIME #2 RF0 Ordered By: SMITH,AUSTIN M
Ordering Provider: VEGA, JULIAN T
Disposition Last updated by VEGA,JULIAN T @ 27 Jun 2016 1017 EDT

Follow up: as needed in 3 with PCM or sooner if there are problems.
30 minutes face-to-face/floor time. >50% of appointment time spent counseling and/or coordinating care.
Note Written by TAFT,ROBERT M @ 27 Jun 2016 0921 EDT

Consult Order
Referring Provider: CALLAHAN, ROBERT C
Date of Request: 01 Jun 2016
Priority: Routine
Encounter for sterilization
Reason for Request:
45yo black male retiree who desires permenant sterilization. Please evaluate and treat, thank you!! pt contact #: 706-326-4585
Signed By VEGA, JULIAN T (Captain, Physician DO PGY 3, Licensed Physician, Family Medicine Resident, MACH) @ 27 Jun
2016 1017
_________________________________________________________________________________________________________
CHANGE HISTORY
2019
Medical Record
2019
The following S/O Note Was Overwritten by VEGA,JULIAN T @ 27 Jun 2016 1017 EDT:
circumstances.

Allergies
.
Current medication
ASA 81 MG EVERY DAY


Updated 6/1/2016
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Family history
CA- mother- bresat
father- DM.
.
Review of systems
Head: No headache.
Physical findings
Vital Signs:
General Appearance:
2019
Medical Record
2019

Lungs:
° Respiration rhythm and depth was normal. ° Exaggerated use of accessory muscles for inspiration was not observed. ° Clear to auscultation. ° No wheezing was
heard. ° No rhonchi were heard. ° No rales/crackles were heard.
Genitalia:
Penis: ° Normal.
Scrotum: ° Normal.
Testes: ° Normal.
Neurological:
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Skin:
Practice Management
Colonoscopy - n/a

.
Patient
The following Disposition Note Was Overwritten by VEGA,JULIAN T @ 27 Jun 2016 1016 EDT:
The Disposition section was last updated by VEGA,JULIAN T @ 27 Jun 2016 1016 EDT - see above.Previous Version of Disposition section was entered/updated by
SMITH,AUSTIN M @ 27 Jun 2016 0945 EDT.
The following A/P Note Was Overwritten by VEGA,JULIAN T @ 27 Jun 2016 1015 EDT:
The A/P section was last updated by VEGA,JULIAN T @ 27 Jun 2016 1015 EDT - see above.Previous Version of A/P section was entered/updated by SMITH,AUSTIN M @ 27
Jun 2016 0937 EDT.
1. Encounter for sterilization
Medication(s): -OXYCODONE/APAP 5MG/325MG ORAL TAB--PO 5M - TAKE ONE EVERY 4-6 HOURS AS NEEDED #10 RF0 Ordered By:
SMITH,AUSTIN M Ordering Provider: VEGA, JULIAN T
-DIAZEPAM (VALIUM)--PO 5MG TAB - TAKE ONE TABLET THIRTY MINUTES PRIOR TO PROCEDURE AND TAKE ANOTHER AT
PROCEDURE TIME #2 RF0 Ordered By: SMITH,AUSTIN M Ordering Provider: VEGA, JULIAN T
2019
Medical Record
2019
01 Jun 2016 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by CALLAHAN,
ROBERT CHARLES
Patient: WAITERS, TOMMIE Date: 01 Jun 2016 1320 EDT Appt Type: 24HR
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02ASTRONG TEAM Provider: CALLAHAN,ROBERT
BENNING CHARLES

Carey/ vasectomy/ 404 421 3064
rmt
Vitals
Vitals Written by BATTLES,YVETTE D @ 01 Jun 2016 1345 EDT
S/O Note Written by CALLAHAN,ROBERT CHARLES @ 01 Jun 2016 1357 EDT

Chief complaint
The Chief Complaint is: Referral for vasectomy.
understands irreversability of procuedre and would not desire further children under any circumstances.
Abdominal pain Currently being referred to GI.
Back pain CHRONIC. NO PAIN TODAY.
Visit is not deployment-related.
Allergies
.
Current medication
ASA 81 MG EVERY DAY


Updated 6/1/2016
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
2019
Medical Record
2019
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Family history
CA- mother- bresat
father- DM.
.
Review of systems
Head: No headache.
Gastrointestinal: No nausea, no vomiting, no bright red blood per rectum, no diarrhea, and no constipation.
Psychological: Not thinking about suicide. No homicidal thoughts.
Physical findings
Vital Signs:
General Appearance:
Head:
Eyes:
General/bilateral:
Pupils: ° Size of the pupil was normal.
Sclera: ° Normal.
Ears:
General/bilateral:
External Auditory Canal: ° External auditory meatus normal.
Oral Cavity:
2019
Medical Record
2019
Functional Exam:
Neurological:
Balance: ° Normal.
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Skin:
Test conclusions
A qualified individual compared the medication list against any orders, and resolved any discrepancies (if required).
A written list of medications was given to the patient.
The patient was educated on the importance of managing medication information.
Practice Management
Colonoscopy - n/a

.
Patient
A/P Written by CALLAHAN,ROBERT C @ 01 Jun 2016 1357 EDT

1. Encounter for sterilization Z30.2: 45yo black male retiree with 5 children who desires permenant sterilization. No concerning
history and patient has discussed with partner who agrees with decision.
- Reviewed procedure with patient
- Referral placed
- Patient reports understanding and agreement, all questions answered.
Consult(s): -Referred To: FPC VASECTOMY (Routine) Specialty: Clinic: FMC SPECIALTY CLINIC Provisional
Diagnosis: Encounter for sterilization Ordered By: CALLAHAN,ROBERT C Ordering Provider:
CALLAHAN,ROBERT CHARLES
Disposition Written by CALLAHAN,ROBERT C @ 01 Jun 2016 1408 EDT

Follow up: as needed with PCM and/or in the AMHM02ASTRONG TEAM clinic.
Signed By CALLAHAN, ROBERT C (DO, PGY-II, Licensed Physician, Family Medicine Residency Program, DPC) @ 01 Jun 2016
1408
_________________________________________________________________________________________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by CALLAHAN,ROBERT C @ 01 Jun 2016 1407 EDT:
S/O Note Written by BATTLES,YVETTE D @ 01 Jun 2016 1346 EDT
Chief complaint
The Chief Complaint is: Referral for vasectomy.
2019
Medical Record
2019
A 45 yr old AAM present today for referral for Vasectomy . Pt already have 5 children.
Allergies
.
Current medication
ASA 81 MG EVERY DAY


Updated 6/1/2016
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Family history
CA- mother- bresat
father- DM.
.
Review of systems
Head: No headache.
Gastrointestinal: No nausea and no vomiting. Abdominal pain Currently being referred to GI. No bright red blood per rectum, no diarrhea, and no constipation.
Musculoskeletal: Back pain CHRONIC. NO PAIN TODAY.
Psychological: Not thinking about suicide. No homicidal thoughts.
Physical findings
Vital Signs:
General Appearance:
Neurological:
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Test conclusions
2019
Medical Record
2019
Practice Management
Colonoscopy - n/a

.
Patient
2019
Medical Record
2019
31 May 2016 at Martin ACH, Fort Benning, GA, Surgery by SALADYGA, ANNE T
Encounter ID: BENN-16507825 Primary Dx: Sclerosing mesenteritis
Patient: WAITERS, TOMMIE Date: 31 May 2016 1430 EDT Appt Type: SPEC
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: SURGERY Provider: SALADYGA,ANNE TERESA
BENNING
AutoCites Refreshed by SALADYGA,ANNE T @ 01 Jun 2016 1716 EDT

Allergies
No Allergies Found.

mesenteric panniculitus-letter sent
crp
S/O Note Written by SALADYGA,ANNE TERESA @ 01 Jun 2016 1719 EDT

Chief complaint
The Chief Complaint is: LUQ pain.
LATE ENTRY: PATIENT SEEN 31May16. This is a 45-year-old male who presents to the general surgery clinic for reevaluation of
the left upper quadrant pain and mesenteric panniculitis. The patient initially presented to the Gen. surgery clinic in 2008 and was a
patient of Dr. McGuigan. In 2008 she completed an extensive workup to include abdominal CT scan and MRI. The patient
underwent mesenteric biopsy which was inconclusive but not suggestive of lymphoma or a mesenteric sclerosis. EGD showed
Helicobacter pylori gastritis for which he was treated but did not resolve his left upper quadrant pain. A subsequent MRI finding
showed resolution of the inflammation at the root of the mesentery. The patient then re- presented in 2013 with continued
complaints of left upper quadrant pain. The patient was given referral for her EGD and colonoscopy for which never occurred, and
the patient was lost to followup.
The patient presents today complaining of increased consistency of his left upper quadrant pain. He notes the pain is 6/10, and feels
almost like a runners cramp. The patient notes the pain has been consistent over the past several months which concerns him. The
patient has not been able to find any aggravating her mitigating factors. Advil does not work for his pain. The patient denies early
satiety. The patient denies nausea, vomiting, fever, chills. He notes that perhaps the pain became worse after eating oysters and
clamps and obtaining food poisoning in 2013.

Allergies
NKDA
.
Current medication
None
.
Reported:
Medical: Reported medical history Helicobacter pylori gastritis treated in 2008, 2011 high blood pressure
.
Surgical / Procedural: Surgical / procedural history Appendectomy 1991
Ganglion cyst left wrist 2001
Laparoscopic mesenteric biopsy of 2008
.
Personal history
Social history reviewed Denies alcohol/tobacco use at present.
Behavioral: No tobacco use history.
Alcohol: Not using alcohol AUDIT-C Date:
Family history
Family medical history Mom - Htn, MI X1
2019
Medical Record
2019
Dad DM.
Review of systems
Head: Headache.
Musculoskeletal: No back pain. Pain localized to one or more joints.
Physical findings
General Appearance:
Head:
Neck:
Eyes:
General/bilateral:
Pupils: ° Size of the pupil was normal. ° Pupil accommodation was not impaired.
Sclera: ° Normal.
Ears:
General/bilateral:
Nose:
General/bilateral:
Lymph Nodes:
were not enlarged.
Lungs:
Cardiovascular:
Abdomen:
Palpation: • Abdominal tenderness Mild tenderness to palpation of the left upper quadrant without peritoneal signs. • A mass
was palpated in the abdomen Slight fullness on the left upper corner and the abdomen. ° Abdomen was soft. ° No
abdominal guarding.
Hernia: ° No hernia was discovered.
Functional Exam:
Neurological:
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Test conclusions
Rad Result Cited by SALADYGA,ANNE T @ 01 Jun 2016 1728 EDT
2019
Medical Record
2019
********** CT ABDOMEN/PELVIS W/ CONTRAST **********
Status: Complete
Procedure: CT ABDOMEN/PELVIS W/ CONTRAST

Event Date: 20-Apr-2016 23:30:00
Exam #: 16040758
Exam Date/Time: 21-Apr-2016 01:25:00
Transcription Date/Time: 21-Apr-2016 09:00:00
Status: COMPLETE
Approved Date: 21-Apr-2016 09:17:00
Report Text:
TECHNIQUE: Axial images were obtained from the lung bases through the pubic
symphysis after oral and intravenous contrast administration.
FINDINGS: The lung bases are unremarkable. The liver, spleen, pancreas,
gallbladder, kidneys and adrenal glands are normal. There are prominent lymph
nodes seen within the root of the mesentery with mild inflammation in the root
of the mesentery. Findings may represent mesenteric panniculitis. Otherwise
there is no mesenteric, retroperitoneal or pelvic lymphadenopathy. There is no
abdominal or pelvic ascites. The bowel is normal without evidence of obstruction
or inflammation. There is no abscess or fluid collection. The urinary bladder
and pelvic structures are unremarkable.
IMPRESSION: Mild inflammation in the root of the mesentery. Findings may

represent mesenteric panniculitis. Otherwise unremarkable CT of the abdomen and
pelvis.
2019
Medical Record
2019
A/P Written by SALADYGA,ANNE T @ 01 Jun 2016 1733 EDT

1. Sclerosing mesenteritis K65.4: Patient with multiple imaging studies and symptoms suggestive of mesenteric panniculitis,
although etiology is unknown. The patient is having increasing symptoms which warrant further evaluation. I will begin with the last
plans evaluation which is EGD and colonoscopy, particularly since the patient has never had evaluation of his colon. In placing a
consult to gastroenterology for evaluation and treatment of mesenteric panniculitis, but also for EGD and colonoscopy.
Gastroenterology may have more ideas on how to treat the patient's pain. I would like to see the patient back, as I feel another
mesentery biopsy is warranted to see if there has been a declaration of the etiology. At this point I have no treatment or surgery to
help the patient's pain, as I discussed with the patient, but the best plan is to continue with evaluation for a cause. The patient will
return to see me in approximately one week after EGD and colonoscopy.
Consult(s): -Referred To: GASTROENTEROLOGY CONSULT (Routine) Specialty: Clinic: GASTROENTEROLOGY
CLINIC Provisional Diagnosis: Sclerosing mesenteritis Order Date: 06/01/2016 17:32 Ordered By:
SALADYGA,ANNE T Ordering Provider: SALADYGA,ANNE TERESA
Disposition Written by SALADYGA,ANNE T @ 01 Jun 2016 1734 EDT

Follow up: 3 to 6 week(s) in the SURGERY clinic or sooner if there are problems.
Note Written by PAUL,CORAZON R @ 31 May 2016 1403 EDT

Consult Order
Referring Provider: LESTER, JOSEPH L
Date of Request: 21 Apr 2016
Priority: Routine
mesenteric panniculitus
Reason for Request:
mesenteric panniculitus per ct scan, wbc = 9.3
Signed By SALADYGA, ANNE T (Major, MC, MD, Martin AHC; Fort Benning, GA) @ 01 Jun 2016 1735
_________________________________________________________________________________________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by SALADYGA,ANNE T @ 01 Jun 2016 1720 EDT:
S/O Note Written by HICE,LAURIE E @ 31 May 2016 1442 EDT
Chief complaint
The Chief Complaint is: LUQ pain.
Pt states he has had discomfort in his LUQ for several years but has worsened over the last several months. States it is a constant discomfort on a scale of 6 - 7.
.
Allergies
NKDA
.
Current medication
None
.
Reported:
Medical: Reported medical history H. Pylori 2011
Htn - trying to control with diet
.
.
Personal history
Family history
Dad DM
2019
Medical Record
2019
20 Apr 2016 at Martin ACH, Fort Benning, GA, ER by BOGARD, MICHAEL A

out
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: EMERGENCY ROOM Provider: BOGARD,MICHAEL A
BENNING
A/P Written by BOGARD,MICHAEL A @ 21 Apr 2016 0456 EDT

documentation scanned into HAIMS and is titled ER chart.
Disposition Written by BOGARD,MICHAEL A @ 21 Apr 2016 0456 EDT

Signed By BOGARD, MICHAEL A (MSA, BMACH EMERGENCY DEPARTMENT) @ 21 Apr 2016 0456
2019
Medical Record
2019
23 Mar 2016 at Martin ACH, Fort Benning, GA, ER by SMITH, TIFFANY S

out
Patient: WAITERS, TOMMIE Date: 23 Mar 2016 2117 EDT Appt Type: EROOM
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: EMERGENCY ROOM Provider: SMITH,TIFFANY S
BENNING
A/P Written by SMITH,TIFFANY S @ 23 Mar 2016 2341 EDT

1. Encounter for observation for other suspected diseases and conditions ruled out:
This documentation is to verify that the patient was seen in the Emergency Department and this note is signed for administrative
purposes only. Patient's encounter documentation scanned into clinical notes section in AHLTA, note is titled Emergency
Department Encounter Note
Disposition Written by SMITH,TIFFANY S @ 23 Mar 2016 2341 EDT

Signed By SMITH, TIFFANY S (MEDICAL SUPPORT ASSISTANT, BMACH EMERGENCY DEPARTMENT) @ 23 Mar 2016 2341
2019
Medical Record
2019
28 Jan 2016 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by WOODS,
STEPHANIA

examinations
Patient: WAITERS, TOMMIE Date: 28 Jan 2016 0920 EST Appt Type: T-CON*
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02DEAGLE TEAM Provider: WOODS,STEPHANIA
BENNING
AutoCites Refreshed by TRIMUEL,SHARITA K @ 28 Jan 2016 0920 EST

Allergies
No Allergies Found.
Labs
No Labs Found.
Rads
No Rads Found.
Vitals
No Vitals Found.
Lab Result Cited by TRIMUEL,SHARITA K @ 28 Jan 2016 0921 EST

Rubeola Virus Ab Site/Specimen 22 Dec 2015 1455
Mumps Virus Ab Site/Specimen 22 Dec 2015 1455

Varicella Virus Ab Site/Specimen 22 Dec 2015 1455

Varicella Zoster Virus Ab SERUM POSITIVE 
Hepatitis B Virus Surface Ab Site/Specimen 22 Dec 2015 1455

Hepatitis B Virus Surface Ab SERUM POSITIVE 
Rubella Virus Ab Site/Specimen 22 Dec 2015 1455

A/P Last Updated by TRIMUEL,SHARITA K @ 28 Jan 2016 0922 EST

1. Encounter for other administrative examinations Z02.89: i do not know this patient. but he is immune to rubella, mumps,
hepb, varicella
Disposition Written by WOODS,STEPHANIA @ 02 Feb 2016 1304 EST

Referred for Appointment
Note Written by WOODS,STEPHANIA @ 02 Feb 2016 1155 EST

PATIENT NOTIFIED OF ABOVE INFO. UNDERSTANDING VOICED.
Signed By WOODS, STEPHANIA (LPN) @ 02 Feb 2016 1304

_________________________________________________________________________________________________________
CHANGE HISTORY
The following Disposition Note Was Overwritten by WOODS,STEPHANIA @ 01 Feb 2016 1118 EST:
The Disposition section was last updated by WOODS,STEPHANIA @ 01 Feb 2016 1118 EST - see above.Previous Version of Disposition section was entered/updated by
TRIMUEL,SHARITA K @ 28 Jan 2016 0922 EST.
2019
Medical Record
2019
05 Jan 2016 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by MCCOMB,
CLARA E
Encounter for general adult medical

examination without abnormal findings
Patient: WAITERS, TOMMIE Date: 05 Jan 2016 0900 EST Appt Type: FTR
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02ASTRONG TEAM Provider: MCCOMB,CLARA E
BENNING
AutoCites Refreshed by MCCOMB,CLARA E @ 05 Jan 2016 0935 EST

Allergies
No Allergies Found.

CAREY/ NEED PHYSICAL FOR NURSING PROGRAM/706-326-4585.
ALR
Screening Written by HERRON,CATHERINE @ 05 Jan 2016 0907 EST

Reason For Appointment: CAREY/ NEED PHYSICAL FOR NURSING PROGRAM/706-326-4585.
Allergen information verified by HERRON, CATHERINE @ 05 Jan 2016 0907 EST
Vitals
Vitals Written by HERRON,CATHERINE @ 05 Jan 2016 0907 EST
Pain Scale: 6/10 Moderate, Pain Scale Comments: lt shoulder/lower back...7/10/Lt side....5/10
S/O Note Written by MCCOMB,CLARA E @ 07 Jan 2016 0537 EST

Chief complaint
The Chief Complaint is: Pt presents for physical for Nursing School.
Pt is a 45 y/o AAM who presents to clinic for annual physical for nursing school. Within the past year, pt had reactive PPD which
was treated with 3mo of appropriate antibiotic therapy. Pt denies any cough/fever/chills/night sweats. Pt CXR 3 days prior was read
within normal limits by radiology.
Pt takes alieve and tramadol prn for L chronic shoulder pain and L chronic abdominal pain - pt had benign abd mass removed in
2012 from abd laproscopy.
Pt does admit to some issues with depression, which he says he hides well but internally is unhappy. Pt requests counseling, denies
SI/HI.
Pt uptodate on Immunizations, takes 1 aspirin a day. Is due for Lipid screening/Testosterone/A1c.

Good general overall feeling /health.
Limb pain.
Visit is not deployment-related. Not thinking about suicide and no homicidal thoughts.
Attending Physician: Layton. Discussed with attending who concurs with the plan.
Pain assessment
Location: lt shoulder/lower back/lt side abd
Duration: 8 yrs
Quality: dull
Factors that correlate with onset:
2019
Medical Record
2019
Frequency:
Average level: constant
What makes it better: pain meds
What makes it worse: ovef exertion
..............
Allergies
.
Current medication
ASA 81 MG EVERY DAY


Updated 1/5/2015
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Annual Screen date:
Family history
CA- mother- bresat
father- DM.
.
Review of systems
2019
Medical Record
2019
Systemic: No fever, no chills, no night sweats, and no recent weight loss.

Pulmonary: No shortness of breath and not during exertion.
Psychological: Depression. No decreased functioning ability.
Physical findings
General:
• Physical examination ABD: Well healed scars present over RLQ (s/p appendectomy) and laproscopic scars faintly present.
Vital Signs:
General Appearance:
Head:
Neck:
Eyes:
General/bilateral:
Pupils: ° PERRL. ° Size of the pupil was normal. ° Pupil accommodation was not impaired.
Sclera: ° Normal.
Ears:
General/bilateral:
Right Ear:
External Auditory Canal: ° Normal.
Tympanic Membrane: ° No bulging tympanic membrane. ° Not erythematous.
Middle Ear: ° No fluid in middle ear.
Left Ear:
Oral Cavity:
Pharynx:
Lymph Nodes:
were not enlarged.
Lungs:
Cardiovascular:
Abdomen:
Hernia: ° No hernia was discovered.
Skin:
Tests
DEPRESSION SCREENING / MONITORING (PHQ-9)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
[2 ] Little interest or pleasure in doing things
[ ] Feeling down depressed or hopeless
[1 ] Trouble sleeping or sleeping too much
[1 ] Feeling tired or little energy
[ 0 ] Poor appetite or overeating
[ 0 ] Feeling bad about self
2019
Medical Record
2019
[1 ] Trouble concentrating on things

[1 ] Moving or speaking slowly or being restless
[ 0 ] Thoughts that you would be better off dead
Difficulty doing work, taking care of things at home, or getting along with others? [ ] Not at all [ ] Somewhat [ ] Very [ ]
Extremely
.............. .
Tests: Value
PHQ-9 Score 5
Test conclusions
Medication list was upated at the beginning of the visit.
Practice Management
Colonoscopy - n/a

.
Patient
A/P Last Updated by MCCOMB,CLARA E @ 07 Jan 2016 0601 EST

1. Encounter for general adult medical examination without abnormal findings: Pt is a 45 y/o AAM with PMHx of HTN, obesity,
ED who presents to clinic for annual physical exam. As pt has not had routine screening labs, will order A1C, Lipid panel, and CMP.
Testosterone and PSA for evaluation of Low -T.
Given family hx of heart disease, will use 24 hour BP cuff to monitor blood pressures and whether medication needs to be adjusted.
-Will review labs with patient
-Discussed weight loss goals
-Pt walks 1 mile a day
Laboratory(ies): -DEAR LIPID PANEL (Routine); HEMOGLOBIN A1C PANEL (Routine); COMPREHENSIVE
METABOLIC PANEL (Routine)
2. Major depressive disorder, single episode, moderate: Pt is a 45 y/o black M who presents to clinic for annual physical
required by nursing school. Pt admits to some past issues with depression. Although pt is quite successful in work, he states that
internally he continues to feel depressed. Pt requests counseling. No SI/HI.
Plan:
-behavioral health consult
-no meds indicated at this time
Consult(s): -Referred To: FPC BEHAVIORAL HEALTH (Routine) Specialty: Clinic: FMC SPECIALTY CLINIC
3. Essential (primary) hypertension: Pt is a 45 y/o M who presents to clinic with normotensive blood pressure (high upper limit)
currently on maxzide. Pt states that he takes his blood pressure at home occasional and it has been elevated >140/90. Pt has
significant family hx for Heart Disease and CAD (father had MI at 55).
Plan:
-24 hour bp monitor
-will consider increasing medication dose if monitor indicates poor control
-discuss weight loss as factor that can contribute to decrease in BP
Medication(s): -MAXZIDE 25 (OR SUBST)37.5/25--PO TAB - TAKE 1 TABLET BY MOUTH EVERY DAY FOR HTN
#90 RF0
Consult(s): -Referred To: CARDIOLOGY 24 HR BP MONITOR (Routine) Specialty: Clinic: CARDIOLOGY CLINIC
4. Testicular hypofunction: Pt is a 45 y/o M who presents request refill of androgel - as pt has not had testosterone rechecked
since 2011, will re-draw fasting testosterone. Pt had run out of gel.
Plan:
-PSA
-testosterone level
2019
Medical Record
2019
If testosterone levels are low, will prescribe androgel.

Laboratory(ies): -PROSTATE SPECIFIC AG (Routine); TESTOSTERONE,FREE AND TOTAL (Routine)
5. Left upper quadrant pain: Pt is a 45 y/o M s/p removal of abdominal mass (benign) in 2012. Pt had had chronic abdominal pain
since this time that is well controlled with prn tramadol.
Plan:
-Refill medication - pt understands risks associated with tramadol.
Medication(s): -TRAMADOL 50MG (ULTRAM)-ORAL TABLET--PO 5 - TAKE 1 TO 2 TABLETS EVERY 4-6 HOURS
AS NEEDED FOR PAIN **NOT TO EXCEED 8 TABLETS PER DAY** #30 RF0
6. Male erectile disorder: Refill of Medication
Medication(s): -SILDENAFIL (VIAGRA) 100MG ORAL TABLET--P - TAKE ONE TABLET 1 HOUR BEFORE SEXUAL
INTERCOURSE NO MORE THAN 1 A DAY #15 RF0
Disposition Last Updated by MCCOMB,CLARA E @ 07 Jan 2016 0601 EST

Signed By MCCOMB, CLARA E (Physician intern, DO, Martin ACH, Fort Benning, GA) @ 07 Jan 2016 0601
Co-Signed By KOENIG, KRISTEN ELIZABETH (Physician) @ 07 Jan 2016 1221
_________________________________________________________________________________________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by MCCOMB,CLARA E @ 07 Jan 2016 0548 EST:
S/O Note Written by HERRON,CATHERINE @ 05 Jan 2016 1007 EST
Chief complaint
Pt also reports having chrlt mionic lt shoulder pain/lower back pain, and lt side abd pain, all of which e has been seen for over the last 8 years.
Limb pain.
Visit is not deployment-related. Not thinking about suicide and no homicidal thoughts.
Pain assessment
Duration: 8 yrs
Quality: dull
Frequency:
..............
Allergies
.
Current medication
ASA 81 MG EVERY DAY
CELEBREX 100MG 2 TIMES DAILY
HYDROCODONE AS 5MG/325MG
Pliva 333 1 tab by mouth three time a day for 21 days
Updated 1/5/2015
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
2019
Medical Record
2019

Children: 3.
Annual Screen date:
Family history
CA- mother- bresat
father- DM.
.
Review of systems
Tests
DEPRESSION SCREENING / MONITORING (PHQ-9)
Over the last 2 weeks, how often have you been bothered by any of the following problems?
[2 ] Little interest or pleasure in doing things
[ ] Feeling down depressed or hopeless
[1 ] Trouble sleeping or sleeping too much
[1 ] Feeling tired or little energy
[ 0 ] Poor appetite or overeating
[ 0 ] Feeling bad about self
[1 ] Trouble concentrating on things
[1 ] Moving or speaking slowly or being restless
[ 0 ] Thoughts that you would be better off dead
Difficulty doing work, taking care of things at home, or getting along with others? [ ] Not at all [ ] Somewhat [ ] Very [ ] Extremely
.............. .
Tests: Value
PHQ-9 Score 5
Practice Management
Colonoscopy - n/a

.
Patient
The following S/O Note Was Overwritten by MCCOMB,CLARA E @ 05 Jan 2016 1006 EST:
S/O Note Written by HERRON,CATHERINE @ 05 Jan 2016 0929 EST
Chief complaint
Pt also reports having chrlt mionic lt shoulder pain/lower back pain, and lt side abd pain, all of which e has been seen for over the last 8 years.
Limb pain.
Pain assessment
Duration: 8 yrs
Quality: dull
Frequency:
..............
2019
Medical Record
2019
Allergies
.
Current medication
ASA 81 MG EVERY DAY
Updated 1/5/2015
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Annual Screen date:
Family history
CA- mother- bresat
father- DM.
.
Review of systems
Practice Management
Colonoscopy - n/a

.
Patient
2019
Medical Record
2019
28 Dec 2015 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by THOMAS,
ROBERT L.
Encounter for screening for respiratory

tuberculosis
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: FMC SPECIALTY CLINIC Provider: THOMAS,ROBERT L
BENNING
AutoCites Refreshed by THOMAS,ROBERT L @ 28 Dec 2015 1025 EST

Allergies
No Allergies Found.

Carey TB shot 706-326-4585
vel
S/O Note Written by THOMAS,ROBERT L @ 28 Dec 2015 1025 EST

Therapy
• Risks, benefits, and limitations discussed and understood Hard copy of signed document and statement of understanding
filed in paper Outpatient Record.
• Administered medications: Medication: ippd___ Dose: 0.1 ml___ Location: right forearm___.
• Documented: medication taken or received Medication(s) at: 1000.
• The drug reactions/side effects are not being monitored: Details -- Patient observed for 15 minutes and no adverse reactions
noted.
• Disposition - discharged home / released from clinic at: 1015.
Practice Management
Patient information sheet: Given to ___Patient___Parent___Guardian
A/P Written by THOMAS,ROBERT L @ 28 Dec 2015 1027 EST

1. Encounter for screening for respiratory tuberculosis
Procedure(s): -Skin Test Anergy Tuberculin Intradermal x 1 - IPPD; Series #: 1; .1 mL; ID; Right Arm; Mfg: Sanofi
Pasteur; Lot: C4652AA.
Disposition Written by THOMAS,ROBERT L @ 28 Dec 2015 1028 EST

Signed By THOMAS, ROBERT L (LPN, Martin ACH, Fort Benning, GA) @ 28 Dec 2015 1028
2019
Medical Record
2019
22 Dec 2015 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by THOMAS,
ROBERT L.

examinations
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: FMC SPECIALTY CLINIC Provider: THOMAS,ROBERT L
BENNING
AutoCites Refreshed by THOMAS,ROBERT L @ 22 Dec 2015 1430 EST

Allergies
No Allergies Found.

Carey Hep B /titr MMR Varicella/706-326-4585
vel
S/O Note Written by THOMAS,ROBERT L @ 22 Dec 2015 1440 EST

Therapy
• Administered medications: Medication: ___ Dose: ___ Location: ___.
noted.
Practice Management
Patient information sheet: Given to x___Patient___Parent___Guardian
A/P Written by THOMAS,ROBERT L @ 22 Dec 2015 1441 EST

1. Encounter for other administrative examinations
Laboratory(ies): -HEPATITIS B SURFACE AB (Routine) Ordered By: THOMAS,ROBERT L Ordering Provider:
TRIMUEL, SHARITA K; MUMPS VIRUS AB (Routine) Ordered By: THOMAS,ROBERT L Ordering
Provider: TRIMUEL, SHARITA K; RUBELLA VIRUS AB (Routine) Ordered By: THOMAS,ROBERT L
Ordering Provider: TRIMUEL, SHARITA K; RUBEOLA VIRUS AB (Routine) Ordered By:
THOMAS,ROBERT L Ordering Provider: TRIMUEL, SHARITA K; VARICELLA VIRUS AB (Routine)
Ordered By: THOMAS,ROBERT L Ordering Provider: TRIMUEL, SHARITA K
Disposition Written by THOMAS,ROBERT L @ 22 Dec 2015 1442 EST

Signed By THOMAS, ROBERT L (LPN, Martin ACH, Fort Benning, GA) @ 22 Dec 2015 1442
2019
Medical Record
2019
30 Oct 2015 at Martin ACH, Fort Benning, GA, ER by CAVANAUGH, MEAGAN A
Encounter for examination and observation

for unspecified reason
Patient: WAITERS, TOMMIE Date: 30 Oct 2015 2125 EDT Appt Type: EROOM
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: EMERGENCY ROOM Provider: CAVANAUGH,MEAGAN A
BENNING
A/P Written by CAVANAUGH,MEAGAN A @ 31 Oct 2015 0104 EDT

1. Encounter for examination and observation for unspecified reason: This documentation is to verify that the patient was seen
in the Emergency Department and this note is signed for administrative purposes only. Patient's encounter documentation scanned
into HAIMS section in AHLTA, note is titled Emergency Department Encounter Note
Disposition Written by CAVANAUGH,MEAGAN A @ 31 Oct 2015 0104 EDT

Signed By CAVANAUGH, MEAGAN A (Medical Support Assistant) @ 31 Oct 2015 0104
2019
Medical Record
2019
23 Mar 2015 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by PYLE,
SAMANTHA L
Encounter ID: BENN-15396590 Primary Dx: Visit for: administrative purpose
Patient: WAITERS, TOMMIE Date: 23 Mar 2015 1223 EDT Appt Type: T-CON*
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02ASTRONG TEAM Provider: PYLE,SAMANTHA LYNN
BENNING
AutoCites Refreshed by KNIGHT,ZONIA B @ 25 Mar 2015 1335 EDT

Allergies
No Allergies Found.
Reason for Telephone Consult:Written by KNIGHT,ZONIA B @ 23 Mar 2015 1223 EDT

Paperwork
Telephone Consult Comments: Written by KNIGHT,ZONIA B @ 23 Mar 2015 1223 EDT
Patient dropped off paperwork to complete for Physical Examination. I have the paperwork up front for Dr. Starbuck. Thank you
S/O Note Written by PYLE,SAMANTHA LYNN @ 25 Mar 2015 0929 EDT

Subjective
Patient needing clearnace to work at health care facility. Has history of latent tb. Noted to have neg cxr and on INH therapy.
Discussed with community health who has cleared patient. Paper work fille dout and placed up front for pick up
S/O Note Written by PYLE,SAMANTHA LYNN @ 25 Mar 2015 0930 EDT

Subjective
Please call patient and let him know that form has been completed and can be picked up from the front
S/O Note Written by KNIGHT,ZONIA B @ 25 Mar 2015 1336 EDT

Subjective
Contacted patient 3/25/15 mailbox full cannot leave a message. Thank you
S/O Note Written by KNIGHT,ZONIA B @ 25 Mar 2015 1408 EDT

Subjective
Contacted patient 3/25/15 advised to pick-up completed paperwork. Thank you
A/P Last Updated by PYLE,SAMANTHA L @ 25 Mar 2015 0930 EDT

1. Visit for: administrative purpose V68.9
Disposition Last Updated by PYLE,SAMANTHA L @ 25 Mar 2015 1528 EDT
Signed By PYLE, SAMANTHA L (Attending Physician, Family Medicine, BMACH) @ 25 Mar 2015 1528
2019
Medical Record
2019
20 Mar 2015 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by THOMAS,
ROBERT L.
Visit for: screening exam pulmonary

tuberculosis
Patient: WAITERS, TOMMIE Date: 20 Mar 2015 1440 EDT Appt Type: EST
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC SPECIALTY CLINIC Provider: THOMAS,ROBERT L
AutoCites Refreshed by THOMAS,ROBERT L @ 20 Mar 2015 1501 EDT

Allergies
No Allergies Found.

TB shot/7063264585
rmr
S/O Note Written by THOMAS,ROBERT L @ 20 Mar 2015 1501 EDT

Therapy
• Administered medications: Medication: ippd___ Dose:0.1ml ___ Location: left fa___.
noted.
Practice Management
Patient information sheet: Given to _x__Patient___Parent___Guardian
A/P Written by THOMAS,ROBERT L @ 20 Mar 2015 1503 EDT

1. Visit for: screening exam pulmonary tuberculosis
Procedure(s): -Skin Test Anergy Tuberculin Intradermal x 1 - IPPD; Series #: 1; .1 mL; ID; Left Arm; Mfg: Sanofi
Pasteur; Lot: C4513BB; VIS given.
Disposition Written by THOMAS,ROBERT L @ 20 Mar 2015 1504 EDT

Signed By THOMAS, ROBERT L (LPN, Martin ACH, Fort Benning, GA) @ 20 Mar 2015 1504
2019
Medical Record
2019
19 Mar 2015 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by PYLE,
SAMANTHA L
ALAJANDRO
Treatment Facility: ACH MARTIN- Clinic: AMHM02ASTRONG TEAM Provider: PYLE,SAMANTHA LYNN
BENNING
Reason for Telephone Consult:Written by RICHARDSON,RHONDA M @ 19 Mar 2015 1215 EDT

starbuck/no appt/physical
Telephone Consult Comments: Written by RICHARDSON,RHONDA M @ 19 Mar 2015 1215 EDT
No Available Appt
What is a good contact number and time to call you back: 706-326-4585
What does Pt need to be seen for: physical
Was Pt offered appt?: no appt with PCM
** Pt notified of 24hr call back time**
S/O Note Written by GAVIN,ALLISON R @ 20 Mar 2015 1507 EDT

Subjective
Called pt back but could not leave voicemail, mailbox was full.
S/O Note Written by GAVIN,ALLISON R @ 23 Mar 2015 0914 EDT

Subjective
Spoke with pt, he doesn't need an appointment but needs paperwork filled out for his new job. He is going to drop it off at the front
desk (I am at North Columbus this week) and have one of the other MSA's leave a message for you to see if it can be filled out or if
he does need to come in for appt. Thank you
A/P Last Updated by PYLE,SAMANTHA L @ 24 Mar 2015 0738 EDT

1. Visit for: administrative purpose V68.9
Disposition Last Updated by PYLE,SAMANTHA L @ 24 Mar 2015 0738 EDT
Signed By PYLE, SAMANTHA L (Attending Physician, Family Medicine, BMACH) @ 24 Mar 2015 0738
2019
Medical Record
2019
20 Feb 2015 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by THOMAS,
ROBERT L.
Encounter ID: BENN-15299029 Primary Dx: Vaccines Prophylactic Need Against Td
Patient: WAITERS, TOMMIE Date: 20 Feb 2015 1320 EST Appt Type: EST
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC SPECIALTY CLINIC Provider: THOMAS,ROBERT L
AutoCites Refreshed by THOMAS,ROBERT L @ 20 Feb 2015 1350 EST

Allergies
No Allergies Found.

mmr2, tetanus/7063264585
rmr
S/O Note Written by THOMAS,ROBERT L @ 20 Feb 2015 1358 EST

Therapy
• Administered medications: Medication: mmr,tdap___ Dose:0.5 ml ___ Location: r/l deltoid___.
noted.
Practice Management
Patient information sheet: Given to _x__Patient___Parent___Guardian
A/P Written by THOMAS,ROBERT L @ 20 Feb 2015 1351 EST

1. Vaccines Prophylactic Need Against Td
Procedure(s): -Tdap Vaccine x 1 - Tdap; Series #: 1; .5 mL; IM; Right Arm; Mfg: Sanofi Pasteur; Lot: 9544Y; VIS given
(Ver: 05/19/13).
-Immunization Administration One Vaccine x 1
2. Need For Vaccination MMR
Procedure(s): -Vaccines Viral Measles, Mumps and Rubella, Live x 1 - MMR; Series #: 2; .5 mL; IM; Left Arm; Mfg:
Merck; Lot: k005175; VIS given (Ver: 04/20/12).
-Immunization Administration One Vaccine x 1
-Immunization Administration Each Additional Vaccine x 1
Disposition Written by THOMAS,ROBERT L @ 20 Feb 2015 1400 EST

Signed By THOMAS, ROBERT L (LPN, Martin ACH, Fort Benning, GA) @ 20 Feb 2015 1400
2019
Medical Record
2019
18 Feb 2015 at Martin ACH, Fort Benning, GA, Community Health by MELENDEZ, ELY J
Visit for: issue repeat prescription for

medication
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: COMMUNITY HEALTH Provider: MELENDEZ,ELY
AutoCites Refreshed by MELENDEZ,ELY @ 18 Feb 2015 1556 EST

Problems Allergies
accession
•GASTRITIS
•HYPERGLYCEMIA
•SLEEP APNEA OBSTRUCTIVE
•HYPERLIPIDEMIA
•OVERWEIGHT
•HYPOGONADISM
•ASTIGMATISM
•Snoring
(LUQ)
•LUMBAGO
DEPRESSED MOOD
HYPERMETROPIA
EPISODE MODERATE
(periumbilical)
DISEASE
EPISODE
exam
•Body Mass Index
INFECTION
2019
Medical Record
2019
•Abdominal pain
•CERVICALGIA
•FOLLICULITIS
•BACKACHE
Active Medications
ISONIAZID, 300 MG, TABLET, ORAL Active TAKE ONE TABLET BY 8 of 8 15 Jan 2015
PYRIDOXINE HCL, 50 MG, TABLET, ORAL Active TAKE ONE TABLET EVERY 8 of 8 15 Jan 2015
DAY #0 RF8
NAPROXEN, 500 MG, TABLET, ORAL Active TAKE ONE TABLET TWICE 1 of 1 09 Jan 2015
A DAY WITH FOOD #0 RF1
Rads
No Rads Found.

INH Refill
jec
Screening Written by MELENDEZ,ELY @ 18 Feb 2015 1626 EST

Reason For Appointment: INH Refill
Reason(s) For Visit (Chief Complaint): Nonspecific Reaction To Test For Tuberculosis (New) ;
Vitals
Vitals Written by MELENDEZ,ELY @ 18 Feb 2015 1626 EST
BP: 149/79, HR: 74, RR: 16, HT: 66 in, WT: 241 lbs, BMI: 38.9, BSA: 2.165 square meters, Tobacco Use: No,
Alcohol Use: No, Pain Scale: 0 Pain Free
Questionnaire AutoCites Refreshed by MELENDEZ,ELY @ 18 Feb 2015 1556 EST

Questionnaires
S/O Note Written by MELENDEZ,ELY @ 18 Feb 2015 1627 EST

Chief complaint
The Chief Complaint is: INH Client Intake Interview Completed 1 months INH.
Reason for Visit
Visit for: INH F/U
Completed 1 months of INH therapy.
He reported: Not feeling tired or poorly, no fever, temperature not taken at home, no night sweats, and no recent weight loss.
No headache. No dyspnea and no hemoptysis. No gastrointestinal symptoms, no vomiting, no jaundice, and no change in stool.
Urine is unchanged in appearance. No localized joint pain. No dizziness, no drowsiness related to medication, and no distal
tingling. No rash.
A/P Written by MELENDEZ,ELY @ 18 Feb 2015 1628 EST

1. Visit for: issue repeat prescription for medication: HArd copy medication script given to patient
Disposition Written by MELENDEZ,ELY @ 18 Feb 2015 1628 EST

Follow up: as needed with PCM. - Comments: monthly
2019
Medical Record
2019
Signed By MELENDEZ, ELY (Public Health Nurse, Ft. Benning, Ga) @ 18 Feb 2015 1629
2019
Medical Record
2019
29 Jan 2015 at Martin ACH, Fort Benning, GA, Community Health by POLLITT, STEPHEN
P
Encounter ID: BENN-14834350 Primary Dx: TUBERCULOSIS LATENT
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: COMMUNITY HEALTH Provider: POLLITT,STEPHEN P
AutoCites Refreshed by POLLITT,STEPHEN P @ 29 Jan 2015 1334 EST

•MESENTERIC PANNICULITIS •no family history of congenital deafness •Other: NKDA: Unknown
•Patient Counseling: (General FHx)
•BURSITIS TROCHANTERIC •family medical history (General FHx)
•Visit for: military services physical •no family history of cancer (General FHx)
accession •no family history of bleeding problems
•Counseling About Travel (General FHx)
•GASTRITIS •family history of supplemental HPI [use
•HYPERGLYCEMIA for free text] (General FHx)
•MCKENZIE POSTERIOR •family history of sleep apnea (General
DERANGEMENT SYNDROME FHx)
•Patient Counseling Medical Management •family history of heart disease
Five To Eight Patients •family history of cancer
•SLEEP APNEA OBSTRUCTIVE •no family history of angina pectoris
•NONORGANIC SLEEP DISORDERS •family history [use for free text]
•HYPERLIPIDEMIA •no family history of mental illness (not
•OVERWEIGHT retardation)
•HYPERTENSION (SYSTEMIC) •no family history of alcoholism
•HYPOGONADISM •no family history of malignant neoplasm of
•ASTIGMATISM the large intestine
•MALE ERECTILE DISORDER •maternal history of arteriosclerotic
•Snoring cardiovascular disease (ASCVD)
•Visit for: vasectomy status (Mother)
•Abdominal pain in the left upper belly •paternal history of type 2 diabetes mellitus
(LUQ) (Father)
•LUMBAGO
DEPRESSED MOOD
HYPERMETROPIA
EPISODE MODERATE
(periumbilical)
DISEASE
EPISODE
exam
•Body Mass Index
INFECTION
2019
Medical Record
2019

•Abdominal pain
•CERVICALGIA
•FOLLICULITIS
•BACKACHE
Other PMHs
No Other PMHs Found.
Active Medications
ISONIAZID, 300 MG, TABLET, ORAL Active TAKE ONE TABLET BY 8 of 8 15 Jan 2015
PYRIDOXINE HCL, 50 MG, TABLET, ORAL Active TAKE ONE TABLET EVERY 8 of 8 15 Jan 2015
DAY #0 RF8
Vitals
Vitals Written by FORD,VANESSA R @ 15 Jan 2015 1320 EST
Use: No,
Comments: Medication reconciliation performed. Denies any OTC meds/supplements. Takes Naprosyn as prescribed for back
pain.
Vitals Written by MELENDEZ,ELY @ 14 Jan 2015 1338 EST

BP: 165/92, HR: 78, RR: 18, HT: 66 in, WT: 226 lbs, BMI: 36.48, BSA: 2.107 square meters, Tobacco Use: No, Alcohol Use: No,
Pain Scale: 3/10 Mild,
Pain Scale Comments: Head ache
Vitals Written by MCNEARNEY,CODY M @ 09 Jan 2015 0822 EST
RR: 12, HT: 66 in, WT: 227 lbs, SpO2: 99%, BMI: 36.64, BSA: 2.111 square meters, Pain Scale: 4/10 Moderate
Reason for Appointment:Written by WILLIAMS,JACQUELINE E @ 29 Jan 2015 1252 EST

LTBI Clinic
S/O Note Written by POLLITT,STEPHEN P @ 29 Jan 2015 1334 EST

He reported: Encounter Background Information: follow up on LTBI Rx. pt reports no adverse effects, will return in 1 month for
recheck.
Physical findings
Growth And Development:
• Patient not examined on this visit.
A/P Written by POLLITT,STEPHEN P @ 29 Jan 2015 1338 EST

1. TUBERCULOSIS LATENT
Disposition Written by POLLITT,STEPHEN P @ 29 Jan 2015 1338 EST

Signed By POLLITT, STEPHEN P (Physician Assistant, Preventive Medicine) @ 29 Jan 2015 1338
2019
Medical Record
2019
15 Jan 2015 at Martin ACH, Fort Benning, GA, Community Health by POLLITT, STEPHEN
P
Encounter ID: BENN-14759499 Primary Dx: TUBERCULOSIS LATENT
Patient: WAITERS, TOMMIE Date: 15 Jan 2015 1239 EST Appt Type: EST
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: COMMUNITY HEALTH Provider: POLLITT,STEPHEN P
AutoCites Refreshed by POLLITT,STEPHEN P @ 15 Jan 2015 1310 EST

•MESENTERIC PANNICULITIS •no family history of congenital deafness •Other: NKDA: Unknown
•Patient Counseling: (General FHx)
•BURSITIS TROCHANTERIC •family medical history (General FHx)
•Visit for: military services physical •no family history of cancer (General FHx)
accession •no family history of bleeding problems
•Counseling About Travel (General FHx)
•GASTRITIS •family history of supplemental HPI [use
•HYPERGLYCEMIA for free text] (General FHx)
•MCKENZIE POSTERIOR •family history of sleep apnea (General
DERANGEMENT SYNDROME FHx)
•Patient Counseling Medical Management •family history of heart disease
Five To Eight Patients •family history of cancer
•SLEEP APNEA OBSTRUCTIVE •no family history of angina pectoris
•NONORGANIC SLEEP DISORDERS •family history [use for free text]
•HYPERLIPIDEMIA •no family history of mental illness (not
•OVERWEIGHT retardation)
•HYPERTENSION (SYSTEMIC) •no family history of alcoholism
•HYPOGONADISM •no family history of malignant neoplasm of
•ASTIGMATISM the large intestine
•MALE ERECTILE DISORDER •maternal history of arteriosclerotic
•Snoring cardiovascular disease (ASCVD)
•Visit for: vasectomy status (Mother)
•Abdominal pain in the left upper belly •paternal history of type 2 diabetes mellitus
(LUQ) (Father)
•LUMBAGO
DEPRESSED MOOD
HYPERMETROPIA
EPISODE MODERATE
(periumbilical)
DISEASE
EPISODE
exam
•Body Mass Index
INFECTION
2019
Medical Record
2019

•Abdominal pain
•CERVICALGIA
•FOLLICULITIS
•BACKACHE
Other PMHs
No Other PMHs Found.
Active Medications
Vitals
Vitals Written by MELENDEZ,ELY @ 14 Jan 2015 1338 EST
Pain Scale: 3/10 Mild,
Pain Scale Comments: Head ache
Reason for Appointment:Written by WILLIAMS,JACQUELINE E @ 15 Jan 2015 1239 EST

LTBI Follow-up
Screening Written by FORD,VANESSA R @ 15 Jan 2015 1322 EST

Reason For Appointment: Notes Entered by: WILLIAMS,JACQUELINE E 15 Jan 2015 1239
------------------------------
LTBI Follow-up
Allergen information verified by FORD, VANESSA R @ 15 Jan 2015 1322 EST

Reason(s) For Visit (Chief Complaint): Patient Counseling: (Follow-Up) : LTBI;
Vitals
Vitals Written by FORD,VANESSA R @ 15 Jan 2015 1320 EST
Comments: Medication reconciliation performed. Denies any OTC meds/supplements. Takes Naprosyn as prescribed for back
pain.
S/O Note Written by POLLITT,STEPHEN P @ 15 Jan 2015 1426 EST

He reported: Encounter Background Information: follow up on LTBI, pt requesting 9 month INH RX.
Physical findings
Vital Signs:
° Normal.
A/P Written by POLLITT,STEPHEN P @ 15 Jan 2015 1431 EST

1. TUBERCULOSIS LATENT: Rx for INH an B6 written, follow up in LTBI clinic monthly
Disposition Written by POLLITT,STEPHEN P @ 15 Jan 2015 1431 EST

2019
Medical Record
2019
Signed By POLLITT, STEPHEN P (Physician Assistant, Preventive Medicine) @ 15 Jan 2015 1431
2019
Medical Record
2019
12 Jan 2015 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by STARBUCK,
AARON K
Visit for: screening exam pulmonary

tuberculosis
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: AMHM02ASTRONG TEAM Provider: STARBUCK,AARON K
AutoCites Refreshed by STARBUCK,AARON K @ 12 Jan 2015 1545 EST

Allergies
No Allergies Found.
Reason for Telephone Consult:Written by STARBUCK,AARON K @ 12 Jan 2015 1544 EST

pos ppd
Questionnaire AutoCites Refreshed by STARBUCK,AARON K @ 12 Jan 2015 1545 EST

Questionnaires
A/P Written by STARBUCK,AARON K @ 12 Jan 2015 1554 EST

1. Visit for: screening exam pulmonary tuberculosis V74.1: missed appointment today so he was called and found that appt was
for a 20 mm positive PPD test with negative chest x-ray. We'll refer him to prev med.
Prev med: 44 yo ret SM had ppd done for potential employment with a 20 mm result. Also chest x-ray negative. Please evaluate and
treat. Available at 706-326-4585.
Consult(s): -Referred To: PREV MED REPORTABLE MED EVENTS (Routine) Specialty: Clinic: PREVENTIVE
MEDICINE Provisional Diagnosis: Visit for: screening exam pulmonary tuberculosis
Disposition Last Updated by STARBUCK,AARON K @ 12 Jan 2015 1546 EST
Signed By STARBUCK, AARON K (Family Medicine, MD, MAJ MC, USA, Martin Army) @ 12 Jan 2015 1554
2019
Medical Record
2019
12 Jan 2015 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by STARBUCK,
AARON K
ALAJANDRO
AutoCites Refreshed by STARBUCK,AARON K @ 12 Jan 2015 0904 EST

Allergies
No Allergies Found.

F/U POSS PPD/7063264585
HJG
Screening Written by CAMPBELL,KELLY R @ 12 Jan 2015 0910 EST

Reason For Appointment: F/U POSS PPD/7063264585
Allergen information verified by CAMPBELL, KELLY R @ 12 Jan 2015 0910 EST
Questionnaire AutoCites Refreshed by STARBUCK,AARON K @ 12 Jan 2015 0904 EST

Questionnaires
S/O Note Written by REGISTER,RALPH O @ 08 Jan 2015 1042 EST

Allergies
.
Current medication
ASA 81 MG EVERY DAY
Amoxicillin 500 mg three times daily.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
2019
Medical Record
2019
Personal history
Children: 3.
Annual Screen date:
CONTACT INFO: 706-326-4585.
Family history
CA- mother- bresat
father- DM.
.
Practice Management
Colonoscopy - n/a

.
Patient
Appointment Cancelled by Facility

Encounter Cancelled by STARBUCK,AARON K @ 12 Jan 2015 1554 EST
2019
Medical Record
2019
09 Jan 2015 at Martin ACH, Fort Benning, GA, Otorhinolaryngology by ANDREWS, JAMIE
NATHAN
TEMPOROMANDIBULAR JOINT-PAIN
DYSFUNCTION SYNDROME
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: OTORHINOLARYNGOLOGY Provider: ANDREWS,JAMIE NATHAN

OTITIS EXTERNA
cjbh
Vitals
S/O Note Written by ANDREWS,JAMIE NATHAN @ 09 Jan 2015 1755 EST

Chief complaint
The Chief Complaint is: Ear ache.
The Patient is a 44 year old male. Source of patient information was patient.
Pt is a 44 yom who presents for eval of chronic RIGHT sided otalgia. This has been present for several months, pt notes difficulty
with chewing d/t pain. He was treated with antibiotics w/o benefit for a presumed oe. +h/o bruxism. hearing test - normal. no
otorrhea, aural fullness, vertigo, occ tinnitus, no prior ear surgeries.
Reliability of source of patient information.
In the Army, retired, visit is deployment-related, and visit is GWOT-related.
Generalized pain.
Hearing loss and earache. No discharge from the ears and no watery nasal discharge. No postnasal drip and no epistaxis.
Nasal passage blockage (stuffiness). No hoarseness, no sore throat, and no lump in the throat.
Gastrointestinal symptoms. No dysphagia and no pain on swallowing.
Musculoskeletal symptoms.
Psychological symptoms.
No sinus pressure. No neck pain and no swollen glands in the neck. No dizziness, no vertigo, and no difficulty with balance.
Reported:
Medical: Reported medical history: reviewed
. No history of cancer.
Surgical / Procedural: Surgical / procedural history: reviewed
.
Medications: Medication history: Current medications reviewed and reconciled.
. Not taking dietary supplements, no vitamin supplements, and no over-the-counter medications.
Diagnoses:
No allergic rhinitis.
No coronary artery disease.
Hypertension.
No esophageal reflux.
No renal disease.
No diabetes mellitus.
No stroke syndrome.
No obstructive sleep apnea.
No coagulation defects
Surgical:
• No otolaryngologic surgery
• No myringotomy with ventilating tube insertion
• No sinus surgery
• No tonsillectomy with adenoidectomy
Personal history
Social history: reviewed
.
2019
Medical Record
2019
Alcohol: Not using alcohol.

Family history
Family medical history: reviewed
No family history of cancer

No family history of bleeding problems
No congenital deafness.
Review of systems
Systemic: No systemic symptoms, no fever, no chills, no night sweats, and no recent weight loss.
Eyes: No eye symptoms.
Cardiovascular: No cardiovascular symptoms.
Pulmonary: No pulmonary symptoms.
Gastrointestinal: No nausea and no vomiting.
Genitourinary: No genitourinary symptoms.
Endocrine: No endocrine symptoms.
Hematologic: No hematologic symptoms.
Neurological: No neurological symptoms.
Skin: No skin symptoms.
Physical findings
Vital Signs:
• Temperature: Reviewed. • RR: Reviewed. • PR: Reviewed. • SBP: Reviewed.
General Appearance:
Neck:
Cervical Mass: ° No cervical mass was seen.
Eyes:
General/bilateral:
Extraocular Movements: ° Normal.
Pupils: ° PERRL.
Sclera: ° Normal.
Ears:
General/bilateral:
Tympanic Membrane: ° Normal. ° No retraction of tympanic membrane. ° Did not have pressure equalization tubes.
° Mobility normal.
Hearing: ° Weber test normal. ° Rinne test normal.
Nose:
General/bilateral:
Cavity: ° Nasal septum normal. ° Nasal mucosa normal. ° Nasal turbinate normal.
Oral Cavity:
• Oral cavity: SEVERAL CLICKING WHICH IS AUDIBLE UPON JAW OPENING, TM/EAC CLEAR INTACT AU.
Pharynx:
Oropharynx: ° Soft palate was normal. ° Uvula showed no abnormalities. ° Tonsils showed no abnormalities.
Lymph Nodes:
were not enlarged.
Neurological:
° Oriented to time, place, and person. ° No learning disability was noted (barriers to learning).
Cranial Nerves: ° Olfactory nerve was normal. ° Optic nerve was not impaired. ° Oculomotor nerve was not impaired.
° Trochlear nerve was not impaired. ° No trigeminal neuropathy. ° Abducens nerve was normal. ° No facial nerve palsy
was noted. ° Vestibulocochlear nerve was not impaired. ° Glossopharyngeal nerve was not impaired. ° Vagus nerve was
not impaired. ° Cranial and spinal accessory nerves were normal. ° Hypoglossal nerve was not impaired.
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Skin:
° Showed no ecchymosis. ° No skin lesions.
Therapy
• No herbal medicines.
Counseling/Education
Patient verbalized understanding and accepted instructions.
2019
Medical Record
2019
A/P Written by ANDREWS,JAMIE N @ 09 Jan 2015 1800 EST

1. TEMPOROMANDIBULAR JOINT-PAIN DYSFUNCTION SYNDROME: Sxs are c/w tmj dysfunction, soft diet, nsaids, and mri tmj
prescribed. Pt advised to trial oral appliance, followup in 6-8 weeks.
Medication(s): -NAPROXEN 500MG (NAPROSYN)-ORAL TABLET--P - TAKE ONE TABLET TWICE A DAY WITH
FOOD #60 RF1 Ordered By: ANDREWS,JAMIE N Ordering Provider: ANDREWS, JAMIE NATHAN
Radiology(ies): -MRI TMJ W/O CONTRAST (Routine) Ordered By: ANDREWS,JAMIE N Ordering Provider: ANDREWS,
JAMIE NATHAN Impression: 44 yom with right tmj pain, please eval tmj joint, thanks
2. Earache
Disposition Written by ANDREWS,JAMIE N @ 09 Jan 2015 1801 EST

Follow up: in the OTORHINOLARYNGOLOGY clinic.
Signed By ANDREWS, JAMIE N (Physician) @ 09 Jan 2015 1801

_________________________________________________________________________________________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by ANDREWS,JAMIE N @ 09 Jan 2015 1704 EST:
S/O Note Written by MCNEARNEY,CODY M @ 09 Jan 2015 0822 EST
Chief complaint
The Chief Complaint is: Ear ache.
The Patient is a 44 year old male. Source of patient information was patient. Reliability of source of patient information.
Generalized pain.
Hearing loss, earache, and discharge from the ears. No watery nasal discharge. No postnasal drip and no epistaxis. Nasal passage blockage (stuffiness). No
hoarseness, no sore throat, and no lump in the throat.
No dizziness and no vertigo. Difficulty with balance.
No sinus pressure. No neck pain and no swollen glands in the neck.
Reported:
.
. Not taking dietary supplements, no vitamin supplements, and no over-the-counter medications.
Diagnoses:
Hypertension.
No renal disease.
No stroke syndrome.
Surgical:
• No otolaryngologic surgery
• No myringotomy with ventilating tube insertion
• No sinus surgery
• No tonsillectomy with adenoidectomy
Personal history
.
Family history

No congenital deafness.
Review of systems
Systemic: No systemic symptoms, no fever, no chills, no night sweats, and no recent weight loss.
Physical findings
Neurological:
° No learning disability was noted (barriers to learning).
Therapy
2019
Medical Record
2019
2019
Medical Record
2019
19 Nov 2014 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by LANIER,
JEFFREY B
Patient: WAITERS, TOMMIE Date: 19 Nov 2014 1556 EST Appt Type: T-CON*
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: AMHM02ASTRONG TEAM Provider: LANIER,JEFFREY BRIAN
Patient Status: Outpatient Call Back Phone: NURSE (706)-326-4585
AutoCites Refreshed by MARRERO,JUANA D @ 21 Nov 2014 1713 EST

•MESENTERIC PANNICULITIS •family medical history (General FHx) No Allergies Found.
•Patient Counseling: •family history of supplemental HPI [use
•BURSITIS TROCHANTERIC for free text] (General FHx)
•Visit for: military services physical •family history of sleep apnea (General
accession FHx)
•Counseling About Travel •family history of heart disease
•GASTRITIS •family history of cancer
•HYPERGLYCEMIA •no family history of angina pectoris
•MCKENZIE POSTERIOR •family history [use for free text]
DERANGEMENT SYNDROME •no family history of mental illness (not
•Patient Counseling Medical Management retardation)
Five To Eight Patients •no family history of alcoholism
•SLEEP APNEA OBSTRUCTIVE •no family history of malignant neoplasm of
•NONORGANIC SLEEP DISORDERS the large intestine
•HYPERLIPIDEMIA •maternal history of arteriosclerotic
•OVERWEIGHT cardiovascular disease (ASCVD)
•HYPERTENSION (SYSTEMIC) (Mother)
•HYPOGONADISM •paternal history of type 2 diabetes mellitus
•ASTIGMATISM (Father)
•Snoring
(LUQ)
•LUMBAGO
DEPRESSED MOOD
HYPERMETROPIA
EPISODE MODERATE
(periumbilical)
DISEASE
EPISODE
exam
•Body Mass Index
INFECTION
2019
Medical Record
2019

•Abdominal pain
•CERVICALGIA
•FOLLICULITIS
•BACKACHE
Active Medications
Reason for Telephone Consult:Written by LLOYD,BRYAN D @ 19 Nov 2014 1556 EST

TB TEST/SECOND EVAL/PCM STARBUCK
Telephone Consult Comments: Written by LLOYD,BRYAN D @ 19 Nov 2014 1556 EST
No Available Appt
What is a good contact number and time to call you back: 706-326-4585
What does Pt need to be seen for: PT WAS TESTED FOR TB AND WAS TOLD THE AREA WAS SHOWING RED. PT
REQUESTSECOND EVAL.
Was Pt offered appt?: NO AVAILABLE
** Pt notified of 72hr call back time**
S/O Note Written by LANIER,JEFFREY BRIAN @ 19 Nov 2014 1700 EST

Subjective
Where was this done? If not done here then I don't have a problem doing it here. If he still has the reaction we could look at it and
verify that it is a true positive as well depending on when he had the test done.
Note Written by MARRERO,JUANA D @ 21 Nov 2014 1713 EST

Pt is coming in 14 days to be tested again. Thank you
A/P Last Updated by LANIER,JEFFREY H @ 23 Nov 2014 1255 EST
1. Visit for: administrative purpose
Disposition Last Updated by LANIER,JEFFREY H @ 23 Nov 2014 1255 EST
Signed By LANIER, JEFFREY H (MD, MAJ, MC, Family Physician) @ 23 Nov 2014 1256
2019
Medical Record
2019
07 Nov 2014 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by STARBUCK,
AARON K
Encounter ID: BENN-14417070 Primary Dx: OTITIS EXTERNA
Patient: WAITERS, TOMMIE Date: 07 Nov 2014 1040 EST Appt Type: EST
ALAJANDRO
AutoCites Refreshed by STARBUCK,AARON K @ 07 Nov 2014 1159 EST

Allergies
No Allergies Found.

Starbuck - f/up labs
cda
Screening Written by OSHEA,VALERIE W @ 07 Nov 2014 1039 EST

Reason For Appointment: Starbuck - f/up labs
Allergen information verified by OSHEA, VALERIE W @ 07 Nov 2014 1039 EST
Vitals
Vitals Written by OSHEA,VALERIE W @ 07 Nov 2014 1034 EST
BP: 134/84 Left Arm, Adult Cuff, HR: 70, RR: 20, T: 96.7 °F, HT: 66 in, WT: 229 lbs, BMI: 36.96, BSA: 2.119
square meters, Tobacco Use: No,
Alcohol Use: No, Pain Scale: 6/10 Moderate, Pain Scale Comments: bilateral knees/ lower back
Questionnaire AutoCites Refreshed by STARBUCK,AARON K @ 07 Nov 2014 1159 EST

Questionnaires
S/O Note Written by STARBUCK,AARON K @ 07 Nov 2014 1709 EST

Chief complaint
The Chief Complaint is: F/U labs.
44 yo AA M presenting for f/u labs collected from recent illness on 4 Nov 2014. All labs were negative and reviewed with patient; pt
currently taking amoxicillin for 10 days and relays improvement in symptoms. continues to have left ear pain and many months h/o
worsening hearing in left ear more than right. w/ h/o hearing loss.
In the previous 21 days, the individual HAS NOT resided or traveled to one or more of the following countries in West Africa: Liberia,
Sierra Leone, Guinea, Nigeria, or in a region where Ebola Virus Disease (EVD) transmission is active.
The patient HAS NOT HAD contact or interaction with someone who might have Ebola, or the body fluids, surroundings or remains
of an Ebola patient during the past 21 days.
The patient HAS NOT HAD a fever OR nausea/vomiting, diarrhea, abdominal/stomach pain, joint and muscle ache, severe
headache, new skin rash or unexplained bruising or bleeding in the past 21 days.
Pain assessment
Location: Bilateral knees/ back
Duration: x 10 years
Quality: dull, sharp, throbbing
Factors that correlate with onset: service injuries
Frequency: constant
Average level: 6/10
Worst level: 9/10
Least level:
What makes it better:
2019
Medical Record
2019
What makes it worse:

..............
PHQ-2 Depression Screen Negative.2.
Patient is compliant with medications.
Allergies
.
Current medication
ASA 81 MG EVERY DAY
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Annual Screen date:
Family history
CA- mother- bresat
father- DM.
.
Review of systems
Systemic: No fever.
Otolaryngeal: No nasal discharge.
2019
Medical Record
2019
Gastrointestinal: No vomiting and no diarrhea.

Genitourinary: No dysuria.
Physical findings
Vital Signs:
General Appearance:
Head:
Eyes:
General/bilateral:
Sclera: ° Normal.
Ears:
General/bilateral:
Outer Ear: • Abnormalities Erythema with significant debris in the outer ear and along the tympanic membrane.
Right Ear:
Left Ear:
External Auditory Canal: • Examined.
Practice Management
Colonoscopy - n/a

.
Patient
A/P Written by STARBUCK,AARON K @ 07 Nov 2014 1715 EST

1. OTITIS EXTERNA 380.10: Audiology: ENT: 44 yo with hearing loss and abnormal appearing TM, concern for significant middle
ear pathology.
Medication(s): -CIPRODEX 0.3-0.1% OTIC DROPS SUSP--OTIC - 4 DROPS IN EAR TWICE A DAY FOR 7 DAYS #1
RF0
Consult(s): -Referred To: AUDIOLOGY CONSULT (Routine) Specialty: Clinic: AUDIOLOGY Provisional Diagnosis:
OTITIS EXTERNA
-Referred To: OTORHINOLARYNGOLOGY CONSULT (Routine) Specialty: Clinic:
OTORHINOLARYNGOLOGY Provisional Diagnosis: OTITIS EXTERNA
2. HEARING LOSS 389.9
Disposition Written by STARBUCK,AARON K @ 07 Nov 2014 1716 EST

2019
Medical Record
2019
Signed By STARBUCK, AARON K (Family Medicine, MD, MAJ MC, USA, Martin Army) @ 07 Nov 2014 1716
_________________________________________________________________________________________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by STARBUCK,AARON K @ 07 Nov 2014 1712 EST:
S/O Note Written by HUNTER,TIMOTHY A @ 07 Nov 2014 1146 EST
Chief complaint
44 yo AA M presenting for f/u labs collected from recent illness on 4 Nov 2014. All labs were negative and reviewed with patient; pt currently taking amoxicillin for 10 days and
relays improvement in symptoms.
In the previous 21 days, the individual HAS NOT resided or traveled to one or more of the following countries in West Africa: Liberia, Sierra Leone, Guinea, Nigeria, or in a
region where Ebola Virus Disease (EVD) transmission is active.
The patient HAS NOT HAD contact or interaction with someone who might have Ebola, or the body fluids, surroundings or remains of an Ebola patient during the past 21 days.
The patient HAS NOT HAD a fever OR nausea/vomiting, diarrhea, abdominal/stomach pain, joint and muscle ache, severe headache, new skin rash or unexplained bruising or
bleeding in the past 21 days.
Pain assessment
Frequency: constant
Average level: 6/10
Worst level: 9/10
Least level:
..............
Allergies
.
Current medication
ASA 81 MG EVERY DAY
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Annual Screen date:
Family history
CA- mother- bresat
2019
Medical Record
2019

father- DM.
.
Practice Management
Colonoscopy - n/a

.
Patient
The following S/O Note Was Overwritten by HUNTER,TIMOTHY A @ 07 Nov 2014 1159 EST:
S/O Note Written by OSHEA,VALERIE W @ 07 Nov 2014 1027 EST
Chief complaint
He reported: Good general overall feeling /health.
Pain assessment
Frequency: constant
Average level: 6/10
Worst level: 9/10
Least level:
..............
Allergies
.
Current medication
ASA 81 MG EVERY DAY
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
2019
Medical Record
2019

Children: 3.
Annual Screen date:
Family history
CA- mother- bresat
father- DM.
.
Practice Management
Colonoscopy - n/a

.
Patient
2019
Medical Record
2019
04 Nov 2014 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by JONES,
RACHEL M
Encounter ID: BENN-14400164 Primary Dx: OTITIS MEDIA
Patient: WAITERS, TOMMIE Date: 04 Nov 2014 0930 EST Appt Type: OPAC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: AMHM02ASTRONG TEAM Provider: JONES,RACHEL M
AutoCites Refreshed by CAMPBELL,KELLY R @ 04 Nov 2014 0930 EST

Allergies
No Allergies Found.

Starbuck/possible flu/ 706-326-4585
MHt
Screening Written by CAMPBELL,KELLY R @ 04 Nov 2014 0930 EST

Reason For Appointment: Starbuck/possible flu/ 706-326-4585
Vitals
Vitals Written by CAMPBELL,KELLY R @ 04 Nov 2014 0930 EST
BP: 136/83 Left Arm, Adult Cuff, HR: 90, RR: 18, T: 98.2 °F Oral, HT: 66 in, WT: 232.2 lbs Upright Scale, Actual,
With Shoes, BMI: 37.48,
BSA: 2.131 square meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 6/10 Moderate, Pain Scale Comments: head
and lower back
S/O Note Written by JONES,RACHEL M @ 05 Nov 2014 1407 EST

Chief complaint
The Chief Complaint is: Possible flu.
Pt is a 44yo male who presents to clinic due to congestion and body aches; pt states that this has been ongoing for the past 5 days;
he states that his son was sick recently with similar symptoms; he states that he has also been having a frontal headache as well;
he states that he has been having nasal congestion as well as rhinorrhea that is yellow to green in coloration; he states that he has
also been having left ear pain as well; he states that he was also febrile last night to 102 and took Children's tylenol at that time; he
states that he has also been taking Nyquil as well; pt states that he was recently put on Metronidazole for a trichomonas infection
but has continued to have increased urination; pt states that he has increased his water intake but wanted to make sure that this
was normal; pt did not want to elaborate further on the trichomonas infection at time of visit; pt has no other concerns at this time
.
In the previous 21 days, the individual HAS NOT resided or traveled to one or more of the following countries in West Africa: Liberia,
Sierra Leone, Guinea, Nigeria, or in a region where Ebola Virus Disease (EVD) transmission is active.
The patient HAS NOT HAD contact or interaction with someone who might have Ebola, or the body fluids, surroundings or remains
of an Ebola patient during the past 21 days.
The patient HAS NOT HAD a fever OR nausea/vomiting, diarrhea, abdominal/stomach pain, joint and muscle ache, severe
headache, new skin rash or unexplained bruising or bleeding in the past 21 days.
Pain assessment: 6/10
Location: headache
Duration: 2 weeks
Quality: pressure
Frequency: daily
2019
Medical Record
2019
Average level:
Worst level:
Least level:
..............
Patient has received After hour care at North Columbus since their last visit with this clinic.
Allergies
None reported per patient
.
Current medication
ASA 81 MG EVERY DAY
Tramodol 1 tab by mouth by mouth every day as needed.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Annual Screen date:
Family history
CA- mother- bresat
father- DM.
.
2019
Medical Record
2019
Review of systems
Systemic: Fever. No chills.
Head: Headache.
Otolaryngeal: Earache, nasal discharge, and nasal passage blockage (stuffiness). No sore throat.
Gastrointestinal: No nausea, no vomiting, no abdominal pain, and no diarrhea.
Genitourinary: Urinary frequency. No urinary urgency. No dysuria.
Physical findings
Vital Signs:
General Appearance:
Head:
Neck:
Eyes:
General/bilateral:
Pupils: ° PERRL. ° Size of the pupil was normal.
Sclera: ° Normal.
Ears:
General/bilateral:
Right Ear:
Left Ear:
External Auditory Canal: • Examined.
Tympanic Membrane: • Bulging tympanic membrane. • Erythematous.
Nose:
General/bilateral:
Discharge: • Nasal discharge seen.
swollen.
Oral Cavity:
Pharynx:
Lymph Nodes:
were not enlarged.
Lungs:
Cardiovascular:
Abdomen:
Neurological:
Psychiatric:
2019
Medical Record
2019
Mood: ° Euthymic.
Affect: ° Normal.
Practice Management
Colonoscopy - n/a

.
Patient
A/P Last updated by JONES,RACHEL M @ 05 Nov 2014 1426 EST

1. OTITIS MEDIA 382.9: Pt is a 44yo AAM who present to the clinic due to HA, fever, and congestion which is most likely secondary
to URI and OM; at this time will treat the pt with Amoxicillin for the next 10 days; have advise the pt that if his symptoms are
worsening or he is not feeling better in the next 48 hours that he should return to clinic for further evaluation; pt was negative for the
flu and strep throat; pt agrees and understands the above plan
Medication(s): -AMOXICILLIN--PO 500MG CAP - TAKE ONE CAPSULE THREE TIMES A DAY FOR TEN DAYS #30
RF0
Laboratory(ies): -INFLUENZA A & B RAPID TEST (Routine) Ordered By: CAMPBELL,KELLY R Ordering Provider:
JONES, RACHEL M; STREP PYOGENES AG (Routine) Ordered By: CAMPBELL,KELLY R Ordering
Provider: JONES, RACHEL M; THROAT CULTURE (Routine) Ordered By: CAMPBELL,KELLY R
Ordering Provider: JONES, RACHEL M
2. UPPER RESPIRATORY INFECTION 465.9: as above
3. Urinary frequency increased 788.41: Pt is a 44yo male with a recent history of trichomonis infection and increased frequency of
urination; at this time obtained G/C probe as well as urinalysis and have advised the pt to follow-up with his PCM for follow-up; pt
states that he agrees and understands the above plan
Laboratory(ies): -URINALYSIS (Routine); GC/CHLAMYDIA PROBE (Routine)
Disposition Written by JONES,RACHEL M @ 05 Nov 2014 1426 EST

Signed By JONES, RACHEL M (FP Resident, BMACH) @ 05 Nov 2014 1426

_________________________________________________________________________________________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by JONES,RACHEL M @ 05 Nov 2014 1324 EST:
S/O Note Written by CAMPBELL,KELLY R @ 04 Nov 2014 0942 EST
Chief complaint
The Chief Complaint is: Boidy aches, fatigue, frequent urination and headache x 2 week.
He reported: Good general overall feeling /health.
Pain assessment: 6/10
Location: headache
Duration: 2 weeks
Quality: pressure
Frequency: daily
Average level:
Worst level:
2019
Medical Record
2019
Least level:
..............
Patient has received After hour care at North Columbus since their last visit with this clinic.
Allergies
None reported per patient
.
Current medication
ASA 81 MG EVERY DAY
Tramodol 1 tab by mouth by mouth every day as needed.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Annual Screen date:
Family history
CA- mother- bresat
father- DM.
.
Practice Management
Colonoscopy - n/a

.
Patient
The following A/P Note Was Overwritten by JONES,RACHEL M @ 04 Nov 2014 1029 EST:
The A/P section was last updated by JONES,RACHEL M @ 04 Nov 2014 1029 EST - see above.Previous Version of A/P section was entered/updated by CAMPBELL,KELLY R
@ 04 Nov 2014 0957 EST.
2019
Medical Record
2019
--> Unassociated Orders, Procedures and Injuries/Accidents <--

THROAT CULTURE (Routine) Ordered By: CAMPBELL,KELLY R Ordering Provider: JONES, RACHEL M
STREP PYOGENES AG (Routine) Ordered By: CAMPBELL,KELLY R Ordering Provider: JONES, RACHEL M
INFLUENZA A & B RAPID TEST (Routine) Ordered By: CAMPBELL,KELLY R Ordering Provider: JONES, RACHEL M
The following S/O Note Was Overwritten by CAMPBELL,KELLY R @ 04 Nov 2014 0954 EST:
S/O Note Written by OSHEA,VALERIE W @ 03 Nov 2014 1531 EST
Chief complaint
The Chief Complaint is: Possible flu.
Allergies
.
Current medication

ASA 81 MG EVERY DAY
HYDROCODONE AS 5MG/325MG.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.
Annual Screen date: 01/29/2013 Retake Hx: 01/29/2014

Family history
CA- mother- bresat
father- DM.
.
Practice Management
Patient's BMI >= 30. Screening Date: 01/29/2013.
The following RFV Note Was Overwritten by CAMPBELL,KELLY R @ 04 Nov 2014 0930 EST:
The Screening section was last updated by CAMPBELL,KELLY R @ 04 Nov 2014 0930 EST - see above.Previous Version of Screening section was entered/updated by
OSHEA,VALERIE W @ 03 Nov 2014 1532 EST.
Reason For Appointment: Starbuck/possible flu/ 706-326-4585
2019
Medical Record
2019
20 Oct 2014 at Martin ACH, Fort Benning, GA, After Hours Clinic(Fam Med Cl) by
ROBERTSON, ROSEMARY T
Encounter ID: BENN-13957675 Primary Dx: TRICHOMONIASIS URETHRITIS
Patient: WAITERS, TOMMIE Date: 20 Oct 2014 1819 EDT Appt Type: OPAC
ALAJANDRO
Treatment Facility: NORTH COLUMBUS Clinic: AFTER HOURS CARE CLINIC Provider: ROBERTSON,ROSEMARY
MEDICAL HOME
AutoCites Refreshed by ROBERTSON,ROSEMARY @ 20 Oct 2014 1944 EDT

•MESENTERIC PANNICULITIS •family medical history (General FHx) No Allergies Found.
•Patient Counseling: •family history of supplemental HPI [use
•BURSITIS TROCHANTERIC for free text] (General FHx)
•Visit for: military services physical •family history of sleep apnea (General
accession FHx)
•Counseling About Travel •family history of heart disease
•GASTRITIS •family history of cancer
•HYPERGLYCEMIA •no family history of angina pectoris
•MCKENZIE POSTERIOR •family history [use for free text]
DERANGEMENT SYNDROME •no family history of mental illness (not
•Patient Counseling Medical Management retardation)
Five To Eight Patients •no family history of alcoholism
•SLEEP APNEA OBSTRUCTIVE •no family history of malignant neoplasm of
•NONORGANIC SLEEP DISORDERS the large intestine
•HYPERLIPIDEMIA •maternal history of arteriosclerotic
•OVERWEIGHT cardiovascular disease (ASCVD)
•HYPERTENSION (SYSTEMIC) (Mother)
•HYPOGONADISM •paternal history of type 2 diabetes mellitus
•ASTIGMATISM (Father)
•Snoring
(LUQ)
•LUMBAGO
DEPRESSED MOOD
HYPERMETROPIA
EPISODE MODERATE
(periumbilical)
DISEASE
EPISODE
exam
•Body Mass Index
INFECTION
2019
Medical Record
2019

•Abdominal pain
•CERVICALGIA
•FOLLICULITIS
•BACKACHE
Active Medications
Labs
No Labs Found.
Reason for Appointment:Written by JOHNSTON,APRIL L @ 20 Oct 2014 1819 EDT

uti/pcm starbuck
Screening Written by PARK,MICHELLE D @ 20 Oct 2014 1935 EDT

Reason For Appointment: Notes Entered by: JOHNSTON,APRIL L 20 Oct 2014 1819
------------------------------
uti/pcm starbuck
Allergen information verified by PARK, MICHELLE D @ 20 Oct 2014 1935 EDT
Vitals
Vitals Written by PARK,MICHELLE D @ 20 Oct 2014 1935 EDT
BP: 127/82, HR: 69, RR: 16, T: 97.7 °F, WT: 242 lbs
S/O Note Written by ROBERTSON,ROSEMARY @ 20 Oct 2014 1952 EDT

Chief complaint
The Chief Complaint is: Patient with history of wife being treated for trichomonas last week. Patient denies any symptomos at
present (pain with urination or intercouse during ejaculation, dischage or irriation inside penis).

PT presents to clinic for possible uti. PT states his wife was treated for UTI last week and was told he needed to be treated as well.
Wife had Trichomoniasis.
.
Current medication

ASA 81 MG EVERY DAY
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
2019
Medical Record
2019

APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.

Family history
CA- mother- bresat
father- DM.
.
Physical findings
Vital Signs:
• Blood pressure less than or equal to 140/90 mmHg. ° Normal.
° Current vital signs reviewed. ° Normal temperature. ° Oral temperature was normal. ° No fever was observed. ° RR was
normal. ° PR was normal. ° Pulse rhythm was regular. ° Blood pressure was normal. ° Stable.
General Appearance:
° Normal. ° Well-appearing. ° Not ill-appearing. ° Patient did not appear uncomfortable. ° Not acutely ill. ° Not chronically ill.
Genitalia:
• Genitalia:
Penis: • Abnormal Exam deferred.
Practice Management
A/P Written by ROBERTSON,ROSEMARY @ 20 Oct 2014 1950 EDT

1. TRICHOMONIASIS URETHRITIS
Medication(s): -METRONIDAZOLE 250MG (FLAGYL)-ORAL TAB--P - 1 TABLET BY MOUTH THREE TIMES A DAY
FOR 7 DAYS. #21 RF0
Disposition Written by ROBERTSON,ROSEMARY @ 20 Oct 2014 1954 EDT

Follow up: as needed with PCM. - Comments: As needed if symptoms do not improve in 7-10 days. Medication reconciled.
Signed By ROBERTSON, ROSEMARY (Physician Assistant, Martin ACH, Fort Benning, GA) @ 20 Oct 2014 1954
_________________________________________________________________________________________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by ROBERTSON,ROSEMARY @ 20 Oct 2014 1946 EDT:
S/O Note Written by PARK,MICHELLE D @ 20 Oct 2014 1941 EDT
Chief complaint
The Chief Complaint is: Uti.
2019
Medical Record
2019

PT presents to clinic for possible uti. PT states his wife was treated for UTI last week and was told he needed to be treated as well. Wife had Trichomoniasis.
.
Current medication

ASA 81 MG EVERY DAY
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.

Family history
CA- mother- bresat
father- DM.
.
Practice Management
2019
Medical Record
2019
26 Aug 2014 at Martin ACH, Fort Benning, GA, ER by WILLIAMS, DANISE N
Encounter ID: BENN-12362089 Primary Dx: Observation For Suspected Condition
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: WILLIAMS,DANISE N
A/P Written by WILLIAMS,DANISE N @ 26 Aug 2014 2047 EDT

1. Observation For Suspected Condition: This documentation is to verify that the patient was seen in the Emergency Department
and this note is signed for administrative purposes only. Patient's encounter documentation scanned into HAIMS section in AHLTA,
note is titled Encounter Note
Disposition Written by WILLIAMS,DANISE N @ 26 Aug 2014 2048 EDT

Signed By WILLIAMS, DANISE N (Medical Support Assistant, BMACH ER) @ 26 Aug 2014 2048
2019
Medical Record
2019
15 May 2014 at Martin ACH, Fort Benning, GA, ER by GREEN, TARA R
Patient: WAITERS, TOMMIE Date: 15 May 2014 1224 EDT Appt Type: EROOM
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: GREEN,TARA R
AutoCites Refreshed by CROUCH,ROBERT J @ 15 May 2014 1306 EDT

Allergies
No Allergies Found.
Active Medications
Labs
No Labs Found.
Rads
No Rads Found.
Vitals
No Vitals Found.
A/P Last updated by GREEN,TARA R @ 15 May 2014 1530 EDT

and this note is signed for administrative purposes only. Patient's encounter documentation scanned into clinical notes section in
AHLTA, note is titled Emergency Department Encounter Note
--> Unassociated orders and procedures <--

NAPROXEN 500MG (NAPROSYN)-ORAL TABLET--P - T1 TAB BID WF #60 RF0 Qt: 60 Rf: 0 Ordered By: CROUCH,ROBERT J
Ordering Provider: CROUCH, ROBERT JOSEPH
METAXALONE--PO 800MG TAB - 1 TAB PO TID #12 RF0 Qt: 12 Rf: 0 Ordered By: CROUCH,ROBERT J Ordering Provider: CROUCH,
ROBERT JOSEPH
HYDROCODONE/APAP 5MG/325MG ORAL TABLET-- - 1 TAB PO TID PRN #9 RF0 Qt: 9 Rf: 0 Ordered By: CROUCH,ROBERT J
Ordering Provider: CROUCH, ROBERT JOSEPH
Disposition Written by GREEN,TARA R @ 15 May 2014 1530 EDT

Signed By GREEN, TARA R (DEM, MEDICAL SUPPORT ASSISTANT) @ 15 May 2014 1530
_________________________________________________________________________________________________________
CHANGE HISTORY
The following A/P Note Was Overwritten by GREEN,TARA R @ 15 May 2014 1530 EDT:
The A/P section was last updated by GREEN,TARA R @ 15 May 2014 1530 EDT - see above.Previous Version of A/P section was entered/updated by CROUCH,ROBERT J
@ 15 May 2014 1329 EDT.

HYDROCODONE/APAP 5MG/325MG ORAL TABLET-- - 1 TAB PO TID PRN #9 RF0 Qt: 9 Rf: 0 Ordered By: CROUCH,ROBERT J Ordering Provider: CROUCH, ROBERT JOSEPH
METAXALONE--PO 800MG TAB - 1 TAB PO TID #12 RF0 Qt: 12 Rf: 0 Ordered By: CROUCH,ROBERT J Ordering Provider: CROUCH, ROBERT JOSEPH
NAPROXEN 500MG (NAPROSYN)-ORAL TABLET--P - T1 TAB BID WF #60 RF0 Qt: 60 Rf: 0 Ordered By: CROUCH,ROBERT J Ordering Provider: CROUCH, ROBERT JOSEPH
2019
Medical Record
2019
13 Nov 2013 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by COX-BEVLEY,
SHARON B
PROBLEM CONCERNING BEHAVIOR

OF CHILD
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC SPECIALTY CLINIC Provider: COXBEVLEY,SHARON B
Patient Status: Outpatient Call Back Phone:
Reason for Telephone Consult:Written by DUNOVANT,GLORIA A @ 13 Nov 2013 0839 EST

child
Telephone Consult Comments: Written by DUNOVANT,GLORIA A @ 13 Nov 2013 0839 EST
Please contact me concerning my child Lyam Waiters/706-326-4585
SO Note Written by COXBEVLEY,SHARON B @ 13 Nov 2013 1226 EST

Subjective
T/C today to Mr. Waiters regarding son Lyam. Left message for return call. Following up on pt's pursuit of family therapy per IBHC
recommendation in August 2013.
A/P Written by COX-BEVLEY,SHARON B @ 13 Nov 2013 1228 EST

1. PROBLEM CONCERNING BEHAVIOR OF CHILD
Disposition Last Updated by COX-BEVLEY,SHARON B @ 13 Nov 2013 1225 EST
Signed By COX-BEVLEY, SHARON B (Clinical Social Worker, LCSW, IBHC, Martin ACH, Fort Benning, GA) @ 13 Nov 2013
1228
2019
Medical Record
2019
02 Nov 2013 at Martin ACH, Fort Benning, GA, ER by BROWN, REGINA S
Patient: WAITERS, TOMMIE Date: 02 Nov 2013 0156 EST Appt Type: EROOM
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: BROWN,REGINA S
A/P Written by BROWN,REGINA S @ 02 Nov 2013 0842 EST

1. Observation For Suspected Condition: THIS DOCUMENTATION IS TO VERIFY THAT THE PATIENT WAS SEEN IN THE
EMERGENCY DEPARTMENT AND THIS NOTE IS SIGNED FOR ADMINISTRATIVE PURPOSES ONLY. PATIENT?S
ENCOUNTER DOCUMENTATION SCANNED INTO CLINICAL NOTES SECTION IN AHLTA, NOTE IS TITLED EMERGENCY
DEPARTMENT ENCOUNTER NOTE
Disposition Written by BROWN,REGINA S @ 02 Nov 2013 0842 EST

Signed By BROWN, REGINA S (MSA, DEM, DEPARTMENT OF EMERGENCY MEDICINE,BMACH) @ 02 Nov 2013 0842
2019
Medical Record
2019
28 Jun 2013 at Martin ACH, Fort Benning, GA, AMH P01B Bears by TO, PHUONG N
Patient: WAITERS, TOMMIE Date: 28 Jun 2013 1513 EDT Appt Type: T-CON*
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: AMHP01BBEARS Provider: TO,PHUONG NGHIEM XUAN
AutoCites Refreshed by TO,PHUONG N @ 28 Jun 2013 1513 EDT

Chronic: •Family medical history (General FHx) No Allergies Found.
•Mesenteric panniculitis •Supplemental HPI [use for free text]
•Patient counseling (General FHx)
•Trochanteric bursitis •Sleep apnea (General FHx)
•Visit for: military services physical for •Family history of heart disease
accession •No family history of angina pectoris
•Counseling about travel •Family history of cancer
•Gastritis •Family history [use for free text]
•Hyperglycemia •No family history of mental illness (not
•McKenzie posterior derangement retardation)
syndrome •No family history of alcoholism
•Counseling for five to eight patients about •No family history of malignant neoplasm
medical management of the large intestine
•Obstructive sleep apnea •Arteriosclerotic cardiovascular disease
•Nonorganic sleep disorders (ASCVD) (Mother)
•Hyperlipidemia •Type 2 diabetes mellitus (Father)
•Overweight
•Hypertension
•Hypogonadism
•Astigmatism
•Male erectile disorder
•Snoring was observed
•LUQ abdominal pain
•Lumbago
•Recurrent major depression in partial
remission
•Adjustment disorder with depressed
mood
•Hypermetropia
•Generalized anxiety disorder
•Moderate single episode major
depression
•Periumbilical pain
•Condition was caused by an occupational
disease
•Anxiety disorder NOS
•Major depression, single episode
•Isolated blood pressure was elevated
•Visit for: occupational health/fitness exam
•Body mass index
•Patient education about a proper diet
•Gastritis due to H. pylori
•Helicobacter pylori (H. pylori) infection
•Testicular neoplasm
•Abdominal pain
•Other physical therapy
•Shoulder joint pain
•Cervicalgia
•Folliculitis
2019
Medical Record
2019
•Migraine headache
•Backache
Active Medications
Reason for Telephone Consult:Written by TO,PHUONG N @ 28 Jun 2013 1513 EDT

Malaria medicine
A/P Written by TO,PHUONG N @ 28 Jun 2013 1718 EDT

1. visit for: administrative purpose: Father of my patient, states family going to africa in 2 days, will not have time to see PCP,
would like prophylaxis for malaria. Will give for pt and his wife.
Medication(s): -DOXYCYCLINE 100MG ORAL CAPSULE--PO 100MG - 1 TABLET DAILY FROM 2 DAYS PRIOR TO
TRAVEL UNTIL 2 WEEKS AFTER RETURN #60 RF0 Qt: 60 Rf: 0 Ordered By: TO,PHUONG N
Ordering Provider: TO, PHUONG NGHIEM
Disposition Written by TO,PHUONG N @ 28 Jun 2013 1719 EDT
Signed By TO, PHUONG N (D.O. - Pediatrician, Martin Army Community Hospital) @ 28 Jun 2013 1719
2019
Medical Record
2019
04 Jun 2013 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M
Encounter ID: BENN-10257311 Primary Dx: MESENTERIC PANNICULITIS
Patient: WAITERS, TOMMIE Date: 04 Jun 2013 1300 EDT Appt Type: EST
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: SURGERY Provider: MCGUIGAN,REBECCA
MARIER

referral for abdominal pain
tmv
Screening Written by OWENS,CHRISTEN A @ 04 Jun 2013 1144 EDT

Reason For Appointment: referral for abdominal pain
Allergen information verified by OWENS, CHRISTEN A @ 04 Jun 2013 1143 EDT
Vitals
Vitals Written by OWENS,CHRISTEN A @ 04 Jun 2013 1144 EDT
BP: 153/95, HR: 80, T: 98.1 °F, SpO2: 98%, Tobacco Use: No, Alcohol Use: No, Pain Scale: 8/10 Severe,
Pain Scale Comments: Left upper quandrant of abdomen
Comments: 508 pulled
nondeployment related
#706-326-4585
SO Note Written by MCGUIGAN,REBECCA MARIER @ 04 Jun 2013 1235 EDT

Chief complaint
The Chief Complaint is: Abdominal pain.
Patient referred for ongoing chronic left upper quadrant and epigastric abdominal pain. I last saw him in 2008 when I worked him up
for question of mesenteric panniculitis/sclerosing mesenteritis versus lymphoma due to the appearance of the mesentery on CT of
the abdomen and MRI. He had a biopsy of the mesentery done laparoscopically which was somewhat inconclusive but not
suggestive of lymphoma or mesenteric sclerosis. MRI findings subsequently resolved. Patient has constant left upper quadrant and
epigastric abdominal pain that has persisted over the last 6 years. He believes the pain is getting somewhat worse. He was treated
for H. pylori with no improvement in his symptoms. He has occasional nausea but no vomiting. No diarrhea. No blood in the stool.
No changes in bowel habits. He has one bowel movement per day. Never had a colonoscopy. I performed an EGD in December of
2008 which demonstrated H. pylori gastritis for which he was treated. He has had additional recent workup to include CT scan of the
abdomen in November 2012 which demonstrated possible mesenteric panniculitis. He had an upper GI which demonstrated a
possible filling defect in the esophagus.
Current medication
Nexium, aspirin, Celebrex as needed. Patient also takes Motrin as needed for abdominal pain. He was prescribed oxycodone but
rarely takes it.
Reported:
Surgical / Procedural: Surgical / procedural history: Appendectomy, cyst removal left wrist, laparoscopic mesenteric biopsy May
of 2008.
Personal history
Nonsmoker, does not drink alcohol.
Family history
Family medical history There is no family history of colon cancer or other GI cancers.
Review of systems
No intentional weight loss, no skin lymph, no neck lumps, no chest pain, no pain with urination, no easy bruising or bleeding, no
fevers or chills, no productive cough, no heart palpitations, no difficulty swallowing, no vomiting.
Physical findings
GEN./CONSTITUTIONAL: Vital signs as measured above. The patient is well-developed and well-nourished.
EYES: Sclerae anicteric.
EARS/NOSE/MOUTH/THROAT: Overall appearance of grossly normal without obvious scars, lesions, or masses. Hearing grossly
normal.
NECK: Overall appearance normal without masses or asymmetry.
2019
Medical Record
2019
RESPIRATORY: Respiratory effort grossly normal without retractions or use of accessory muscles.
MUSCULOSKELETAL: Gait grossly normal. Normal movement of all extremities.
PSYCHIATRIC: Mood and affect normal. Judgment and insight grossly normal.
SKIN: Normal color and temperature. No diffuse rashes.
ABDOMEN: PATIENT IS MODERATELY OBESE. NO MASSES. WELL-HEALED TROCAR INCISIONS STATUS POST
LAPAROSCOPY. TENDERNESS TO PALPATION IN THE LEFT UPPER QUADRANT AND EPIGASTRIUM.
Tests
CT scan from November of 2012 reviewed with radiologist. There is mild haziness of the mesenteric fat without any significant
lymphadenopathy. Findings are relatively stable from previous scans, although his mesenteric changes seem to wax and wane.
Rad Result Cited by MCGUIGAN,REBECCA M @ 04 Jun 2013 1240 EDT
WAITERS, TOMMIE ALAJANDRO 20/262-65-1757 42yo 18 Aug 1970 M

********** CT IVP **********
Status: Complete
Procedure: CT IVP
Event Date: 20-Nov-2012 19:49:00
Reason for Order:
42 yr old male w/ 5 weeks of LUQ abd pain adn flank pain. Ct abd w/out evid of
pain source. Labs essentially normal. Please do CT IVP to further eval.
THANKS.
Exam #: 12097140
Exam Date/Time: 28-Nov-2012 07:59:00
Transcription Date/Time: 28-Nov-2012 09:24:00
AMHM02DYELLOW TEAM MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Approved Date: 28-Nov-2012 09:18:00
Report Text:
FINDINGS: The lung bases are clear except for bibasilar atelectasis. There is
linear scarring versus atelectasis at the right lung base.
Precontrast images are unremarkable except for a punctate calcification within

the right pelvis. The kidneys are symmetric in size and contour and demonstrate
normal enhancement and excretion of contrast into the ureters. Delayed images
demonstrate normal appearing ureters without ureteral filling defect or
external compression. The left ureter is completely opacified appears normal in
appearance. The distal most aspect of the right ureter is not well visualized
likely secondary peristalsis. The bladder is normal in appearance without
evidence of filling defect.
The liver, spleen, pancreas and adrenal glands are unremarkable. The visualized
portions of the large and small bowel and stomach are unremarkable on this
noncontrast evaluation. The major branches of the abdominal aorta and hepatic
and portal venous systems appear unremarkable.
2019
Medical Record
2019
Incidental note of mild haziness of the mesenteric fat with multiple

subcentimeter mesenteric lymph nodes.
IMPRESSION: 1. No evidence of obstructive uropathy or renal collecting system

filling defect. The distal most aspect of the right ureter is not well
visualized likely secondary peristalsis. 2. Mesenteric panniculitis which is a
nonspecific finding but can be seen in infectious or inflammatory processes and
also has an association with lymphoma. Clinical and laboratory correlation is
recommended as well as a six-month follow-up abdomen pelvis CT to evaluate for
interval change.
A/P Written by MCGUIGAN,REBECCA M @ 04 Jun 2013 1244 EDT

1. MESENTERIC PANNICULITIS: Will repeat CT scan because it has been 6 months. Pain may be secondary to ongoing mild
mesenteric panniculitis. The patient notes that the pain is improved with taking NSAIDs. Patient should have an EGD and
colonoscopy to further eval for any infectious or other causes of mesenteric inflammation/adenitis, reassess for presence of H.
pylori, evaluate possible filling defect on upper GI. Will refer to gastroenterology for additional evaluation and management.
Radiology(ies): -CT ABDOMEN & PELVIS W/ CONTRAST (Routine) Ordered By: MCGUIGAN,REBECCA M Ordering
Provider: MCGUIGAN, REBECCA MARIER Impression: follow up mesenteric panniculitis seen on CT
scan in 11/2012
Consult(s): -Referred To: GASTROENTEROLOGY CONSULT (Routine) Specialty: Clinic: SURGERY Primary
Diagnosis:
Disposition Written by MCGUIGAN,REBECCA M @ 04 Jun 2013 1244 EDT

Follow up: with PCM. - Comments: f/u w/ me after GI eval
Signed By MCGUIGAN, REBECCA M (MD, LTC, MC, Physician, General Surgery Clinic) @ 04 Jun 2013 1244
2019
Medical Record
2019
30 May 2013 at Martin ACH, Fort Benning, GA, ER by WILLIAMS, DANISE N
ALAJANDRO
A/P Written by WILLIAMS,DANISE N @ 31 May 2013 0031 EDT

and this note is signed for administrative purposes only. Patient?s encounter documentation scanned into clinical notes section in
Disposition Written by WILLIAMS,DANISE N @ 31 May 2013 0031 EDT

Signed By WILLIAMS, DANISE N (Medical Support Assistant, BMACH ER) @ 31 May 2013 0031
2019
Medical Record
2019
03 May 2013 at Martin ACH, Fort Benning, GA, AMH M02A Strong Team by STARBUCK,
AARON K
Encounter ID: BENN-10147200 Primary Dx: Abdominal pain
Patient: WAITERS, TOMMIE Date: 03 May 2013 1000 EDT Appt Type: OPAC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: AMHM02AGREEN TEAM Provider: STARBUCK,AARON K
AutoCites Refreshed by RAINA,ARWYN @ 03 May 2013 0936 EDT

Allergies
No Allergies Found.

Starbuck/ pain left side of torso 706 3264585
cow
Screening Written by GRILLO,ALLENA C @ 03 May 2013 0929 EDT

Reason For Appointment: Starbuck/ pain left side of torso 706 3264585
Allergen information verified by GRILLO, ALLENA C @ 03 May 2013 0929 EDT
Vitals
Vitals Written by GRILLO,ALLENA C @ 03 May 2013 0922 EDT
BP: 122/78, HR: 72, RR: 16, T: 97.0 °F, HT: 66 in, WT: 229.8 lbs, BMI: 37.09, BSA: 2.122 square meters
SO Note Written by STARBUCK,AARON K @ 03 May 2013 1452 EDT

Chief complaint
The Chief Complaint is: Pain on left side of torso.
She's had extensive workup for his left upper quadrant abdominal pain which is constant in nature. It feels like a "running cramps ".
She was treated for H. pylori which did not improve his pain. He says that ibuprofen completely eliminate his pain however she does
not desire to take ibuprofen continuously. He recently had a CT scan and endoscopy with results below. He was referred to
gastroenterologist but this consultation was derailed due to the fact that he retired from military service.
Medication list reviewed with patient, reconciliation completed.
Fair general overall feeling.
Not currently on active duty and visit is not deployment-related.
Pain assessment: Pain is located on left side of torso. Pain is described as crampy and constant.
Patient feels safe at home.
Patient has had specialty care, ER visit, or hospitalization since last visit.
Current medication

ASA 81 MG EVERY DAY
Reported:
2019
Medical Record
2019

HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.

Family history
CA- mother- bresat
father- DM.
.
Physical findings
Vital Signs:
General Appearance:
Neck:
Lymph Nodes:
were not enlarged.
Lungs:
° Respiration rhythm and depth was normal. ° Clear to auscultation. ° No wheezing was heard. ° No rhonchi were heard.
° No rales/crackles were heard.
Cardiovascular:
Abdomen:
Palpation: • Abdominal tenderness Left upper quadrant with deep palpation mild discomfort. ° No mass was palpated in the
abdomen.
2019
Medical Record
2019

Practice Management
A/P Written by STARBUCK,AARON K @ 03 May 2013 1456 EDT

1. abdominal pain: Contents of gastroenterology consult:42 Y/O MALE WITH CHRONIC ABDOMINAL PAIN LLQ / FLANK.
TREATED FOR H PYLORI LAST YEAR. RECENT UGI REVEALS FILLING DEFECT GASTRIC MUCOSA. CT ABD REVEALS
MESSENTERIC PANNICULLITIS. CONSIDER LOWER AND UPPER ENDOSCOPY please eval and treat 706-326-4585
Consult(s): -Referred To: GASTROENTEROLOGY CONSULT (Routine) Specialty: Clinic: SURGERY Primary
Diagnosis: abdominal pain
Disposition Written by STARBUCK,AARON K @ 03 May 2013 1456 EDT

Signed By STARBUCK, AARON K (Family Medicine, MD, MAJ MC, USA, Martin Army) @ 03 May 2013 1456
_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by STARBUCK,AARON K @ 03 May 2013 1455 EDT:
SO Note Written by GRILLO,ALLENA C @ 03 May 2013 0923 EDT
Chief complaint
The Chief Complaint is: Pain on left side of torso.
He reported: Medication list reviewed with patient, reconciliation completed.
Fair general overall feeling.
Pain assessment: Pain is located on left side of torso. Pain is described as crampy and constant.
Patient has had specialty care, ER visit, or hospitalization since last visit.
Current medication

ASA 81 MG EVERY DAY
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Personal history
Children: 3.

2019
Medical Record
2019

Family history
CA- mother- bresat
father- DM.
.
Practice Management
2019
Medical Record
2019
30 Mar 2013 at Martin ACH, Fort Benning, GA, ER by WILLIAMS, DANISE N
ALAJANDRO
A/P Written by WILLIAMS,DANISE N @ 31 Mar 2013 0321 EDT

and this note is signed for administrative purposes only. Patient?s encounter documentation scanned into clinical notes section in
Disposition Written by WILLIAMS,DANISE N @ 31 Mar 2013 0321 EDT

Signed By WILLIAMS, DANISE N (Medical Support Assistant, BMACH ER) @ 31 Mar 2013 0321
2019
Medical Record
2019
29 Jan 2013 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by ZAGORSKI,
KIM J
Encounter ID: BENN-9785272 Primary Dx: Abdominal pain
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: AMHM02DYELLOW TEAM Provider: ZAGORSKI,KIM JOSEPH

Zagorski- Discuss stool sample findings 7063264585
lkr
Vitals
Vitals Written by MORRIS,TARA C @ 29 Jan 2013 0928 EST
BP: 141/91, HR: 90, RR: 20, T: 98.3 °F, HT: 66 in, WT: 226 lbs, SpO2: 97%, BMI: 36.48,
BSA: 2.107 square meters
SO Note Written by ZAGORSKI,KIM JOSEPH @ 29 Jan 2013 1246 EST

Chief complaint
The Chief Complaint is: OCCULT STOOL POSITIVE.
42 Y/O AD MALE ON TERMINAL LEAVE PRESENTS TODAY FOR 6 MONTH HX OF LLQ PAIN. STARTED WORKUP UP WITH
HIS EXIT PHYSICAL AT THE VA. HE TESTED + OCC BLOOD STOOL, AND ACBE VS CT ABD PENDING AT COL DX. NO
UNEXPECTED WEIGHT LOSS, HEMATACHEZIA OR MELENA. NO HX COLON CANCER POLYP OR DIVERTICULAR
DISEASE. NO FAMILY HX COLON MALIGNANCY
.
Currently on active duty. Visit is not deployment-related.
Good general overall feeling.
Abdominal pain LLQ FOR 6 MONTHS.
Pain assessment: ABDOMINAL PAIN.

Attending Physician:ZAGORSKI.
Patient has NOT had specialty care, ER visit, or hospitalization since last visit.
Current medication

ASA 81 MG EVERY DAY
MAXZIDE 37.5MG-25MG EVERY DAY.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
2019
Medical Record
2019
APPENDECTOMY
ABD LAPROSCOPY 2012
.
Medications: No medication noncompliance.
Personal history

Family history
CA- mother- bresat
father- DM.
.
Review of systems
Gastrointestinal: Appetite not decreased. No dysphagia, no nausea, no vomiting, no hematemesis, no jaundice, no bright red
blood per rectum, no diarrhea, and no constipation.
Genitourinary: No hematuria and no pain in the flank.
Neurological: No dizziness, no lightheadedness, and no fainting.
Physical findings
Vital Signs:
General Appearance:
Neck:
Eyes:
General/bilateral:
Sclera: ° Normal.
Nose:
General/bilateral:
Cavity: ° Nasal mucosa normal.
Pharynx:
Oropharynx: ° Normal.
Lymph Nodes:
were not enlarged.
Lungs:
° Respiration rhythm and depth was normal. ° Clear to auscultation.
Cardiovascular:
Heart Rate And Rhythm: • Abnormal.
Heart Sounds: ° Normal S1 and S2.
Abdomen:
Auscultation: ° Bowel sounds were not diminished or absent. ° No bruit was heard over the abdominal aorta (midline).
Palpation: • Abdominal tenderness TENDER LLQ. AREA SOFT NOT GUARDED NO ECCHYMOSIS NO MASS PALPATED.
° No mass was palpated in the abdomen.
Practice Management
2019
Medical Record
2019
Lab Result Cited by ZAGORSKI,KIM J @ 29 Jan 2013 1243 EST

Hemogram+Differential Auto Site/Specimen 29 Jan 2013 0957 Units Ref Rng
WBC BLOOD 8.4 x10(3)/mcL (4.9-10.0)
RBC BLOOD 5.35 x10(6) (4.7-6.1)
Hematocrit BLOOD 45.7 % (42-52)
MCHC BLOOD 34.7 % (32-36)
RDW CV BLOOD 13.3 % (11.5-14.5)
MPV BLOOD 9.7 fL (6.8-10)
Neutrophils BLOOD 3.3 x10(3)/mcL (1.4-6.5)
Lymphocytes BLOOD 4.2 (H) x10(3)/mcL (1.0-4.0)
Monocytes BLOOD 0.5 x10(3)/mcL (0.0-1.0)
Eosinophils BLOOD 0.2 x10(3)/mcL (0-.5)
Basophils BLOOD 0.1 x10(3)/mcL (0.0-0.2)
Comprehensive Metabolic Panel Site/Specimen 29 Jan 2013 0957 Units Ref Rng
Bilirubin PLASMA 0.7 mg/dL (0.2-1.3)
Glucose PLASMA 110 (H) mg/dL (74-106)
Anion Gap PLASMA 16.1 mmol/L (10-20)
Lipase Site/Specimen 29 Jan 2013 0957 Units Ref Rng

Triacylglycerol Lipase PLASMA 205 U/L (23-300)
Amylase Site/Specimen 29 Jan 2013 0957 Units Ref Rng

Amylase PLASMA 94 U/L (25-115)
Rad Result Cited by ZAGORSKI,KIM J @ 29 Jan 2013 1245 EST

********** CT IVP **********
Status: Complete
Procedure: CT IVP
Event Date: 20-Nov-2012 19:49:00
Reason for Order:
2019
Medical Record
2019
THANKS.
Exam #: 12097140
Status: COMPLETE
Report Text:



interval change.

********** CT ABDOMEN & PELVIS W/ CONTRAST **********
2019
Medical Record
2019
Status: Complete
Procedure: CT ABDOMEN & PELVIS W/ CONTRAST

Event Date: 01-Nov-2012 09:42:00
Reason for Order:
42 yr old AD obese male w/ 2 weeks of dull LUQ and L flank pain. No hematuria,
no constipation per patient. UA clear. AAS normal. No h/o kidney stones.
Please eval w/ CT abd/pelvis w/ contrast to
further eval.
Exam #: 12091812
Status: COMPLETE
Report Text:
History of hematuria. There is small pleural base nodule seen in the posterior
gutter at the level of the left hilum probably related to scarring.
The liver and spleen appeared unremarkable. Normal appearing gallbladder and
normal in the glands and kidneys. Normal appearing abdominal aorta. No
retroperitoneal lymphadenopathy. No delayed films were obtained to evaluate the
intrarenal collecting system , ureters and urinary bladder with intraluminal
contrast. This can be performed with CT IVP.

********** ABDOMEN SERIES ACUTE **********
Status: Complete
Procedure: ABDOMEN SERIES ACUTE

Event Date: 31-Oct-2012 15:02:00
Reason for Order:
no constipation per patient. No h/o kidney stones. Please eval w/ AAS. THANKS>
Exam #: 12091630
Exam Date/Time: 31-Oct-2012 15:33:00
Transcription Date/Time: 31-Oct-2012 17:49:00
2019
Medical Record
2019
Status: COMPLETE
Approved Date: 31-Oct-2012 17:45:00
Report Text:
FINDINGS: The frontal view of the chest shows no acute infiltrate or

subdiaphragmatic free air. The heart is normal.
The supine and upright views of the abdomen show a normal bowel gas pattern. No
abnormal calcification, definable soft tissue mass or any other significant
finding is seen.
A/P Written by ZAGORSKI,KIM J @ 30 Jan 2013 0939 EST

1. abdominal pain 789.00: GASTROENTEROLOGY TO EVALUATE AND TREAT. 42 Y/O MALE WITH CHRONIC ABDOMINAL
PAIN LLQ / FLANK. TREATED FOR H PYLORI LAST YEAR. RECENT UGI REVEALS FILLING DEFECT GASTRIC MUCOSA.
CT ABD REVEALS MESSENTERIC PANNICULLITIS. CONSIDER LOWER AND UPPER ENDOSCOPY
Laboratory(ies): -HEMOGRAM AUTO+COMP AUTO DIFF (Routine) Ordered By: ZAGORSKI,KIM J Ordering Provider:
ZAGORSKI, KIM JOSEPH; COMPREHENSIVE METABOLIC PANEL (Routine) Ordered By:
ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH; LIPASE (Routine) Ordered By:
ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH; AMYLASE (Routine) Ordered By:
ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH; OCCULT BLOOD. (Routine) Ordered
By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH; OCCULT BLOOD. (Routine)
Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH; OCCULT BLOOD.
(Routine) Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH
Consult(s): -Referred To: GASTROENTEROLOGY CONSULT (Routine) Specialty: Clinic:
GASTROENTEROLOGY CLINIC Primary Diagnosis: abdominal pain Order Date: 01/30/2013 09:37
Disposition Written by ZAGORSKI,KIM J @ 30 Jan 2013 0939 EST

Note Written by MORRIS,TARA C @ 29 Jan 2013 1314 EST
2019
Medical Record
2019
Signed By ZAGORSKI, KIM J (Physician) @ 30 Jan 2013 0940

_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by ZAGORSKI,KIM J @ 29 Jan 2013 0959 EST:
SO Note Written by MORRIS,TARA C @ 29 Jan 2013 0930 EST
Chief complaint
The Chief Complaint is: OCCULT STOOL POSITIVE.
He reported: Medication list reviewed with patient, reconciliation completed.
Attending Physician:ZAGORSKI.
Pain assessment: ABDOMINAL PAIN.
2019
Medical Record
2019

Patient has NOT had specialty care, ER visit, or hospitalization since last visit.
Current medication

ASA 81 MG EVERY DAY
MAXZIDE 37.5MG-25MG EVERY DAY.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
.
Medications: No medication noncompliance.
Personal history

Family history
CA- mother- bresat
father- DM.
.
Practice Management
2019
Medical Record
2019
30 Nov 2012 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by CLAY, EMILY
C
Abdominal pain in the left upper belly

(LUQ)
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: AMHM02DYELLOW TEAM Provider: CLAY,EMILY C
AutoCites Refreshed by CLAY,EMILY C @ 30 Nov 2012 2109 EST

Allergies
No Allergies Found.
Reason for Telephone Consult:Written by CLAY,EMILY C @ 30 Nov 2012 2109 EST

F/u ct ivp- clay
Rad Result Cited by CLAY,EMILY C @ 03 Dec 2012 1609 EST

********** CT IVP **********
Status: Complete
Procedure: CT IVP
Event Date: 20-Nov-2012 19:49:00
Reason for Order:
THANKS.
Exam #: 12097140
Status: COMPLETE
Report Text:

2019
Medical Record
2019



interval change.
A/P Written by CLAY,EMILY C @ 03 Dec 2012 1613 EST

1. abdominal pain in the left upper belly (LUQ): Relay health message sent ot pt that his CT results did not show kidney stone,
but rather inflammation of mesentery- asked that he book f/u appt w/ me so i can reexamine him. Consider gen surgery consult to
further eval of abd pain.
Disposition Written by CLAY,EMILY C @ 03 Dec 2012 1614 EST

Signed By CLAY, EMILY C (MD, FAAFP, Staff Family Physician, Martin ACH, Fort Benning, GA) @ 03 Dec 2012 1614
2019
Medical Record
2019
27 Nov 2012 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by POLLITT,
STEPHEN P
Visit for: occupational health / fitness

exam
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: OCCUPATIONAL HEALTH FBGA Provider: POLLITT,STEPHEN P
AutoCites Refreshed by POLLITT,STEPHEN P @ 03 Dec 2012 1307 EST

•Patient counseling •Sleep apnea (General FHx)
•Trochanteric bursitis •Family history of heart disease
•Visit for: military services physical for •No family history of angina pectoris
accession •Family history of cancer
•Counseling about travel •Family history [use for free text]
•Gastritis •No family history of mental illness (not
•Hyperglycemia retardation)
•McKenzie posterior derangement •No family history of alcoholism
syndrome •No family history of malignant neoplasm
•Counseling for five to eight patients about of the large intestine
medical management •Arteriosclerotic cardiovascular disease
•Obstructive sleep apnea (ASCVD) (Mother)
•Nonorganic sleep disorders •Type 2 diabetes mellitus (Father)
•Hyperlipidemia
•Overweight
•Hypertension
•Hypogonadism
•Astigmatism
•Lumbago
•Observation for suspected condition
remission
mood
•Hypermetropia
depression
disease
•Body mass index
•Abdominal pain
2019
Medical Record
2019
•Cervicalgia
•Folliculitis
•Backache
Acute:
•Visit for: screening for cardiovascular
disorders
•Visit for: respiratory exam
Active Medications
ASPIRIN, 325 MG, TABLET DR, ORAL Active TAKE ONE TABLET DAILY 3 of 3 04 Oct 2012
SILDENAFIL CITRATE, 100 MG, TABLET, ORAL Active TAKE ONE TABLET BY 8 of 11 25 Sep 2012
MOUTH 1 HOUR BEFORE
SEXUAL INTERCOURSE NO
MORE THAN 1 A DAY
RANITIDINE HCL, 150 MG, TABLET, ORAL Active TAKE ONE TABLET BY 5 of 5 16 Jun 2012
MOUTH TWICE A DAY
Vitals
Vitals Written by CAIN,LOIS R @ 27 Nov 2012 1407 EST
BP: 130/75, HR: 92, HT: 66.5 in, WT: 220 lbs, BMI: 34.98, BSA: 2.094 square meters, Tobacco Use: No, Alcohol Use: No, Pain
Scale: 0 Pain Free
BP: 129/77, HR: 89, HT: 66.5 in, WT: 220 lbs, BMI: 34.98, BSA: 2.094 square meters, Tobacco Use: No, Alcohol Use: No, Pain
Scale: 0 Pain Free

PRE-EMPLOYMENT PHYS PART 2 POLICE
BRY

Reason For Appointment: PRE-EMPLOYMENT PHYS PART 2 POLICE
Reason(s) For Visit (Chief Complaint): visit for: occupational health / fitness exam (New) : Pre-placement Physical Exam - Part 2;
Comments: POSITION APPLIED FOR: DES Police Officer
Vitals
BP: 130/75, HR: 92, HT: 66.5 in, WT: 220 lbs, BMI: 34.98, BSA: 2.094 square meters, Tobacco Use: No, Alcohol
Use: No, Pain Scale: 0 Pain Free
SO Note Written by POLLITT,STEPHEN P @ 03 Dec 2012 1307 EST

Reason for Visit
Visit for: periodic physical.
Review of systems
Systemic: No systemic symptoms.
Head: No head symptoms.
Neck: No neck symptoms.
Otolaryngeal: No otolaryngeal symptoms.
Breasts: No breast symptoms.
Gastrointestinal: No gastrointestinal symptoms.
Musculoskeletal: No musculoskeletal symptoms.
Psychological: No psychological symptoms.
Physical findings
2019
Medical Record
2019
Vital Signs:
° Normal.
Standard Measurements:
° Normal.
General Appearance:
° Normal.
Head:
° Normal.
Neck:
° Normal.
Eyes:
General/bilateral:
° Eyes: normal.
Ears, Nose, Throat:
° ENT: normal.
Lymph Nodes:
° Normal.
Chest:
° Normal.
Lungs:
° Normal.
Cardiovascular:
° System: normal.
Back:
° Normal.
Abdomen:
° Normal.
General/bilateral: ° Musculoskeletal system: normal.
Neurological:
° System: normal.
Psychiatric:
° Exam: normal.
Skin:
° Normal.
Hair:
° Normal.
Nails:
° Normal.
Lab Result Cited by CAIN,LOIS R @ 27 Nov 2012 1409 EST

Color URINE YELLOW
Urobilinogen URINE <2.0
Protein URINE TRACE
pH URINE 5.5
RBC URINE <1
Mucus URINE RARE
WBC URINE 1

Hepatitis B Virus Surface Ab SERUM POSITIVE 
MMR Panel Site/Specimen 20 Nov 2012 0924

2019
Medical Record
2019

Varicella Zoster Virus Ab SERUM POSITIVE 
Basic Metabolic Panel Site/Specimen 20 Nov 2012 0923

Sodium PLASMA 142
Chloride PLASMA 105
Anion Gap PLASMA 12.1 
Calcium PLASMA 9.4

LDL Cholesterol PLASMA 146 (H)
Hemogram+Differential Auto Site/Specimen 20 Nov 2012 0923 <o>

WBC BLOOD 7.0
RBC BLOOD 5.16
MCV BLOOD 86.8
MCH BLOOD 29.7
MCHC BLOOD 34.2
RDW CV BLOOD 13.1
MPV BLOOD 8.9
Platelets BLOOD 271
Lymphocytes BLOOD 52.7 (H)
Monocytes BLOOD 0.4
Monocytes BLOOD 5.9
Basophils BLOOD 0.0
Basophils BLOOD 0.5
Comprehensive Metabolic Panel Site/Specimen 19 Nov 2012 1258

Albumin PLASMA 4.2
Bilirubin PLASMA 0.7 
Calcium PLASMA 9.5
Chloride PLASMA 102
Protein PLASMA 8.1
Sodium PLASMA 142
Hemogram+Differential Auto Site/Specimen 19 Nov 2012 1258

WBC BLOOD 6.9
RBC BLOOD 5.20
MCV BLOOD 85.8
MCH BLOOD 29.6
MCHC BLOOD 34.5
RDW CV BLOOD 13.1
2019
Medical Record
2019
MPV BLOOD 8.9

Platelets BLOOD 283
Lymphocytes BLOOD 46.2 (H)
Monocytes BLOOD 0.5
Monocytes BLOOD 6.6
Basophils BLOOD 0.0
Basophils BLOOD 0.5
A/P Written by POLLITT,STEPHEN P @ 03 Dec 2012 1309 EST

1. visit for: occupational health / fitness exam(PERIODIC PREVENTION EXAMINATION)
Disposition Written by POLLITT,STEPHEN P @ 03 Dec 2012 1309 EST

Signed By POLLITT, STEPHEN P (Physician/Workstation) @ 03 Dec 2012 1309
2019
Medical Record
2019
27 Nov 2012 at Martin ACH, Fort Benning, GA, Cardiology (EKG) by CHATMAN,
BERNIECE H
Visit for: screening exam cardiovascular

disorders
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: CARDIOLOGY(EKG) Provider: CHATMAN,BERNIECE H
AutoCites Refreshed by CHATMAN,BERNIECE H @ 27 Nov 2012 1137 EST

•Patient counseling •Sleep apnea (General FHx)
•Trochanteric bursitis •Family history of heart disease
•Visit for: military services physical for •No family history of angina pectoris
accession •Family history of cancer
•Counseling about travel •Family history [use for free text]
•Gastritis •No family history of mental illness (not
•Hyperglycemia retardation)
•McKenzie posterior derangement •No family history of alcoholism
syndrome •No family history of malignant neoplasm
•Counseling for five to eight patients about of the large intestine
medical management •Arteriosclerotic cardiovascular disease
•Obstructive sleep apnea (ASCVD) (Mother)
•Nonorganic sleep disorders •Type 2 diabetes mellitus (Father)
•Hyperlipidemia
•Overweight
•Hypertension
•Hypogonadism
•Astigmatism
•Lumbago
remission
mood
•Hypermetropia
depression
disease
•Body mass index
•Abdominal pain
2019
Medical Record
2019
•Cervicalgia
•Folliculitis
•Backache
Acute:
•Visit for: respiratory exam
Active Medications
MOUTH 1 HOUR BEFORE
MORE THAN 1 A DAY
MOUTH TWICE A DAY
Reason for Appointment:Written by SAMPSON,LINDA M @ 27 Nov 2012 1125 EST

EKG
Appointment Comments: Written by SAMPSON,LINDA M @ 27 Nov 2012 1125 EST
LMS
SO Note Written by CHATMAN,BERNIECE H @ 27 Nov 2012 1137 EST

Chief complaint
The Chief Complaint is: EKG.
A/P Written by CHATMAN,BERNIECE H @ 27 Nov 2012 1137 EST

1. visit for: screening exam cardiovascular disorders
Procedure(s): -ECG Performance of Tracing Only x 1
Disposition Written by CHATMAN,BERNIECE H @ 27 Nov 2012 1138 EST

Signed By CHATMAN, BERNIECE H (Cardiology Technician, Martin ACH, Fort Benning, GA) @ 27 Nov 2012 1138
2019
Medical Record
2019
20 Nov 2012 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by GRIFFIN,
STEPHANIE D

(LUQ)
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: AMHM02DYELLOW TEAM Provider: GRIFFIN,STEPHANIE D

Allergies
No Allergies Found.

F/u labs-clay
Lab Result Cited by CLAY,EMILY C @ 20 Nov 2012 1946 EST

Urinalysis Site/Specimen 31 Oct 2012 1630 Units Ref Rng
Helicobacter pylori
Order # 121109-01816 (Ft. Benning)
Filler # 121119 MI 7829 (Ft. Benning)
Status: Final
Ordering Provider: CLAY, EMILY C
Priority: ROUTINE
Date Ordered: 09 Nov 2012 1235
Date Resulted: 19 Nov 2012 1542
COLLECT_SAMPLE: BLOOD
BACTERIOLOGY RESULT: POSITIVE FOR HELICOBACTER PYLORI.
Specimen: Serum
Collected: 19 Nov 2012 1257
Results:
Final report
Urine Culture
Status: Final
Ordering Provider: CLAY, EMILY C
Priority: ROUTINE
Date Ordered: 31 Oct 2012 1501
Date Resulted: 03 Nov 2012 1304
COLLECT_SAMPLE: URINE/CC
BACTERIOLOGY RESULT: NO GROWTH IN 24 HOURS.

BACTERIOLOGY RESULT: <10,000 COL/ML CONSISTENT WITH SKIN CONTAMINATION
Specimen: Urine
Collected: 31 Oct 2012 1630
Results:
Final report
Lab Result Cited by CLAY,EMILY C @ 20 Nov 2012 1946 EST

Lipids Site/Specimen 20 Nov 2012 0923 Units Ref Rng
2019
Medical Record
2019

LDL Cholesterol PLASMA 146 (H) mg/dL (0-129)
Triglyceride PLASMA 59 mg/dL (0-149)
Hemogram+Differential Auto Site/Specimen 20 Nov 2012 0923 <o> Units Ref

Rng
WBC BLOOD 7.0 x10(3)/mcL (4.9-10.0)
RBC BLOOD 5.16 x10(6) (4.7-6.1)
MCHC BLOOD 34.2 % (32-36)
RDW CV BLOOD 13.1 % (11.5-14.5)
Lymphocytes BLOOD 3.7 x10(3)/mcL (1.0-4.0)
Comprehensive Metabolic Panel Site/Specimen 19 Nov 2012 1258 Units Ref Rng
Bilirubin PLASMA 0.7 mg/dL (0.2-1.3)
Anion Gap PLASMA 15.3 mmol/L (10-20)
Hemogram+Differential Auto Site/Specimen 19 Nov 2012 1258 Units Ref Rng

WBC BLOOD 6.9 x10(3)/mcL (4.9-10.0)
RBC BLOOD 5.20 x10(6) (4.7-6.1)
MCHC BLOOD 34.5 % (32-36)
RDW CV BLOOD 13.1 % (11.5-14.5)
Hemoglobin A1c Panel Site/Specimen 19 Nov 2012 1257 Units Ref Rng
Hemoglobin A1c BLOOD 5.0 % (4.0-5.6)
2019
Medical Record
2019
Estimated Average Glucose BLOOD 97 mg/dL
Lipase Site/Specimen 19 Nov 2012 1257 Units Ref Rng

Triacylglycerol Lipase PLASMA 204 U/L (23-300)
Urea Nitrogen Site/Specimen 02 Nov 2012 1357 Units Ref Rng

Urea Nitrogen PLASMA 10 <o> mg/dL (7-18)
Creatinine Site/Specimen 02 Nov 2012 1357 Units Ref Rng

Creatinine PLASMA 1.0 <o> mg/dL (0.66-1.25)

Color URINE YELLOW
Appearance URINE CLEAR (CLEAR)
Specific Gravity URINE 1.020 (1.005-1.035)
Urobilinogen URINE <2.0 EU/dL (0.0-3.0)
Bilirubin URINE NEGATIVE (NEGATIVE)
Glucose URINE NEGATIVE mg/dL (NEGATIVE)
Protein URINE NEGATIVE mg/dL (NEGATIVE)
pH URINE 5.5 (5.0-7.5)
Nitrite URINE NEGATIVE (NEGATIVE)
Leukocyte Esterase URINE NEGATIVE (NEGATIVE)
Ketones URINE NEGATIVE mg/dL (NEGATIVE)
Blood URINE NEGATIVE (NEGATIVE)
RBC URINE <1 /HPF (0-2)
Mucus URINE RARE (0-OCC)
WBC URINE <1 /HPF (0-5)
Rad Result Cited by CLAY,EMILY C @ 20 Nov 2012 1948 EST

Status: Complete

Event Date: 01-Nov-2012 09:42:00
Reason for Order:
further eval.
Exam #: 12091812
Status: COMPLETE
Report Text:
2019
Medical Record
2019
A/P Last Updated by CLAY,EMILY C @ 20 Nov 2012 1950 EST

1. abdominal pain in the left upper belly (LUQ): 42 yr old male w/ 5 weeks of LUQ abd pain adn flank pain. Ct abd w/out evid of
Radiology(ies): -CT IVP (ASAP) Impression: 42 yr old male w/ 5 weeks of LUQ abd pain adn flank pain. Ct abd w/out
evid of pain source. Labs essentially normal. Please do CT IVP to further eval. THANKS.
2. Gastritis
Laboratory(ies): -H PYLORI AG, STOOL (Routine)
Disposition Written by GRIFFIN,STEPHANIE D @ 21 Nov 2012 1345 EST

Follow up: with PCM and/or in the AMHM02DYELLOW TEAM clinic.
Note Written by CLAY,EMILY C @ 20 Nov 2012 1950 EST

Attempted to call pt to discuss lab results. VM not set up.
Please call pt and see how LUQ and L flank pain is doing. Seen by me 31Oct most
recently. Labs all essentially normal. Since serum h.pylori positive, now needs stool
pylori test to confirm positive antigen prior to treatment. Serum test shows + antibodies,
but unknown if recent or old.
If still having pain, may call radiology to schedule CT IVP to look further at renal system
for pssible stone. F/u with PCM after CT IVP for reevaluation of abd pain.
Note Written by GRIFFIN,STEPHANIE D @ 21 Nov 2012 1000 EST

Contact Info: 706-326-4585-Cell Phone
No answer @ 0957, no voice mail
LMTCB @ 404-421-3064 with spouse @ 1000
Note Written by GRIFFIN,STEPHANIE D @ 21 Nov 2012 1345 EST

Spoke with patient, discussed lab results. Advised needs stool specimen in order to confirm dx of
h.pylori to tx. To go to lab for specimen cup. Patient continues to have abdominal pain, scheduled
for CT IVP as ordered, 11/28/2012 @ 0800, advised NPO 4hrs prior to exam. Verbalized
understanding. Telecon closed.
Signed By GRIFFIN, STEPHANIE D (Registered Nurse, Family Medical Home Ft. Benning) @ 21 Nov 2012 1345
2019
Medical Record
2019
16 Nov 2012 at Martin ACH, Fort Benning, GA, Occupational Health FBGA by CAIN, LOIS
R

exam
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: OCCUPATIONAL HEALTH FBGA Provider: CAIN,LOIS R
AutoCites Refreshed by CAIN,LOIS R @ 16 Nov 2012 1507 EST

Allergies
No Allergies Found.
Active Medications
MOUTH 1 HOUR BEFORE
MORE THAN 1 A DAY
MOUTH TWICE A DAY

PRE-EMPLOYMENT PHYS POLICE PART 1
BRY

Reason For Appointment: PRE-EMPLOYMENT PHYS POLICE PART 1
Reason(s) For Visit (Chief Complaint): visit for: occupational health / fitness exam (New) ;
Comments: POSITION APPLIED FOR: DES Police Officer
NOTE: Currently an MP in the Army. ETS date 22 Nov 12.
Vitals
BP: 129/77, HR: 89, HT: 66.5 in, WT: 220 lbs, BMI: 34.98, BSA: 2.094 square meters, Tobacco Use: No, Alcohol
Questionnaire AutoCites Refreshed by CAIN,LOIS R @ 16 Nov 2012 1507 EST

Questionnaires
SO Note Written by CAIN,LOIS R @ 16 Nov 2012 1508 EST

Seen today for Pre-placement physical exam - Part 1.

Allergies
No allergies . Denies latex sensitivity.
Vaccinations
Tetanus from 2004.
Reported:
Denial of any significant medical history, no active problems, and no prior serious illness.
2019
Medical Record
2019
Surgical / Procedural: Surgical / procedural history HX: appendectomy, 1991.

Medications: Medication history Tylenol - PRN, Test. Cream.
Personal history
Physical findings
General Appearance:
° Well-appearing. ° Alert.
Eyes:
General/bilateral:
Visual Assessment: • Distance binocular acuity w/o Rx: 20/ 20 Depth: 9/ 9 Color vision: 6/ 6 Peripheral vision to 80*
left & right. • Near vision was abnormal: OU: 20 / 20.
Right Eye:
Visual Assessment: • Distance right acuity without Rx: 20/ 20. • Right eye w/o Rx: 20/ 20 NEAR.
Left Eye:
Visual Assessment: • Distance left acuity without Rx: 20/ 20. • Left eye w/o Rx: 20/ 20 NEAR.
Tests
Lab tests & EKG ordered.
Laboratory Studies:
Pulmonary Function Tests:
Pulmonary function tests Complete PFT is filed in candidate's health record at OHS, spirometry greater than spirometry
performed sitting; good effort. Normal spirometric values, pre-bronchodilator, FVC: 3.11 L = 81%, FEV1: 2.77 L = 88%, and FEV1
(FEV1/FVC): 0.89 = 109%.
Audiometry:
Audiometry: 2216, WNL; Repeat in one year.
A/P Written by CAIN,LOIS R @ 16 Nov 2012 1521 EST

1. visit for: occupational health / fitness exam(OCCUPATIONAL EXAMINATION)
Procedure(s): -Threshold Audiogram (Pure Tone) x 1
-Screening Test Of Visual Acuity, Quantitative, Bilateral x 1
Laboratory(ies): -URINALYSIS (Routine): Pre-placement physical exam. Thanx, L. Cain, RN Ordered By: CAIN,LOIS R
Ordering Provider: POLLITT, STEPHEN P; HEMOGRAM AUTO+COMP AUTO DIFF (Routine): Pre-
placement physical exam. Thanx, L. Cain, RN Ordered By: CAIN,LOIS R Ordering Provider: POLLITT,
STEPHEN P; BASIC METABOLIC PANEL (Routine) Ordered By: CAIN,LOIS R Ordering Provider:
POLLITT, STEPHEN P; LIPIDS (Routine) Ordered By: CAIN,LOIS R Ordering Provider: POLLITT,
STEPHEN P; HEPATITIS B SURFACE AB (Routine) Ordered By: CAIN,LOIS R Ordering Provider:
POLLITT, STEPHEN P; MEASLES MUMPS RUBELLA PANEL (Routine) Ordered By: CAIN,LOIS R
Ordering Provider: POLLITT, STEPHEN P; VARICELLA VIRUS AB (Routine) Ordered By: CAIN,LOIS R
Ordering Provider: POLLITT, STEPHEN P
2. visit for: respiratory exam
Procedure(s): -Spirometry Pre-bronchodilator x 1
3. Patient Counseling:: OSHA Respirator Questionnaire completed and reviewed with candidate.
Disposition Written by CAIN,LOIS R @ 16 Nov 2012 1522 EST

Follow up: 4 day(s) in the OCCUPATIONAL HEALTH FBGA clinic or sooner if there are problems.
Signed By CAIN, LOIS R (RN, COHN-S, Occupational Health Service) @ 16 Nov 2012 1523
2019
Medical Record
2019
16 Nov 2012 at JB San Antonio Military Treatment Facility, TX 78205, SRP Primary Care
Clinic BAMC by CARTER, AMANDA T
Encounter ID: WHMC-4111776 Primary Dx: Visit for: administrative purpose
Patient: WAITERS, TOMMIE Date: 16 Nov 2012 0711 CST Appt Type: WELL
ALAJANDRO
Treatment Facility: SAN ANTONIO Clinic: PRE POST DEPLOYMENT FSH Provider: CARTER,AMANDA T
MILITARY MEDICAL CENTER-SAMMC
AutoCites Refreshed by CARTER,AMANDA T @ 16 Nov 2012 0712 CST

•Trochanteric bursitis •Sleep apnea (General FHx)
•Visit for: military services physical for •Family history of heart disease
accession •No family history of angina pectoris
•Counseling about travel •Family history of cancer
•Gastritis •Family history [use for free text]
•Hyperglycemia •No family history of mental illness (not
•McKenzie posterior derangement retardation)
syndrome •No family history of alcoholism
•Counseling for five to eight patients about •No family history of malignant neoplasm
medical management of the large intestine
•Obstructive sleep apnea •Arteriosclerotic cardiovascular disease
•Nonorganic sleep disorders (ASCVD) (Mother)
•Hyperlipidemia •Type 2 diabetes mellitus (Father)
•Overweight
•Hypertension
•Hypogonadism
•Astigmatism
•Lumbago
remission
mood
•Hypermetropia
depression
disease
•Body mass index
•Abdominal pain
•Cervicalgia
2019
Medical Record
2019

•Folliculitis
•Backache
Reason for Appointment:Written by CARTER,AMANDA T @ 16 Nov 2012 0711 CST

LABS
A/P Last Updated by CARTER,AMANDA T @ 16 Nov 2012 0713 CST

1. visit for: administrative purpose
Laboratory(ies): -G6PD QN (Routine) Ordered By: CARTER,AMANDA T Ordering Provider: RHEA, ANTHONY E
Disposition Last Updated by CARTER,AMANDA T @ 16 Nov 2012 0805 CST

Signed By CARTER, AMANDA T (CNA, TMC,FMSMcWethy) @ 16 Nov 2012 0806
2019
Medical Record
2019
07 Nov 2012 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by CLAY, EMILY
C

(LUQ)
ALAJANDRO

Allergies
No Allergies Found.

F/u abd ct-clay

Status: Complete

Event Date: 01-Nov-2012 09:42:00
Reason for Order:
further eval.
Exam #: 12091812
Status: COMPLETE
Report Text:
2019
Medical Record
2019

A/P Written by CLAY,EMILY C @ 09 Nov 2012 1236 EST

1. abdominal pain in the left upper belly (LUQ): Notified pt of ct results- no findings to explain is now 1 month of L flank/ LUQ abd
pain. He said it is still pretty painful. Rec'd that he get labs done early next week and book f/u appt w/ me or PCM Zagorski to
further eval. Consider surg consult or other imaging.
Pt also sent invitation to Relay Health today.

Laboratory(ies): -HEMOGRAM AUTO+COMP AUTO DIFF (Routine) Start Date: 11/09/2012 Order Date: 11/09/2012
12:34; COMPREHENSIVE METABOLIC PANEL (Routine) Start Date: 11/09/2012 Order Date:
11/09/2012 12:34; HELIBACTER PYLORI (Routine) Start Date: 11/09/2012 Order Date: 11/09/2012
12:35; LIPASE (Routine) Start Date: 11/09/2012 Order Date: 11/09/2012 12:35; URINALYSIS (Routine)
Start Date: 11/09/2012 Order Date: 11/09/2012 12:35; URINE CULTURE (Routine) Start Date:
11/09/2012 Order Date: 11/09/2012 12:35; HEMOGLOBIN A1C PANEL (Routine) Start Date:
11/09/2012 Order Date: 11/09/2012 12:35; LIPIDS (Routine) Start Date: 11/09/2012 Order Date:
11/09/2012 12:35
Disposition Written by CLAY,EMILY C @ 09 Nov 2012 1237 EST

Signed By CLAY, EMILY C (MD, FAAFP, Staff Family Physician, Martin ACH, Fort Benning, GA) @ 09 Nov 2012 1237
2019
Medical Record
2019
31 Oct 2012 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by CLAY, EMILY
C

(LUQ)
Patient: WAITERS, TOMMIE Date: 31 Oct 2012 1420 EST Appt Type: OPAC
ALAJANDRO
AutoCites Refreshed by CLAY,EMILY C @ 31 Oct 2012 1447 EST

Allergies
No Allergies Found.

ZAGORSKI/SIDE PAIN
RXH
Screening Written by HOLLIS,GEORGE S @ 31 Oct 2012 1421 EST

Reason For Appointment: ZAGORSKI/SIDE PAIN
Allergen information verified by HOLLIS, GEORGE S @ 31 Oct 2012 1420 EDT
Vitals
Vitals Written by HOLLIS,GEORGE S @ 31 Oct 2012 1421 EDT
BP: 123/81 Left Arm, Adult Cuff, HR: 76 Regular, Radial Artery, RR: 18, T: 98.7 °F Oral, HT: 66 in Actual, Without
Shoes,
WT: 226.2 lbs Upright Scale, Actual, Without Shoes, SpO2: 97%, BMI: 36.51, BSA: 2.108 square meters
SO Note Written by CLAY,EMILY C @ 31 Oct 2012 1504 EST

Chief complaint
The Chief Complaint is: Left Side Pain x 2 weeks.
A PHA has been completed in past year. Date: Feb/march, 2012.
<<Note accomplished in TSWF CORE>> 42 yr old AD male (HR tech), new to me today, here w/ 2 weeks of LUQ/ L flank pain that
is dull. No pain w/ eating. NO constipation- has one BM daily. No diarrhea. NO hematuria. No nausea. Feels bloated. Has tried
motrin and vicodin.
.
Abdominal pain.
Pain assessment: Left side dull and slightly cramping pain in left side and is constant.
Attending Physician: Dr. Clay.
Allergies
NKDA.
Current medication
(Levitra) 20Mg-take one table 60 minutes prior to intercourse;no more than 1 per day
Cyclobenzaprine HCL(Flexerill) 10Mg-take 1 tab three times daily as needed
Hydrocodone Bit/Acetaminophen 5Mg/500Mg-take 1 to 2 tabs by mouth every 4 to 6 hours as needed.
Reported:
2019
Medical Record
2019
Medical: Reported medical history HTN

DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
.
Medications: Medication history: ( ) No Medications
( x ) Current Medications Reviewed and Reconciled
T#3/darvocet
( ) Vitamins ( ) Dietary Supplements
( ) Herbals ( )Weight Loss Meds. No medication noncompliance.
Environmental Exposure: No exposure to fumes and no secondhand cigarette smoke exposure. No exposure to respiratory
irritants.
Previous therapy
• History of analgesics;
History of physical activity restrictions
Personal history
Family of 5
3 children
Next of Kin: Kadidia Waiters-Wife.
Behavioral: No tobacco use in the last 10 years. Never a smoker / Never Used Tobacco Products.
Alcohol: No consumption of alcohol and not using alcohol Screening Date: 2 nOVEMBER 2011.
Habits: Exercising regularly (Engaged in Routine / Regular Activity to Improve Your Health)
.
History Annual Screening Date: 2 November 2011
What is Your Preferred Method of Learning? [ x]Verbal [x ]Written [x ]Visual
[ ]Other (Specify):
Do You Feel Safe at Home? [ x]Yes [ ] No
Advanced Directives in Record? [ x]Yes [ ] No
Patient Consented to Allow Shadowing Personnel into the Room for Observation? [ ]Yes [ ] No [ x ]N/A
.
Family history
Family medical history CA- mother- bresat
father- DM.
Review of systems
Head: No headache.
Otolaryngeal: No earache, no nasal discharge, no nasal passage blockage, and no sore throat.
Gastrointestinal: No nausea, no vomiting, no bright red blood per rectum, no diarrhea, and no constipation.
Physical findings
Vital Signs:
General Appearance:
° Oriented to time, place, and person. ° Well developed. ° Well nourished. ° In no acute distress.
Eyes:
General/bilateral:
Pupils: ° PERRL.
Sclera: ° Normal.
Lungs:
2019
Medical Record
2019

Cardiovascular:
Abdomen:
Palpation: • Abdominal tenderness Very mild TTP w/ deep palpation left mid abd- no rebound or guarding. No palp masses.
Normal BS. Scar RLQ from emergency appendectomy 1991. ° No mass was palpated in the abdomen.
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Lab Result Cited by CLAY,EMILY C @ 31 Oct 2012 1629 EST

Color URINE YELLOW
pH URINE 5.5 (5.0-7.5)
WBC URINE <1 /HPF (0-5)

********** ABDOMEN SERIES ACUTE **********
Status: Complete
Procedure: ABDOMEN SERIES ACUTE

Event Date: 31-Oct-2012 15:02:00
Reason for Order:
no constipation per patient. No h/o kidney stones. Please eval w/ AAS. THANKS>
Exam #: 12091630
Status: COMPLETE
2019
Medical Record
2019

Report Text:
FINDINGS: The frontal view of the chest shows no acute infiltrate or

subdiaphragmatic free air. The heart is normal.
The supine and upright views of the abdomen show a normal bowel gas pattern. No
abnormal calcification, definable soft tissue mass or any other significant
finding is seen.
A/P Written by CLAY,EMILY C @ 01 Nov 2012 0942 EST

1. abdominal pain in the left upper belly (LUQ): Nonspecific dull deep LUQ/left-mid abd abd pain. Ddx: early shingles w/out rash,
constipation, diverticulitis, kidney stone, muscular strain, scar tissue from prior surgery, ileus, PUD/gastritis.
Will check UA and AAS today; consider CT pending those results.
Xray: 42 yr old AD obese male w/ 2 weeks of dull LUQ and L flank pain. No hematuria, no constipation per patient. No h/o kidney
stones. Please eval w/ AAS.
Addendum: Talked to pt 1nov at 0940 and let him know UA and AAS were normal. Still w/ abd pain- unknown etiology. Will check
CT to further eval.
CT: 42 yr old AD obese male w/ 2 weeks of dull LUQ and L flank pain. No hematuria, no constipation per patient. UA clear. AAS
normal. No h/o kidney stones. Please eval w/ CT abd/pelvis w/ contrast to further eval.
Medication(s): -HYDROCODON/APAP (VICODIN)5/500MG--PO TAB - TAKE 1 TAB PO BID PRN FOR ABDOMINAL
OR BACK PAIN #30 RF0 Qt: 30 Rf: 0
Laboratory(ies): -URINALYSIS (Routine); URINE CULTURE (Routine)
Radiology(ies): -ABDOMEN SERIES ACUTE (Routine) Impression: 42 yr old AD obese male w/ 2 weeks of dull LUQ
and L flank p
-CT ABDOMEN & PELVIS W/ CONTRAST (ASAP) Start Date: 11/01/2012 Order Date: 11/01/2012
09:42 Impression: 42 yr old AD obese male w/ 2 weeks of dull LUQ and L flank pain. No hematuria, no
constipation per patient. UA clear. AAS normal. No h/o kidney stones. Please eval w/ CT abd/pelvis w/
contrast to
further eval.
Disposition Written by CLAY,EMILY C @ 01 Nov 2012 0942 EST

Signed By CLAY, EMILY C (MD, FAAFP, Staff Family Physician, Martin ACH, Fort Benning, GA) @ 01 Nov 2012 0942
_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by CLAY,EMILY C @ 31 Oct 2012 1501 EST:
SO Note Written by HOLLIS,GEORGE S @ 31 Oct 2012 1423 EDT
Chief complaint
The Chief Complaint is: Left Side Pain.
A PHA has been completed in past year. Date: Feb/march, 2012.
Attending Physician: Dr. Zagorski, Kim J.

Pain assessment: Left side dull and slightly cramping pain in left side and is constant.
2019
Medical Record
2019
Allergies
NKDA.
Current medication
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
.
T#3/darvocet
Environmental Exposure: No exposure to fumes and no secondhand cigarette smoke exposure. No exposure to respiratory irritants.
Previous therapy
Personal history
Family of 5
3 children
.
What is Your Preferred Method of Learning? [ x]Verbal [x ]Written [x ]Visual [ ]Other (Specify):
.
Family history
father- DM
2019
Medical Record
2019
16 Oct 2012 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by NOEL, MARY A
Encounter ID: BENN-8364287 Primary Dx: BURSITIS TROCHANTERIC
Patient: WAITERS, TOMMIE Date: 16 Oct 2012 0925 EDT Appt Type: PROC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC SPECIALTY CLINIC Provider: NOEL,MARY
AutoCites Refreshed by NEAL,CALVIN @ 16 Oct 2012 0915 EDT

Allergies
No Allergies Found.

BURSITIS TROCHANTERIC
jdm
Screening Written by NEAL,CALVIN @ 16 Oct 2012 0915 EDT

Reason For Appointment: BURSITIS TROCHANTERIC
Allergen information verified by NEAL, CALVIN @ 16 Oct 2012 0915 EDT
Vitals
Vitals Written by NEAL,CALVIN @ 16 Oct 2012 0914 EDT
SO Note Written by NOEL,MARY @ 17 Oct 2012 1128 EDT

Chief complaint
The Chief Complaint is: Bursitis Trochanteric.
<<Note accomplished in TSWF CORE>>
42-year-old male who has had 3 weeks of left thigh pain. Pain is located on the outer portion of L thigh. He states the pain is dull
and 8/10. Hurts worse with walking, it improves with rest. No history of trauma or infection. Patient has tried stretches, ibuprofen,
Flexeril without relief. He states when he walks he feels like he is walking barefoot on concrete and radiates up his leg. Patient
denies fevers, chills, weight loss. No numbness or tingling of extremities.
.
Medication list reviewed with patient, reconciliation completed, and list given to patient.
Back pain chronic LBP.
Not currently on active duty and visit is not deployment-related. Not thinking about suicide and no homicidal thoughts.
Pain assessment: The pain has been located in LT KNEE for a period of 4+ YRS. The patient describes the pain as DULL and
has tried MED with relief and reports MOVEMENT makes it worse.
.
Pain Severity 8/ 10.
Attending Physician: Dr. Cobb.
Procedure: Possible limitations and risks include infection.
Procedure: Possible limitations and risks include bleeding.
Procedure: Possible limitations and risks include pain.
Procedure: Possible limitations and risks include partial success requiring repetition of procedure.
Procedure: Checklist - Verified the signed consent form is in the chart.
[ x ] Yes [ ] No Patient was identified using full name plus any suffix and DOB.
[ x ] Yes [ ] No Patient was evaluated and medical record reviewed to include medical history and laboratory findings, if ordered.
2019
Medical Record
2019
[ x ] Yes [ ] No [ ] N/A Radiographs are properly oriented and correct laterality has been visually confirmed (if applicable).
[ x ] Yes [ ] No [ ] N/A Procedure and site/side matches the consent form (if applicable).
[ x ] Yes [ ] No [ ] N/A Patient was involved in the site/side marking (if applicable).
[ x ] Yes [ ] No Final Time Out - Physician paused (if alone) or verbally confirmed with the procedure team that this is the correct
patient, procedure and site/side (if applicable). The patient has been positioned correctly for the procedure. All necessary
equipment and implants are available.
Procedure: Possible limitations and risks include complications from anesthesia.
Procedure: Peri-operative risks, benefits, and limitations discussed and understood - Patient wished to proceed.
Allergies
NKDA.
Current medication
Levitra 20Mg-take one tablet by mouth 60 minutes prior to intercourse;no more than 1 per day
Cyclobenzaprine HCL(Flexeril) 10Mg-take 1 tab by mouth three times daily as needed for pain
Motrin 800mg - take one tablet by mouth every 8 hours as needed for pain
Maxzide 37.5/25mg - Take 1 tab daily by mouth
Lunesta 3mg - Take 1 tab by mouth every night
Androgel 1% - Appy one pump to each arm daily
Aspirin 325mg - take one tablet daily by mouth
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
.
T#3/darvocet
irritants.
Previous therapy
Personal history
Family of 5
3 children
.
History ANNUAL SCREENING DATE:16 OCT 12
What is your preferred method of learning? [ X] Verbal [ X ] Written [ ] Visual [ ] Other (Specify):
Do you have a learning disability, language barrier, hearing/vision deficit? [ ] Yes [ X ] No Specify:
Advanced directives completed? [ ] Yes [ X ] No
Do you have any cultural or religious beliefs that may affect your care? [ ] Yes [ X ] No
Are you enrolled in EFMP? [ ] Yes [ X ] No
Do you use a Personal Health Record (PHR)? [ ] Yes [X ] No Specify:
Contact info: 706-326-4585/ 558 HARTSOCK LP APT B FTB GA.
Family history
2019
Medical Record
2019
father- DM.
Review of systems
Endocrine: No flushing.
Musculoskeletal: No muscle aches, no localized joint pain, no localized joint swelling, and no limb pain.
Skin: No pruritus.
Physical findings
General:
• Physical examination -Positive Ober's test.
Vital Signs:
General Appearance:
Lungs:
° Respiration rhythm and depth was normal.
Buttocks:
General/bilateral: ° Left buttock showed no tenderness on palpation.
Hips:
Left Hip: • Hip was tender on palpation directly over greater trochanter. • Pain was elicited by motion with internal rotation
of hip. ° No erythema. ° No misalignment. ° Motion was normal. ° No instability was noted. ° No hip tenderness
was observed with ambulation.
Thigh:
Left Thigh: • Thigh was tender on palpation over greater trochanter. ° No swelling.
Neurological:
Motor (Motor Strength): ° No weakness of the left hip was observed.
Balance: ° Normal.
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Tests
CORTICOSTEROID INJECTION
The skin overlying the L greater trochanteric bursa was prepped with betadine. A 22 gauge needle was used to inject 4mL 1%
Lidocaine, 4mL 0.5% marcaine, and 1mL Kenalog 40 into L greater trochanteric bursa. The patient tolerated the procedure well.
Practice Management
Preventive medicine services Lipid Panel - 04/2012
Fasting Blood Sugar - 04/2012
Aspirin Prophylaxis - n/a
HIV Screen - 07/2012
Colonoscopy - n/a
Tetanus (Td/Tdap) - 07/2004 ( Td )
Influenza -?
Zoster - n/a
Pneumococcal -n/a
Men:
Aortic Aneurysm Screen - n/a
Prostate Screen - 04/2012
Rad Result Cited by NOEL,MARY @ 17 Oct 2012 1126 EDT

********** HIP LT **********
Status: Complete
Procedure: HIP LT
Event Date: 19-Sep-2012 11:25:00
Reason for Order:
42 Y/O MALE AD SOLDIER WITH LEFT LATERAL HIP PAIN AT THE GREATER TROCHANTER.
2019
Medical Record
2019
Exam #: 12079198
AMH FP YELLOW TEAM MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Report Text:
FINDINGS:
No fracture-dislocation or definite stress related changes. No degenerative

change. No soft tissue abnormality
A/P Last Updated by NOEL,MARY @ 17 Oct 2012 1126 EDT

1. BURSITIS TROCHANTERIC 726.5: 42-year-old male with a three-week history of left trochanteric bursitis. Radiology report
reviewed that showed no acute fracture or degeneration. Options for treatment were discussed with patient include rest, medication,
physical therapy, steroid injection, further evaluation by orthopedic surgery. Patient elected to try corticosteroid injection today.
Risks and benefits of procedure were discussed with patient. Procedure performed as stated above. Patient tolerated procedure
well. Instructed to limit activity for one week and given profile. Patient to followup in 3-4 weeks or sooner if needed if pain persists.
Patient also being seen by physical therapy for back, instructed patient to continue hip stretches at physical therapy.
Procedure(s): -(20600) Corticosteroids Injection Intrabursal x 1 ADDITIONAL PROVIDER(S): COBB,CLARK H.
-(J3301) INJECTION,TRIAMCINOLONE ACETONIDE,NOS,10 MG x 4 ADDITIONAL PROVIDER(S):
COBB,CLARK H.
Disposition Last Updated by NOEL,MARY @ 17 Oct 2012 1127 EDT

Note Written by COBB,CLARK H @ 17 Oct 2012 1138 EDT

Co-signer Note
Discussed with resident team. Performed independent exam. Supervised procedure. Agree with plan.
Signed By NOEL, MARY (CPT, MC, USA, FMRP PGY-1) @ 17 Oct 2012 1129
Co-Signed By COBB, CLARK H (Physician, Martin ACH, Fort Benning, GA) @ 17 Oct 2012 1138
_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by NOEL,MARY @ 17 Oct 2012 1129 EDT:
Chief complaint
42-year-old male who has had 3 weeks of left hip pain. He states the pain is dull and 8/10. Hurts worse with walking, it improves with rest. Patient has tried stretches,
ibuprofen, Flexeril without relief. He states when he walks he feels like he is walking barefoot on concrete and radiates up his leg. Patient denies fevers, chills, weight loss. No
numbness or tingling of extremities.
2019
Medical Record
2019
Pain assessment: The pain has been located in LT KNEE for a period of 4+ YRS. The patient describes the pain as DULL and has tried MED with relief and reports
MOVEMENT makes it worse.
.
Procedure: Possible limitations and risks include complications from anesthesia.
Procedure: Possible limitations and risks include partial success requiring repetition of procedure.
Procedure: Peri-operative risks, benefits, and limitations discussed and understood - Patient wished to proceed.
[ x ] Yes [ ] No Patient was identified using full name plus any suffix and DOB.
[ x ] Yes [ ] No Patient was evaluated and medical record reviewed to include medical history and laboratory findings, if ordered.
[ x ] Yes [ ] No [ ] N/A Radiographs are properly oriented and correct laterality has been visually confirmed (if applicable).
[ x ] Yes [ ] No [ ] N/A Procedure and site/side matches the consent form (if applicable).
[ x ] Yes [ ] No [ ] N/A Patient was involved in the site/side marking (if applicable).
[ x ] Yes [ ] No Final Time Out - Physician paused (if alone) or verbally confirmed with the procedure team that this is the correct patient, procedure and site/side (if
Allergies
NKDA.
Current medication
Levitra 20Mg-take one tablet by mouth 60 minutes prior to intercourse;no more than 1 per day
Cyclobenzaprine HCL(Flexeril) 10Mg-take 1 tab by mouth three times daily as needed for pain
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
.
T#3/darvocet
Previous therapy
Personal history
Family of 5
3 children
.
Family history
father- DM.
Review of systems
Musculoskeletal: No muscle aches, no localized joint pain, no localized joint swelling, and no limb pain.
Skin: No pruritus.
2019
Medical Record
2019
Physical findings
General:
• Physical examination -Positive Ober's test.
Vital Signs:
General Appearance:
Lungs:
° Respiration rhythm and depth was normal.
Buttocks:
Hips:
Left Hip: • Hip was tender on palpation directly over greater trochanter. • Pain was elicited by motion with internal rotation of hip. ° No erythema. ° No
misalignment. ° Motion was normal. ° No instability was noted. ° No hip tenderness was observed with ambulation.
Thigh:
Left Thigh: • Thigh was tender on palpation over greater trochanter. ° No swelling.
Neurological:
Balance: ° Normal.
Psychiatric:
Mood: ° Euthymic.
Affect: ° Normal.
Tests
The skin overlying the L greater trochanteric bursa was prepped with betadine. A 22 gauge needle was used to inject 4mL 1% Lidocaine, 4mL 0.5% marcaine, and 1mL
Kenalog 40 into L greater trochanteric bursa. The patient tolerated the procedure well.
Practice Management
Colonoscopy - n/a
Influenza -?
Zoster - n/a
Pneumococcal -n/a
Men:
The following Signature(s) No Longer Applies because this Encounter Was Opened for Amendment by NOEL,MARY @ 17 Oct 2012 1128 EDT:
Signed NOEL, MARY (CPT, MC, USA, FMRP PGY-1) @ 17 Oct 2012 1127
SO Note Written by NEAL,CALVIN @ 16 Oct 2012 0859 EDT
Chief complaint

Patient states when they have these symptoms, they last ALL THE TIME and occurs DAILY.
Patient states they have had these symptoms before
No change in symptoms.
.
Pain assessment: The pain has been located in LT KNEE for a period of 4+ YRS. The patient describes the pain as DULL and has tried MED with relief and reports
MOVEMENT makes it worse.
.
Allergies
NKDA.
Current medication
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
2019
Medical Record
2019
.
T#3/darvocet
Previous therapy
Personal history
Family of 5
3 children
.
Family history
father- DM.
Practice Management
Colonoscopy - n/a
Influenza -?
Zoster - n/a
Pneumococcal -n/a
Men:
The following SO Note Was Overwritten by NEAL,CALVIN @ 16 Oct 2012 0901 EDT:
SO Note Written by OSHEA,VALERIE W @ 15 Oct 2012 0944 EDT
Chief complaint

Allergies
NKDA.
Current medication
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
.
T#3/darvocet
Previous therapy
Personal history
2019
Medical Record
2019
Family of 5
3 children
.
.
Family history
father- DM.
Practice Management
Colonoscopy - n/a
Influenza -?
Zoster - n/a
Pneumococcal -n/a
Men:
2019
Medical Record
2019
19 Sep 2012 at Martin ACH, Fort Benning, GA, AMH M02D Eagle Team by ZAGORSKI,
KIM J
Encounter ID: BENN-7866408 Primary Dx: BURSITIS TROCHANTERIC
Patient: WAITERS, TOMMIE Date: 19 Sep 2012 1120 EDT Appt Type: OPAC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: AMH FP YELLOW TEAM Provider: ZAGORSKI,KIM JOSEPH

Zagorski- hip pain
jhm
Screening Written by HOLLIS,GEORGE S @ 19 Sep 2012 1112 EDT

Reason For Appointment: Zagorski- hip pain
Allergen information verified by HOLLIS, GEORGE S @ 19 Sep 2012 1112 EDT
Vitals
Vitals Written by HOLLIS,GEORGE S @ 19 Sep 2012 1112 EDT
BP: 147/83 Left Arm, Adult Cuff, HR: 84 Regular, Radial Artery, RR: 18, T: 98.4 °F Oral, HT: 66 in Actual, Without
Shoes,
WT: 227.8 lbs Upright Scale, Actual, With Shoes, SpO2: 98%, BMI: 36.77, BSA: 2.114 square meters
SO Note Written by ZAGORSKI,KIM JOSEPH @ 19 Sep 2012 1129 EDT

Chief complaint
The Chief Complaint is: Severe Left Hip Pain.
A PHA has been completed in past year. Date:
42 Y/O AD MALE WITH 2 WEEK HX LEFT LATERAL HIP PAIN. DENIES RECENT TRAUMA / FALL / REPETATIVE USE
INJURY. PAIN 7/10 W/ ACTIVITY AT LEFT GREATER TROCHANTER.
Muscle aches and limb pain.
Pain assessment: Severe intense and throbbing pain to left hip area.
Allergies
NKDA.
Current medication
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
2019
Medical Record
2019
.
APPENDECTOMY
.
T#3/darvocet
irritants.
Previous therapy
Personal history
Family of 5
3 children
.
[ ]Other (Specify):
.
Family history
father- DM.
Review of systems
Systemic: No fever, no chills, no night sweats, and no recent weight loss.
Endocrine: No hot flashes.
Musculoskeletal: No localized joint pain LEFT LATERAL HIP NOT RADIATING FROM BACK and no localized joint swelling.
Neurological: No motor disturbances and no sensory disturbances.
Skin: No skin lesions and no rash.
Physical findings
Vital Signs:
General Appearance:
Lungs:
Cardiovascular:
Buttocks:
Hips:
Left Hip: • Hip was tender on palpation LATERAL THIGH. • Pain was elicited by motion LATERAL THIGH. ° No
erythema. ° No misalignment. ° Motion was normal. ° No instability was noted. ° No hip tenderness was observed
with ambulation.
Thigh:
Left Thigh: • Thigh was tender on palpation LATERAL , GREATER TROCHANTER. ° No swelling.
Neurological:
2019
Medical Record
2019
Rad Result Cited by ZAGORSKI,KIM J @ 19 Sep 2012 1324 EDT

********** HIP LT **********
Status: Complete
Procedure: HIP LT
Event Date: 19-Sep-2012 11:25:00
Reason for Order:
42 Y/O MALE AD SOLDIER WITH LEFT LATERAL HIP PAIN AT THE GREATER TROCHANTER.
Exam #: 12079198
Status: COMPLETE
Report Text:
FINDINGS:
No fracture-dislocation or definite stress related changes. No degenerative

A/P Written by ZAGORSKI,KIM J @ 19 Sep 2012 1416 EDT

1. BURSITIS TROCHANTERIC
Medication(s): -CELECOXIB (CELEBREX)--PO 100MG CAP - 1 PO BID WF FOR 30 DAYS #60 RF0 Qt: 60 Rf: 0
Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH
Radiology(ies): -HIP LT (Routine) Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH
Impression: 42 Y/O MALE AD SOLDIER WITH LEFT LATERAL HIP PAIN AT THE GRE
Consult(s): -Referred To: PHYSICAL THERAPY CONSULT (Routine) Specialty: Clinic: PHYSICAL THERAPY
Primary Diagnosis: BURSITIS TROCHANTERIC
-Referred To: FPC SPORTS MED (Routine) Specialty: Clinic: FMC SPECIALTY CLINIC Primary
Diagnosis: BURSITIS TROCHANTERIC
Patient Instruction(s): -Return To Clinic If Worse Or New Symptoms
Disposition Written by ZAGORSKI,KIM J @ 19 Sep 2012 1417 EDT

2019
Medical Record
2019
Signed By ZAGORSKI, KIM J (D.O., STAFF PHYSICIAN, MARTIN ACH) @ 19 Sep 2012 1417
_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by ZAGORSKI,KIM J @ 19 Sep 2012 1134 EDT:
SO Note Written by HOLLIS,GEORGE S @ 19 Sep 2012 1113 EDT
Chief complaint
The Chief Complaint is: Severe Left Hip Pain.
A PHA has been completed in past year. Date:

Pain assessment: Severe intense and throbbing pain to left hip area.
Allergies
NKDA.
Current medication
Maxide, celebrex, androgel, viagra, naproxen, flexeril, CPAP, ear drops Vardenafil(Levitra) 20Mg-take one table 60 minutes prior to intercourse;no more than 1 per day
Reported:
HTN, chronic back pain, allergies, h/o ulcers, ED, ear pain, sleep apnea, depression
OVERWEIGHT
MECHANICAL LBP.
APPENDECTOMY
GANGLION RIGHT WRIST.
T#3/darvocet
Previous therapy
Personal history
Family of 5
3 children
.
.
Family history
father- DM
2019
Medical Record
2019
11 Jul 2012 at Reynolds Army Community Hospital Ft. Sill, OK, OST Clinic by ROWE, JOHN
D
Encounter ID: SILL-6695369 Primary Dx: Vaccines Prophylactic Need Against DTP
Patient: WAITERS, JOSHUA RYAN Date: 11 Jul 2012 1455 CDT Appt Type: WELL
Treatment Facility: SGT BLEAK TROOP Clinic: OST IMMUNIZATION Provider: ROWE,JOHN D.
MEDICAL CLINIC
Reason for Appointment: IMM
SO Note Written by GLASSER,DORIS H @ 12 Jul 2012 2252 CDT

The Patient is an 18 year old male.
DAY 4 visit:
Immunizations administered based on previous screening, IAW ASIP guidelines. The OST nursing staff provided counseling to
each patient on the immunization they have received and scribed the immunzations provided to the patient. I have reviewed the
scribed note and confirm it as accurrately documenting the services provided to the patient. Today the patient received the following
immunizations and/or injections:Tdap : 0.5 mL IM, IPV : 0.5 mL IM, MGC : 0.5 mL IM, Bicillin : 1,200,000 units/2mL IM, adenovirus :
type 4 and type 7 : 1 pill of each by mouth.
A/P Last Updated by GLASSER,DORIS H @ 12 Jul 2012 2254 CDT

1. Vaccines Prophylactic Need Against DTP
Procedure(s): -Immunization Admin By Intranasal / Oral Route One Vaccine x 1
-Immunization Administration Each Additional Vaccine x 3
-Meningococcal Conjugate Vaccine Tetravalent (A C Y W-135) x 1
-Vaccines Viral Polio, Inactivated (Salk) x 1
-Vaccines Adenovirus Type 4 Live, For Oral Use x 1
-Vaccines Adenovirus Type 7 Live, For Oral Use x 1
-Tdap Vaccine x 1
-Dr. Supervised Injection Intramuscular Antibiotic x 1
-Immunization Admin Intranasal / Oral Each Additional Vaccine x 1
2. Vaccine needed prophylactically against bacterial diseases
3. Need For Vaccination Poliomyelitis
4. Vaccines Prophylactic Need Against Viral Diseases
5. Vaccines Prophylactic Need
Disposition Last Updated by GLASSER,DORIS H @ 12 Jul 2012 2254 CDT

Signed By ROWE, JOHN D (Physician/Workstation) @ 13 Jul 2012 0849
2019
Medical Record
2019
11 Jul 2012 at Reynolds Army Community Hospital Ft. Sill, OK, OST Clinic by ZWALKER,
CYNTHIA D
Encounter ID: SILL-6695282 Primary Dx:
Patient: WAITERS, JOSHUA RYAN Date: 11 Jul 2012 1444 CDT Appt Type: WELL
Treatment Facility: SGT BLEAK TROOP Clinic: OST IMMUNIZATION Provider: WALKER,CYNTHIA D
MEDICAL CLINIC
Reason for Appointment: IMM

Encounter Cancelled by WALKER,CYNTHIA D @ 11 Jul 2012 1456 CDT
2019
Medical Record
2019
09 Jul 2012 at Reynolds Army Community Hospital Ft. Sill, OK, OST Optometry by ROSA,
JUAN L
Visit for: military services physical

Encounter ID: SILL-6656753 Primary Dx:
accession
Patient: WAITERS, TOMMIE Date: 09 Jul 2012 1046 CDT Appt Type: SPEC
ALAJANDRO
Treatment Facility: REYNOLDS ACH Clinic: OST OPTOMETRY Provider: ROSA,JUAN L
Reason for Appointment: OST IET
Vitals
Vitals Written by ROSA,JUAN L @ 09 Jul 2012 1046 CDT
Uncorr OD: 20/20, Uncorr OS: 20/20, Pain Scale: 0 Pain Free
SO Note Written by ROSA,JUAN L @ 09 Jul 2012 1047 CDT

Chief complaint
The Chief Complaint is: Initial entry eye screening.
Physical findings
VIVID RED / GREEN PASS.
A/P Last Updated by ROSA,JUAN L @ 09 Jul 2012 1047 CDT

1. visit for: military services physical accession(PERIODIC PREVENTION EXAMINATION)
Procedure(s): -Screening Test Of Visual Acuity, Quantitative, Bilateral x 1
Disposition Last Updated by ROSA,JUAN L @ 09 Jul 2012 1047 CDT

Signed By ROSA, JUAN L (paraprofessional) @ 10 Jul 2012 1237
2019
Medical Record
2019
16 Jun 2012 at Martin ACH, Fort Benning, GA, ER by SCHMIDT, MELISSA KAY
Encounter ID: BENN-6348664 Primary Dx: ATYPICAL CHEST PAIN
Patient: WAITERS, TOMMIE Date: 16 Jun 2012 1054 EDT Appt Type: EROOM
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: SCHMIDT,MELISSA KAY
AutoCites Refreshed by FAGA,MELISSA K @ 16 Jun 2012 1202 EDT

Chronic: • Family medical history (General FHx) No Allergies Found.
• Counseling about travel • Sleep apnea (General FHx)
• Gastritis • Of heart disease
• Hyperglycemia • No Family History of angina pectoris
• McKenzie posterior derangement • Of cancer
syndrome • Family history [use for free text]
• Counseling for five to eight patients • No Family History of mental illness (not
about medical management retardation)
• Obstructive sleep apnea • No Family History of alcoholism
• Nonorganic sleep disorders • No Family History of malignant neoplasm
• Hyperlipidemia of the large intestine
• Overweight • Arteriosclerotic cardiovascular disease
• Hypertension (ASCVD) (Mother)
• Hypogonadism • Type 2 diabetes mellitus (Father)
• Astigmatism
• Male erectile disorder
• Snoring was observed
• Visit for: vasectomy status
• LUQ abdominal pain
• Lumbago
• Observation for suspected condition
• Recurrent major depression in partial
remission
• Adjustment disorder with depressed
mood
• Hypermetropia
• Generalized anxiety disorder
• Moderate single episode major
depression
• Periumbilical pain
• Condition was caused by an
occupational disease
• Anxiety disorder NOS
• Major depression, single episode
• Isolated blood pressure was elevated
• Visit for: occupational health/fitness
exam
• Body mass index
• Patient education about a proper diet
• Gastritis due to H. pylori
• Helicobacter pylori (H. pylori) infection
• Testicular neoplasm
• Abdominal pain
• Other physical therapy
• Shoulder joint pain
• Cervicalgia
• Folliculitis
• Migraine headache
2019
Medical Record
2019
• Backache
Active Medications
Triamterene 37.5mg + Active TAKE ONE TABLET BY 0 of 1 16 Jun
Hydrochlorothiazide 25mg, (Maxzide- MOUTH EVERY DAY 2012
25), Tablet, Oral
SILDENAFIL CITRATE, 100 MG, TABLET, Active TAKE ONE TABLET BY 10 of 11 08 Jun
ORAL MOUTH 1 HOUR BEFORE 2012
MORE THAN 1 A DAY
Testosterone 1%, Gel/Jelly, Active USE 1 PUMP IN EACH ARM 4 of 5 22 May
Transdermal, 1.25g EVERY DAY 2012
TRIAZOLAM (TRIAZOLAM), 0.25 MG, Active NR 03 May
TABLET, ORAL, GREENSTONE LLC., 10 ea. 2009
BOTTLE
A/P Written by FAGA,MELISSA K @ 16 Jun 2012 1202 EDT

1. ATYPICAL CHEST PAIN
Disposition Written by FAGA,MELISSA K @ 16 Jun 2012 1202 EDT

Signed By FAGA, MELISSA K (Physician/Workstation) @ 16 Jun 2012 1202
2019
Medical Record
2019
09 May 2012 at Martin ACH, Fort Benning, GA, Community Health by TAYLOR, KEVIN M
Encounter ID: BENN-5852816 Primary Dx: Counseling About Travel
Patient: WAITERS, TOMMIE Date: 09 May 2012 1101 EDT Appt Type: SPEC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: COMMUNITY HEALTH Provider: TAYLOR,KEVIN MICHAEL
Reason for Appointment: Travel Medicine
AutoCites Refreshed by MELENDEZ,ELY @ 09 May 2012 1116 EDT

Problems Allergies
Chronic: No Allergies Found.
• Gastritis
• Hyperglycemia
• McKenzie posterior derangement
syndrome
• Counseling for five to eight patients
about medical management
• Obstructive sleep apnea
• Nonorganic sleep disorders
• Hyperlipidemia
• Overweight
• Hypertension
• Hypogonadism
• Astigmatism
• Lumbago
remission
mood
• Hypermetropia
depression
exam
• Body mass index
• Abdominal pain
• Cervicalgia
• Folliculitis
• Backache
2019
Medical Record
2019
Active Medications
Esomeprazole Magnesium Trihydrate Active TAKE ONE CAPSULE BY NR 28 Apr
40mg, Capsule, Oral MOUTH EVERY DAY 2012
SUCRALFATE, 1 G, TABLET, ORAL Active TAKE ONE TABLET FOUR NR 28 Apr
TIMES A DAY BEFORE 2012
MEALS AND AT BEDTIME
Triamterene 37.5mg + Active TAKE ONE TABLET BY 0 of 1 05 Apr
25), Tablet, Oral
SILDENAFIL CITRATE, 100 MG, TABLET, Active TAKE ONE TABLET BY 11 of 11 20 Mar
MORE THAN 1 A DAY
Testosterone 1%, Gel/Jelly, Active USE 1 PUMP IN EACH ARM 5 of 5 20 Mar
BOTTLE
Screening Written by MELENDEZ,ELY @ 09 May 2012 1113 EDT

Reason For Appointment: Travel Medicine
Reason(s) For Visit (Chief Complaint): Counseling About Travel (New) ;
Vitals
Vitals Written by MELENDEZ,ELY @ 09 May 2012 1114 EDT
BP: 116/70, HR: 94, RR: 16, HT: 66 in, WT: 211 lbs, BMI: 34.06, BSA: 2.046 square meters,
Tobacco Use: No, Alcohol Use: No, Pain Scale: 7/10 Severe,
Pain Scale Comments: LBP, Seen physical therapy and taken muscle relaxer
Comments: Medication reconcilliation reviwed
SO Note Written by TAYLOR,KEVIN MICHAEL @ 11 May 2012 1421 EDT

He reported: Encounter Background Information: 41 y/o M presents for travel health consultation. Traveling to Burkina Faso on
2 July 2012 for 2 weeks. Will be visiting wife's family. Lodging and meals will be provided by family/friends. Locale will be primarily
rural. Plans on drinking bottled water; unclear if bed nets will be available.
Reviewed Travax summary report for Burkina Faso with patient; risk of falciparum malaria and yellow fever is high throughout
entire country.
Reported History:
Past medical history: no chronic medical conditions; not currently on any medications. Denies history of medication allergies or
allergic reactions to vaccines.
Vaccination history: hep A #2 in 2005; hep B #3 in 2007; adult polio booster in 2004; Td in 2004; meningococcal vaccine in
2004; typhoid in 2004; MMR in 2004; varicella in 2005; influenza in Sep 2011; no record of yellow fever vaccine.
.
Physical findings
Vital signs:
• Vital signs: reviewed.
Rad AutoCites Refreshed by MELENDEZ,ELY @ 09 May 2012 1116 EDT

Rads
No Rads Found.
A/P Written by TAYLOR,KEVIN M @ 11 May 2012 1428 EDT

1. Counseling About Travel(TRAVEL MEDICINE EDUCATION): Provided completed order form and instructed patient to report to
the immunization clinic for the following vaccinations: Tdap, typhoid, yellow fever. Strongly recommended malaria prophylaxis
considering high risk of falciparum malaria throughout all of Bukina Faso. Provided self-treatment for traveler's diarrhea as well as
educational handout on taking medication. Provided additional counseling on insect precautions, rabies prevention, food/water
precautions, and post-travel illness. Provided written guidance in the form of Travax traveler health summary for Burkina Faso and
Shoreland's Travel Health Companion.
2019
Medical Record
2019
Medication(s): -LOPERAMIDE (IMODIUM) 2MG--PO 2MG CAP - FOR TRAVELER'S DIARRHEA, TAKE 2 CAPSULES
WITH FIRST DOSE, THEN ONE CAPSULE WITH EACH ADDITIONAL LOOS Qt: 20 Rf: 0 Ordered By:
TAYLOR,KEVIN M Ordering Provider: TAYLOR, KEVIN MICHAEL
-CIPROFLOXACIN--PO 500MG TAB - FOR TRAVELER'S DIARRHEA, TAKE ONE TABLET TWICE A
DAY FOR 3 DAYS #6 RF0 Qt: 6 Rf: 0 Ordered By: TAYLOR,KEVIN M Ordering Provider: TAYLOR,
KEVIN MICHAEL
-MALARONE 250/100MG--PO TAB - ONE TABLET DAILY, START 2 DAYS PRIOR TO TRAVEL AND
CONTINUE UNTIL 7 DAYS FOLLOWING RETURN #25 RF0 Qt: 25 Rf: 0 Ordered By: TAYLOR,KEVIN
M Ordering Provider: TAYLOR, KEVIN MICHAEL
2. Vaccines Prophylactic Need Against DTP
3. Need For Vaccination Typhoid
4. Need For Vaccination Yellow Fever
Disposition Written by TAYLOR,KEVIN M @ 11 May 2012 1428 EDT

Signed By TAYLOR, KEVIN M (Chief, Department of Preventive Medicine, Bldg 2616, Soldiers Plaza, Fort Benning, GA) @ 11
May 2012 1429
2019
Medical Record
2019
01 May 2012 at Martin ACH, Fort Benning, GA, Physical Therapy by HOUSER, JEREMY D
MCKENZIE POSTERIOR
Patient: WAITERS, TOMMIE Date: 01 May 2012 1530 EDT Appt Type: EST
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: PHYSICAL THERAPY Provider: HOUSER,JEREMY D
Reason for Appointment: follow up back

sah
SO Note Written by HOUSER,JEREMY D @ 01 May 2012 1542 EDT

He reported: Lower back pain. No lower back pain radiating, not to the buttocks, and not to the groin.
Visit is not deployment-related Pt is a 41yo male with chronic hx of LBP. Pt states pain is progressively getting worse after
MVA 2010. Pt states constant pain of 6-7/10. However, pt does not appear to be in any acute distress. Worse: unknown
Better:Unknown - medication does not help. No tingling of the limbs and no numbness of the limbs
5/01/12 Pt with f/u for LBP. PT states no change in pain since onset of PT. PT states ROM is better but states constant pain.
Will refer to Ortho for further management.
Allergies
No allergy to latex.
Previous therapy
Do not history of request lab results from x-ray department
Physical findings
General appearance:
• In acute distress.
Musculoskeletal system:
General/bilateral: • Flexion in standing maneuver with pain at the end range of movement. • Extension in standing
maneuver with pain at the end range of movement. ° Lumbosacral spine motion was normal. ° Lumbosacral spine
flexion was normal. ° Lumbosacral spine extension was normal. ° Neurodynamic tests of the lumbosacral spine
were not performed. ° A straight-leg raising test was negative.
Posture:
General/bilateral: • Standing posture was abnormal. • Standing posture was flexed.
Neurological:
Motor (Motor Strength): ° Dorsiflexion strength of the ankles was normal. ° Plantar flexion strength of the ankles was normal.
° Eversion strength of the ankles was normal. ° Extension strength of the first toes was normal.
Reflexes: ° Knee jerk was normal. ° Ankle jerk reflex was normal.
Therapy
• No education and instructions: Barriers to Treatment (Age, Learning, Cultural, and Distance) were assessed and are
appropriate at this time.
• Physical therapy session segments, 15 minutes each will refer to Ortho for further mangement.
• General physical therapy goals: independence in home exercise program x today.
• McKenzie extension.
• Patient goals get rid of the pain and learn how to prevent in the future
A/P Written by HOUSER,JEREMY D @ 01 May 2012 1543 EDT

1. MCKENZIE POSTERIOR DERANGEMENT SYNDROME
Procedure(s): -Physical Medicine Physical Therapy Re-Evaluation x 1
Consult(s): -Referred To: ORTHOPEDIC ACTIVE DUTY ONLY (Routine) Specialty: Clinic: ORTHOPEDIC Primary
Diagnosis: MCKENZIE POSTERIOR DERANGEMENT SYNDROME
Disposition Written by HOUSER,JEREMY D @ 01 May 2012 1543 EDT

Follow up: in the PHYSICAL THERAPY clinic. - Comments: Refered to Ortho for further management.
2019
Medical Record
2019
Signed By HOUSER, JEREMY D (Physical Therapist/DPT) @ 01 May 2012 1543
2019
Medical Record
2019
28 Apr 2012 at Martin ACH, Fort Benning, GA, ER by CROUCH, ROBERT J
Encounter ID: BENN-5765108 Primary Dx: GASTRITIS
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: CROUCH,ROBERT JOSEPH
**Limited System Patient Data at time of Encounter**
AutoCites Refreshed by CROUCH,ROBERT J @ 28 Apr 2012 1308 EDT **Data in Autocites may be incomplete**
Allergies
No Allergies Found.
Active Medications
Triamterene 37.5mg + Active TAKE ONE TABLET BY 0 of 1 05 Apr
25), Tablet, Oral
MORE THAN 1 A DAY
BOTTLE
Labs
No Labs Found.
Vitals
No Vitals Found.
SO Note Written by CROUCH,ROBERT JOSEPH @ 28 Apr 2012 1418 EDT

Chief complaint
The Chief Complaint is: Observation for suspected condition.
Subjective
This documentation is to verify this patient was seen in the Emergency Department, all medical documentation can be found in the
Patient's Outpatient treatment record.
Rad AutoCites Refreshed by CROUCH,ROBERT J @ 28 Apr 2012 1308 EDT

Rads
No Rads Found.
A/P Written by CROUCH,ROBERT J @ 28 Apr 2012 1418 EDT

1. GASTRITIS
Medication(s): -SUCRALFATE--PO 1GM TAB - T1 TAB QID ACHS #120 RF0 Qt: 120 Rf: 0 Ordered By:
CROUCH,ROBERT J Ordering Provider: CROUCH, ROBERT JOSEPH
-ESOMEPRAZOLE (NEXIUM)--PO 40MG CAP - T1 CAP PO QD #30 RF0 Qt: 30 Rf: 0 Ordered By:
CROUCH,ROBERT J Ordering Provider: CROUCH, ROBERT JOSEPH
Disposition Written by CROUCH,ROBERT J @ 28 Apr 2012 1419 EDT

2019
Medical Record
2019
Signed By CROUCH, ROBERT J (Physician) @ 28 Apr 2012 1419
2019
Medical Record
2019
03 Apr 2012 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by CALDWELL,
JACQUELINE K
Encounter ID: BENN-5523337 Primary Dx: Visit for: military services physical
Patient: WAITERS, TOMMIE Date: 03 Apr 2012 1400 EDT Appt Type: EST
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC SPECIALTY CLINIC Provider: CALDWELL,JACQUELINE K
Reason for Appointment: pha3

lam
AutoCites Refreshed by PATEL,DHRUVANG J @ 03 Apr 2012 1340 EDT

Allergies
No Allergies Found.
Screening Written by PATEL,DHRUVANG J @ 03 Apr 2012 1338 EDT

Reason For Appointment: pha3
Allergen information verified by PATEL, DHRUVANG J @ 03 Apr 2012 1338 EDT
Vitals
Vitals Written by PATEL,DHRUVANG J @ 03 Apr 2012 1335 EDT
BSA: 2.083 square meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 7/10 Severe, Pain Scale
Comments: lower back
Questionnaire AutoCites Refreshed by PATEL,DHRUVANG J @ 03 Apr 2012 1340 EDT

Questionnaires
SO Note Written by PATEL,DHRUVANG J @ 03 Apr 2012 1338 EDT

Chief complaint
The Chief Complaint is: Pha 3.
41 yrs old male sm comes for periodic health assesment.

General overall feeling - Very Good.
Pain Severity / 10.

Pain assessment:
Allergies
NKDA.
Current medication
Vardenafil(Levitra) 20Mg-take one table 60 minutes prior to intercourse;no more than 1 per day
Reported History:
OVERWEIGHT
MECHANICAL LBP.
2019
Medical Record
2019
Surgical / procedural: Surgical / procedural history

APPENDECTOMY
Reported medications: Medication history: ( ) No Medications
T#3/darvocet
Environmental exposure: No exposure to fumes and no secondhand cigarette smoke exposure. No exposure to respiratory
irritants.
Previous therapy
Personal history
Family of 5
3 children
Behavioral history: No tobacco use in the last 10 years. Never a smoker / Never Used Tobacco Products.
.
[ ]Other (Specify):
.
Family history
father- DM
SO Note Written by CALDWELL,JACQUELINE K @ 04 Apr 2012 1333 EDT

Chief complaint
The Chief Complaint is: PHA completion.
Ad male here for PHA completion with multiple medical problems. Has been followed by his PCM but does reveal some
oncompliance with f/u as he should. He reports having a permanent U2 profile for back pain written in 2008/2009, He has suffered
from some depression and anxiety in the past. He admits to fasting for his labs for this PHA which shows hyperglycemia. His
mother, grandmother and father all have DM.
Current medication
Maxide, celebrex, androgel, viagra, naproxen, flexeril, CPAP, ear drops.
Reported History:
HTN, chronic back pain, allergies, h/o ulcers, ED, ear pain, sleep apnea, depression.
Review of systems
Systemic symptoms: No fever, no chills, and no recent weight loss.
Head symptoms: Headache.
Otolaryngeal symptoms: Earache. No nasal discharge, no nasal passage blockage, and no sore throat.
Cardiovascular symptoms: No chest pain or discomfort.
Pulmonary symptoms: No dyspnea and no cough.
Gastrointestinal symptoms: No nausea and no vomiting. Abdominal pain. No bright red blood per rectum, no diarrhea, and no
constipation.
Genitourinary symptoms: No change in urinary frequency and no feelings of urinary urgency. No dysuria.
Endocrine symptoms: Sexual complaints.
Musculoskeletal symptoms: Back pain.
Neurological symptoms: No lightheadedness.
2019
Medical Record
2019
Psychological symptoms: Sleep disturbances. Not thinking about suicide. No homicidal thoughts.
Physical findings
Vital signs:
General appearance:
Neck:
Eyes:
General/bilateral:
Pupils: ° PERRL.
External Eye: ° Conjunctiva exhibited no abnormalities.
Sclera: ° Normal.
Ears:
General/bilateral:
Tympanic Membrane: ° Normal.
Nose:
General/bilateral:
Pharynx:
Oropharynx: ° Posterior pharyngeal wall was normal.
Lymph Nodes:
were not enlarged.
Lungs:
Cardiovascular system:
Lab Result Cited by PATEL,DHRUVANG J @ 03 Apr 2012 1334 EDT

Glucose Fasting Site/Specimen 28 Mar 2012 1558
Glucose Fasting PLASMA 132 (H)

Comprehensive Metabolic Panel Site/Specimen 28 Mar 2012 1558
Albumin PLASMA 4.2
Bilirubin PLASMA 0.4 
Calcium PLASMA 8.9
Chloride PLASMA 103
Glucose PLASMA 144 (H) 
Protein PLASMA 7.4
Sodium PLASMA 141

Lipids Site/Specimen 28 Mar 2012 1558
Triglyceride PLASMA 185 (H)
2019
Medical Record
2019

Prostate Specific Ag Site/Specimen 28 Mar 2012 1558
Prostate Specific Ag SERUM 1.01 
A/P Written by CALDWELL,JACQUELINE K @ 03 Apr 2012 1428 EDT

1. visit for: military services physical(PERIODIC PREVENTION EXAMINATION)
2. HYPERGLYCEMIA: Sm to f/u with PCM asap
Laboratory(ies): -GLUCOSE FASTING (Routine)
3. Hyperlipidemia
4. Hypertension
5. Hypogonadism
6. Overweight
7. Obstructive sleep apnea
8. Lumbago
9. Generalized anxiety disorder: SWS consult placed in chcs
Disposition Written by CALDWELL,JACQUELINE K @ 04 Apr 2012 1339 EDT

Signed By CALDWELL, JACQUELINE K (PA-C, MPAS, GLWACH) @ 04 Apr 2012 1339
2019
Medical Record
2019
29 Mar 2012 at Martin ACH, Fort Benning, GA, Physical Therapy by HOUSER, JEREMY D
MCKENZIE POSTERIOR
Patient: WAITERS, TOMMIE Date: 29 Mar 2012 0830 EDT Appt Type: SPEC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: PHYSICAL THERAPY Provider: HOUSER,JEREMY D
Reason for Appointment: SPRAIN LUMBAR

SAH
SO Note Written by HOUSER,JEREMY D @ 29 Mar 2012 0954 EDT

He reported: Lower back pain. No lower back pain radiating, not to the buttocks, and not to the groin.
Visit is not deployment-related Pt is a 41yo male with chronic hx of LBP. Pt states pain is progressively getting worse after
MVA 2010. Pt states constant pain of 6-7/10. However, pt does not appear to be in any acute distress. Worse: unknown
Better:Unknown - medication does not help. No tingling of the limbs and no numbness of the limbs.
Allergies
Previous therapy
Physical findings
General appearance:
• In acute distress.
Lumbar / Lumbosacral Spine (Motion):
General/bilateral: • Lumbosacral spine motion was abnormal. • Lumbosacral spine flexion was abnormal. • Lumbosacral
spine extension was abnormal. • Flexion in standing maneuver with pain at the end range of movement. • Extension
in standing maneuver with pain at the end range of movement. ° Neurodynamic tests of the lumbosacral spine were
not performed. ° A straight-leg raising test was negative.
Posture:
General/bilateral: • Standing posture was abnormal. • Standing posture was flexed.
Neurological:
Motor (Motor Strength): ° Dorsiflexion strength of the ankles was normal. ° Plantar flexion strength of the ankles was normal.
° Eversion strength of the ankles was normal. ° Extension strength of the first toes was normal.
Reflexes: ° Knee jerk was normal. ° Ankle jerk reflex was normal.
Therapy
• No education and instructions: Barriers to Treatment (Age, Learning, Cultural, and Distance) were assessed and are
appropriate at this time.
• Physical therapy session segments, 15 minutes each Pt was given HEP for DKTC, HS stretch, Prone press ups, Standing
Extension, Lumbar Rotation, Pelvic Rotation, sitting lumbar flexion x 2 daily. Performed TENS unit today but pt states min relief and
did not like. Will f/u with me in 2 weeks. Instructed pt on the importance of walking and exercise.
• General physical therapy goals: independence in home exercise program x today.
• McKenzie extension.
• Patient goals get rid of the pain and learn how to prevent in the future
A/P Written by HOUSER,JEREMY D @ 29 Mar 2012 1007 EDT

Procedure(s): -Physical Medicine Physical Therapy Evaluation x 1
-Physical Therapy: ___ Session Segments, 15 Minutes Each x 1
-Modalities Electrical Stimulation x 1
Disposition Written by HOUSER,JEREMY D @ 29 Mar 2012 1008 EDT

Follow up: in the PHYSICAL THERAPY clinic. - Comments: Will f/u with me in 2 weeks for reassessment.
2019
Medical Record
2019
Note Written by SCRUGGS,CAROLYN M @ 29 Mar 2012 0827 EDT

Consult Order
Referring Provider: ZAGORSKI, KIM J
Date of Request: 26 Mar 2012
Priority: Routine
SPRAIN LUMBAR
Reason for Request:
PLEASE EVALUATE AND TREAT. 41 Y/O AD MALE WITH EXACERBATION OF LUMBAR STRAIN. PLEASE ASSIST WITH
INCREASING ROM / CORE STRENGTHENING. OTHER MODALITIES TO REDUCE PAIN. (706) 326 - 4585
Signed By HOUSER, JEREMY D (Physical Therapist/DPT) @ 29 Mar 2012 1008
2019
Medical Record
2019
28 Mar 2012 at Martin ACH, Fort Benning, GA, Physical Therapy by BRANNIN,
JENNIFER A
Patient: WAITERS, TOMMIE Date: 28 Mar 2012 1400 EDT Appt Type: SPEC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: PHYSICAL THERAPY Provider: BRANNIN,JENNIFER

jrb

Consult Order
Priority: Routine
SPRAIN LUMBAR
Reason for Request:
PLEASE EVALUATE AND TREAT. 41 Y/O AD MALE WITH EXACERBATION OF LUMBAR STRAIN. PLEASE ASSIST WITH
INCREASING ROM / CORE STRENGTHENING. OTHER MODALITIES TO REDUCE PAIN. (706) 326 - 4585

Encounter Cancelled by SCRUGGS,CAROLYN M @ 28 Mar 2012 1446 EDT
2019
Medical Record
2019
26 Mar 2012 at Martin ACH, Fort Benning, GA, ER by SCHMIDT, MELISSA KAY
Encounter ID: BENN-5485184 Primary Dx: VIRAL SYNDROME
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: FAGA,MELISSA K
AutoCites Refreshed by FAGA,MELISSA K @ 27 Mar 2012 0023 EDT

• Counseling for five to eight patients • Sleep apnea (General FHx)
about medical management • Of heart disease
• Obstructive sleep apnea • No Family History of angina pectoris
• Nonorganic sleep disorders • Of cancer
• Hyperlipidemia • Family history [use for free text]
• Overweight • No Family History of mental illness (not
• Hypertension retardation)
• Hypogonadism • No Family History of alcoholism
• Astigmatism • No Family History of malignant neoplasm
• Male erectile disorder of the large intestine
• Snoring was observed • Arteriosclerotic cardiovascular disease
• Visit for: vasectomy status (ASCVD) (Mother)
• LUQ abdominal pain • Type 2 diabetes mellitus (Father)
• Lumbago
remission
mood
• Hypermetropia
depression
exam
• Body mass index
• Abdominal pain
• Cervicalgia
• Folliculitis
• Backache
Active Medications
CYCLOBENZAPRINE HCL, 5 MG, TABLET, Active TAKE ONE TABLET BY NR 26 Mar
2019
Medical Record
2019
ORAL MOUTH THREE TIMES A 2012

DAY AND TAKE TWO
TABLETS AT BEDTIME
CELECOXIB, 100 MG, CAPSULE, ORAL Active TAKE ONE CAPSULE BY NR 26 Mar
MOUTH TWICE A DAY 2012
MORE THAN 1 A DAY
Triamterene 37.5mg + Active TAKE ONE TABLET BY 1 of 1 02 Nov
25), Tablet, Oral
BOTTLE
A/P Written by FAGA,MELISSA K @ 27 Mar 2012 0024 EDT

1. VIRAL SYNDROME
Disposition Written by FAGA,MELISSA K @ 27 Mar 2012 0024 EDT

Signed By FAGA, MELISSA K (Physician/Workstation) @ 27 Mar 2012 0024
2019
Medical Record
2019
26 Mar 2012 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J
Encounter ID: BENN-5484280 Primary Dx: SPRAIN LUMBAR
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC YELLOW CLINIC Provider: ZAGORSKI,KIM JOSEPH
Reason for Appointment: Zagorski/ f/u on back pain/706-326-4585

MHT
AutoCites Refreshed by ZAGORSKI,KIM J @ 26 Mar 2012 1510 EDT

Chronic: • Sleep apnea (General FHx) No Allergies Found.
• Counseling for five to eight patients • Family medical history (General FHx)
• Lumbago
remission
mood
• Hypermetropia
depression
exam
• Body mass index
• Abdominal pain
• Cervicalgia
• Folliculitis
• Backache
Active Medications
2019
Medical Record
2019

MORE THAN 1 A DAY
25), Tablet, Oral
BOTTLE
Screening Written by HOLLIS,GEORGE S @ 26 Mar 2012 1459 EDT

Reason For Appointment: Zagorski/ f/u on back pain/706-326-4585
Allergen information verified by HOLLIS, GEORGE S @ 26 Mar 2012 1459 EDT
Vitals
Vitals Written by HOLLIS,GEORGE S @ 26 Mar 2012 1459 EDT
BP: 133/80 Left Arm, Adult Cuff, HR: 74 Regular, Radial Artery, RR: 18, T: 99.9 °F Oral, HT: 66
in Actual, Without Shoes,
WT: 220 lbs Upright Scale, Actual, Without Shoes, SpO2: 99%, BMI: 35.51, BSA: 2.083 square meters
SO Note Written by ZAGORSKI,KIM JOSEPH @ 26 Mar 2012 1512 EDT

Chief complaint
The Chief Complaint is: F/U on Severe Back Pain and Medication Refill (Hydrocodone w/Acetaminophen).
41 Y/O AAM PRESENTS WITH 2 WEEK HX LOW BACK PAIN / TIGHTNESS. NO FALL / TRAUMA / OVERUSE. NO F/C/S. NO
WEIGHT LOSS. NO HX CA.
Lower back pain with muscle spasm bilaterally.
Not currently on active duty and visit is not deployment-related. No leg weakness, no numbness of the right leg, and not of the
left leg.
Pain assessment: Severe Back Pain-Constant and throbbing.
Allergies
NKDA.
Current medication
Reported History:
OVERWEIGHT
MECHANICAL LBP.
APPENDECTOMY
T#3/darvocet
irritants.
Previous therapy
2019
Medical Record
2019
Personal history
Family of 5
3 children
.
[ ]Other (Specify):
.
Family history
father- DM.
Review of systems
Systemic symptoms: No fever, no chills, no night sweats, and no recent weight loss.
Gastrointestinal symptoms: No diarrhea. No fecal incontinence.
Genitourinary symptoms: No hematuria. No painful inability to urinate. No urinary loss of control and no dysuria. No flank pain.
Neurological symptoms: No motor disturbances and no sensory disturbances. No perineal numbness.
Physical findings
Vital signs:
General appearance:
° Alert. ° Well developed. ° Well nourished. ° In no acute distress.
Neck:
Lymph Nodes:
were not enlarged.
Lungs:
Thoracic Spine:
General/bilateral: ° Thoracic spine had a normal appearance. ° Palpation of the thoracic spine revealed no abnormalities.
° Thoracic spine exhibited no spasm of the paraspinal muscles.
Thoracolumbar Spine:
General/bilateral: ° Thoracolumbar spine had a normal appearance. ° Thoracolumbar spine did not demonstrate
tenderness on palpation. ° Thoracolumbar spine demonstrated full range of motion. ° Thoracolumbar spine pain
was not elicited by motion. ° Flexion in standing maneuver with no pain during movement. ° Extension in standing
maneuver with no pain during movement. ° No psoas sign was present.
General/bilateral: • Lumbosacral spine exhibited an abnormal appearance ELEVATED PSIS LEFT W/ SPASM AND
CURVE CONCAVITY RIGHT. • Lumbosacral spine exhibited tenderness on palpation. • Lumbosacral spine
exhibited muscle spasms. • Lumbosacral spine motion was abnormal DECREASED FLEXION. • Lumbosacral spine
pain was elicited by motion. ° Lumbosacral spine exhibited no step deformity. ° A straight-leg raising test was
negative. ° A contralateral straight-leg raising test was negative.
A/P Written by ZAGORSKI,KIM J @ 26 Mar 2012 1517 EDT

1. SPRAIN LUMBAR
Medication(s): -CELECOXIB (CELEBREX)--PO 100MG CAP - 1 PO BID #60 RF0 Qt: 60 Rf: 0 Ordered By:
ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH
-CYCLOBENZAPRINE--PO 5MG TAB - 1 PO TID AND 2 HS #35 RF0 Qt: 35 Rf: 0 Ordered By:
2019
Medical Record
2019

Consult(s): -Referred To: PHYSICAL THERAPY CONSULT (Routine) Specialty: Clinic: PHYSICAL THERAPY
Primary Diagnosis: SPRAIN LUMBAR Ordered By: ZAGORSKI,KIM J Ordering Provider:
ZAGORSKI,KIM JOSEPH
Disposition Written by ZAGORSKI,KIM J @ 26 Mar 2012 1517 EDT

Follow up: as needed in 2 week(s) or sooner if there are problems.
Signed By ZAGORSKI, KIM J (Physician/Workstation) @ 26 Mar 2012 1517

_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by ZAGORSKI,KIM J @ 26 Mar 2012 1512 EDT:
SO Note Written by HOLLIS,GEORGE S @ 26 Mar 2012 1506 EDT
Chief complaint
The Chief Complaint is: F/U on Severe Back Pain and Medication Refill (Hydrocodone w/Acetaminophen).
He reported: Medication list reviewed with patient, reconciliation completed, and list given to patient.
Pain assessment: Severe Back Pain-Constant and throbbing.
Allergies
NKDA.
Current medication
Reported History:
OVERWEIGHT.
APPENDECTOMY
T#3/darvocet
Environmental exposure: No exposure to fumes and no secondhand cigarette smoke exposure. No exposure to respiratory irritants.
Personal history
Family of 5
3 children
.
.
Family history
father- DM
2019
Medical Record
2019
20 Mar 2012 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by CALDWELL,
JACQUELINE K
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC SPECIALTY CLINIC Provider: CALDWELL,JACQUELINE K
Reason for Telephone Consult: PHA 2
A/P Last Updated by MASON,SLOAN @ 20 Mar 2012 1013 EDT

Laboratory(ies): -COMPREHENSIVE METABOLIC PANEL (Routine) Ordered By: MASON,SLOAN Ordering Provider:
CALDWELL, JACQUELINE K; GLUCOSE FASTING (Routine) Ordered By: MASON,SLOAN Ordering
Provider: CALDWELL, JACQUELINE K; LIPIDS (Routine) Ordered By: MASON,SLOAN Ordering
Provider: CALDWELL, JACQUELINE K; PROSTATE SPECIFIC AG (Routine) Ordered By:
MASON,SLOAN Ordering Provider: CALDWELL, JACQUELINE K
Disposition Last Updated by MASON,SLOAN @ 20 Mar 2012 1015 EDT

Signed By CALDWELL, JACQUELINE K (PA-C, MPAS, GLWACH) @ 26 Mar 2012 0920
2019
Medical Record
2019
19 Mar 2012 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J
Encounter ID: BENN-5456704 Primary Dx: MALE ERECTILE DISORDER
ALAJANDRO
Patient Status: Outpatient Call Back Phone: 706-326-4585 cell
Reason for Telephone Consult: ZAGORSKI/Rx Refill

Appointment Comments: Written by MATTHEWS,ROYCE D @ 19 Mar 2012 1152 EDT
Pt's phone number: 706-326-4585 cell
Medications:
TESTOSTERONE (ANDROGEL-1%)1.25 A 2 02 Nov 2011 5 of 5
LEVITRA 20MG (VARDENAFIL) ORAL E 6 13 Sep 2011 7 of 11
Pick up pharmacy: yes
Patient has been informed they will not be receiving call back.
AutoCites Refreshed by ZAGORSKI,KIM J @ 19 Mar 2012 1719 EDT

Chronic: • Sleep apnea (General FHx) No Allergies Found.
• Counseling for five to eight patients • Family medical history (General FHx)
• Lumbago
remission
mood
• Hypermetropia
depression
exam
• Body mass index
• Abdominal pain
2019
Medical Record
2019
• Cervicalgia
• Folliculitis
• Backache
Active Medications
Testosterone 1%, Gel/Jelly, Active USE 1 PUMP IN EACH ARM 5 of 5 02 Nov
25), Tablet, Oral
BOTTLE
A/P Written by ZAGORSKI,KIM J @ 19 Mar 2012 1721 EDT

1. MALE ERECTILE DISORDER
Medication(s): -VIAGRA 100MG (SILDENAFIL) ORAL TABLET--P - T1 TAB 1 HOUR BEFORE SEXUAL
INTERCOURSE NO MORE THAN 1 A DAY #6 RF11 Qt: 6 Rf: 11 Ordered By: ZAGORSKI,KIM J
Ordering Provider: ZAGORSKI, KIM JOSEPH
2. HYPOGONADISM
Medication(s): -TESTOSTERONE (ANDROGEL-1%)1.25G GEL PUMP - USE 1 PUMP IN EACH ARM DAILY #2 RF5
Qt: 2 Rf: 5 Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH
Disposition Written by ZAGORSKI,KIM J @ 19 Mar 2012 1721 EDT

Signed By ZAGORSKI, KIM J (Physician/Workstation) @ 19 Mar 2012 1721
2019
Medical Record
2019
07 Feb 2012 at Martin ACH, Fort Benning, GA, Internal Med Sleep Clinic by CARTER,
KEVIN A
NONORGANIC SLEEP APNEA

OBSTRUCTIVE
Patient: WAITERS, TOMMIE Date: 07 Feb 2012 1542 EST Appt Type: PROC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: INTERNAL MED SLEEP CLINIC Provider: CARTER,KEVIN ALLEN
Reason for Appointment: PAP Titration Study
Questionnaire AutoCites Refreshed by CARTER,KEVIN A @ 07 Feb 2012 1601 EST

Questionnaires
SO Note Written by THORNBURG,BRADLEY W @ 07 Feb 2012 1544 EST

Reason for Visit
Visit for: POSITIVE AIRWAY PRESSURE DEVICE TITRATION STUDY. Referred by Sleep Medicine Clinic Staff.
He reported: Past medical history reviewed, problem list reviewed, medication list reviewed, and family history reviewed.
Reported History:
No recent change in medical history.
Physical findings
Growth and development:
Tests
Laboratory studies:
Sleep Testing:
Sleep testing was performed THE PATIENT WORE THEIR PRESCRIBED POSITIVE AIRWAY PRESSURE (PAP) DEVICE
AND MASK INTERFACE FOR A PERIOD DESCRIBED IN THE REPORT. THE DATA FROM THE PAP DEVICE WAS
COLLECTED, DOWNLOADED, AND INTERPRETED WITH ASSOCIATED RECOMMENDATIONS.
A/P Last Updated by THORNBURG,BRADLEY W @ 07 Feb 2012 1546 EST

1. SLEEP APNEA OBSTRUCTIVE
Procedure(s): -Spec Dr. Serv Collect/Interp Of Physiol Data, Minim 30 Min x 1
Disposition Last Updated by CARTER,KEVIN A @ 07 Feb 2012 1601 EST

Note Written by CARTER,KEVIN A @ 07 Feb 2012 1601 EST
2019
Medical Record
2019
Signed By CARTER, KEVIN ALLEN (Director, The Sleep Medicine Center, BMACH) @ 07 Feb 2012 1601

2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
07 Feb 2012 at Martin ACH, Fort Benning, GA, Internal Med Sleep Clinic by CARTER,
KEVIN A

OBSTRUCTIVE
ALAJANDRO
Reason for Appointment: F/U CPAP

Appointment Comments: Written by SAMPSON,LINDA M @ 07 Feb 2012 0757 EST
LMS
NOTIFY PT
Questionnaire AutoCites Refreshed by CARTER,KEVIN A @ 07 Feb 2012 1548 EST

Questionnaires
SO Note Written by CARTER,KEVIN ALLEN @ 07 Feb 2012 1556 EST

Chief complaint
The Chief Complaint is: F/u CPAP.
Reason for Visit
Visit for: pt sts diff. breathing with mask, doesn't feel like enough pressure. Also, was out in the field for 1 week and didn't use
cpap.
Back pain.
PainSeverity 5 / 10.
HPI: Respiratory Disturbance = 14/hr. ~Date of study: Jan 2012~Diagnosis: Mild OSA.
Allergies
NKA.
Reported History:
Medical: Past medical history was reported by the patient.
Personal history
Behavioral history: No tobacco use in the last 10 years.
Alcohol: Not using alcohol Screening Date:
Review of systems
PATIENT'S ASSESSMENT OF THERAPY: poor.
Physical findings
Head:
Examination Of Face: • Chin showed abnormalities.
Objective
Recommend sleeping in the lateral position, obtaining 7-8 hours of sleep per night, avoidance of alcohol or other sedatives and
maintaining an ideal body weight as these can improve sleep apnea and sleep quality. Recommend treatment of chronic sinus
congestion if needed. GENERAL DISCUSSION OF POSITIVE PRESSURE THERAPY, ITS GOALS AND ITS EFFECT ON SLEEP
AND PHYSIOLOGY, APPARENTLY UNDERSTOOD BY PATIENT.
GENERAL DISCUSSION OF SLEEP HYGEINE: REGULAR USE OF CPAP/BiPAP IS RECOMMENDED DURING ALL HOURS OF
SLEEP, INCLUDING NAPS AND WHILE AWAY FROM HOME; ELIMINATION FROM BEDROOM OF NON SLEEP-RELATED
STIMULI; AVOIDANCE OF EXERCISE EXERTION, STIMULANTS AND ALCOHOL NEAR BEDTIME; DEVELOPMENT OF
SLEEP-RELATED ROUTINES AND HABITS.TO PREVENT DAMAGE TO EQUIPMENT DURING TRIPS, SLEEP RELATED
EQUIPMENT SHOULD BE TRANSPORTED AS CARRY-ON BAG, AND NOT STORED IN CHECKED LUGGAGE.
BECAUSE A SLEEP DISORDER HAS BEEN DIAGNOSED, DRIVING PRECAUTIONS ARE URGED.
PATIENT IS ASKED TO CONTINUE SLEEP THERAPY AND TO CONTACT THE SLEEP DISORDERS CLINIC IN CASE OF
MALFUNCTIONING SLEEP-RELATED EQUIPMENT, OTHER EQUIPMENT NEEDS, SIGNIFICANT WEIGHT LOSS OR GAIN,
OR MAJOR CHANGE IN HEALTH STATUS.
PATIENT IS ASKED TO AVOID DRIVING DURING ALL PERIODS WHEN CPAP/BIPAP IS NOT USED AND WHENEVER
2019
Medical Record
2019
SOMNOLENCE OR FATIGUE OCCUR.THE PATIENT WAS INSTRUCTED TO FOLLOW-UP AS NEEDED AND AT LEAST
ANNUALLY. ALSO, INSTRUCTED TO BRING THEIR CPAP DATA CARD WITH THEM TO ALL SLEEP CLINIC APPOINTMENTS.
A/P Last updated by CARTER,KEVIN A @ 07 Feb 2012 1556 EST

1. SLEEP APNEA OBSTRUCTIVE: pt's APAP changed to 8-16 cm H20. pt given lunesta to help with compliance and to get data to
determine response. will walk-in in 2-3 wks.
Medication(s): -ESZOPICLONE (LUNESTA) 3MG--PO 3MG TAB - 1 TAB PO QHS #14 RF0 Qt: 14 Rf: 0 Ordered By:
CARTER,KEVIN A Ordering Provider: CARTER, KEVIN ALLEN
Disposition Last Updated by CARTER,KEVIN A @ 07 Feb 2012 1559 EST

Signed By CARTER, KEVIN ALLEN (Director, The Sleep Medicine Center, BMACH) @ 07 Feb 2012 1559

Preventive Service Performed:
Anti-Tobacco Counseling

2019
Medical Record
2019
_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by CARTER,KEVIN A @ 07 Feb 2012 1556 EST:
SO Note Written by THORNBURG,BRADLEY W @ 07 Feb 2012 1541 EST
Chief complaint
The Chief Complaint is: F/u CPAP.
Back pain.
Allergies
NKA.
Personal history
The following A/P Note Was Overwritten by CARTER,KEVIN A @ 07 Feb 2012 1556 EST:
2019
Medical Record
2019
The A/P section was last updated by CARTER,KEVIN A @ 07 Feb 2012 1556 EST - see above.Previous Version of A/P section was entered/updated by
THORNBURG,BRADLEY W @ 07 Feb 2012 1542 EST.
2019
Medical Record
2019
27 Jan 2012 at Martin ACH, Fort Benning, GA, Internal Med Sleep Clinic by CARTER,
KEVIN A
Patient Counseling Medical Management

Patient: WAITERS, TOMMIE Date: 27 Jan 2012 1315 EST Appt Type: GRP
ALAJANDRO
Reason for Appointment: Group CPAP Clinic

LMS
AutoCites Refreshed by CARTER,KEVIN A @ 27 Jan 2012 1352 EST

Allergies
No Allergies Found.
Active Medications
IBUPROFEN, 800 MG, TABLET, ORAL Active TAKE ONE TABLET THREE NR 23 Jan
TIMES DAILY WITH FOOD 2012
Ondansetron Hydrochloride 8mg, Active TAKE ONE TABLET BY NR 23 Jan
(Zofran), Tablet, Oral MOUTH EVERY SIX HOURS 2012
AS NEEDED FOR NAUSEA
AND VOMITING
Antipyrine + Glycerin + Benzocaine, Active INSTILL 2 DROPS TO NR 23 Jan
Solution, Otic EACH EAR THREE TIMES A 2012
DAY FOR 5 DAYS
Pseudoephedrine Hydrochloride 60mg + Active TAKE ONE TABLET TWICE NR 23 Jan
Guaifenesin 600mg, Tablet, Oral DAILY 2012
DIPHENHYDRAMINE HCL, 25 MG, CAPSULE, Active TAKE ONE CAPSULE THREE NR 23 Jan
ORAL TIMES DAILY 2012
25), Tablet, Oral
VARDENAFIL HCL, 20 MG, TABLET, ORAL Active TAKE 1 TABLET 60 7 of 11 13 Sep
MINUTES PRIOR TO 2011
INTERCOURSE; NO MORE
THAN 1 PER DAY
BOTTLE
Questionnaire AutoCites Refreshed by CARTER,KEVIN A @ 27 Jan 2012 1352 EST

Questionnaires
SO Note Written by CARTER,KEVIN ALLEN @ 27 Jan 2012 1352 EST

Chief complaint
The Chief Complaint is: GROUP CPAP CLINIC.
Reason for Visit
Visit for: follow-up exam.
He reported: Medication list reviewed.
Feeling fine. Symptoms unchanged since last visit, feeling tired or poorly, and lethargy.
Frequent breathing through the mouth, snoring loudly, and has been witnessed.
2019
Medical Record
2019
Decreased concentrating ability.

Daytime somnolence and sleep apnea.
Reported History:
No recent change in medical history.
Diagnosis History:
Obstructive sleep apnea
Previous therapy
No history of continuous positive airway pressure ventilation
Personal history
Home environment: DME in home: no CPAP.
Physical findings
General appearance:
° Normal. ° Well-appearing.
Neurological:
° Level of consciousness was normal.
Tests
The patient was counseled to maintain an ideal body weight to reduce the severity of the disease and related complications. The
risks of alcohol and other sedatives were discussed. The patient was educated on positional therapy. The patient was counseled to
avoid driving while excessively sleepy. Education session conducted on diagnosis of Obstructive Sleep Apnea (OSA) including
anatomy, pathophysiology, risk factors-i.e. hypertension, heart disease, pulmonary vascular disease, reduced quality of life, and
treatment options. Primary treatment recommendation is Continuous Positive Airway Pressure (CPAP) therapy, the safest, most
effective therapy available for OSA. Other treatment modalities discussed included weight loss, positional therapy, avoidance of
ETOH/ sedatives, good sleep hygiene measures, oral appliance, and surgical intervention. Counseled on risks of untreated OSA,
including excessive daytime sleepiness, increased traffic /occupational accidents, and poor attention or lack of concentration during
activities requiring alertness and vigilance. Medical-legal concerns related to driving with OSA. Patient was strongly cautioned
against driving while sleepy or participating in other high risk activities until effective treatment of OSA is established. Education
was provided regarding the use, care of, & travel with CPAP, maintenance of machine, fitting and selection of CPAP masks,
common problems encountered with CPAP, and CPAP desensitization program. Patient was fitted for a mask and instructed on
how to adjust mask and comfort features on the CPAP machine. Educational materials were provided.Results of patient's
diagnostic PSG/CPAP titration were reviewed and questions addressed in an individualized forum. Patient was given a copy of
polysomnogram reportPt given M series 510 Auto adjustable CPAP. The duration of the encounter was 90 minutes.
A/P Written by CARTER,KEVIN A @ 27 Jan 2012 1353 EST

1. Patient Counseling Medical Management Five To Eight Patients(OTHER SPECIFIED COUNSELING): An educational
session was conducted over a period of 60 minutes on the diagnosis of Obstructive Sleep Apnea (OSA) including anatomy,
pathophysiology, risk factors-i.e. hypertension, heart disease, pulmonary vascular disease, reduced quality of life, and treatment
options. Primary treatment recommendation is Continuous Positive Airway Pressure (CPAP) therapy, the safest, most effective
therapy available for OSA. Other treatment modalities discussed included weight loss, positional therapy, avoidance of ETOH/
sedatives, good sleep hygiene measures, oral appliance, and surgical intervention. The patient also understands that a negative
test for Obstructive Sleep Apnea (OSA) is not absolute and a formal level I in-lab PSG is needed to fully exclude OSA.
The patient was counseled on risks of untreated OSA, including excessive daytime sleepiness, increased traffic /occupational
accidents, and poor attention or lack of concentration during activities requiring alertness and vigilance. Medical-legal concerns
related to driving with OSA. Patient was strongly cautioned against driving while sleepy or participating in other high risk activities
until effective treatment of OSA is established.
F/U APPT GIVEN FOR 2-3 WKS.
Procedure(s): -Dr.-Supervised Group Educational Services x 1
Disposition Written by CARTER,KEVIN A @ 27 Jan 2012 1353 EST

Follow up: in the INTERNAL MED SLEEP CLINIC clinic.
Signed By CARTER, KEVIN A (Director, The Sleep Medicine Center, BMACH) @ 27 Jan 2012 1353
2019
Medical Record
2019
KEVIN A

OBSTRUCTIVE
ALAJANDRO
Reason for Appointment: F/U PSG

Appointment Comments: Written by SAMPSON,LINDA M @ 25 Jan 2012 0624 EST
LMS
Notify PT
AutoCites Refreshed by CARTER,KEVIN A @ 25 Jan 2012 1432 EST

Allergies
No Allergies Found.
Active Medications
IBUPROFEN, 800 MG, TABLET, ORAL Active TAKE ONE TABLET THREE NR 23 Jan
TIMES DAILY WITH FOOD 2012
Ondansetron Hydrochloride 8mg, Active TAKE ONE TABLET BY NR 23 Jan
(Zofran), Tablet, Oral MOUTH EVERY SIX HOURS 2012
AS NEEDED FOR NAUSEA
AND VOMITING
Antipyrine + Glycerin + Benzocaine, Active INSTILL 2 DROPS TO NR 23 Jan
Solution, Otic EACH EAR THREE TIMES A 2012
DAY FOR 5 DAYS
Pseudoephedrine Hydrochloride 60mg + Active TAKE ONE TABLET TWICE NR 23 Jan
Guaifenesin 600mg, Tablet, Oral DAILY 2012
DIPHENHYDRAMINE HCL, 25 MG, CAPSULE, Active TAKE ONE CAPSULE THREE NR 23 Jan
ORAL TIMES DAILY 2012
ACETAMINOPHEN, 325 MG, TABLET, ORAL Active TAKE 2 TABLETS BY NR 23 Jan
MOUTH EVERY SIX HOURS 2012
AS NEEDED -- NOT TO
EXCEED 9 TABLETS PER
DAY
25), Tablet, Oral
THAN 1 PER DAY
BOTTLE
Questionnaire AutoCites Refreshed by CARTER,KEVIN A @ 25 Jan 2012 1432 EST

Questionnaires
SO Note Written by CARTER,KEVIN ALLEN @ 25 Jan 2012 1433 EST

Chief complaint
The Chief Complaint is: F/u PSG.
Reason for Visit
2019
Medical Record
2019
Visit for: 41 y.o. AD man with a long h/o snoring, nonrestorative sleep, waking up with a dry mouth, and EDS. TODAY PT STS
NO CHANGE IN SX.
He reported: Past medical history reviewed, medication list reviewed with patient, and family history reviewed with patient.
Military service.
Feeling tired or poorly, lethargy, and recent weight change. No recent weight loss. Recent weight gain.
No nasal discharge and no nasal passage blockage. Snoring loudly and has been witnessed. No throat pain.
Genitourinary symptoms.
No fainting followed by prolonged sleepiness. Confusion not occurring upon awakening and no transient limb weakness when
falling asleep or awakening (sleep paralysis). Restless movements during sleep. Involuntary movements during sleep without vivid
dream recall.
No anxiety, no persistent anxiety about insomnia, and depression not accompanied by sleeping more. Daytime somnolence.
Not suddenly falling asleep during the day and no initial insomnia. Middle-night awakening. No insomnia due to pain. Morning
grogginess and nonrestorative sleep. No sleep apnea.
No sinus pressure. No vision problems. No chest pain or discomfort. No dyspnea and no cough. No heartburn at night in
bed. No muscle weakness and no loss of hair from the head or body. The legs do not feel restless. No asthma nighttime
symptoms.
Allergies
NKA.
Current medication
Levitra, vicodin.
Reported History:
- medical history reviewed No recent change in medical history and no prior serious illness.
Recent events: No recent events.
Medical: No cardiac history.
Reported medications: Medication history - medication list reviewed with patient to include OTC and herbal medications.
Medication reconciliation completed.
Diagnosis History:
Hypertension.
No asthma.
No morbid obesity.
No obstructive sleep apnea
Personal history
Social history reviewed.
Behavioral history: No caffeine use. No tobacco use in the last 10 years. Not a current smoker.
Alcohol: No consumption of alcohol. Not using alcohol Screening Date:
Military: Military history.
Family history
Sleep apnea.
Review of systems
Head symptoms: No headache and headache not present upon awakening. No sinus pain.
Otolaryngeal symptoms: No frequent breathing through the mouth, no hoarseness, and no choking.
Cardiovascular symptoms: No palpitations.
Pulmonary symptoms: No paroxysmal nocturnal dyspnea and no orthopnea.
Gastrointestinal symptoms: No heartburn and no nausea.
Genitourinary symptoms: No nocturia.
Endocrine symptoms: No temperature intolerance and no decreased libido. No inadequacy of penile erection.
Neurological symptoms: No transient limb paralysis with intense emotions (cataplexy).
Psychological symptoms: No nightmares.
review of systems [use for free text].
Physical findings
Vital signs:
• Weight was not within normal limits. • Patient was observed to be obese. • Body build was mesomorphic.
General appearance:
° Well-appearing. ° Awake. ° Alert. ° Oriented to time, place, and person. ° Not ill-appearing. ° Patient did not appear acutely
exhausted. ° Not poorly hydrated.
Head:
Cranial Bruit: ° No cranial bruit.
Examination Of Face: ° No micrognathia was observed.
Neck:
Appearance: • Neck circumference.
2019
Medical Record
2019
Eyes:
General/bilateral:
Pupils: ° PERRL.
Nose:
General/bilateral:
Nasal Discharge: ° No nasal discharge seen.
External Nasal Deformities: ° No external nose deformities.
Cavity: ° Nasal mucosa normal. ° Nasal turbinate normal.
Erythema: ° No nasal erythema was noted.
Edema: ° No nasal edema was noted.
Upper Airway:
° Flaring nasal alae were not observed. ° Mouth breathing was not seen. ° No stridor was observed.
Oral cavity:
Teeth: ° Showed no malocclusion.
Pharynx:
Oropharynx: • Mallampati class 4 airway Modified Mallampati Score: ° Uvula was not enlarged. ° Tonsils were enlarged
symmetrically.
Lymph Nodes:
° Anterior cervical lymph nodes were not enlarged.
Chest:
° Normal.
Lungs:
Jugular Venous Distention: ° JVD not increased.
Arterial Pulses: • Not normal.
Abdomen:
Visual Inspection: • Showed a scaphoid-shaped abdomen.
Neurological:
Speech: ° Voice was not hyponasal.
Objective
There were no barriers to learning. Patient's needs were assessed and patient education was provided. Verbal teaching on the risk
factors for sleep apnea, associated diseases, diagnostic evaluation, and treatment options. Conservative treatment options to
include sleep position modification and weight loss were recommended. Patient was strongly cautioned against driving while sleepy
or participating in other high risk activities until evaluation and treatment are completed. Patient verbalized understanding of the
condition and issues involved.
Drawing/Image Written by CARTER,KEVIN A @ 25 Jan 2012 1439 EST
2019
Medical Record
2019
Drawing/Image Written by CARTER,KEVIN A @ 25 Jan 2012 1439 EST
2019
Medical Record
2019
A/P Last updated by CARTER,KEVIN A @ 25 Jan 2012 1441 EST

1. SLEEP APNEA OBSTRUCTIVE: The patient was educated about OSA (epidemiology, causes, signs/symptoms, long-term
outcomes, risks of untreated OSA, and treatment options) and counseled to maintain an ideal body weight to reduce the severity of
the disease and related complications. The risks of alcohol and other sedatives were discussed. The patient was educated on
positional therapy. The patient was counseled to avoid driving while excessively sleepy.
Pt given f/u instructions and appt in 6 weeks. The patient should send in his CPAP smart card 4 weeks after receiving his CPAP and
at least 2 weeks prior to their first followup appointment.
Initiating and Rx a M series 510 Auto adjustable CPAP with setting of 4-14 cm H2O.
Patient will followup in 2 days for our group in CPAP clinic
Procedure(s): -Continuous Positive Airway Pressure Ventilation x 1
Consult(s): -Referred To: DURABLE MEDICAL EQUIPMENT (Routine) Specialty: Clinic: SOCIAL WORK Primary
Diagnosis: SLEEP APNEA OBSTRUCTIVE Ordered By: CARTER,KEVIN A Ordering Provider:
CARTER,KEVIN ALLEN
2. NONORGANIC SLEEP DISORDERS
Disposition Written by CARTER,KEVIN A @ 25 Jan 2012 1442 EST

Follow up: 2 day(s) in the INTERNAL MED SLEEP CLINIC clinic or sooner if there are problems.
Note Written by CARTER,KEVIN A @ 25 Jan 2012 1442 EST
2019
Medical Record
2019
_________________________________________________________________________________________________________
CHANGE HISTORY
The following A/P Note Was Overwritten by CARTER,KEVIN A @ 25 Jan 2012 1441 EST:
The A/P section was last updated by CARTER,KEVIN A @ 25 Jan 2012 1441 EST - see above.Previous Version of A/P section was entered/updated by
THORNBURG,BRADLEY W @ 25 Jan 2012 1421 EST.
The following SO Note Was Overwritten by CARTER,KEVIN A @ 25 Jan 2012 1433 EST:
SO Note Written by THORNBURG,BRADLEY W @ 25 Jan 2012 1421 EST
Chief complaint
The Chief Complaint is: F/u PSG.
Allergies
NKA.
2019
Medical Record
2019
Personal history
2019
Medical Record
2019
23 Jan 2012 at Martin ACH, Fort Benning, GA, ER by SCHMIDT, MELISSA KAY
Encounter ID: BENN-4768346 Primary Dx: VIRAL SYNDROME
Patient: WAITERS, TOMMIE Date: 23 Jan 2012 1226 EST Appt Type: EROOM
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: FAGA,MELISSA K
A/P Last Updated by FAGA,MELISSA K @ 23 Jan 2012 1311 EST

1. VIRAL SYNDROME
Disposition Last Updated by FAGA,MELISSA K @ 23 Jan 2012 1311 EST

Signed By FAGA, MELISSA K (Physician/Workstation) @ 23 Jan 2012 1311
Note Written by JOHNSON,VERONICA J @ 24 Jan 2012 1035 EST

ED DISCHARGE NOTE
2019
Medical Record
2019
2019
Medical Record
2019
KEVIN A
Encounter ID: BENN-4695148 Primary Dx: NONORGANIC SLEEP DISORDERS
Patient: WAITERS, TOMMIE Date: 12 Jan 2012 2030 EST Appt Type: PROC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: Internal Med Sleep Clinic Provider: CARTER, KEVIN A
SO Note Written by CARTER, KEVIN A @ 17 Jan 2012 0945 EST

Reason for Visit
Visit for: Sleep Testing. Referred by Sleep Medicine Clinic Staff.
Physical findings
Tests
Laboratory studies:
Sleep Testing:
A sleep study attended by a technologist and polysomnography with four or more additional sleep parameters was performed.
Lab AutoCites Refreshed by CARTER, KEVIN A @ 17 Jan 2012 0908 EST

Questionnaires
A/P Last Updated by CARTER, KEVIN A @ 17 Jan 2012 0947 EST

1. NONORGANIC SLEEP DISORDERS: see attached report.
Procedure(s): -Polysomnography With Four Or More Additional Sleep Parameter x 1
-Spec Dr. Serv Collect/Interp Of Physiol Data, Minim 30 Min x 1
-Pulse Oximetry With Continuous Overnight Monitoring x 1
Disposition Last Updated by CARTER, KEVIN A @ 17 Jan 2012 0947 EST

Note Written by THORNBURG, BRADLEY W @ 23 Jan 2012 0918 EST

Sleep Study Results
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019

Sleep Study Results
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019

Sleep Study Results
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
Note Written by THORNBURG,BRADLEY W @ 23 Jan 2012 0919 EST

Sleep Study Results
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
15 Dec 2011 at Martin ACH, Fort Benning, GA, Internal Med Sleep Clinic by CARTER,
KEVIN A
Encounter ID: BENN-4454228 Primary Dx: Snoring
Patient: WAITERS, TOMMIE Date: 15 Dec 2011 1000 EST Appt Type: SPEC
ALAJANDRO
Reason for Appointment: Snoring

Appointment Comments: Written by SAMPSON,LINDA M @ 15 Dec 2011 0708 EST
LMS/PER DR. CARTER BOOK AFTER 28DAY
Remind pt
AutoCites Refreshed by CARTER,KEVIN A @ 15 Dec 2011 1029 EST

Allergies
No Allergies Found.
Active Medications
25), Tablet, Oral
THAN 1 PER DAY
BOTTLE
Vitals
Vitals Written by THORNBURG,BRADLEY W @ 15 Dec 2011 1019 EST
BP: 142/82, HR: 66, RR: 18, HT: 66 in, WT: 212 lbs, SpO2: 98%, BMI: 34.22, BSA: 2.05 square meters
Comments: Neck: 17.5"
Questionnaire AutoCites Refreshed by CARTER,KEVIN A @ 15 Dec 2011 1029 EST

Questionnaires
SO Note Written by CARTER,KEVIN ALLEN @ 15 Dec 2011 1318 EST

Chief complaint
The Chief Complaint is: Trouble falling/staying asleep, snoring.
Reason for Visit
Visit for: 41 y.o. AD man with a long h/o snoring, nonrestorative sleep, waking up with a dry mouth, and EDS.
The Patient is a 41 year old male
He reported: Past medical history reviewed, medication list reviewed with patient, and family history reviewed with patient.
Military service.
Feeling tired or poorly and lethargy. Recent weight change. No recent weight loss. Recent 8 lbs weight gain.
No nasal discharge and no nasal passage blockage. Snoring loudly and has been witnessed. No throat pain.
Genitourinary symptoms was three.
No fainting followed by prolonged sleepiness. Confusion not occurring upon awakening and no transient limb weakness when
falling asleep or awakening (sleep paralysis). Restless movements during sleep. Involuntary movements during sleep without vivid
dream recall.
No anxiety, no persistent anxiety about insomnia, and depression not accompanied by sleeping more. Daytime somnolence.
Not suddenly falling asleep during the day and no initial insomnia. Middle-night awakening. No insomnia due to pain. Morning
grogginess and nonrestorative sleep. No sleep apnea.
2019
Medical Record
2019
No sinus pressure. No vision problems. No chest pain or discomfort. No dyspnea and no cough. No heartburn at night in
bed. No muscle weakness and no loss of hair from the head or body. The legs do not feel restless. No asthma nighttime
symptoms.
Allergies
NKA.
Current medication
Levitra, vicodin.
Reported History:
- medical history reviewed No recent change in medical history and no prior serious illness.
Reported medications: Medication history - medication list reviewed with patient to include OTC and herbal medications.
Medication reconciliation completed.
Diagnosis History:
Hypertension.
No asthma.
No morbid obesity.
Personal history
Behavioral history: No caffeine use. No tobacco use in the last 10 years. Not a current smoker.
Family history
Sleep apnea.
Review of systems
Head symptoms: No headache and headache not present upon awakening. No sinus pain.
Otolaryngeal symptoms: No frequent breathing through the mouth, no hoarseness, and no choking.
Endocrine symptoms: No temperature intolerance and no decreased libido. No inadequacy of penile erection.
Neurological symptoms: No transient limb paralysis with intense emotions (cataplexy).
Physical findings
Vital signs:
• Weight was not within normal limits. • Patient was observed to be obese. • Body build was mesomorphic.
General appearance:
° Well-appearing. ° Awake. ° Alert. ° Oriented to time, place, and person. ° Not ill-appearing. ° Patient did not appear acutely
exhausted. ° Not poorly hydrated.
Head:
Cranial Bruit: ° No cranial bruit.
Examination Of Face: ° No micrognathia was observed.
Neck:
Neck Appearance: Value
Neck circumference 17 in
Eyes:
General/bilateral:
Pupils: ° PERRL.
Nose:
General/bilateral:
Nasal Discharge: ° No nasal discharge seen.
External Nasal Deformities: ° No external nose deformities.
Cavity: ° Nasal mucosa normal. ° Nasal turbinate normal.
Erythema: ° No nasal erythema was noted.
Edema: ° No nasal edema was noted.
Upper Airway:
° Flaring nasal alae were not observed. ° Mouth breathing was not seen. ° No stridor was observed.
Oral cavity:
2019
Medical Record
2019
Teeth: ° Showed no malocclusion.

Pharynx:
Oropharynx: • Mallampati class 4 airway Modified Mallampati Score: ° Uvula was not enlarged. ° Tonsils were enlarged
symmetrically.
Lymph Nodes:
° Anterior cervical lymph nodes were not enlarged.
Chest:
° Normal.
Lungs:
Jugular Venous Distention: ° JVD not increased.
Arterial Pulses: • Not normal.
Abdomen:
Visual Inspection: • Showed a scaphoid-shaped abdomen.
Neurological:
Speech: ° Voice was not hyponasal.
Objective
Drawing/Image Written by CARTER,KEVIN A @ 15 Dec 2011 1322 EST
2019
Medical Record
2019
A/P Last updated by CARTER,KEVIN A @ 15 Dec 2011 1321 EST

1. Snoring: The patient has signs/symptoms consistent with Obstructive Sleep Apnea (OSA), sending for an overnight Diagnostic
Polysomnogram (Sleep Study), the patient will follow-up with me to review the results.
Moderate-High PTP for OSA. Pt will f/u with me to review the results. appt for PSG booked.
Patient Instruction(s): -Abstinence From Alcohol
-Anticipatory Guidance: Concerns About Sleeping
-Anticipatory Guidance: Sleeping Position
-Circadian System Adjustment By Light / Dark Exposure
-Duration Of Encounter - Coordination Of Care (___ min)
-Duration Of Encounter - Counseling (___ min)
-Goals General - Improve Quality of Life
-Lose Weight
2. NONORGANIC SLEEP DISORDERS: ensure a TST = 7-8 hrs/night.
Procedure(s): -Pulse Oximetry x 1
Disposition Written by CARTER,KEVIN A @ 15 Dec 2011 1322 EST

Note Written by BYRD,ANTONIO C @ 15 Dec 2011 0958 EST

Consult Order
2019
Medical Record
2019

Date of Request: 02 Nov 2011
Priority: Routine
Snoring
Reason for Request:
PLEASE EVALUATE AND TREAT. 41 Y/O ACTIVE DUTY SOLDIER WITH LOUD SNORING AND DAYTIME SOMNOLENCE.
Signed By CARTER, KEVIN A (Director, The Sleep Medicine Center, BMACH) @ 15 Dec 2011 1322
_________________________________________________________________________________________________________
CHANGE HISTORY
The following A/P Note Was Overwritten by CARTER,KEVIN A @ 15 Dec 2011 1321 EST:
The A/P section was last updated by CARTER,KEVIN A @ 15 Dec 2011 1321 EST - see above.Previous Version of A/P section was entered/updated by
THORNBURG,BRADLEY W @ 15 Dec 2011 1022 EST.
Procedure(s): -Pulse Oximetry x 1
The following SO Note Was Overwritten by CARTER,KEVIN A @ 15 Dec 2011 1030 EST:
SO Note Written by THORNBURG,BRADLEY W @ 15 Dec 2011 1020 EST
Chief complaint
Allergies
NKA.
Current medication
Levitra, vicodin.
Personal history
2019
Medical Record
2019
07 Nov 2011 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by MARTINEZ, HONEY
M
Encounter ID: BENN-4125083 Primary Dx: HYPOGONADISM
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC YELLOW CLINIC Provider: MARTINEZ,HONEY M
Reason for Telephone Consult: TESTOSTERON LEVEL LOW T
A/P Last Updated by ZAGORSKI,KIM J @ 08 Nov 2011 0852 EST

1. HYPOGONADISM
Disposition Last Updated by MARTINEZ,HONEY M @ 10 Nov 2011 0830 EST

Follow up: with PCM and/or in the FMC YELLOW CLINIC clinic. - Comments: asap
Note Written by ZAGORSKI,KIM J @ 08 Nov 2011 0850 EST

NURSING INSTRUCTION
PLEASE NOTIFY PATIENT OF LOW TRESTOSTERONE. HAVE PATIENT FOLLOW UP WITH PCM
FOR TREATMENT. KJZ
Note Written by MARTINEZ,HONEY M @ 10 Nov 2011 0828 EST

Left several voice messages with call back number, no response. Sent 4700 to home address requesting patient to schedule
appointment for low testosterone levels. HMM - RN
Signed By MARTINEZ, HONEY M (Registered Nurse, BMACH) @ 10 Nov 2011 0830

_________________________________________________________________________________________________________
CHANGE HISTORY
The following Disposition Note Was Overwritten by MARTINEZ,HONEY M @ 10 Nov 2011 0828 EST:
The Disposition section was last updated by MARTINEZ,HONEY M @ 10 Nov 2011 0828 EST - see above.Previous Version of Disposition section was entered/updated by
ZAGORSKI,KIM J @ 08 Nov 2011 0852 EST.
2019
Medical Record
2019
03 Nov 2011 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J
ALAJANDRO
Reason for Telephone Consult: LABORATORY
AutoCites Refreshed by ZAGORSKI,KIM J @ 03 Nov 2011 0934 EST

Chronic: Loading... No Allergies Found.
• Overweight
• Hypertension
• Hypogonadism
• Astigmatism
• Lumbago
remission
mood
• Hypermetropia
depression
exam
• Body mass index
• Visit for: administrative purposes
• Abdominal pain
• Cervicalgia
• Folliculitis
• Backache
Acute:
• Normal routine history and physical
Active Medications
2019
Medical Record
2019

25), Tablet, Oral
THAN 1 PER DAY
BOTTLE
Lab Result Cited by ZAGORSKI,KIM J @ 03 Nov 2011 0959 EST

A/P Written by ZAGORSKI,KIM J @ 03 Nov 2011 1001 EST

1. visit for: administrative purpose: LABS REVIEWED.
2. HYPERLIPIDEMIA: DISCUSSED REFERRAL FOR LOW FAT DIET AND WEIGHT LOSS. FOLLOW UP 2 MONTHS.
Consult(s): -Referred To: NUTRITION CONSULT (Routine) Specialty: Clinic: NUTRITION Primary Diagnosis:
HYPERLIPIDEMIA Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI,KIM JOSEPH
Disposition Written by ZAGORSKI,KIM J @ 03 Nov 2011 1001 EST

Signed By ZAGORSKI, KIM J (Physician/Workstation) @ 03 Nov 2011 1001
2019
Medical Record
2019
02 Nov 2011 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J
Encounter ID: BENN-4074574 Primary Dx: ROUTINE HISTORY AND PHYSICAL
Patient: WAITERS, TOMMIE Date: 02 Nov 2011 1120 EST Appt Type: WELL
ALAJANDRO
Reason for Appointment: ZAGORSKI. 5YR MALE PHYSICAL

YNE
AutoCites Refreshed by ZAGORSKI,KIM J @ 02 Nov 2011 1147 EST

• Astigmatism • Of heart disease
• Male erectile disorder • No Family History of angina pectoris
• Snoring was observed • Of cancer
• Visit for: vasectomy status • Family history [use for free text]
• LUQ abdominal pain • No Family History of mental illness (not
• Lumbago retardation)
• Observation for suspected condition • No Family History of alcoholism
• Recurrent major depression in partial • No Family History of malignant neoplasm
remission of the large intestine
• Adjustment disorder with depressed • Arteriosclerotic cardiovascular disease
mood (ASCVD) (Mother)
• Hypermetropia • Type 2 diabetes mellitus (Father)
depression
exam
• Body mass index
• Abdominal pain
• Cervicalgia
• Folliculitis
• Backache
Active Medications
THAN 1 PER DAY
2019
Medical Record
2019
BOTTLE
Screening Written by HOLLIS,GEORGE S @ 02 Nov 2011 1136 EST

Reason For Appointment: ZAGORSKI. 5YR MALE PHYSICAL
Allergen information verified by HOLLIS, GEORGE S @ 02 Nov 2011 1136 EDT
Vitals
Vitals Written by HOLLIS,GEORGE S @ 02 Nov 2011 1136 EDT
in Stated, Without Shoes,
WT: 220.2 lbs Upright Scale, Actual, Without Shoes, SpO2: 100%, BMI: 35.54, BSA: 2.084 square meters
SO Note Written by ZAGORSKI,KIM JOSEPH @ 02 Nov 2011 1205 EST

Chief complaint
The Chief Complaint is: Complete Physical with Labs.
41 Y/O AAM PRESENTS FOR PHYSICAL.
General overall feeling - Very Good. Not feeling tired (fatigue).
Snoring.
No depression Screen: Negative PHQ-2 (Score < 3). Daytime somnolence.
PSC-21: having trouble sleeping, RAISING THREE CHILDREN SINGLE PARENT, STUDIES LATE FOR COLLEGE.
PROBABLY GETTING < SIX HOURS A NIGHT.
No military service . PHA in last year? <Yes Date: > <No>, visit is not deployment-related, and no military duty-related
information - (Not on PRP/SCI/PSP).
Severe Lower Back Pain and Headache x 3 weeks.
Dr. Zagorski, Kim J.
Allergies
NKDA.
Current medication
Reported History:
OVERWEIGHT.
APPENDECTOMY
T#3/darvocet
irritants.
Personal history
Family of 5
3 children
.
[ ]Other (Specify):
2019
Medical Record
2019

.
Family history
father- DM.
Review of systems
Systemic symptoms: No fever, no chills, no night sweats, and no recent weight loss.
Head symptoms: No headache.
Neck symptoms: No swollen glands in the neck.
Otolaryngeal symptoms: No earache, no nasal discharge, no nasal passage blockage, and no sore throat.
Pulmonary symptoms: No dyspnea and no cough.
Gastrointestinal symptoms: Appetite not decreased. No nausea, no vomiting, no abdominal pain, no bright red blood per rectum,
no diarrhea, and no constipation.
Genitourinary symptoms: No hematuria, no change in urinary frequency, and no feelings of urinary urgency. No dysuria and no
pain in the flank.
Endocrine symptoms: No polydipsia and no temperature intolerance.
Musculoskeletal symptoms: No back pain.
Neurological symptoms: No dizziness, no lightheadedness, no motor disturbances, and no sensory disturbances.
Physical findings
Vital signs:
• Temperature: Reviewed. • RR: Reviewed. • PR: Reviewed. • Blood pressure: Reviewed LAST SEVERAL BPs ALL
ELEVATED. DISCUSSED TREATMENT.
.
General appearance:
Neck:
Eyes:
General/bilateral:
Pupils: ° PERRL.
Sclera: ° Normal.
Optic Disc: ° Normal.
Ears:
General/bilateral:
Nose:
General/bilateral:
Pharynx:
Lymph Nodes:
were not enlarged.
Lungs:
Abdomen:
Palpation: ° No abdominal tenderness. ° No mass was palpated in the abdomen.
Hepatic Findings: ° Liver was normal to palpation.
Splenic Findings: ° Spleen was normal to palpation.
Genitalia:
Penis: ° Normal.
Testes: ° Normal.
Rectal Exam:
2019
Medical Record
2019
Anus: ° Anal sphincter tone was normal. ° No hemorrhoids were seen.

Rectum: ° Normal. ° Had no mass.
Prostate: ° Normal (on digital exam).
General/bilateral: ° Normal movement of all extremities.
Other Findings:
General/bilateral: ° No muscle tenderness was seen.
Neurological:
Motor: ° Strength was normal.
Balance: ° Normal.
Psychiatric Exam:
Mood: ° Euthymic.
Affect: ° Normal.

Hemoglobin A1c Panel Site/Specimen 02 Nov 2011 1307
Hemoglobin A1c BLOOD 5.0 
Estimated Average Glucose BLOOD 98 

Potassium Site/Specimen 02 Nov 2011 1307


Prostate Specific Ag Site/Specimen 02 Nov 2011 1307
Prostate Specific Ag SERUM 1.02 
A/P Written by ZAGORSKI,KIM J @ 02 Nov 2011 1237 EST

1. NORMAL ROUTINE HISTORY AND PHYSICAL
Laboratory(ies): -PROSTATE SPECIFIC AG (Routine) Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI,
KIM JOSEPH; LIPIDS (Routine) Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM
JOSEPH; HEMOGLOBIN A1C PANEL (Routine) Ordered By: ZAGORSKI,KIM J Ordering Provider:
ZAGORSKI, KIM JOSEPH; POTASSIUM (Routine) Ordered By: ZAGORSKI,KIM J Ordering Provider:
ZAGORSKI, KIM JOSEPH
2. HYPERTENSION (SYSTEMIC)
Medication(s): -MAXZIDE 25 (OR SUBST)37.5/25--PO TAB - 1 PO DAILY #90 RF1 Qt: 90 Rf: 1 Ordered By:
Patient Instruction(s): -Regular Exercise
-Lose Weight
-Low Sodium Diet
3. OVERWEIGHT: WEIGHT / BMI DISCUSSED. RECOMMENDED REGULAR WALKING PROGRAM BUILDING DISTANCE AND
INTENSITY OVER SIX WEEKS. DECREASING PORTION SIZES, RED MEATS, FAT, JUNK FOOD AND ALCOHOL.
DISCUSSED HOLDING BACK WHITE BREAD, PASTA, RICE AND POTATOES. DO NOT SKIP MEALS. MORE FRUITS AND
VEGITABLES. DISCUSSED CALORIES EVEN IN HEALTHY FOODS, NUTS, FRUITS, TRAIM MIX, GRANOLA.
Consult(s): -Referred To: NUTRITION CONSULT (Routine) Specialty: Clinic: NUTRITION Primary Diagnosis:
OVERWEIGHT
Patient Instruction(s): -Weight Loss Diet
4. HYPOGONADISM
Medication(s): -TESTOSTERONE (ANDROGEL-1%)1.25G GEL PUMP - 1 PULMP EACH ARM DAILY #2 RF5 Qt: 2
Rf: 5 Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH
Laboratory(ies): -TESTOSTERONE (Routine) Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM
2019
Medical Record
2019
JOSEPH
5. Snoring: RECONSULT SLEEP STUDY PATIENT CANCELLED INITIAL CONSULT ON 17 MAR 2011
Consult(s): -Referred To: SLEEP STUDY MTF (Routine) Specialty: Clinic: INTERNAL MED SLEEP CLINIC
Primary Diagnosis: Snoring Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI,KIM
JOSEPH
Disposition Written by ZAGORSKI,KIM J @ 02 Nov 2011 1237 EST

Follow up: as needed . - Comments:
Signed By ZAGORSKI, KIM J (Physician/Workstation) @ 02 Nov 2011 1708

_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by ZAGORSKI,KIM J @ 02 Nov 2011 1205 EST:
SO Note Written by HOLLIS,GEORGE S @ 02 Nov 2011 1139 EST
Chief complaint
The Chief Complaint is: Complete Physical with Labs.
He reported: Medication list reviewed with patient, reconciliation completed, and list given to patient.
General overall feeling - Very Good.
No military service . PHA in last year? <Yes Date: > <No> and visit is not deployment-related.
Dr. Zagorski, Kim J.
Severe Lower Back Pain and Headache x 3 weeks.
Allergies
NKDA.
Current medication
Reported History:
Medical: Reported medical history none.
Surgical / procedural: Surgical / procedural history Appendectomy
Cyst removed from rt wrist.
T#3/darvocet
Personal history
Family of 5
3 children
Alcohol: No consumption of alcohol. Not using alcohol Screening Date: 2 nOVEMBER 2011.
.
.
Family history
father- DM
2019
Medical Record
2019
12 Oct 2011 at Martin ACH, Fort Benning, GA, ER by REEDY, GARY W
Encounter ID: BENN-3763853 Primary Dx: BACKACHE
Patient: WAITERS, TOMMIE Date: 12 Oct 2011 2232 EDT Appt Type: EROOM
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: REEDY, JR,GARY W
SO Note Written by REEDY, JR,GARY W @ 13 Oct 2011 0542 EDT

Subjective
The scanned images are a scanned version of part of the medical record from this Emergency Department visit, provided to
facilitate follow-up care. Due to current space restraints, this is not the complete medical record. The remainder of the scanned
record can be found in the Clinical Notes module. If the complete medical record is required, or the scanned document is not
visible, please consult the hard copy in the outpatient record.
A/P Last Updated by REEDY,GARY W @ 13 Oct 2011 0543 EDT

1. BACKACHE
Disposition Last Updated by REEDY,GARY W @ 13 Oct 2011 0543 EDT

Signed By REEDY, JR,GARY W (Physician Assistant, Dept of Emergency Medicine) @ 13 Oct 2011 0544
Note Written by JOHNSON,VERONICA J @ 13 Oct 2011 1255 EDT

ED DISCHARGE NOTE
2019
Medical Record
2019
2019
Medical Record
2019
13 May 2011 at Martin ACH, Fort Benning, GA, ER by REEDY, GARY W
Encounter ID: BENN-2333355 Primary Dx: ABRASION OR FRICTION BURN
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: REEDY,GARY W
SO Note Written by REEDY,GARY W @ 14 May 2011 0328 EDT

Subjective
A/P Last Updated by REEDY,GARY W @ 14 May 2011 0329 EDT

1. ABRASION OR FRICTION BURN
Disposition Last Updated by REEDY,GARY W @ 14 May 2011 0329 EDT

Signed By REEDY, GARY W (Physician Assistant, Dept of Emergency Medicine) @ 14 May 2011 0329
Note Written by JONES,MELVIN J @ 14 May 2011 1711 EDT

ED DISCHARGE NOTE
2019
Medical Record
2019
2019
Medical Record
2019
24 Feb 2011 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J
Encounter ID: BENN-1103967 Primary Dx: HYPOGONADISM
ALAJANDRO
Reason for Appointment: Zazorgski- f/u on testosterom

jhm
Vitals
Vitals Written by KELLIERROBERTS,KEREAN P @ 24 Feb 2011 1542 EST
BP: 134/85, HR: 103, RR: 20, T: 98.2 °F, HT: 66 in, WT: 211.8 lbs, SpO2: 98%, BMI: 34.18,
SO Note Written by ZAGORSKI,KIM JOSEPH @ 24 Feb 2011 1557 EST

Chief complaint
The Chief Complaint is: F/U for testastorone.
FOLLOW UP TESTOSTERONE LEVEL, ABNORMALLY LOW 207. ERECTILE DYSFUNCTION, TREAT TODAY.
2) SLEEP STUDY FOR SNORING, DAYTIME SOMNOLENCE, SCHEDULED FOR 17 MAR 2011.
3) HIV FOR FORCE TESTING, NEGATIVE.
General overall feeling - Good
. Feeling tired (fatigue).
Snoring.
No depression Screen: Negative PHQ-2 (Score < 3). Daytime somnolence and middle-night awakening with a sore throat
AND DAYTIME / AM.
PSC-21: having trouble sleeping, RAISING THREE CHILDREN SINGLE PARENT, STUDIES LATE FOR COLLEGE.
PROBABLY GETTING < SIX HOURS A NIGHT.
No military duty-related information - (Not on PRP/SCI/PSP).
Allergies
NKDA.
NKDA.
Reported History:
Medical: Reported medical history none. Reported medical history none.
Surgical / procedural: Surgical / procedural history Appendectomy
Cyst removed from rt wrist. Surgical / procedural history appy 1991.
T#3/darvocet
( ) Herbals ( )Weight Loss Meds. Medication history: ( ) No Medications
(x ) Current Medications Reviewed and Reconciled
( ) Herbals ( )Weight Loss Meds.
irritants.
Personal history
Behavioral history: Never a smoker / Never Used Tobacco Products.
Alcohol: No consumption of alcohol.
.
History
[ ]Other (Specify):
2019
Medical Record
2019
.
Family history
father- DM.
Review of systems
Military service: Visit is not deployment-related Location: Date:
Systemic symptoms: No fever and no chills.
Pulmonary symptoms: No dyspnea and no paroxysmal nocturnal dyspnea.
Endocrine symptoms: No polydipsia.
Neurological symptoms: No lightheadedness and no fainting.
Psychological symptoms: Ability to communicate effectively - No Learning Disablility, Language Barrier or Learning Barrier was
Identified.
Physical findings
Vital signs:
• Blood pressure: Reviewed FOLLOW UP 4 WEEKS. ° Normal temperature: Reviewed. ° RR was normal: Reviewed. ° PR
was normal: Reviewed.
General appearance:
° Alert. ° Oriented to time, place, and person. ° Well developed. ° Well nourished. ° In no acute distress. ° Not acutely ill.
Neck:
Suppleness: ° Neck demonstrated no decrease in suppleness.
Eyes:
General/bilateral:
Pupils: ° PERRL.
Pharynx:
Oropharynx: • Mallampati class 3 airway.
Lungs:
Heart Sounds: ° S2 normal.
Genitalia:
Penis: ° Had been circumcised. ° Not swollen. ° Showed no lesion(s).
Scrotum: ° Not tender. ° Not edematous. ° Did not demonstrate a varicocele.
Testes: ° No tenderness. ° No swelling. ° No mass.
Psychiatric Exam:
Mood: ° Euthymic.
Affect: ° Normal.
Lab Result Cited by ZAGORSKI,KIM J @ 24 Feb 2011 1547 EST

Testosterone Site/Specimen 09 Feb 2011 0937
Testosterone SERUM 207.4 (L)
Lab Result Cited by ZAGORSKI,KIM J @ 24 Feb 2011 1547 EST

HIV-1/O/2 Ab Site/Specimen 09 Feb 2011 0937
HIV-1/O/2 Ab SERUM NEGATIVE 
A/P Written by ZAGORSKI,KIM J @ 24 Feb 2011 1557 EST

1. HYPOGONADISM
Medication(s): -TESTOSTERONE (ANDROGEL-1%)1.25G GEL PUMP - 1 PUMP EACH UPPER ARM / BODY DAILY
#1 RF5 Qt: 1 Rf: 5 Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH
Medication(s): -VARDENAFIL (LEVITRA) 20MG--PO 20MG TAB - T 1 TB 60 MINUTES PRIOR TO INTERCOURSE;
NO MORE THAN 1 PER DAY #6 RF11 Qt: 6 Rf: 11 Ordered By: ZAGORSKI,KIM J Ordering Provider:
ZAGORSKI, KIM JOSEPH
3. Snoring: SLEEP STUDY SCHEDULED FOR 17 MAR 2011
2019
Medical Record
2019
Disposition Written by ZAGORSKI,KIM J @ 24 Feb 2011 1604 EST

Signed By ZAGORSKI, KIM J (Physician, Martin ACH, Fort Benning, GA) @ 24 Feb 2011 1604
_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by ZAGORSKI,KIM J @ 24 Feb 2011 1557 EST:
SO Note Written by KELLIERROBERTS,KEREAN P @ 24 Feb 2011 1539 EST
Chief complaint
The Chief Complaint is: F/U for testastorone.
He reported: General overall feeling - Excellent / Very Good / Good
.
No depression Screen: Negative PHQ-2 (Score < 3).
Allergies
NKDA.
NKDA.
Reported History:
Medical: Reported medical history none. Reported medical history none.
Surgical / procedural: Surgical / procedural history appy 1991. Surgical / procedural history Appendectomy
Cyst removed from rt wrist.
( ) Herbals ( )Weight Loss Meds. Medication history: ( ) No Medications
T#3/darvocet
Personal history
.
History
.
Family history
father- DM.
Review of systems
Psychological symptoms: Ability to communicate effectively - No Learning Disablility, Language Barrier or Learning Barrier was Identified.
The following Vitals Entry Was Overwritten by KELLIERROBERTS,KEREAN P @ 24 Feb 2011 1542 EST:
Vitals Written by KELLIERROBERTS,KEREAN P @ 24 Feb 2011 1542 EST
BP: 134/85, HR: 103, RR: 20, T: 98.2 °F, HT: 66 in, WT: 211.8 lbs, BMI: 34.18, BSA: 2.049 square meters
2019
Medical Record
2019
10 Feb 2011 at Martin ACH, Fort Benning, GA, Optometry by COSTALES, CESAR A
REFRACTIVE ERROR -
HYPERMETROPIA
Patient: WAITERS, TOMMIE Date: 10 Feb 2011 0900 EST Appt Type: SPEC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: OPTOMETRY Provider: COSTALES,CESAR A
Reason for Appointment: ROUTINE EYE EXAM 706 326 4585

AJJ
AutoCites Refreshed by COSTALES,CESAR A @ 10 Feb 2011 0904 EST

Chronic: • Family medical history (General FHx) • No Known Allergies
• Visit for: vasectomy status • Of heart disease
• LUQ abdominal pain • No Family History of angina pectoris
• Lumbago • Of cancer
• Observation for suspected condition • Family history [use for free text]
• Recurrent major depression in partial • No Family History of mental illness (not
remission retardation)
• Adjustment disorder with depressed • No Family History of alcoholism
mood • No Family History of malignant neoplasm
• Hypermetropia of the large intestine
• Generalized anxiety disorder • Arteriosclerotic cardiovascular disease
• Moderate single episode major (ASCVD) (Mother)
depression • Type 2 diabetes mellitus (Father)
exam
• Body mass index
• Abdominal pain
• Cervicalgia
• Folliculitis
• Backache
Acute:
Active Medications
Fexofenadine Hydrochloride 60mg + Active T1 TAB PO Q12H NR 09 Feb
Pseudoephedrine Hydrochloride 120mg, 2011
Extended release tablet, Oral
Omeprazole 20mg, Extended release Active CD 11 of 11 18 Sep
capsule, Oral 2010
2019
Medical Record
2019

BOTTLE
A/P Last Updated by COSTALES,CESAR A @ 10 Feb 2011 0935 EST

1. REFRACTIVE ERROR - HYPERMETROPIA
Procedure(s): -Ophthalmological New Patient Start Comprehensive Care x 1
-Spectacles Services Fitting Monofocals (Not For Aphakia) x 1
2. ASTIGMATISM
Disposition Last Updated by COSTALES,CESAR A @ 10 Feb 2011 0935 EST

Follow up: 12 month(s) in the OPTOMETRY clinic or sooner if there are problems.
Note Written by PAUGH,SUZANNE M @ 10 Feb 2011 1355 EST
2019
Medical Record
2019
Signed By COSTALES, CESAR A (CPT, OD, Optometrist, Ft. Benning) @ 10 Feb 2011 1453
2019
Medical Record
2019
09 Feb 2011 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J
Encounter ID: BENN-884811 Primary Dx: Snoring
ALAJANDRO
Reason for Appointment: pcm zagorski- personal- (zagorski)

sid
Vitals
Vitals Written by FLETCHER,LITITIA K @ 09 Feb 2011 0913 EST
SO Note Written by ZAGORSKI,KIM JOSEPH @ 09 Feb 2011 0935 EST

Chief complaint
The Chief Complaint is: Personal.
SEVERAL REQUESTS TODAY
1) SORE THROAT, SNORING, DAYTIME SOMNOLENCE
2) HIV FOR FORCE TESTING
3) ERECTILE DYSFUNCTION, DESIRE AND LIBIDO INTACT.
General overall feeling -Very Good
and feeling tired (fatigue).
Nasal passage blockage. Snoring and sore throat.
No depression Screen: Negative PHQ-2 (Score < 3). Daytime somnolence and middle-night awakening with a sore throat
AND DAYTIME / AM.
No military duty-related information - (Not on PRP/SCI/PSP). No cough.
Allergies
NKDA.
Reported History:
Surgical / procedural: Surgical / procedural history appy 1991.
T#3/darvocet
irritants.
Personal history
Family history
father- DM.
Review of systems
Head symptoms: No sinus pain.
Otolaryngeal symptoms: No earache.
Pulmonary symptoms: No dyspnea and no paroxysmal nocturnal dyspnea.
Gastrointestinal symptoms: No nausea. No vomiting.
Endocrine symptoms: No polydipsia.
Neurological symptoms: No lightheadedness and no fainting.
Psychological symptoms: Ability to communicate effectively - No Learning Disablility, Language Barrier or Learning Barrier was
2019
Medical Record
2019
Identified.
Physical findings
Vital signs:
• Blood pressure: Reviewed. ° Normal temperature: Reviewed. ° RR was normal: Reviewed. ° PR was normal: Reviewed.
General appearance:
° Alert. ° Oriented to time, place, and person. ° Well developed. ° Well nourished. ° In no acute distress. ° Not acutely ill.
Neck:
Eyes:
General/bilateral:
Pupils: ° PERRL.
External Eye: ° No hyperemia of the conjunctiva. ° No discharge from the conjunctiva.
Sclera: ° Normal.
Ears:
Right ear:
Left ear:
Nose:
General/bilateral:
Nasal Discharge: • Seen.
Cavity: • Nasal mucosa edematous. ° Nasal mucosa no crusts/sores.
Oral cavity:
Pharynx:
Oropharynx: • Mallampati class 3 airway. • Posterior pharyngeal wall was erythematous. ° Tonsils were not inflamed.
° Tonsils showed no exudate.
Mucosal Findings: ° Pharynx had no exudate. ° Pharynx did not have a lesion.
Lymph Nodes:
° Cervical lymph nodes were not enlarged. ° Submandibular lymph nodes were not enlarged.
Lungs:
Heart Sounds: ° S2 normal.
Psychiatric Exam:
Mood: ° Euthymic.
Affect: ° Normal.
A/P Written by ZAGORSKI,KIM J @ 09 Feb 2011 0941 EST

1. Snoring
Consult(s): -Referred To: SLEEP STUDY MTF (Routine) Specialty: Clinic: INTERNAL MED BENN Primary
Diagnosis: Snoring
2. RHINITIS
Medication(s): -P-EPHED/FEXO (ALLEGRA-D 12HR)--PO 120/60 - 1 PO Q 12 HRS FOR 10 DAYS #10 RF0 Qt: 10
Rf: 0 Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH
3. Laboratory Studies: FORCE TESTING
Laboratory(ies): -HIV-1/O/2 (Routine) Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM JOSEPH
Laboratory(ies): -TESTOSTERONE (Routine) Ordered By: ZAGORSKI,KIM J Ordering Provider: ZAGORSKI, KIM
JOSEPH
5. Blood Pressure Isolated Elevated: MONITOR
Disposition Written by ZAGORSKI,KIM J @ 09 Feb 2011 0941 EST

2019
Medical Record
2019
Signed By ZAGORSKI, KIM J (Physician, Martin ACH, Fort Benning, GA) @ 09 Feb 2011 0941
_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by ZAGORSKI,KIM J @ 09 Feb 2011 0935 EST:
SO Note Written by FLETCHER,LITITIA K @ 09 Feb 2011 0909 EST
Chief complaint
The Chief Complaint is: Personal.
He reported: General overall feeling - Excellent / Very Good / Good
.
No military duty-related information - (Not on PRP/SCI/PSP). No depression Screen: Negative PHQ-2 (Score < 3).
Allergies
NKDA.
Reported History:
T#3/darvocet
Personal history
Family history
father- DM.
Review of systems
Psychological symptoms: Ability to communicate effectively - No Learning Disablility, Language Barrier or Learning Barrier was Identified.
2019
Medical Record
2019
15 Nov 2010 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by ADAMS, JOSHUA
A
Encounter ID: BENN-485010 Primary Dx: Visit for: vasectomy status
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC SPECIALTY CLINIC Provider: ADAMS,JOSHUA A
Reason for Appointment: pre op vas

rrl
AutoCites Refreshed by ADAMS,JOSHUA A @ 15 Nov 2010 1547 EST

Allergies
• No Known Allergies
Vitals
Vitals Written by FLETCHER,LITITIA K @ 15 Nov 2010 1514 EST
HT: 66 in, WT: 228.4 lbs, BMI: 36.86, BSA: 2.116 square meters
Vitals Written by FLETCHER,LITITIA K @ 15 Nov 2010 1513 EST
BP: 144/81, HR: 91, RR: 20, T: 97.4 °F
SO Note Written by ADAMS,JOSHUA A @ 15 Nov 2010 1617 EST

Chief complaint
Reason for Visit
Visit for: examination and counseling for Vasectomy.
He reported: Patient not accompanied by wife.
Undesired fertility: No more children desired by patient and spouse.
No previous history of inguinal pain.
Reported History:
Reported medications: Not taking aspirin.
Physical trauma: No trauma to the genital region.
Diagnosis History:
No hypertension.
No unspecified psychoactive substance dependence.
No depression
No inhibited sexual excitement
No male erectile disorder.
No mumps
No venereal disease.
No adverse reaction to anesthesia
Therapeutic History:
No hernia repair
Personal history
Family: Family social history Number of children:4.
Sexual: Birth control method.
Family history
No bleeding problems.
Physical findings
Abdomen:
Hernia: ° No inguinal hernia was discovered.
Genitalia:
Penis: ° Normal.
Scrotum: ° Normal. ° Did not demonstrate a hydrocele. ° Did not demonstrate a varicocele.
2019
Medical Record
2019
Testes: ° Normal.
Vas Deferens / Spermatic Cord: ° Vas deferens/spermatic cord was palpable bilaterally.
Therapy
• General goals: Patient understands goal is permenent sterility. While reversal procedures are available, they are more
extensive surgeries and have a high failure rate.
• Risks, benefits, and limitations discussed and understood - patient wishes to proceed: Alternative contraceptive choices
discussed. Patient understands that this is a PERMANENT procedure.
• Pre-op visit nurse's checklist: a consent form was signed for the procedure.
• Pre-procedure teaching: Discussed with patient nature of the procedure, and the expected course of recovery
• Pre-op teaching about the administration of medications for anesthesia and pre-procedure
Discussed
: Discussed with patient the risks of procedure to include (but not limited to) bleeding, infection, pain, hematoma, sperm granuloma,
chronic groin pain, vasectomy failure, and loss of testicle.
A/P Written by ADAMS,JOSHUA A @ 15 Nov 2010 1619 EST

1. visit for: vasectomy status: 40 yo male desires sterility. Pt good candidate. We discussed risks/benefits as described above.
He accepts risks and signed informed consent. Is not available this friday for vasectomy so will try and reschedule later in the
month. Percocet/valium written for to take prior to procedure. 706-326-4585.
Medication(s): -DIAZEPAM (VALIUM)--PO 10MG TAB - TAKE ONE TAB PRIOR TO VASECTOMY #1 RF0 Qt: 1 Rf: 0
-PERCOCET 5/325--PO TAB - TAKE 2 TABS PRIOR TO VASECTOMY AND THEN 1-2 TABS EVERY
4-6 HRS FOR PAIN POST OP #15 RF0 Qt: 15 Rf: 0
Disposition Written by ADAMS,JOSHUA A @ 15 Nov 2010 1619 EST

Signed By ADAMS, JOSHUA A (MD, PGY2) @ 15 Nov 2010 1619

_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by ADAMS,JOSHUA A @ 15 Nov 2010 1617 EST:
SO Note Written by FLETCHER,LITITIA K @ 15 Nov 2010 1514 EST
Chief complaint
2019
Medical Record
2019
03 Nov 2010 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by MISTRETTA,
PATRICIA W
Encounter ID: BENN-463751 Primary Dx: X-Ray
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC YELLOW CLINIC Provider: MISTRETTA,PATRICIA W
Reason for Telephone Consult: abd US result
AutoCites Refreshed by MISTRETTA,PATRICIA W @ 03 Nov 2010 0829 EST

Allergies
Rad Result Cited by MISTRETTA,PATRICIA W @ 03 Nov 2010 0830 EST

********** US ABDOMEN-3 STUDIES **********
Status: Complete
Procedure: US ABDOMEN-3 STUDIES

Event Date: 04-Oct-2010 10:56:00
Reason for Order:
yo AD soldier with epigastric/LUQ pain x 2 weeks with nausea- CT scan 27
Sept at
Ft Jackson showed pancreatitis- lipase/amylase slightly elevated last
week-
normal today- pt still with pain- pleae
s eval with US the gallbaldder and gall bladder duct /pancreas
Exam #: 10085295
Provider: MISTRETTA, PATRICIA W
FMC YELLOW CLINIC MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Report Text:
Abdomen ultrasound:
The body of the pancreas measures within normal limits. The head and
detail of
the pancreas could not be visualized due to overlying gas. The left lobe
liver
appears homogeneous. The right lobe liver also appears homogeneous and
2019
Medical Record
2019
reveal no
mass lesion. There is mild diffuse increase in the resistive liver
suspicious of
low-grade of diffuse fatty infiltrate. The liver span is 13 cm. The
common bile
duct measures 4.2 mm in diameter. This is within normal limits. The
gallbladder
appears unremarkable. The right kidney measures 10.2 cm in length and 4.4
cm in
AP diameter. The left kidney appears unremarkable as well and measures
11.3 x
4.9 cm. The spleen is not enlarged.
IMPRESSION:
Probably Mild diffuse fatty infiltrated in the liver otherwise negative

study.
A/P Written by MISTRETTA,PATRICIA W @ 03 Nov 2010 0831 EST

1. X-Ray: letter sent to pt requesting he followup with Dr Zagorski in FMC
Disposition Written by MISTRETTA,PATRICIA W @ 03 Nov 2010 0831 EST

Signed By MISTRETTA, PATRICIA W (Physician/Workstation) @ 03 Nov 2010 0832
2019
Medical Record
2019
26 Oct 2010 at Martin ACH, Fort Benning, GA, Gastroenterology Clinic by SIDDIQUI,
DABIR A
Patient: WAITERS, TOMMIE Date: 26 Oct 2010 1345 EDT Appt Type: SPEC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: GASTROENTEROLOGY CLINIC Provider: SIDDIQUI,DABIR A
Reason for Appointment: Abdominal Pain(training S Carolina will was not able to make next day appt)
acb,con/track talked with patient
Note Written by SIDDIQUI,DABIR A @ 28 Oct 2010 0850 EDT

Consult Order
Referring Provider: RANDALL, WILLIAM L
Date of Request: 26 Sep 2010
Priority: 72 Hours
Abdominal Pain
Reason for Request:
40 y/o AA male with peri-umbilical pain for ten days. Recurrent for twoyears.pt phone # 706-326-4585

Encounter Cancelled by SIDDIQUI,DABIR A @ 28 Oct 2010 1219 EDT
2019
Medical Record
2019
18 Oct 2010 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by MISTRETTA,
PATRICIA W
Encounter ID: BENN-424663 Primary Dx: X-Ray
Patient: WAITERS, TOMMIE Date: 18 Oct 2010 0910 EDT Appt Type: T-CON*
ALAJANDRO
Reason for Telephone Consult: re- order US
AutoCites Refreshed by JOYCE,MARK T @ 18 Oct 2010 0910 EDT

Allergies
A/P Last Updated by JOYCE,MARK T @ 18 Oct 2010 0919 EDT

1. X-Ray
Radiology(ies): -US ABDOMEN-3 STUDIES (ASAP) Ordered By: JOYCE,MARK T Ordering Provider: MISTRETTA,
PATRICIA W Impression: RESUBMITTEDslightly elevated last week- normal today- pt still with pain-
pleae
Disposition Written by MISTRETTA,PATRICIA W @ 20 Oct 2010 0820 EDT

Signed By MISTRETTA, PATRICIA W (Physician/Workstation) @ 20 Oct 2010 0820
2019
Medical Record
2019
18 Oct 2010 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by LEE, RACHEL R
Encounter ID: BENN-424603 Primary Dx: Visit for: sterilization
Patient: WAITERS, TOMMIE Date: 18 Oct 2010 0900 EDT Appt Type: T-CON*
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC SPECIALTY CLINIC Provider: LEE,RACHEL R
Reason for Telephone Consult: pt wants vasectomy
A/P Last Updated by LEE,RACHEL R @ 27 Oct 2010 1303 EDT

1. visit for: sterilization
Disposition Last Updated by LEE,RACHEL R @ 27 Oct 2010 1304 EDT
Note Written by LEE,RACHEL R @ 25 Oct 2010 1149 EDT

Attempted to call pt. Phone was not able to accept messages. Will attempt to call later.
Note Written by LEE,RACHEL R @ 27 Oct 2010 1302 EDT
Spoke with pt. Vasectomy was scheduled on 19Nov2010.
Signed By LEE, RACHEL R (RN, Martin ACH, Fort Benning, GA) @ 27 Oct 2010 1304
2019
Medical Record
2019
04 Oct 2010 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by MISTRETTA,
PATRICIA W
Encounter ID: BENN-392801 Primary Dx: PANCREATITIS
Patient: WAITERS, TOMMIE Date: 04 Oct 2010 0920 EDT Appt Type: OPAC
ALAJANDRO
Reason for Appointment: Zagorski/f/u for pancreatitis/meds/labs

rdm
AutoCites Refreshed by MCFADDEN,WANDA L @ 04 Oct 2010 0926 EDT

Family History
• Heart disease
• No Family History of angina pectoris
• Cancer
• Family history [use for free text]
• No Family History of mental illness (not
retardation)
• No Family History of alcoholism
• No Family History of malignant neoplasm
of the large intestine
• Arteriosclerotic cardiovascular disease
(ASCVD) (Mother)
• Type II diabetes mellitus (Father)
Screening Written by MCFADDEN,WANDA L @ 04 Oct 2010 0926 EDT

Reason For Appointment: Zagorski/f/u for pancreatitis/meds/labs
Allergen information verified by MCFADDEN, WANDA L @ 04 Oct 2010 0926 EDT
Vitals
Vitals Written by MCFADDEN,WANDA L @ 04 Oct 2010 0926 EDT
in Stated, With Shoes,
WT: 228.4 lbs Upright Scale, Actual, With Shoes, BMI: 36.86, BSA: 2.116 square meters
SO Note Written by MISTRETTA,PATRICIA W @ 04 Oct 2010 0949 EDT

Chief complaint
The Chief Complaint is: Follow-Up.
Follow-Up from ER and Ft Jackson-
diagnosis of pancreatitis-
not doing well- still having pain- with nausea but no emeis snd no fever. Pai epigastric and LUQ - griping-type pain and no radiation
never had ETOH ever in whole life, no h/o elevated TG
has not taken any meds in past month prior to onset
symptosm started 16 Sept several days after eatring oysters
has lost 6 pounds in past week.
Nausea.

Allergies
NKDA.
Reported History:
2019
Medical Record
2019

T#3/darvocet
Personal history
Behavioral history: Never smoked / Never Used Tobacco Products.
Family history
father- DM.
Review of systems
Gastrointestinal symptoms: No vomiting.
Physical findings
Vital signs:
° Normal temperature: Reviewed. ° RR was normal: Reviewed. ° PR was normal: Reviewed. ° Blood pressure was normal:
Reviewed.
General appearance:
Neck:
Eyes:
General/bilateral:
Pupils: ° PERRL.
Sclera: ° Normal.
Lungs:
° Respiration rhythm and depth was normal. ° Clear to auscultation. ° No wheezing was heard. ° No rhonchi were heard:
Heart Sounds: ° S1 normal. ° S2 normal. ° No gallop was heard. ° No pericardial friction rub heard.
Abdomen:
Auscultation: • Bowel sounds were diminished.
Palpation: • Abdominal tenderness epigastri and LUQ pain with rebound LUQ and refereed rebound epigastric- abd distended
and firm. ° No mass was palpated in the abdomen.
Lab Result Cited by MISTRETTA,PATRICIA W @ 04 Oct 2010 1050 EDT

Amylase Site/Specimen 04 Oct 2010 1013Units Ref Rng
Amylase PLASMA 61 U/L (25-115)

Magnesium Site/Specimen 04 Oct 2010 1013Units Ref Rng
Magnesium PLASMA 1.9 mg/dL (1.8-2.4)

Lipids Site/Specimen 04 Oct 2010 1013Units Ref Rng
LDL Cholesterol PLASMA 140 (H) mg/dL (0-129)

Lipase Site/Specimen 04 Oct 2010 1013Units Ref Rng
2019
Medical Record
2019
Lipase PLASMA 123.0 U/L (73-393)

Comprehensive Metabolic Panel Site/Specimen 04 Oct 2010 1013Units Ref Rng
Sodium PLASMA 135 (L) mmol/L (136-145)
Anion Gap PLASMA 6.1 (L) mmol/L (10-20)

Hemogram+Differential Auto Site/Specimen 04 Oct 2010 1013Units Ref Rng
WBC BLOOD 5.0 x10(3)/mcL (4.9-10.0)
RBC BLOOD 5.11 x10(6) (4.7-6.1)
MCHC BLOOD 35.6 % (32-36)
RDW CV BLOOD 12.8 % (11.5-14.5)
Lymphocytes BLOOD 31.1 % (20-40)

Lipids Site/Specimen 20 May 2010 0717Units Ref Rng
LDL Cholesterol PLASMA 146.8 (H) mg/dL (0-129)

Chem 7 Site/Specimen 27 Sep 2010 2050Units Ref Rng
Urea Nitrogen PLASMA 11.0 mg/mL (7-22)
Chloride PLASMA 103.0 mmol/L (99-111)
Carbon Dioxide PLASMA 28.0 mmol/L (20-30)

Liver Panel Site/Specimen 27 Sep 2010 2050Units Ref Rng
Alkaline Phosphatase PLASMA 88.0 U/L (33-113)
2019
Medical Record
2019

Lactate Dehydrogenase PLASMA 166 U/L (125-286)
Gamma-Glutamyl Transferase PLASMA 23.0 U/L (5-61)
Alanine Aminotransferase PLASMA 43.0 U/L (5-49)

Amylase Site/Specimen 27 Sep 2010 2050Units Ref Rng
Amylase PLASMA 69 U/L (15-115)

Lipase Site/Specimen 27 Sep 2010 2050Units Ref Rng
Lipase PLASMA 101.0 (H) U/L (1-65)

Lipase Site/Specimen 28 Sep 2010 1945Units Ref Rng
Lipase PLASMA 89.0 (H) U/L (1-65)
Rad Result Cited by MISTRETTA,PATRICIA W @ 04 Oct 2010 0931 EDT

********** MACH CT,ABD&PEL,W/(PG) **********
POC Enc: #E496480 POC Fac: 20th Medical Group
Status: Complete
Procedure: MACH CT,ABD&PEL,W/(PG)

Event Date: 28-Sep-2010 19:30:00
Order Comment: MD REQUIRES ABDOMEN ONLY
Reason for Order:
40yo M c/o worsening LUQ pain; elevated lipase
Exam #: 10053201
MACH IMMEDIATE CARE CLINIC MONCRIEF ARMY COMMUNITY HOSP
Status: COMPLETE
Report Text:
CHCS 10053201
CT as the abdomen and pelvis was performed after oral and IV contrast
History: Left upper quadrant pain
FINDINGS: No mass, lymphadenopathy, free gas, fat stranding or abnormal

fluid
collection is visualized. The pancreatic head appears full. Trace
peripancreatic head fat stranding is suggested. No gross fluid
collections or
2019
Medical Record
2019
frank pancreatic gland edema.
Splenule noted. Multifocal regions of hepatic low density, compatible

with
hepatic steatosis. The remainder of the exam is unremarkable for age.
IMPRESSION: 1. Findings suggestive of acute pancreatitis.
A/P Written by MISTRETTA,PATRICIA W @ 04 Oct 2010 1056 EDT

1. PANCREATITIS: 706-326-4585
Medication(s): -HYDROCODON/APAP (VICODIN)5/500MG--PO TAB [PENDING PDTS] - TAKE 1 TAB PO Q 6 HRS
PRN PAIN #30 RF0 Qt: 30 Rf: 0
Laboratory(ies): -HEMOGRAM AUTO+COMP AUTO DIFF (Routine); COMPREHENSIVE METABOLIC PANEL
(Routine); AMYLASE (Routine); LIPASE (Routine); MAGNESIUM (Routine); LIPIDS (Routine)
Radiology(ies): -US ABDOMEN-3 STUDIES (ASAP) Impression: 40 yo AD soldier with epigastric/LUQ pain x 2 weeks
with nausea- CT scan 27 Sept at Ft Jackson showed pancreatitis- lipase/amylase slightly elevated last
week- normal today- pt still with pain- pleae
Disposition Written by MISTRETTA,PATRICIA W @ 04 Oct 2010 1112 EDT

Signed By MISTRETTA, PATRICIA W (Physician/Workstation) @ 04 Oct 2010 1112

_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by MISTRETTA,PATRICIA W @ 04 Oct 2010 0939 EDT:
SO Note Written by MCFADDEN,WANDA L @ 04 Oct 2010 0927 EDT
Chief complaint
The Chief Complaint is: Follow-Up.
Follow-Up.
2019
Medical Record
2019
28 Sep 2010 at 20th Medical Group, MAHC Immediate Care Clinic by KEIGER, CHRISTINA
M
Encounter ID: SHAW-289517 Primary Dx: PANCREATITIS
Patient: WAITERS, TOMMIE Date: 28 Sep 2010 1839 EDT Appt Type: ACUT
ALAJANDRO
Treatment Facility: MONCRIEF ACH Clinic: MACH IMMEDIATE CARE CLINIC Provider: KEIGER,CHRISTINA M
Reason for Appointment: 40yo m returns for follow-up
AutoCites Refreshed by SWEATT,CAROLYN M @ 28 Sep 2010 1840 EDT

Problems Allergies
Chronic: • No Known Allergies
• Lumbago
remission
mood
• Rhinitis
• Hypermetropia
depression
exam
• Body mass index
• Abdominal pain
• Laboratory studies
• Cervicalgia
• Folliculitis
• Backache
Acute:
• Constipation
• Pancreatitis
Active Medications
ACETAMINOPHEN, 325 MG, TABLET, ORAL Active T 1-2 TABS PO Q4-6H NR 27 Sep 2010
PROPOXYPHENE/ACETAMINOPHEN, 100-650 Active T1 TAB OP Q6H PFP NR 27 Sep 2010
MG, TABLET, ORAL
PROPOXYPHENE/ACETAMINOPHEN, 100-650 Active T1 TAB OP Q6H PFP NR 27 Sep 2010
MG, TABLET, ORAL
2019
Medical Record
2019
CODEINE PHOS/ACETAMINOPHEN, 30-300MG, Active TAKE ONE TAB Q4-6H PRN NR 26 Sep 2010
TABLET, ORAL FOR PAIN
Omeprazole 20mg, Extended release capsule, Active CD 11 of 11 18 Sep 2010
Oral
Screening Written by SWEATT,CAROLYN M @ 28 Sep 2010 1842 EDT

Reason For Appointment: 40yo m returns for follow-up
Allergen information verified by SWEATT, CAROLYN M @ 28 Sep 2010 1842 EDT
Vitals
Vitals Written by SWEATT,CAROLYN M @ 28 Sep 2010 1843 EDT
BP: 139/88, HR: 71, RR: 20, T: 97.9 °F, SpO2: 98%, Pain Scale: 5/10 Moderate,
Pain Scale Comments: abd pain
SO Note Written by SWEATT,CAROLYN M @ 28 Sep 2010 1842 EDT

Seen i n ucc last pm /dr keiger, dx abd pain. poss pancraetitis. told to return for ct scan tonight.
Generalized pain.
No nausea and no vomiting. Abdominal pain. No diarrhea.
Triage Category
Time:___
By:___
___ I Emergent
___ II Urgent
x___ III Non-Urgent
___ IV Routine.
Reported History:
Medical: No previous emergency room visit.
SO Note Written by KEIGER,CHRISTINA M @ 29 Sep 2010 0921 EDT

Chief complaint
The Chief Complaint is: Left upper quadrant abdominal pain.
Patient is a 40-year-old male who comes to the UCC with left upper quadrant abdominal pain. He was seen the night before and it
was recommended that he get a CT with contrast to further evaluate his pancreas. The patient returns for that CT. He states his
pain is 5/10. The Darvocet helps with the pain and allows him to attend class. He had an elevated lipase on September 17. It was
170. He was seen in the UCC and repeat lipase was 101. He denies any fever chills nausea vomiting.
In the Army. Visit is not deployment-related and visit is not GWOT-related.
Abdominal pain Left upper quadrant abdominal pain to direct palpation no splenomegaly.
Allergies
Allergy information in Autocite area was reviewed and verified with patient.
Current medication
Current medications reviewed and reconciled.
Darvocet Prilosec.
Reported History:
Medical: Reported medical history: Reviewed
.
Surgical / procedural: Surgical / procedural history: Reviewed
.
Personal history
: Reviewed
Patient is here tdy he does not smoke or drink.
Behavioral history: Tobacco use.
Alcohol: Alcohol use.
Review of systems
2019
Medical Record
2019

Otolaryngeal symptoms: No nasal discharge, no nasal passage blockage, and no sore throat.
Pulmonary symptoms: No dyspnea, no cough, and no wheezing.
Gastrointestinal symptoms: No nausea, no vomiting, no diarrhea, and no constipation.
Genitourinary symptoms: No change in urinary frequency and no feelings of urinary urgency. No dysuria.
Physical findings
Vital signs:
• Vital signs: Blood pressure 139/88, heart rate 71, • Temperature: Reviewed. • RR: Reviewed. • PR: Reviewed. • SBP:
Reviewed.
General appearance:
Neck:
Lymph Nodes:
were not enlarged.
Lungs:
Heart Sounds: ° S1 normal. ° S2 normal. ° No S3 heard. ° No S4 heard. ° No gallop was heard. ° No pericardial friction rub
heard.
Abdomen:
Palpation: • Abdominal tenderness Left upper quadrant pain to direct palpation.
Neurological:
Lab Result Cited by KEIGER, CHRISTINA M @ 29 Sep 2010 0931 EDT

Test / Result Name Site/Specimen Collection Date / Result Values Origin
MTF/Facility Units Ref Rng Result Comments
Interpretations
Test / Result Name Site/Specimen Collection Date / Result Values Units Ref
Rng
Lipase Site/Specimen 28 Sep 2010 1945 Units Ref Rng
Lipase PLASMA 89.0 ???? U/L (1-65)
Rad Result Cited by KEIGER, CHRISTINA M @ 29 Sep 2010 0931 EDT
Rad Result Cited by KEIGER, CHRISTINA M @ 29 Sep 2010 0930 EDT
A/P Last updated by KEIGER, CHRISTINA M @ 29 Sep 2010 0936 EDT

1. PANCREATITIS: ORDERS: @ 1910 lipase, INT, contrast and CT of the abdomen
Patient was allowed to return to his unit. I arranged to call him with the results of the CT scan.
His lipase is now 89 which suggests his pancreatitis is improving.
Patient CT showed changes consistent with acute pancreatitis. The pancreatic head appeared full there was trace as the
peripancreatic head fat stranding. There is no gross fluid collections or frank pancreatic gland edema.
I will encourage the patient to primary care provider upon returning to his duty station on Thursday.
50% of this clinic visit was spent coordinating care and counseling the patient.
TRIED TO CALL PATIENT RESULTS OF CT @ 0930. NO ANS WILL CALL BACK TODAY
Laboratory(ies): -LIPASE (ASAP) Ordered By: ANDERSONDAVIS, SIMIRA
Radiology(ies): -MACH CT,ABD&PEL,W/(PG) (ASAP) Ordered By: ANDERSONDAVIS, SIMIRA Impression: 40yo M
c/o worsening LUQ pain; elevated lipase
2019
Medical Record
2019
Comment: MD REQUIRES ABDOMEN ONLY

2. CONSTIPATION: Patient was given Dulcolax for his constipation.
Disposition Written by KEIGER, CHRISTINA M @ 29 Sep 2010 0936 EDT

Follow up: with PCM. - Comments: PATIENT IS TO F/U WITH PCP AT FT BENNING UPON HIS RETURN
Note Written by ANDERSONDAVIS, SIMIRA @ 28 Sep 2010 2209 EDT

NSG
discharge
2208-Pt. given d/c instructions by MD. #20 gauge INT d/c'd without difficulty. No redness, streaking, swelling or warmth noted at
site. Pt. given colace from pick point, per MD order. Given medication teaching. Pt. ambulated from UCC without incident.
Note Written by WALLIS, LINDA M. @ 28 Sep 2010 2206 EDT

Nursing
Discharge
Pt discharged by provider - INT removed by Ms. Puckhaber & site secured.

NSG
1951-Contacted Rad tech and notified that pt. completed contrast at 1949hrs.

NSG
Procedure
1945-Pt. allergies verified, ID verified x2. Pt. given oral CT contrast. The (L) hand, was prepped using aseptic
technique. #20 gauge INT placed (L) hand without complication or complaint. Bloodwork drawn and sent to lab. Site
patent. Good blood return visible, flushes with 3cc of NS without difficulty. Pt. verbalized understanding as to reason
for procedure. Tolerated well.
1949-Pt. completed oral CT contrast. Called Rad. tech., no answer.
Signed By KEIGER, CHRISTINA M (Staff Physician, Urgent Care Clinic) @ 29 Sep 2010 0937
_________________________________________________________________________________________________________
CHANGE HISTORY
The following A/P Note Was Overwritten by KEIGER, CHRISTINA M @ 29 Sep 2010 0932 EDT:
The A/P section was last updated by KEIGER, CHRISTINA M @ 29 Sep 2010 0932 EDT - see above.Previous Version of A/P section was entered/updated by
ANDERSONDAVIS, SIMIRA @ 28 Sep 2010 1935 EDT.

MACH CT,ABD&PEL,W/(PG) (ASAP) Ordered By: ANDERSONDAVIS, SIMIRA Impression: 40yo M c/o worsening LUQ pain; elevated lipase
Comment: MD REQUIRES ABDOMEN ONLY
LIPASE (ASAP) Ordered By: ANDERSONDAVIS, SIMIRA
2019
Medical Record
2019
27 Sep 2010 at 20th Medical Group, MAHC Immediate Care Clinic by KEIGER, CHRISTINA
M
Encounter ID: SHAW-287417 Primary Dx: PANCREATITIS
Patient: WAITERS, TOMMIE Date: 27 Sep 2010 1833 EDT Appt Type: ACUT
ALAJANDRO
Treatment Facility: MONCRIEF ACH Clinic: MACH IMMEDIATE CARE CLINIC Provider: KEIGER,CHRISTINA M
Reason for Appointment: 40yo m c/o pain L side abd x10 days
AutoCites Refreshed by CALDWELL,EDD @ 27 Sep 2010 1834 EDT

Chronic: • Heart disease • No Known Allergies
• Lumbago • No Family History of angina pectoris
• Observation for suspected condition • Cancer
• Recurrent major depression in partial • Family history [use for free text]
remission • No Family History of mental illness (not
• Adjustment disorder with depressed retardation)
mood • No Family History of alcoholism
• Rhinitis • No Family History of malignant neoplasm
depression • Type II diabetes mellitus (Father)
exam
• Body mass index
• Abdominal pain
• Cervicalgia
• Folliculitis
• Backache
Active Medications
CODEINE PHOS/ACETAMINOPHEN, 30-300MG, Active TAKE ONE TAB Q4-6H PRN NR 26 Sep 2010
TABLET, ORAL FOR PAIN
Trimethoprim 160mg + Sulfamethoxazole 800mg, Active T1 TAB PO BID UNTIL NR 18 Sep 2010
(Septra DS), Tablet, Oral FINISHED
Omeprazole 20mg, Extended release capsule, Active CD 11 of 11 18 Sep 2010
Oral
2019
Medical Record
2019
Screening Written by BULLOCK,SHIRLEY @ 27 Sep 2010 1853 EDT

Reason For Appointment: 40yo m c/o pain L side abd x10 days
Allergen information verified by BULLOCK, SHIRLEY @ 27 Sep 2010 1853 EDT
Vitals
Vitals Written by REED, TAMMY O @ 27 Sep 2010 2113 EDT
BP: 127/89, HR: 65,
Comments: Recheck of BP
Vitals Written by BULLOCK,SHIRLEY @ 27 Sep 2010 1853 EDT
BP: 140/88, HR: 80, RR: 18, T: 98.7 °F Oral, SpO2: 96%, Pain Scale: 8/10 Severe, Pain Scale Comments: lt side of abd
SO Note Written by BULLOCK,SHIRLEY @ 27 Sep 2010 1855 EDT

C/o pain in lt side of abd x 10 days. no pcm as here for tng from ft benning. nad. to rm 4.
Triage Category
Time:_1855__
By:__sb_
___ I Emergent
___ II Urgent
__x_ III Non-Urgent
___ IV Routine.
Therapy
• Transportation to an urgent care center Ambulatory on Arrival to Emergency Department and in a private vehicle.
SO Note Written by KEIGER,CHRISTINA M @ 27 Sep 2010 2226 EDT

Chief complaint
The Chief Complaint is: LUQ ABD PAIN FOR 10 DAYS.
Patient is a 40-year-old male SFC who comes to the UCC complaining of left upper quadrant abdominal pain for the last 10 days.
Patient is stationed at Fort Benning. He is TDY @ Fort Jackson until Thursday. Patient states he's been to the emergency room at
Fort Benning twice. He states he was told nothing and Septra, Tylenol with codeine and Omeprazole. Patient had a CT scan during
one of these visits. His pain is 8/10. It is just under his left rib cage. He denies any trauma. He denies any fever chills nausea
vomiting. He's had no diarrhea cough or shortness of breath. He has no chest pain. The patient was placed on Septra his last visit at
Fort Benning because of pancreatitis.
In the Army and currently on active duty. Visit is not deployment-related and visit is not GWOT-related.
Allergies
Allergy information in Autocite area was reviewed and verified with patient.
Current medication
Current medications reviewed and reconciled. No known drug allergies//current medications include Septra and Tylenol #3.
Reported History:
Migraine headaches.
Exploratory laparoscopic surgery for "growth in his abdomen".
Personal history
Social history: Reviewed
SFC does not smoke or drink.
Behavioral history: No tobacco use.
Family history
Family medical history: Reviewed
Diabetes, coronary artery disease, peripheral vascular disease.
Review of systems
Head symptoms: No head symptoms, no headache, and no sinus pain.
Neck symptoms: No neck symptoms and no swollen glands in the neck.
Otolaryngeal symptoms: No nasal symptoms and no throat symptoms.
2019
Medical Record
2019
Pulmonary symptoms: No pulmonary symptoms, no dyspnea, no cough, and no wheezing.

Gastrointestinal symptoms: Appetite not decreased. No heartburn, no nausea, no vomiting, and no abdominal swelling /bloating.
Abdominal pain. No epigastric pain, not in the RUQ, not in the LUQ, and not in the RLQ. LLQ abdominal pain. No radiating
abdominal pain. Steady, severe abdominal pain. No hematochezia. No constipation.
Genitourinary symptoms: No genitourinary symptoms and no dysuria. No male genital symptoms were present.
Physical findings
Vital signs:
• Pain level (0-10): Reviewed pain 8/10.
° Current vital signs reviewed Blood pressure 140/88 heart rate 80 respirations 18 temperature 98.7 O2 sat 96%.
General appearance:
° Well-appearing. ° Alert. ° Oriented to time, place, and person.
Head:
Neck:
Ears:
General/bilateral:
Pharynx:
Oropharynx: ° Normal.
Lymph Nodes:
° Cervical lymph nodes were not enlarged.
Lungs:
° Exaggerated use of accessory muscles for inspiration was not observed. ° Clear to auscultation. ° Normal breath
sounds/voice sounds: ° No wheezing was heard. ° No rales/crackles were heard.
Heart Sounds: ° Normal.
Abdomen:
Auscultation: ° Bowel sounds were normal.
Palpation: • Abdominal tenderness. • Direct tenderness in the LUQ of the abdomen. • Direct tenderness in the LLQ of the
abdomen. • Rebound tenderness in the abdomen. • Rebound tenderness in the LUQ of the abdomen. • Referred
rebound abdominal tenderness with palpation of LLQ. ° Abdomen was soft. ° No direct epigastric tenderness. ° No
direct tenderness in the RUQ of the abdomen. ° No direct tenderness in the RLQ of the abdomen. ° No direct
periumbilical tenderness. ° No direct suprapubic tenderness. ° No diffuse direct tenderness. ° No rebound tenderness in
the RUQ of the abdomen. ° No rebound tenderness in the RLQ of the abdomen. ° No rebound tenderness in the LLQ of
the abdomen. ° No rebound periumbilical tenderness.
Neurological:
Lab Result Cited by REED, TAMMY O @ 27 Sep 2010 2125 EDT

Test / Result Name Site/Specimen Collection Date / Result Values
CBC Site/Specimen 27 Sep 2010 2015
WBC BLOOD 7.03
RBC BLOOD 5.3
MCV BLOOD 82.3
MCH BLOOD 29.5
MCHC BLOOD 35.8
Platelets BLOOD 269.0
Monocytes BLOOD 7.0
MPV BLOOD 11.5
Basophils BLOOD 0.6
RDW SD BLOOD 39.6
2019
Medical Record
2019

Chem 7 Site/Specimen 27 Sep 2010 2050
Urea Nitrogen PLASMA 11.0 
Sodium PLASMA 140
Chloride PLASMA 103.0
Carbon Dioxide PLASMA 28.0

Liver Panel Site/Specimen 27 Sep 2010 2050
Alkaline Phosphatase PLASMA 88.0
Lactate Dehydrogenase PLASMA 166 
Gamma-Glutamyl Transferase PLASMA 23.0
Alanine Aminotransferase PLASMA 43.0 

Lipase Site/Specimen 27 Sep 2010 2050
Lipase PLASMA 101.0 (H)

Amylase Site/Specimen 27 Sep 2010 2050
Amylase PLASMA 69
A/P Last updated by KEIGER, CHRISTINA M @ 28 Sep 2010 0753 EDT

1. PANCREATITIS: I was able to obtain the patient's medical records from his 2 ER visits. The patient had a noncontrasted CT
scan. His lipase was 170 on his initial visit on September 17. He was started on Prilosec and Septra. When he returned on the 20
26th of September he was given Tylenol #3 for the pain. He was told to followup. Patient did not want to repeat his CT scan tonight
using contrast. I feel is important that he have a contrast CT to better evaluate the solid organs. Patient will come back to the UCC
tomorrow afternoon after class for his CT scan. He will return if his pain gets worse. He was discharged on Darvocet. His
medications were reconciled. I stressed to this patient the importance of following up this problem
Greater than 50% of this clinic visit was spent coordinating the care of this patient and obtaining past medical records
2. abdominal pain in the left upper belly (LUQ): ORDERS:@ 2000 recheck blood pressure, get ER report from Fort Benning for 2
ER visits within the last 10 days, flat and upright x-ray, CBC, Chem-7, LFTs, amylase and lipase, int
patient's repeat blood pressure is 127/89 heart rate of 65. The patient's amylase is 69 his lipase is 101 which is elevated(upper
limits of normal is 65 units per liter), total bili 0.3 mg per deciliter, alkaline phosphatase 88 units per liter, AST 26 units per liter, LDH
166 units per liter ALT 43 units per liter GGT 23 units per liter Chem-7 within normal limits. WBC 7.0 3K. Patient's flat and upright
abdominal films showed nonspecific bowel pattern. He had a large amount of stool in his bowel. Patient refused fleets
Laboratory(ies): -AMYLASE (ASAP) Ordered By: REED, TAMMY O; AMYLASE (ASAP) Ordered By: REED, TAMMY O;
CBC MACH(SHAW NOT ALLOWED) (STAT) Ordered By: REED, TAMMY O; CHEM 7 MONCRIEF
(ASAP) Ordered By: REED, TAMMY O; CHEM 7 MONCRIEF (ASAP) Ordered By: REED, TAMMY O;
LIPASE (ASAP) Ordered By: REED, TAMMY O; LIPASE (ASAP) Ordered By: REED, TAMMY O; LIVER
PANEL MACH (ASAP) Ordered By: REED, TAMMY O; LIVER PANEL MACH (ASAP) Ordered By:
REED, TAMMY O
Radiology(ies): -MACH ABDOMEN FLAT & UPRIGHT (STAT) Ordered By: REED, TAMMY O Impression: c/o left sided
abdominal pain x 10 days
3. CONSTIPATION: Patient heart large amount of stool in his bowel and refused a fleets enema
Disposition Written by KEIGER, CHRISTINA M @ 28 Sep 2010 0753 EDT

Released w/ Work/Duty Limitations
Follow up: with PCM. - Comments: Patient will return to the UCC Wednesday for a CT scan
2019
Medical Record
2019
Note Written by REED, TAMMY O @ 27 Sep 2010 2348 EDT

nsg
discharge
pt id and med allergies verified. pt discharged from the UCC in stable condition w/ NAD noted. respirations are unlabored. skin warm
and dry to touch. pt was rx'd and received Darvocet #5 (2 bottles) and Tylenol. verbal and written instructions for meds and f/u care
given. pt advised to return to the UCC on tomorrow (28 Sep) for CT of abdomen. pt was further instructed not to eat or drink
anything after lunchtime per the provider instructions. pt voiced understanding of info provided. #20g iv was discontinued from the
pt's right hand w/ the catheter straight and intact. pt left UCC ambulatory w/o assist.

nsg
pt id verified. pt started on a liter of NS, bolus, as ordered by the provider.

nsg
2110: Authorization to Disclose form faxed to Martin Army Community Hospital (Ft. Benning, GA) ER @ (706) 544-2144 for DOS 26
Sep 2010 & 16 Sep 2010.

nsg
pt id verified. specimens for Chem 7, Lipase, Amylase and LFTs were recollected from the pt's left hand w/ a 23g butterfly needle w/
the 1st attempt successful. prior specimens hemolyzed. pt tolerated venipuncture well. will con't to monitor pt.

nsg
2015: pt id verified. pt transported to radiology, ambulatory, for abd xray, flat & upright. pt ambulatory w/o difficulty.

nsg
2005: pt id verified. #20g IV placed to the pt's right hand w/ the 1st attempt successful. tolerated iv placement well w/o difficulty.
specimens for Chem 7, CBC, LFTs, Amylase and Lipase collected from the IV site w/o difficulty. site flushes w/o difficulty, pain or
swelling.
Signed By KEIGER, CHRISTINA M (Staff Physician, Urgent Care Clinic) @ 28 Sep 2010 0756
_________________________________________________________________________________________________________
CHANGE HISTORY
The following A/P Note Was Overwritten by KEIGER, CHRISTINA M @ 27 Sep 2010 2245 EDT:
The A/P section was last updated by KEIGER, CHRISTINA M @ 27 Sep 2010 2245 EDT - see above.Previous Version of A/P section was entered/updated by REED, TAMMY
O @ 27 Sep 2010 2053 EDT.

MACH ABDOMEN FLAT & UPRIGHT (STAT) Ordered By: REED, TAMMY O Impression: c/o left sided abdominal pain x 10 days
CBC MACH(SHAW NOT ALLOWED) (STAT) Ordered By: REED, TAMMY O
CHEM 7 MONCRIEF (ASAP) Ordered By: REED, TAMMY O
LIVER PANEL MACH (ASAP) Ordered By: REED, TAMMY O
AMYLASE (ASAP) Ordered By: REED, TAMMY O
LIPASE (ASAP) Ordered By: REED, TAMMY O
CHEM 7 MONCRIEF (ASAP) Ordered By: REED, TAMMY O
LIVER PANEL MACH (ASAP) Ordered By: REED, TAMMY O
LIPASE (ASAP) Ordered By: REED, TAMMY O
AMYLASE (ASAP) Ordered By: REED, TAMMY O
2019
Medical Record
2019
26 Sep 2010 at Martin ACH, Fort Benning, GA, ER by RANDALL, WILLIAM L
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: RANDALL,WILLIAM LEWIS
AutoCites Refreshed by RANDALL,WILLIAM L @ 26 Sep 2010 2023 EDT

Chronic: • Heart disease • No Known Allergies
• Lumbago • No Family History of angina pectoris
• Observation for suspected condition • Cancer
• Recurrent major depression in partial • Family history [use for free text]
remission • No Family History of mental illness (not
• Adjustment disorder with depressed retardation)
mood • No Family History of alcoholism
• Rhinitis • No Family History of malignant neoplasm
depression • Type II diabetes mellitus (Father)
exam
• Body mass index
• Abdominal pain
• Cervicalgia
• Folliculitis
• Backache
Active Medications
Trimethoprim 160mg + Sulfamethoxazole Active T1 TAB PO BID UNTIL NR 18 Sep
800mg, (Septra DS), Tablet, Oral FINISHED 2010
Omeprazole 20mg, Extended release Active CD 11 of 11 18 Sep
capsule, Oral 2010
BOTTLE
SO Note Written by RANDALL,WILLIAM LEWIS @ 26 Sep 2010 2023 EDT

Chief complaint
2019
Medical Record
2019

Subjective
A/P Written by RANDALL,WILLIAM L @ 26 Sep 2010 2023 EDT

1. Observation For Suspected Condition
Disposition Written by RANDALL,WILLIAM L @ 26 Sep 2010 2023 EDT

Signed By RANDALL, WILLIAM L (Physician/Workstation) @ 26 Sep 2010 2024
2019
Medical Record
2019
17 Sep 2010 at Martin ACH, Fort Benning, GA, ER by RANDALL, WILLIAM L
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: RANDALL,WILLIAM LEWIS
SO Note Written by RANDALL,WILLIAM LEWIS @ 18 Sep 2010 0210 EDT

Chief complaint
Subjective
A/P Written by RANDALL,WILLIAM L @ 18 Sep 2010 0210 EDT

Disposition Written by RANDALL,WILLIAM L @ 18 Sep 2010 0210 EDT

Signed By RANDALL, WILLIAM L @ 18 Sep 2010 0210
2019
Medical Record
2019
20 May 2010 at Martin ACH, Fort Benning, GA, FMC Specialty Clinic by HOLTZCLAW,
KAREN ROMA
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC SPECIALTY CLINIC Provider: HOLTZCLAW,KAREN ROMA
Reason for Appointment: PHA Phase III

cda
AutoCites Refreshed by HOLTZCLAW,KAREN R @ 20 May 2010 1353 EDT

Allergies
Screening Written by JOHNSON,SYRA K @ 20 May 2010 1329 EDT

Reason For Appointment: PHA Phase III
Allergen information verified by JOHNSON, SYRA K @ 20 May 2010 1329 EDT
Vitals
Vitals Written by JOHNSON,SYRA K @ 20 May 2010 1330 EDT
SO Note Written by HOLTZCLAW,KAREN ROMA @ 25 May 2010 1229 EDT

Reason for Visit
Visit for: Periodic Health Assessment (PHA). Visit for: examination.
He reported: Military service in the Army and currently on active duty.
No new symptoms.
Allergies
No allergy to certain foods.
Reported History:
At risk for cardiac disorders mom had heart attack 3-4 years ago. currently on medications.
Recent events: No recent events: Have you recently had any medical problems or symptoms that bother you?.
Medical: Previous hospitalizations had an appendicytis in 2001 and preulcer conditions in 2009 and for a GI problem. No
previous fracture.
Reported medications: Currently taking medication prozac.
Reported prior tests: Blood pressure was normal and a hearing test was normal.
Exposure: No exposure to jobs or hobbies which involve chemicals, dust or loud noises.
Previous therapy
History of eye surgery results: vision not noted:(Free Test Here)
Personal history
Personal history: No recent emotional stress.
Critical stress history: No critical stress history.
Diet: : Do you eat more than one serving of high fat or cholecterol food (eg., red meat, eggs, cheese, chocolate, fried foods, milk,
etc.) per day? Do you eat fewer than 5 servings of fruits or vegetables each day? Eating less than five servings of fruits and
vegetables per day.
Behavioral history: Caffeine use drinks mountain dew about 3 a day. No tobacco use.
Drug use: Not using drugs.
Habits: Using a seatbelt. Not using earplugs and not wearing protective gloves.
Family: No remarkable family social history: Do you have serious problems dealing with your spouse, parents, children or friends?.
Sexual: No sexual history reported: In the past year, have you been counseled on the risks & prevention of sexually transmitted
2019
Medical Record
2019
diseases?.
Family history
DIABETES patients father has type 1
No ischemic heart disease before age 50: Prior to 55 y/o?
Cancer breast cancer on moms side
Heart disease
No angina pectoris.
Physical findings
Vital signs:
° Normal temperature: Reviewed. ° RR was normal: Reviewed. ° PR was normal: Reviewed. ° Blood pressure was normal:
Reviewed.
General appearance:
Neck:
Eyes:
General/bilateral:
Pupils: ° PERRL.
Sclera: ° Normal.
Ears:
General/bilateral:
Nose:
General/bilateral:
Pharynx:
Lymph Nodes:
° Cervical lymph nodes were not enlarged. ° Submandibular lymph nodes were not enlarged.
Lungs:
° Clear to auscultation.
Abdomen:
Neurological:
Balance: ° Normal.
Skin:
° Showed no ecchymosis. ° Temperature was normal. ° No skin lesions:
Lab Result Cited by HOLTZCLAW, KAREN R @ 25 May 2010 1230 EDT

Interpretations
Lipids Site/Specimen 20 May 2010 0717 Units Ref Rng
LDL Cholesterol PLASMA 146.8 (H) mg/dL (0-129)
A/P Written by HOLTZCLAW, KAREN R @ 25 May 2010 1603 EDT

1. visit for: military services physical(PERIODIC PREVENTION EXAMINATION): PHA complete in MEDPROS
2019
Medical Record
2019
2. visit for: screening exam: CHO 209, LDL 146. Need follow-up with PCM. Discussed importance of low saturated fat, low
cholesterol diet and maintaining proper weight and healthy eating habits.
Disposition Written by HOLTZCLAW, KAREN R @ 25 May 2010 1603 EDT

20 minutes face-to-face/floor time..
Signed By HOLTZCLAW, KAREN R (Nurse Practitioner, 66P) @ 25 May 2010 1603

_________________________________________________________________________________________________________
CHANGE HISTORY
The following SO Note Was Overwritten by HOLTZCLAW, KAREN R @ 25 May 2010 1229 EDT:
SO Note Written by JOHNSON,SYRA K @ 20 May 2010 1330 EDT
Reason for Visit
Visit for: Periodic Health Assessment (PHA). Visit for: examination.
He reported: Military service in the Army and currently on active duty.
No new symptoms.
Allergies
No allergy to certain foods.
Reported History:
At risk for cardiac disorders mom had heart attack 3-4 years ago. currently on medications.
Recent events: No recent events: Have you recently had any medical problems or symptoms that bother you?.
Medical: Previous hospitalizations had an appendicytis in 2001 and preulcer conditions in 2009 and for a GI problem. No previous fracture.
Reported medications: Currently taking medication prozac.
Reported prior tests: Blood pressure was normal and a hearing test was normal.
Exposure: No exposure to jobs or hobbies which involve chemicals, dust or loud noises.
Previous therapy
History of eye surgery results: vision not noted:(Free Test Here)
Personal history
Personal history: No recent emotional stress.
Critical stress history: No critical stress history.
Diet: : Do you eat more than one serving of high fat or cholecterol food (eg., red meat, eggs, cheese, chocolate, fried foods, milk, etc.) per day? Do you eat fewer than 5
servings of fruits or vegetables each day? Eating less than five servings of fruits and vegetables per day.
Behavioral history: Caffeine use drinks mountain dew about 3 a day. No tobacco use.
Habits: Using a seatbelt. Not using earplugs and not wearing protective gloves.
Family: No remarkable family social history: Do you have serious problems dealing with your spouse, parents, children or friends?.
Sexual: No sexual history reported: In the past year, have you been counseled on the risks & prevention of sexually transmitted diseases?.
Family history
DIABETES patients father has type 1
No ischemic heart disease before age 50: Prior to 55 y/o?
Cancer breast cancer on moms side
Heart disease
No angina pectoris
2019
Medical Record
2019
26 Apr 2010 at Martin ACH, Fort Benning, GA, Optometry by RAMIREZ, HABY I
REFRACTIVE ERROR -
HYPERMETROPIA
Patient: WAITERS, TOMMIE Date: 26 Apr 2010 0911 EDT Appt Type: SPEC
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: OPTOMETRY Provider: RAMIREZ,HABY
Reason for Appointment: Eye Exam
AutoCites Refreshed by RAMIREZ, HABY I @ 05 May 2010 0950 EDT

Problems Active Family History Allergies
• BACKACHE • Type II diabetes mellitus (Father) • No Known Allergies
• MIGRAINE HEADACHE • Arteriosclerotic cardiovascular disease
• FOLLICULITIS (ASCVD) (Mother)
• visit for: screening exam • No family history of malignant neoplasm
• CERVICALGIA of the large intestine
• joint pain, localized in the shoulder • No family history of alcoholism
• Other Physical Therapy • No family history of mental illness (not
• Laboratory Studies retardation)
• abdominal pain
• visit for: administrative purpose
• visit for: follow-up exam
• visit for: preoperative exam
INFECTION
• Body Mass Index
• visit for: occupational health / fitness
exam
• visit for: military services physical
EPISODE
DISEASE
• abdominal pain around the belly button
(periumbilical)
• MAJOR DEPRESSION SINGLE
EPISODE MODERATE
HYPERMETROPIA
• RHINITIS
• ADJUSTMENT DISORDER WITH
DEPRESSED MOOD
• MAJOR DEPRESSION, RECURRENT
• Observation For Suspected Condition
• LUMBAGO
• MULTIPLE BLISTERS
Active Medications
Active Medications Status Sig Refills Left Last

Filled
BOTTLE
2019
Medical Record
2019
A/P Written by RAMIREZ,HABY I @ 05 May 2010 1310 EDT

1. REFRACTIVE ERROR - HYPERMETROPIA
Disposition Written by RAMIREZ,HABY I @ 05 May 2010 1311 EDT

Follow up: as needed in 12 month(s) or sooner if there are problems.
Note Written by RAMIREZ, HABY I @ 05 May 2010 0951 EDT
2019
Medical Record
2019
Signed By RAMIREZ, HABY I (Physician/Workstation) @ 05 May 2010 1311
2019
Medical Record
2019
22 Apr 2010 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by AVERA, CYNTHIA D
Encounter ID: CDR-84263394 Primary Dx: Visit for: military services physical
Patient: WAITERS, TOMMIE Date: 22 Apr 2010 0909 EDT Appt Type: T-CON*
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC YELLOW CLINIC Provider: AVERA,CYNTHIA D
Patient Status: Outpatient Call Back Phone: 706-405-6984
Reason for Telephone Consult: ZAGORSKI/need to schedule second part of PHA

Appointment Comments: Written by COVINGTON, NIKKI M @ 22 Apr 2010 0909 EDT
706-326-4585
72 hrs advised
AutoCites Refreshed by AVERA,CYNTHIA D @ 05 May 2010 1518 EDT

Chronic: • No Family History of mental illness (not • No Known Allergies
• Lumbago retardation)
• Observation for suspected condition • No Family History of alcoholism
• Recurrent major depression in partial • No Family History of malignant neoplasm
remission of the large intestine
• Adjustment disorder with depressed • Arteriosclerotic cardiovascular disease
mood (ASCVD) (Mother)
• Rhinitis • Type II diabetes mellitus (Father)
• Hypermetropia
depression
exam
• Body mass index
• Abdominal pain
• Cervicalgia
• Folliculitis
• Backache
Active Medications
2019
Medical Record
2019

BOTTLE
A/P Last Updated by AVERA,CYNTHIA D @ 11 May 2010 1457 EDT

Disposition Last Updated by AVERA,CYNTHIA D @ 05 May 2010 1524 EDT
Note Written by AVERA,CYNTHIA D @ 05 May 2010 1549 EDT

Pt is amber on physical exam, HIV, and vision. Attempted to contact pt at number provided but vm is full and cannot leave a
message. Will attempt to call again.
Note Written by AVERA,CYNTHIA D @ 19 May 2010 1140 EDT

Pt is still amber on several items and am still unable to contact pt to complete phase II.
Signed By AVERA, CYNTHIA D (RN/ Family Medicine Clinic, Martin ACH, Fort Benning, GA) @ 19 May 2010 1141
2019
Medical Record
2019
25 Feb 2010 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by HOLTZCLAW,
KAREN ROMA
Encounter ID: BENN-140811 Primary Dx: MULTIPLE BLISTERS
Patient: WAITERS, TOMMIE Date: 25 Feb 2010 1520 EST Appt Type: ROUT
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC YELLOW CLINIC Provider: HOLTZCLAW,KAREN ROMA
Reason for Appointment: blisters on stomach

sid
AutoCites Refreshed by MCFADDEN,WANDA L @ 25 Feb 2010 1523 EST
Screening Written by MCFADDEN,WANDA L @ 25 Feb 2010 1523 EST

Reason For Appointment: blisters on stomach
Allergen information verified by MCFADDEN, WANDA L @ 25 Feb 2010 1523 EST
Vitals
Vitals Written by MCFADDEN,WANDA L @ 25 Feb 2010 1523 EST
BP: 126/84 Right Arm, Adult Cuff, HR: 81 Regular, Radial Artery, RR: 18, T: 97.2 °F Oral, HT: 66 in Stated, With Shoes,
WT: 208.0 lbs Upright Scale, Actual, With Shoes, BMI: 33.57, BSA: 2.034 square meters, Tobacco Use: No, Alcohol Use: No,
Comments: non-deployed related
SO Note Written by HOLTZCLAW,KAREN ROMA @ 25 Feb 2010 1555 EST

Chief complaint
The Chief Complaint is: Blisters.
39 yo c/o blisters on abdomen presented of unknown orgin. Use spandex belt around wiast new belt same noticed 4 days ago.
In the Army and currently on active duty.
Skin symptoms.
Current medication
Current medications reviewed and reconciled.
Prozac.
Reported History:
Depression.
Biopsy of multiple lymph nodes
Appendicitis
Glanglion cyst removed twice
Soldier bite on chest.
Personal history
Social history: Reviewed
Recruiter.
Physical findings
Vital signs:
• Temperature: Reviewed. • RR: Reviewed. • PR: Reviewed. • SBP: Reviewed.
General appearance:
Eyes:
General/bilateral:
Pupils: ° PERRL.
Ears:
General/bilateral:
Lungs:
2019
Medical Record
2019
Abdomen:
Neurological:
Psychiatric Exam:
Mood: ° Euthymic.
Affect: ° Normal.
Skin:
• Skin: Blisters on abdomen linear herpetic. • Showed ecchymosis. • Lesions:
A/P Written by HOLTZCLAW, KAREN R @ 01 Mar 2010 1801 EST

1. MULTIPLE BLISTERS
Consult(s): -Referred To: DERMATOLOGY CONSULT (Routine) Specialty: Clinic: DERMATOLOGY Primary
Diagnosis: MULTIPLE BLISTERS Order Date: 03/01/2010 18:01 Ordered By: HOLTZCLAW, KAREN R
Disposition Written by HOLTZCLAW, KAREN R @ 01 Mar 2010 1801 EST

Signed By HOLTZCLAW, KAREN R (Nurse Practitioner, 66P) @ 01 Mar 2010 1801
2019
Medical Record
2019
24 Feb 2010 at Martin ACH, Fort Benning, GA, Nutrition by WICKER-ARMOLT,

JENNIFER C
Encounter ID: CDR-80387252 Primary Dx: Patient Education - Dietary
Patient: WAITERS, TOMMIE Date: 24 Feb 2010 0837 EST Appt Type: GRP
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: NUTRITION Provider: WICKER-ARMOLT,JENNIFER
C
Reason for Appointment: adwtl
AutoCites Refreshed by WICKER-ARMOLT, JENNIFER C @ 25 Feb 2010 1227 EST

Problems Allergies
• BACKACHE • No Known Allergies
• FOLLICULITIS
• visit for: screening exam
• CERVICALGIA
• joint pain, localized in the shoulder
• Laboratory Studies
• abdominal pain
INFECTION
• Body Mass Index
exam
EPISODE
DISEASE
(periumbilical)
EPISODE MODERATE
HYPERMETROPIA
• RHINITIS
DEPRESSED MOOD
• nausea with vomiting
• LUMBAGO
Active Medications

Dexmethylphenidate Hydrochloride 10mg, Active T1 CAP PO QD NR 29 Jan 2010
Extended release capsule, Oral
2019
Medical Record
2019
TRIAZOLAM (TRIAZOLAM), 0.25MG, TABLET, Active NR 03 May 2009

Fluoxetine Hydrochloride 20mg, (Prozac), Capsule, Active CD 6 of 6 27 Mar 2009
Oral
HYOSCYAMINE SULFATE, 0.125 MG, TAB Active T1 TAB PO Q8H 2 of 2 18 Mar 2009
SUBL, SUBLINGUAL
Screening Written by WICKER-ARMOLT, JENNIFER C @ 25 Feb 2010 1227 EST

Reason(s) For Visit (Chief Complaint): Patient Education - Dietary (New) ;
Vitals
Vitals Written by WICKER-ARMOLT, JENNIFER C @ 25 Feb 2010 1227 EST
HT: 66 in, WT: 228.3 lbs, BMI: 36.85, BSA: 2.116 square meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 0 Pain Free
Comments: Weight taken in uniform and boots.
SO Note Written by WICKER-ARMOLT,JENNIFER C @ 25 Feb 2010 1228 EST

Referred here
To attend the Weight Control Class.
Reported History:
Reported medications: Not taking dietary supplements. Taking vitamin supplements.
Personal history
Diet: 2 meals per day, 0 snacks per day, irregular frequency of meals with extended periods between meals, and infrequent meals.
Habits: Exercising regularly. Moderately exercising 3+ times a week.
Physical findings
Vital signs:
Vital Signs/Measurements Value
Weight (Small-Large Frame, 1983 MHWT) 228.3 lbs
Body mass index 36 kg/m2
Height 167.64 cm
• Weight was recorded. • Weight was not within normal limits.
Weight: Value
Goal weight 170 lbs
• Patient was observed to be obese. ° Weight was not proportional to the height.
Weight: Value
Ideal weight 123-156 lbs
Objective
Education: (Pt attended Nutrition Clinic Weight Control Class)~Material covered: Basic principles of healthy dietary habits,
including food selection and preparation, portion control, appropriate weight loss, and benefits of exercise in weight management.
Pt demonstrated knowledge of the information by both asking and answering appropriate questions in a group setting.~Handouts
provided: Food Guide Pyramid, Folate, & Performance Nutrition.~Goal of Therapy: Achieve BMI<25 and/or body fat % IAW AR
600-9. ~Patient Goals: 1. Eat Regularly 2. Avoid fad diets and dietary supplements 3. Exercise 3-5 times per week
(minimum of 30 minutes/session) 4. Reduce portion sizes 5. Make healthy food choices~.
A/P Written by WICKER-ARMOLT, JENNIFER C @ 25 Feb 2010 1230 EST

1. Patient Education - Dietary: Pt was referred to the Nutrition Clinic for weight loss education in accodance with AR 600-9. Pt was
instructed on general principles of Nutrition including; weight reduction, the food guide pyramid, food preparation methods, behavior
modification, fad diets and the importance of exercise pertaining to weight loss. The nutrition goal for this Patient is to have a 4-8# /
month weight loss through healthy eating and exercise. Patient has been provided with a copy of the 1,800 calorie food guide
pyramid and the name and number of the RD for further assistance if needed. Recommend for the Patient to keep a food journal
and follow-up in 1 month.
Goal of Therapy: Weight loss through proper dietary means to achieve a healthy body weight and fat percentage.
Time with pt: 1hour
Procedure(s): -Medical Nutrition Therapy Group (2 or More Individual(s)) x 2

2. Body Mass Index
Disposition Written by WICKER-ARMOLT, JENNIFER C @ 25 Feb 2010 1230 EST

2019
Medical Record
2019
Signed By WICKER-ARMOLT, JENNIFER C (Registered Dietitian, Martin ACH, Fort Benning, GA) @ 25 Feb 2010 1230
2019
Medical Record
2019
22 Oct 2009 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by ZAGORSKI, KIM J
Encounter ID: BENN-88274 Primary Dx: LUMBAGO
Patient: WAITERS, TOMMIE Date: 22 Oct 2009 0820 EDT Appt Type: EST
ALAJANDRO
Reason for Appointment: f/u for profile update

yne
AutoCites Refreshed by MORRIS,TARA C @ 22 Oct 2009 0830 EDT

Chronic: • No Family History of mental illness (not • No Known Allergies
• Observation for suspected condition retardation)
• Recurrent major depression in partial • No Family History of alcoholism
remission • No Family History of malignant neoplasm
• Adjustment disorder with depressed of the large intestine
mood • Arteriosclerotic cardiovascular disease
• Rhinitis (ASCVD) (Mother)
• Hypermetropia • Type II diabetes mellitus (Father)
depression
exam
• Body mass index
• Abdominal pain
• Cervicalgia
• Folliculitis
• Backache
Acute:
• Nausea with vomiting
Active Medications
TRIAZOLAM (TRIAZOLAM), 0.25MG, Active NR 03 May
TABLET, ORAL, GREENSTONE LTD., 10 ea. 2009
BOTTLE
Fluoxetine Hydrochloride 20mg, Active CD 6 of 6 27 Mar
(Prozac), Capsule, Oral 2009
HYOSCYAMINE SULFATE, 0.125MG, TAB Active T1 TAB PO Q8H 2 of 2 18 Mar
SUBL, SUBLINGUAL 2009
2019
Medical Record
2019
Screening Written by MORRIS,TARA C @ 22 Oct 2009 0831 EDT

Reason For Appointment: f/u for profile update
Allergen information verified by MORRIS, TARA C @ 22 Oct 2009 0831 EDT
Vitals
Vitals Written by MORRIS,TARA C @ 22 Oct 2009 0831 EDT
BSA: 2.042 square meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 7/10 Severe, Pain Scale
Comments: Left side of abdomen
SO Note Written by ZAGORSKI,KIM JOSEPH @ 22 Oct 2009 0846 EDT

Chief complaint
The Chief Complaint is: Update profile for chronic back pain.
Also requesting follow up w/ GI for chronic abdominal pain, laproscopy 12/2008, (indeterminate).
He reported: Normal appetite. Nausea, LUQ abdominal pain, and periumbilical. No radiating abdominal pain. Crampy/colicky
abdominal pain which is chronic/recurring frequently, exacerbated by running. No jaundice, no change in stool, no diarrhea, and no
constipation.
Allergies
NKDA.
Reported History:
Medical: Reported medical history, reviewed EMR.
Surgical / procedural: Surgical / procedural history, reviewed EMR.
Reported medications: Medication history, reviewed EMR.
Personal history
Military: Military history, AD w/ Jacksonville Recruiting Batallion, stationed Warrner Robins AFB.
Review of systems
Systemic symptoms: Not feeling tired or poorly. No fever and no chills.
Cardiovascular symptoms: No chest pain or discomfort and no palpitations.
Pulmonary symptoms: No dyspnea and no wheezing.
Musculoskeletal symptoms: No arthralgias.
Neurological symptoms: No limb weakness.
Physical findings
Vital signs:
Body mass index 33.89 kg/m2
• Pain level (0-10), reviewed.
° Current vital signs reviewed. ° Normal temperature.
Vital Signs: Value
Blood pressure was normal 134/83 mmHg
Weight: Value
Weight was recorded 210 lb
A/P Written by ZAGORSKI,KIM J @ 22 Oct 2009 0857 EDT

1. LUMBAGO
GASTROENTEROLOGY CLINIC Primary Diagnosis: abdominal pain Ordered By: ZAGORSKI,KIM J
Ordering Provider: ZAGORSKI,KIM JOSEPH
2. abdominal pain
Disposition Written by ZAGORSKI,KIM J @ 22 Oct 2009 0857 EDT

2019
Medical Record
2019
Signed By ZAGORSKI, KIM J (Physician, Martin ACH, Fort Benning, GA) @ 22 Oct 2009 0857
2019
Medical Record
2019
13 Oct 2009 at Martin ACH, Fort Benning, GA, CTMC Ambulatory Primary Clinic by
SNODDY, ROBERT O
Encounter ID: CDR-74423596 Primary Dx: Nausea with vomiting
Patient: WAITERS, TOMMIE Date: 13 Oct 2009 0644 EDT Appt Type: ACUT
ALAJANDRO
Treatment Facility: FT. BENNING Clinic: CTMC AMBULATORY PRIMARY Provider: SNODDY,ROBERT O JR
BATTALION AID STATION CLINIC
Reason for Appointment: upset stomach /vomiting
AutoCites Refreshed by SNODDY, ROBERT O @ 13 Oct 2009 0655 EDT

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
INFECTION
• Body Mass Index
exam
EPISODE
DISEASE
(periumbilical)
EPISODE MODERATE
HYPERMETROPIA
• RHINITIS
DEPRESSED MOOD
Active Medications

ORAL, GREENSTONE LTD., 10 ea. BOTTLE
Oral
2019
Medical Record
2019
HYOSCYAMINE SULFATE, 0.125MG, TAB SUBL, Active T1 TAB PO Q8H 2 of 2 18 Mar 2009
SUBLINGUAL
Screening Written by HANKERSON, BENJAMIN @ 13 Oct 2009 0650 EDT
Allergen information verified by HANKERSON, BENJAMIN @ 13 Oct 2009 0650 EDT
Vitals
Vitals Written by HANKERSON, BENJAMIN @ 13 Oct 2009 0645 EDT
T: 98.2 °F, HT: 66 in, WT: 200 lbs, SupBP: 129/82 , SupHR: 67 , SitBP: 124/83 , SitHR: 76 , StaBP: 117/82 , StaHR: 76 , BMI:
32.28, BSA: 2 square meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 2/10 Mild, Pain Scale Comments: lower abdomen
Comments: not deployment related
meds reviewed
assessment completed 10/13/2009
SO Note Written by SNODDY,ROBERT O JR @ 13 Oct 2009 0703 EDT

Chief complaint
The Chief Complaint is: Nausea and vomiting for 24 hours.
He reported: Medication list reviewed.
Nausea, vomiting last at 4 AM this Am, and crampy/colicky abdominal pain right side of abdomen without radiation. No
hematochezia. No diarrhea.
No fever.
Reported History:
Medical: Reported medical history previous RX for H. Pylori gastritis in last 6 months.
Surgical / procedural: Surgical / procedural history appendectomy 1991.
Review of systems
Otolaryngeal symptoms: No sore throat.
Pulmonary symptoms: No cough.
Genitourinary symptoms: No genitourinary symptoms.
Neurological symptoms: No dizziness and no lightheadedness.
Physical findings
Vital signs:
General appearance:
• General appearance: ° Awake. ° Alert. ° Well hydrated. ° In no acute distress. ° Not ill-appearing.
Neck:
Pharynx:
Mucosal Findings: ° Pharynx had no mucosal abnormalities.
Abdomen:
Auscultation: ° Abdominal auscultation revealed no abnormalities.
Percussion: ° Abdominal percussion was normal.
Palpation: • Abdominal palpation revealed abnormalities mild right upper and lower tenderness without rebound, no mass, BS+.
Skin:
° Turgor was normal.
A/P Written by SNODDY, ROBERT O @ 13 Oct 2009 0706 EDT

1. nausea with vomiting: Probably acute gastroenteritis. Clear liquids until nausea resolves, precautions discussed.
Medication(s): -ONDANSETRON (ZOFRAN)--PO 4MG TAB - 1 Q 6 HOURS PRN NAUSEA #12 RF0 Qt: 12 Rf: 0
Ordering Provider: SNODDY, ROBERT O
Disposition Written by SNODDY, ROBERT O @ 13 Oct 2009 0706 EDT

Sick at Home / Quarters - for 48 Hours
Follow up: as needed . - Comments: Meds reconciled
2019
Medical Record
2019
Signed By SNODDY,ROBERT O JR (Physician, Winder TMC Martin ACH, Fort Benning, GA) @ 13 Oct 2009 0706
Note Written by YOUNGBLOOD, COSANDRA L @ 14 Oct 2009 1014 EDT

RESPECT-Mil screening
MEDCOM FORM 774 positive for depression and PTSD. No additional paperwork attached, reviewed by the Provider.
2019
Medical Record
2019
21 Aug 2009 at Martin ACH, Fort Benning, GA, ER by REEDY, GARY W
Encounter ID: CDR-71751999 Primary Dx: Observation For Suspected Condition
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: EMERGENCY ROOM Provider: REEDY,GARY W
AutoCites Refreshed by REEDY, GARY W @ 21 Aug 2009 0410 EDT

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
INFECTION
• Body Mass Index
exam
EPISODE
• MARITAL PROBLEM
DISEASE
(periumbilical)
EPISODE MODERATE
HYPERMETROPIA
• RHINITIS
DEPRESSED MOOD
Active Medications

ORAL, GREENSTONE LTD., 10 ea. BOTTLE
Oral
CLONAZEPAM, 0.5MG, TABLET, ORAL Active T.5 TAB PO QAM AND T1 1 of 1 27 Mar 2009
TAB PO QHS PRN
2019
Medical Record
2019
SUBLINGUAL
SO Note Written by REEDY,GARY W @ 21 Aug 2009 0410 EDT

Subjective
A/P Written by REEDY, GARY W @ 21 Aug 2009 0411 EDT

Disposition Written by REEDY, GARY W @ 21 Aug 2009 0411 EDT

Signed By REEDY,GARY W (SR Physician Assistant, 75th Ranger Regiment) @ 21 Aug 2009 0411
Note Written by NIKSADAT, SUSAN M @ 21 Aug 2009 1413 EDT

er visit
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
03 Apr 2009 at Martin ACH, Fort Benning, GA, FMC Red Clinic by ZAGORSKI, KIM J
Encounter ID: BENN-5850 Primary Dx: RHINITIS
Patient: WAITERS, TOMMIE Date: 03 Apr 2009 0820 EDT Appt Type: EST
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC STAFF CLINIC Provider: ZAGORSKI,KIM JOSEPH
Reason for Appointment: update profile

sid
AutoCites Refreshed by ZAGORSKI,KIM J @ 03 Apr 2009 0843 EDT

Problems Allergies
Chronic: • No Known Allergies
• Hypermetropia
depression
exam
• Body mass index
• Abdominal pain
• Cervicalgia
• Folliculitis
• Backache
Acute:
• Marital problem
Active Medications
CLONAZEPAM, 0.5MG, TABLET, ORAL Active T.5 TAB PO QAM AND T1 1 of 1 27 Mar
TAB PO QHS PRN 2009
Fluoxetine Hydrochloride 20mg, Active CD 6 of 6 27 Mar
(Prozac), Capsule, Oral 2009
HYOSCYAMINE SULFATE, 0.125MG, TAB Active T1 TAB PO Q8H 2 of 2 18 Mar
SUBL, SUBLINGUAL 2009
Vitals
Vitals Written by SIBLEY,ANGELA L @ 03 Apr 2009 0828 EDT
BP: 148/85, HR: 85, RR: 18, T: 100.2 °F, HT: 66 in, WT: 208.4 lbs, BMI: 33.64, BSA: 2.035 square
meters, Tobacco Use: No, Alcohol Use: No,
Pain Scale: 6/10 Moderate, Pain Scale Comments: stomach
SO Note Written by ZAGORSKI,KIM JOSEPH @ 03 Apr 2009 0925 EDT
2019
Medical Record
2019
Chief complaint
The Chief Complaint is: Upper Respiratory Infection.
He reported: Past medical history reviewed and medication list reviewed with patient.
No earache. Yellow nasal discharge and sneezing.
Cough. Cough not causing awakening from sleep. Not coughing up sputum.
Visit is not deployment-related. No sinus pain.
Allergies
No allergies.
Diagnosis History:
No sinusitis.
No pneumonia
No asthma
Personal history
Review of systems
Systemic symptoms: No fever.
Head symptoms: No headache.
Otolaryngeal symptoms: No sore throat.
Gastrointestinal symptoms: No vomiting.
Musculoskeletal symptoms: No myalgias.
Physical findings
Vital signs:
General appearance:
° Alert. ° In no acute distress. ° Not acutely ill.
Neck:
Eyes:
General/bilateral:
External Eye: ° No hyperemia of the conjunctiva. ° No discharge from the conjunctiva.
Ears:
General/bilateral:
Nose:
General/bilateral:
Nasal Discharge: • Seen.
Cavity: • Nasal mucosa edematous.
Upper Airway:
° Flaring nasal alae were not observed. ° No stridor was observed.
Oral cavity:
Pharynx:
Oropharynx: • Posterior pharyngeal wall was erythematous. ° Tonsils were not inflamed. ° Tonsils showed no exudate.
Mucosal Findings: ° Pharynx had no exudate.
Lymph Nodes:
Lungs:
Lab Result Cited by SIBLEY,ANGELA L @ 03 Apr 2009 0832 EDT

Urea Nitrogen Site/Specimen 18 Mar 2009 1637Units Ref Rng
Lab Result Cited by SIBLEY,ANGELA L @ 03 Apr 2009 0831 EDT

Creatinine Site/Specimen 18 Mar 2009 1637Units Ref Rng
2019
Medical Record
2019
A/P Written by ZAGORSKI,KIM J @ 03 Apr 2009 0847 EDT

1. RHINITIS
Medication(s): -GUAIF/P-EPHED (MUCINEX D)--PO 600MG/60MG - 1 PO BID #36 RF0 Qt: 36 Rf: 0 Ordered By:
-LORATADINE (CLARITIN) 10MG TAB--PO 10MG - TD #90 RF0 Qt: 90 Rf: 0 Ordered By:
Disposition Written by ZAGORSKI,KIM J @ 03 Apr 2009 0927 EDT

Follow up: as needed . - Comments: Could not access profile data. Requires Perm profile w/ board.
Signed By ZAGORSKI, KIM J (Physician, Martin ACH, Fort Benning, GA) @ 03 Apr 2009 0927
2019
Medical Record
2019
01 Apr 2009 at Martin ACH, Fort Benning, GA, Optometry by STOWE, JENNIFER S
REFRACTIVE ERROR -
Encounter ID: CDR-61304748 Primary Dx:
HYPERMETROPIA
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: OPTOMETRY Provider: STOECKLIN,JENNIFER L
Reason for Appointment: eye exam

cjbh rt eye exam
AutoCites Refreshed by STOECKLIN, JENNIFER S @ 01 Apr 2009 0850 EDT

• abdominal pain
INFECTION
• Body Mass Index
exam
EPISODE
• MARITAL PROBLEM
DISEASE
EPISODE MODERATE
Active Medications

Oral
CLONAZEPAM, 0.5MG, TABLET, ORAL Active T.5 TAB PO QAM AND T1 1 of 1 27 Mar 2009
TAB PO QHS PRN
SUBLINGUAL
Expired Medications
Expired Medications Status Sig Refills Left Last Filled

Iopamidol 61%, Solution, Injection Expired USE AS DIRECTED FOR NR 27 Mar 2009
CONTRAST MEDIA
2019
Medical Record
2019
Hydrocortisone + Neomycin Sulfate + Polymyxin B Expired PUT 2 DROPS IN EAR(S) NR 20 Jan 2009
Sulfate, Suspension, Otic Q6H
CODEINE PHOS/ACETAMINOPHEN, 30-300MG, Expired T1 TAB PO Q6H NR 20 Jan 2009
TABLET, ORAL
Maalox/Donnatal/Lidocaine Solution 3:2:1 Oral Expired T 30 CC PO TID NR 20 Jan 2009
CLARITHROMYCIN, 500MG, TABLET, ORAL Expired T1 BID F14 #28 RF0 NR 15 Jan 2009
AMOXICILLIN TRIHYDRATE, 500MG, CAPSULE, Expired T2 CAPS BID F14 NR 15 Jan 2009
ORAL
Omeprazole 20mg, Extended release capsule, Expired T1 CAP PO BID F14 NR 15 Jan 2009
Oral
Esomeprazole Magnesium Trihydrate 40mg, Expired CHS NR 03 Dec 2008
Capsule, Oral
Iopamidol 61%, Solution, Injection Expired USE AS DIRECTED FOR NR 26 Nov 2008
CONTRAST MEDIA
Esomeprazole Magnesium Trihydrate 20mg, Expired CD NR 26 Nov 2008
Capsule, Oral
Ondansetron Hydrochloride 8mg, (Zofran), Tablet, Expired T1 TAB PO Q8H PRN FOR NR 26 Nov 2008
Oral NAUSEA #10 RF0
TRAMADOL HCL, 50MG, TABLET, ORAL Expired TAKE 1 TAB PO Q 4-6 H NR 02 Nov 2008
PRN FOR PAIN
DOCUSATE SODIUM, 100MG, CAPSULE, ORAL Expired T1 CAP BID NR 19 May 2008
Oxycodone Hydrochloride + Acetaminophen, Expired T1-2 TABS Q4-6H PP NR 19 May 2008
Tablet, Oral
TRAMADOL HCL, 50MG, TABLET, ORAL Expired T 1-2 TABS PO QID PRN NR 21 Apr 2008
FOR PAIN
TRAMADOL HCL, 50MG, TABLET, ORAL Expired T1-2 TABS PO Q6H PP #30 NR 20 Mar 2008
RF0
METOCLOPRAMIDE HCL, 10MG, TABLET, ORAL Expired T1 TAB PO TID #15 RF0 NR 20 Mar 2008
Oxycodone Hydrochloride + Acetaminophen, Expired T 1-2 TABS Q4-6H PP #15 NR 15 Mar 2008
Tablet, Oral
Gadopentetate Dimeglumine 496.01mg/mL, Expired U UD FOR CONTRAST NR 11 Mar 2008
Solution, Injection MEDIA
DICYCLOMINE HCL, 20MG, TABLET, ORAL Expired T1 TAB PO Q6H PRN F NR 09 Mar 2008
ABDOMINAL PAIN
Codeine Phosphate + Guaifenesin, Syrup, Oral Expired TAKE 1-2 TSP Q4-6H PRN F NR 07 Mar 2008
COUGH
IBUPROFEN, 800MG, TABLET, ORAL Expired T1 TAB PO TID WF NR 07 Mar 2008
ACETAMINOPHEN, 325MG, TABLET, ORAL Expired TAKE 1 TO 2 TABLETS Q4- NR 07 Mar 2008
6H NOT TO EXCEED 12
TABLETS PER DAY
IBUPROFEN, 800MG, TABLET, ORAL Expired TT WF #30 NR 26 Jan 2008
METHOCARBAMOL, 500MG, TABLET, ORAL Expired T2 TAB QID #40 RF5 5 of 5 26 Jan 2008
Cephalexin 250mg + Cephalexin Monohydrate, Expired T1 CAP Q6H OR QID F10D NR 09 Jan 2008
Capsule, Oral
MELOXICAM, 7.5MG, TABLET, ORAL Expired T1 TAB PO BID F 7 DAYS 1 of 1 16 Oct 2007
THEN 1 TAB PO QD
ACETAMINOPHEN, 325MG, TABLET, ORAL Expired T1-2 TABS PO Q4-6H PRN NR 11 Oct 2007
**MAX OF 12 TABS PER
DAY**
Ceftriaxone Sodium 20mg/mL + Dextrose, Iso- Expired 1GM IV IN ER NR 14 Sep 2007
osmotic, Solution, Intravenous, 50mL
Albuterol Sulfate 0.83mg/mL + Ipratropium Expired NEB TX IN ER X1 NR 14 Sep 2007
Bromide 0.5mg/3mL, Solution, Inhalation
ACETAMINOPHEN, 650MG, SUPP.RECT, Expired 650MG PR X1 IN ER NR 14 Sep 2007
RECTAL
Metoclopramide 5mg/5mL, Syrup, Oral Expired 10MG IV GIVEN IN ER NR 14 Sep 2007
Azithromycin 250mg, (Zithromax Z-Pak), Tablet, Expired TAKE 2 TABLETS AT ONCE NR 11 Sep 2007
Oral ON DAY 1, THEN TAKE 1
TABLET DAILY ON DAYS 2-
5.
Pseudoephedrine Hydrochloride 120mg + Expired TBD NR 11 Sep 2007
Guaifenesin 600mg, Extended release tablet, Oral
Albuterol 90mcg, Aerosol powder, Inhalation Expired INHALE 2 PUFFS PRN QID NR 11 Sep 2007
#1 RF0
IBUPROFEN, 800MG, TABLET, ORAL Expired T1 TAB PO TID PFP NR 08 Jul 2007
DESLORATADINE, 5MG, TABLET, ORAL Expired T1 TAB BID FOR ALLERGY NR 05 Dec 2005
BISMUTH SUBSALICYLATE, 262MG, TAB Expired CHEW 1 TAB PO QH UNTIL NR 10 Dec 2004
CHEW, ORAL RELIEF **MAX 8 TAB PER
2019
Medical Record
2019
DAY** #24 RF0

Cefazolin Sodium 1g, Reconstituted solution, Expired NR Not Recorded
Injection
Cefazolin Sodium 1g, Reconstituted solution, Expired NR Not Recorded
Injection
Vitals
Vitals Written by KAY,CHRISTOPHER MICHEAL @ 18 Mar 2009 1458 EDT
BP: 134/79, HR: 78, RR: 17, T: 98.1 °F, HT: 66 in, WT: 200 lbs, BMI: 32.28, BSA: 2 square meters, Tobacco Use: No, Alcohol Use:
No, Pain Scale: 7/10 Severe, Pain Scale Comments: Pt states he currently has pain in his ULQ 7.5/10.
Comments: cmk
Questionnaire AutoCites Refreshed by STOECKLIN, JENNIFER S @ 01 Apr 2009 0850 EDT

Questionnaires
No Questionnaires Found.
SO Note Written by STOECKLIN,JENNIFER L @ 01 Apr 2009 0954 EDT

Chief complaint
The Chief Complaint is: Routine eye exam.. No c/o eye pain.
He reported: No worsening near vision, no difficulty seeing at night, no diplopia, no blurred vision at far, and no photopsia.
Reported History:
Past medical history see old nores.
Physical findings
Vital signs:
° Current vital signs reviewed Allergies and Autocite reviewed.
General appearance:
Eyes:
General/bilateral:
Visual Assessment: • Cycloplegic drops used also with Proparacaine HCL 0.5% OU. • Cycloplegia using tropicamide was
performed. • Cycloplegia using tropicamide: binocular.
Intraocular Pressure: ° Normal IOP nct od: 15 os: 16 @ 9:00. ° Normal NCT IOP.
Pupils: ° PERRLA. ° No Marcus Gunn pupil was seen.
External Eye: ° Showed no abnormalities. ° Eyelids showed no abnormalities. ° Conjunctiva exhibited no abnormalities.
Sclera: ° Normal.
Cornea: ° Normal.
Anterior Chamber: ° Angles had no abnormalities present
OD - OPEN AND QUIET
OS - OPEN AND QUIET.
Uveal Tract: ° Normal.
Lens: ° Normal.
Vitreous: ° Normal.
Optic Disc: ° Normal od: 0.35/0.35 os: 0.3/0.35.
Retina: ° Normal. ° Macula was normal Flat with foveal light reflex. ° Vessels were normal A/V ratio 2/3 in both eyes.
Visual Fields Exam: ° Peripheral vision was full to confrontation bilaterally by simultaneous, central, finger counting.
Right eye:
Visual Assessment: • Distance right acuity without Rx: 20/ 20-2. • Distance manifest: right:
OD: +0.50ds 20/20 pl 20/20.
Left eye:
Visual Assessment: • Left distance acuity without Rx: / 20. • Distance manifest: left:
OS: +0.75-0.50x 125 20/20 pl 20/20.
Objective
Patient education on effects of dilation drops and agrees to continue with dilation.. Referance DA FORM 4700 Optometry Routine
Exam Form.
Lab AutoCites Refreshed by STOECKLIN, JENNIFER S @ 01 Apr 2009 0850 EDT

Labs
Test Name Site Specimen Result Units Ref Range
2019
Medical Record
2019
18 Mar 2009 1637

Urea Nitrogen Site Specimen Result Units Ref Range
18 Mar 2009 1637

Creatinine Site Specimen Result Units Ref Range
Rad AutoCites Refreshed by STOECKLIN, JENNIFER S @ 01 Apr 2009 0850 EDT

Rads
********** CT ABDOMEN AND PELVIS W CONTRAST,PG **********

Status: Complete
Procedure: CT ABDOMEN AND PELVIS W CONTRAST,PG

Event Date: 27-Mar-2009 11:03:00
Reason for Order:
YO MALE WITH RECURRENT PERI-UMBILICAL PAIN AND H/O MESENTERIC ADENITIS
SEVERAL MONTHS AGO WITH SOME LYMPHADENOPATHY. PLEASE EVAL FOR INTRA-
ABDOMINAL
PROCESS.
Exam #: 09029145
Exam Date/Time: 30-Mar-2009 15:15:00
Transcription Date/Time: 30-Mar-2009 16:36:00
Provider: SISK, CHAD MICHAEL
GASTROENTEROLOGY CLINIC MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Interpreted By: WYCHE, LENNON D JR
Approved By: WYCHE, LENNON D JR
Approved Date: 30-Mar-2009 16:19:00
Report Text:
CT abdomen and pelvis with contrast
HISTORY: 38 yo male with recurrent periumbilical pain and history of mesenteric

adenitis.
Contiguous axial images through the chest and abdomen at 3 and 5 mm intervals
respectively, were obtained after IV injection of Ultravist 370. Oral contrast
had already been given. No infiltrates are seen in the lower lung fields. Heart
size is normal, liver, spleen, pancreas, adrenals, gallbladder, kidneys,
inferior vena cava and aorta are within normal limits. A few scattered lymph
nodes in the mesentery, none of which measure up to 1.2 cm. Compared to earlier
CT scan dated 3/9/2008, these lymph nodes are less numerous and smaller and
there is no overall increase radiodensity to the mesentery at that time.
Today's study is more similar in appearance to 11/26/2008 the scan on the lymph
nodes are smaller less numerous than previous study from March 2008. There is
no bowel obstruction. The gallbladder is negative for stones. No obstructive
changes of the stomach. Gas and stool and contrast seen in colon. Could not
2019
Medical Record
2019
identify the appendix but no pericecal masses are identified. No obstructive

changes of the small bowel or colon.
CONCLUSION: 1. Stable appearance since 11/26/2008 CT scan showing scattered

mesenteric lymph nodes but none are greater than 1.2 cm and they are unchanged
in appearance since last study of 11/26/2008. 2. No increase density of the
mesentery seen at this time. 3. No small bowel or colonic obstruction. 4. No
renal mass or renal obstruction. 5. Could not identify the appendix but no
pericecal masses are seen. 6. No gallstones or pancreatitis identified.
A/P Written by STOECKLIN, JENNIFER S @ 01 Apr 2009 0956 EDT

1. REFRACTIVE ERROR - HYPERMETROPIA: Glasses Ordered
Disposition Written by STOECKLIN, JENNIFER S @ 01 Apr 2009 0956 EDT

Follow up: as needed in 12 month(s) or sooner if there are problems.
Signed By STOECKLIN, JENNIFER S (O.D. F.A.A.O, Martin ACH, Fort Benning, GA) @ 01 Apr 2009 0956
2019
Medical Record
2019
18 Mar 2009 at Martin ACH, Fort Benning, GA, Gastroenterology Clinic by SISK, CHAD M
Abdominal pain around the belly button

(periumbilical)
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: GASTROENTEROLOGY CLINIC Provider: SISK,CHAD MICHAEL
Reason for Appointment: f/u

kfc/talk to pt. 5mar.09
AutoCites Refreshed by KAY, CHRISTOPHER MICHEAL @ 18 Mar 2009 1456 EDT

• abdominal pain
INFECTION
• Body Mass Index
exam
EPISODE
• MARITAL PROBLEM
DISEASE
Active Medications
No Active Medications Found.
Screening Written by KAY, CHRISTOPHER MICHEAL @ 18 Mar 2009 1458 EDT
Allergen information verified by KAY, CHRISTOPHER MICHEAL @ 18 Mar 2009 1458 EDT
Vitals
Vitals Written by KAY, CHRISTOPHER MICHEAL @ 18 Mar 2009 1458 EDT
BP: 134/79, HR: 78, RR: 17, T: 98.1 °F, HT: 66 in, WT: 200 lbs, BMI: 32.28, BSA: 2 square
meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 7/10 Severe, Pain Scale Comments: Pt
states he currently has pain in his ULQ 7.5/10.
Comments: cmk
SO Note Written by SISK,CHAD MICHAEL @ 18 Mar 2009 1544 EDT

Chief complaint
The Chief Complaint is: GI Complaint: persistent peri-umbilical pain.
2019
Medical Record
2019

Gastrointestinal symptoms. Appetite not decreased. No pain on swallowing, no heartburn, no nausea, and no vomiting.
Abdominal pain periumbilical. No radiating abdominal pain. Steady, severe abdominal pain which is chronic/recurring frequently.
Abdominal pain does not gradually resolve on its own. No jaundice, no bowel urgency, no change in stool, no bright red blood per
rectum, and no diarrhea.
Depression as a chronic condition.
Visit is not deployment-related. No systemic symptoms, no fever, and no chills. No headache. No otolaryngeal symptoms.
No cardiovascular symptoms. No pulmonary symptoms. No genitourinary symptoms and no oliguria. No endocrine symptoms. No
hematologic symptoms. No musculoskeletal symptoms. No neurological symptoms. No skin symptoms.
Reported History:
Medical: No previous hospitalizations. Past medical history was reported by the patient as noted above.
Surgical / procedural: No surgical / procedural history.
Reported prior tests: Prior tests were performed as previously noted.
Exposure: No exposure.
Physical trauma: No physical trauma and no trauma to the abdomen.
Dietary: No reported dietary history.
Diagnosis History:
Personal history
Family history
Family history reviewed.
Review of systems
Gastrointestinal symptoms: No hematemesis, no hematemesis ('coffee grounds'), no flatus, no melena, no hematochezia, no red
blood on the surface of the stool, and no mucus in the stool. No constipation.
Genitourinary symptoms: Urine is not dark or cloudy. No dysuria and no pain in the flank.
Physical findings
( ) Oburator Sign Negative
( ) Heel Tap Negative
( x ) Psoas Sign Negative.
Vital signs:
General appearance:
° Alert. ° Well developed. ° Well nourished. ° Well hydrated. ° In no acute distress. ° Patient did not appear uncomfortable.
Neck:
Oral cavity:
Buccal Mucosa: ° Moist.
Lymph Nodes:
Lungs:
° Chest did not demonstrate dullness to percussion. ° Clear to auscultation.
Abdomen:
Palpation: ° Abdomen was soft. ° Abdominal muscle guarding was not demonstrated. ° Abdominal muscle rigidity was not
demonstrated. ° No direct tenderness in the abdomen. ° No rebound tenderness in the abdomen. ° Murphy's sign was
not observed. ° No mass was palpated in the abdomen.
Hepatic Findings: ° Liver was not enlarged. ° Liver was not tender.
Splenic Findings: ° Spleen was not enlarged. ° Spleen was not tender.
Neurological:
° System: normal.
Psychiatric Exam:
° Normal.
Appearance: ° Normal.
Demonstrated Behavior: ° Behavior demonstrated no abnormalities.
Mood: ° Euthymic.
2019
Medical Record
2019
Affect: ° Normal.
Skin:
° Normal. ° General appearance was normal. ° Color and pigmentation were normal.
A/P Written by SISK,CHAD M @ 18 Mar 2009 1549 EDT

1. abdominal pain around the belly button (periumbilical): History of mesenteric adenitis, ?etiology in the past. Records
revieweed. s/p therapy for h.pylori with no change in s/s. r/o other pathology, recurrent adenitis, ?IBS.
Medication(s): -HYOSCYAMINE (LEVSIN) 0.125MG--SL 0.125MG - T1 Q8H #60 RF2 Qt: 60 Rf: 2 Ordered By:
SISK,CHAD M Ordering Provider: SISK, CHAD MICHAEL
Radiology(ies): -CT ABD W/WO CONTRAST (ASAP) Ordered By: SISK,CHAD M Ordering Provider: SISK, CHAD
MICHAEL Impression: 38 y/o male with recurrent peri-umbilical pain and history o
2. Helicobacter pylori (H. pylori) infection: s/p therapy for h.pylori, with no improvement in his chronic abdominal pain. Do not
think h.pylori is the root of his problems.
3. Anxiety disorder NOS: Seems to havee some personal/work stress which may be aggrevating his GI issues. Continue f/u with
psychology as planned.
Disposition Written by SISK,CHAD M @ 18 Mar 2009 1549 EDT

Follow up: 2 to 3 week(s) in the GASTROENTEROLOGY CLINIC clinic or sooner if there are problems.
Signed By SISK, CHAD M (Chief, Gastroenterology Service, Martin ACH, Fort Benning, GA) @ 18 Mar 2009 1550
2019
Medical Record
2019
26 Jan 2009 at Martin ACH, Fort Benning, GA, FMC Yellow Clinic by HIGDON, MARK L
Encounter ID: CDR-55120700 Primary Dx: Visit for: military services physical
Patient: WAITERS, TOMMIE Date: 26 Jan 2009 1305 EST Appt Type: WELL
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC TEACHING CLINIC Provider: HIGDON,MARK LOWELL
Reason for Appointment: part 3 physical

kts
AutoCites Refreshed by HIGDON, MARK L @ 26 Jan 2009 1256 EST

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
INFECTION
• Body Mass Index
Active Medications

Esomeprazole Magnesium Trihydrate 40mg, Active CHS NR 03 Dec 2008
Capsule, Oral
Vitals
Vitals Written by EDMONDS,TONIA T @ 21 Jan 2009 1352 EST
BP: 122/83, HR: 74, RR: 20, T: 97.8 °F, HT: 66 in, WT: 211.0 lbs, BMI: 34.06, BSA: 2.046 square meters, Tobacco Use: No,
Alcohol Use: No, Pain Scale: 7/10 Severe, Pain Scale Comments: abdomen
Comments: Not related to deployment
Meds have been reconciled

Vitals Written by WICKER-ARMOLT, JENNIFER C @ 14 Jan 2009 1457 EST
HT: 66.5 in, WT: 217.5 lbs, BMI: 34.58, BSA: 2.084 square meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 0 Pain Free
Comments: Weight in uniform and boots.
Vitals Written by KAY, CHRISTOPHER MICHEAL @ 23 Dec 2008 1015 EST
Pain Scale: 7/10 Severe, Pain Scale Comments: Pt states he currently has a headache 6/10 and ULQ abdominal pain 6/10.
Comments: cmk
Vitals Written by GRACE, DAISY V @ 02 Dec 2008 1117 EST
BP: 131/88, HR: 109, RR: 22, T: 98.8 °F, WT: 212.3 lbs, Tobacco Use: No, Alcohol Use: No, Pain Scale: 0 Pain Free
Vitals Written by KELLIERROBERTS,KEREAN P @ 01 Dec 2008 1511 EST
BP: 137/80 Left Arm, Adult Cuff, HR: 86 Apical, Regular, RR: 20, T: 99.5 °F Oral, HT: 66 in Stated, With Shoes, WT: 204 lbs, BMI:
32.93, BSA: 2.017 square meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 7/10 Severe, Pain Scale Comments: abd
Vitals Written by BRYSON, CAROLYN E. @ 04 Nov 2008 1148 EST
BP: 139/80, HR: 77, T: 98.9 °F, WT: 214 lbs, SpO2: 95%, Pain Scale: 7/10 Severe, Pain Scale Comments: abdomen
Comments: medical record not avail
2019
Medical Record
2019
Vitals
Vitals Written by HIGDON, MARK L @ 26 Jan 2009 1327 EST
Comments: Med Reconciliation Completed

Vitals Written by HIGDON, MARK L @ 26 Jan 2009 1326 EST
BP: 144/83, HR: 73, RR: 14, T: 98.3 °F, Tobacco Use: No, Alcohol Use: No, Pain Scale: 5/10 Moderate, Pain Scale Comments:
Abdomen
SO Note Written by HIGDON,MARK LOWELL @ 26 Jan 2009 1329 EST

Chief complaint
The Chief Complaint is: PHA physical (see online form).
He reported: Past medical history reviewed, problem list reviewed, medication list reviewed, family history reviewed, and
surgical history reviewed.
Review of systems
Completed PHA online.
Physical findings
Vital signs:
General appearance:
° Well-appearing. ° Not acutely ill.
Eyes:
General/bilateral:
External Eye: ° Showed no abnormalities.
Sclera: ° Normal.
Ears:
General/bilateral:
° Ears: normal.
Nose:
General/bilateral:
° Nose: normal.
Oral cavity:
° Normal.
Lymph Nodes:
° Normal.
Lungs:
Auscultation: ° Normal.
Lab Result Cited by HIGDON, MARK L @ 26 Jan 2009 1312 EST

Hemogram+Differential Auto Site/Specimen 21 Jan 2009 1524
WBC BLOOD 5.4
RBC BLOOD 5.47
MCV BLOOD 84.1
MCH BLOOD 28.9
MCHC BLOOD 34.3
RDW CV BLOOD 12.8
MPV BLOOD 9.9
Platelets BLOOD 222
Monocytes BLOOD 0.6
Monocytes BLOOD 11.8 (H)
Basophils BLOOD 0.0
Basophils BLOOD 0.9
2019
Medical Record
2019

MTF/Facility Units
Lipids Site/Specimen 21 Jan 2009 1524 Units
Cholesterol PLASMA 192 mg/dL
HDL Cholesterol PLASMA 52 mg/dL
LDL Cholesterol PLASMA 118 mg/dL
Triglyceride PLASMA 110 mg/dL

Metabolic Panel Comprehensive Site/Specimen 21 Jan 2009 1524
Albumin PLASMA 3.7
Calcium PLASMA 9.0
Chloride PLASMA 103
Protein PLASMA 7.9
Sodium PLASMA 140
Anion Gap PLASMA 8.4 (L) 
A/P Written by HIGDON, MARK L @ 26 Jan 2009 1320 EST

1. visit for: military services physical(PERIODIC PREVENTION EXAMINATION): PHA completed. Undergoing work-up with GI
and Gen Surg currently due to possible lymphoma vs mastocytosis.
Medication(s): -ASPIRIN--PO 81MG TBEC - TAKE 1 TAB PO QD #90 RF3 Qt: 90 Rf: 3 Ordered By: HIGDON, MARK
L
Consult(s): -Referred To: PSYCHIATRY COUNSELING CONSULT (Routine) Specialty: Clinic: OUTPATIENT
PSYCHIATRY Primary Diagnosis: Eval for PTSD Ordered By: HIGDON, MARK L
2. Blood Pressure Isolated Elevated: Recommend weight loss and low salt diet. No evidence of end organ damage per lab
review or historical data.
Disposition Written by HIGDON, MARK L @ 26 Jan 2009 1329 EST

Follow up: 1 month(s) with PCM or sooner if there are problems. - Comments: follow up for elevated blood pressure
Signed By HIGDON, MARK L (LTC, MC, Martin ACH, Fort Benning, GA) @ 26 Jan 2009 1332
2019
Medical Record
2019
21 Jan 2009 at Martin ACH, Fort Benning, GA, FMC Red Clinic by JOYCE, MARK T.
Encounter ID: CDR-55446037 Primary Dx: Laboratory Studies
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC STAFF CLINIC Provider: JOYCE,MARK T
Reason for Telephone Consult: laboratory
AutoCites Refreshed by ZAGORSKI, KIM J @ 21 Jan 2009 1845 EST

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
INFECTION
• Body Mass Index
Active Medications

Hydrocortisone + Neomycin Sulfate + Polymyxin B Active PUT 2 DROPS IN EAR(S) NR 20 Jan 2009
CODEINE PHOS/ACETAMINOPHEN, 30-300MG, Active T1 TAB PO Q6H NR 20 Jan 2009
TABLET, ORAL
Maalox/Donnatal/Lidocaine Solution 3:2:1 Oral Active T 30 CC PO TID NR 20 Jan 2009
CLARITHROMYCIN, 500MG, TABLET, ORAL Active T1 BID F14 #28 RF0 NR 15 Jan 2009
AMOXICILLIN TRIHYDRATE, 500MG, CAPSULE, Active T2 CAPS BID F14 NR 15 Jan 2009
ORAL
Omeprazole 20mg, Extended release capsule, Active T1 CAP PO BID F14 NR 15 Jan 2009
Oral
Capsule, Oral
METHOCARBAMOL, 500MG, TABLET, ORAL Active T2 TAB QID #40 RF5 5 of 5 26 Jan 2008
Lab Result Cited by ZAGORSKI, KIM J @ 21 Jan 2009 1845 EST

Interpretations
Rng
WBC BLOOD 5.4 x10(3)/mcL (4.9-10.0)
RBC BLOOD 5.47 x10(6) (4.7-6.1)
MCHC BLOOD 34.3 % (32-36)
2019
Medical Record
2019
RDW CV BLOOD 12.8 % (11.5-14.5)

Monocytes BLOOD 11.8 (H) % (0-10)

Interpretations
Rng
Lipids Site/Specimen 21 Jan 2009 1524 Units Ref Rng
Cholesterol PLASMA 192 mg/dL (0-199)

Interpretations
Rng
Metabolic Panel Comprehensive Site/Specimen 21 Jan 2009 1524 Units Ref Rng
A/P Written by ZAGORSKI, KIM J @ 21 Jan 2009 1845 EST

1. Laboratory Studies
Disposition Last updated by JOYCE, MARK T. @ 29 Jan 2009 1115 EST

Follow up: with PCM. - Comments: Pt seen by Dr. higdon on 26 Jan 09 and discussedl lab results
Discussed: Medication(s)/Treatment(s) with Patient who indicated understanding.
Note Written by ZAGORSKI, KIM J @ 21 Jan 2009 1845 EST

Nursing Instruction
Mark. Please notify patient of normal lipids / glucose / CBC. KJZ
Signed By JOYCE, MARK T. (Nurse, Martin ACH, Fort Benning, GA) @ 29 Jan 2009 1115
_________________________________________________________________________________________________________
2019
Medical Record
2019
CHANGE HISTORY
The following Disposition Note Was Overwritten by JOYCE, MARK T. @ 29 Jan 2009 1115 EST:
The Disposition section was last updated by JOYCE, MARK T. @ 29 Jan 2009 1115 EST - see above.Previous Version of Disposition section was entered/updated by
ZAGORSKI, KIM J @ 21 Jan 2009 1848 EST.
2019
Medical Record
2019
21 Jan 2009 at Martin ACH, Fort Benning, GA, FMC Red Clinic by CANNON, DAPHNE A

exam
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC STAFF CLINIC Provider: CANNON,DAPHNE A
Reason for Appointment: Part 2 Physical
AutoCites Refreshed by EDMONDS, TONIA T @ 21 Jan 2009 1351 EST

• abdominal pain
INFECTION
• Body Mass Index
Active Medications

Hydrocortisone + Neomycin Sulfate + Polymyxin B Active PUT 2 DROPS IN EAR(S) NR 20 Jan 2009
CODEINE PHOS/ACETAMINOPHEN, 30-300MG, Active T1 TAB PO Q6H NR 20 Jan 2009
TABLET, ORAL
Maalox/Donnatal/Lidocaine Solution 3:2:1 Oral Active T 30 CC PO TID NR 20 Jan 2009
CLARITHROMYCIN, 500MG, TABLET, ORAL Active T1 BID F14 #28 RF0 NR 15 Jan 2009
AMOXICILLIN TRIHYDRATE, 500MG, CAPSULE, Active T2 CAPS BID F14 NR 15 Jan 2009
ORAL
Omeprazole 20mg, Extended release capsule, Active T1 CAP PO BID F14 NR 15 Jan 2009
Oral
Capsule, Oral
Screening Written by EDMONDS, TONIA T @ 21 Jan 2009 1352 EST
Allergen information verified by EDMONDS, TONIA T @ 21 Jan 2009 1352 EST
Vitals
Vitals Written by EDMONDS, TONIA T @ 21 Jan 2009 1352 EST
BP: 122/83, HR: 74, RR: 20, T: 97.8 °F, HT: 66 in, WT: 211.0 lbs, BMI: 34.06, BSA: 2.046 square meters, Tobacco Use: No,
Alcohol Use: No, Pain Scale: 7/10 Severe, Pain Scale Comments: abdomen
2019
Medical Record
2019
Questionnaire AutoCites Refreshed by EDMONDS, TONIA T @ 21 Jan 2009 1351 EST

Questionnaires
A/P Written by CANNON, DAPHNE A @ 21 Jan 2009 1358 EST

1. visit for: occupational health / fitness exam(PERIODIC PREVENTION EXAMINATION)
Laboratory(ies): -LIPIDS (Routine) Ordered By: CANNON, DAPHNE A Ordering Provider: ZAGORSKI, KIM JOSEPH;
COMPREHENSIVE METABOLIC PANEL (Routine) Ordered By: CANNON, DAPHNE A Ordering
Provider: ZAGORSKI, KIM JOSEPH; HEMOGRAM AUTO+COMP AUTO DIFF (Routine) Ordered By:
CANNON, DAPHNE A Ordering Provider: ZAGORSKI, KIM JOSEPH
Disposition Written by CANNON, DAPHNE A @ 28 Jan 2009 0931 EST

Note Written by CANNON, DAPHNE A @ 28 Jan 2009 0931 EST

Appt made for part 3.
Signed By CANNON, DAPHNE A (RN, Martin ACH, Fort Benning, GA) @ 28 Jan 2009 0932
2019
Medical Record
2019
21 Jan 2009 at Martin ACH, Fort Benning, GA, FMC Red Clinic by CANNON, DAPHNE A
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC STAFF CLINIC Provider: CANNON,DAPHNE A
Reason for Telephone Consult: Part 2 Physical

Encounter Cancelled by HARVILLE, KATINA T @ 21 Jan 2009 1327 EST
2019
Medical Record
2019
14 Jan 2009 at Martin ACH, Fort Benning, GA, Nutrition by WICKER-ARMOLT,

JENNIFER C
Encounter ID: CDR-54148689 Primary Dx: Patient Education - Dietary
Patient: WAITERS, TOMMIE Date: 14 Jan 2009 1410 EST Appt Type: GRP
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: NUTRITION Provider: WICKER-ARMOLT,JENNIFER
C
AutoCites Refreshed by WICKER-ARMOLT, JENNIFER C @ 14 Jan 2009 1457 EST

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
INFECTION
Active Medications

Capsule, Oral
Screening Written by WICKER-ARMOLT, JENNIFER C @ 14 Jan 2009 1457 EST

Reason(s) For Visit (Chief Complaint): Patient Education - Dietary (New) ;
Vitals
Vitals Written by WICKER-ARMOLT, JENNIFER C @ 14 Jan 2009 1457 EST
HT: 66.5 in, WT: 217.5 lbs, BMI: 34.58, BSA: 2.084 square meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 0 Pain Free
SO Note Written by WICKER-ARMOLT,JENNIFER C @ 14 Jan 2009 1457 EST

Referred here
To attend the Weight Control Class.
Reported History:
Reported medications: Not taking dietary supplements and no vitamin supplements.
Personal history
Diet: 2 meals per day, 1 snacks per day, and irregular frequency of meals with extended periods between meals.
Habits: Exercising regularly. Moderately exercising 3+ times a week.
Physical findings
Vital signs:
Weight (Small-Large Frame, 1983 MHWT) 217.5 lbs
Body mass index 34 kg/m2
2019
Medical Record
2019
Height 168.91 cm
• Weight was recorded. • Weight was not within normal limits.
Weight: Value
Goal weight 170 lbs
• Patient was observed to be obese. ° Weight was not proportional to the height.
Weight: Value
Ideal weight 131-159 lbs
Objective
Education: (Pt attended Nutrition Clinic Weight Control Class)~Material covered: Basic principles of healthy dietary habits,
including food selection and preparation, portion control, appropriate weight loss, and benefits of exercise in weight management.
Pt demonstrated knowledge of the information by both asking and answering appropriate questions in a group setting.~Handouts
provided: Food Guide Pyramid, Folate, & Performance Nutrition.~Goal of Therapy: Achieve BMI<25 and/or body fat % IAW AR
600-9. ~Patient Goals: 1. Eat Regularly 2. Avoid fad diets and dietary supplements 3. Exercise 3-5 times per week
(minimum of 30 minutes/session) 4. Reduce portion sizes 5. Make healthy food choices~.
A/P Written by WICKER-ARMOLT, JENNIFER C @ 14 Jan 2009 1459 EST

1. Patient Education - Dietary: Pt was referred to the Nutrition Clinic for weight loss education pertaining to IAW AR 600-9. Pt was
instructed on general principles of Nutrition including; weight reduction, the food guide pyramid, food preparation methods, behavior
modification, fad diets and the importance of exercise pertaining to weight loss. The nutrition goal for this class is for the patient to
have a 4-8# / month weight loss through healthy eating and exercise. Patient has been provided with a copy of the 1,600 calorie
food guide pyramid and the name and number of the RD for further assistance if needed. Recommend for Patient to follow-up in 2-3
weeks with food journal to evaluate weight loss and food intake.
Goal of Therapy: Weight loss through proper dietary and exercise habits.
Time with pt: 1hour
Procedure(s): -Medical Nutrition Therapy Group (2 or More Individual(s)) x 2

2. Body Mass Index
Disposition Written by WICKER-ARMOLT, JENNIFER C @ 14 Jan 2009 1459 EST

Signed By WICKER-ARMOLT, JENNIFER C (Registered Dietitian, Martin ACH, Fort Benning, GA) @ 14 Jan 2009 1500
2019
Medical Record
2019
09 Jan 2009 at Martin ACH, Fort Benning, GA, Gastroenterology Clinic by SISK, CHAD M
Encounter ID: CDR-53679572 Primary Dx: GASTRITIS DUE TO H. PYLORI
ALAJANDRO
Reason for Telephone Consult: needs RX refill
AutoCites Refreshed by SISK, CHAD M @ 09 Jan 2009 1207 EST

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
INFECTION
Active Medications

Capsule, Oral
Vitals
No Vitals Found.
A/P Written by SISK, CHAD M @ 09 Jan 2009 1208 EST

1. GASTRITIS DUE TO H. PYLORI
Disposition Written by SISK, CHAD M @ 09 Jan 2009 1208 EST
Note Written by SISK, CHAD M @ 09 Jan 2009 1208 EST

Provider Telecon Note
Pt did not pick up his therapy for H.pylori previously. I re-entered for pick-up. Pt to f/u with me as planned in couple of weeks.
Signed By SISK, CHAD M (Chief, Gastroenterology Service, Martin ACH, Fort Benning, GA) @ 09 Jan 2009 1208
2019
Medical Record
2019
23 Dec 2008 at Martin ACH, Fort Benning, GA, Gastroenterology Clinic by SISK, CHAD M
HELICOBACTER PYLORI (H. PYLORI)

INFECTION
Patient: WAITERS, TOMMIE Date: 23 Dec 2008 1000 EST Appt Type: SPEC
ALAJANDRO
Reason for Appointment: abdominal pain

kfc/mailout4dec.08
AutoCites Refreshed by KAY, CHRISTOPHER MICHEAL @ 23 Dec 2008 1010 EST

• abdominal pain
Active Medications

Omeprazole 20mg, Extended release capsule, Active TAKE 1 CAP PO BID FOR 14 NR 12 Dec 2008
Oral DAYS #28 RF0
Capsule, Oral
Esomeprazole Magnesium Trihydrate 20mg, Active CD NR 26 Nov 2008
Capsule, Oral
Screening Written by KAY, CHRISTOPHER MICHEAL @ 23 Dec 2008 1012 EST
Allergen information verified by KAY, CHRISTOPHER MICHEAL @ 23 Dec 2008 1012 EST
Vitals
Pain Scale: 7/10 Severe, Pain Scale Comments: Pt states he currently has a headache 6/10 and ULQ abdominal pain 6/10.
Comments: cmk
SO Note Written by SISK,CHAD MICHAEL @ 23 Dec 2008 1105 EST

Chief complaint
The Chief Complaint is: GI Complaint: eval upper abdominal pain.
Gastrointestinal symptoms. Appetite not decreased. No dysphagia. Heartburn. No nausea and no vomiting. Bloating and
epigastric pain. No radiating abdominal pain. Dull, boring, or aching abdominal pain which is chronic/recurring frequently which is
intermittent. No regurgitation, no jaundice, no bowel urgency, and no diarrhea.
Visit is not deployment-related. No systemic symptoms, no fever, and no chills. No headache. No otolaryngeal symptoms.
No cardiovascular symptoms. No pulmonary symptoms. No genitourinary symptoms and no oliguria. No endocrine symptoms. No
2019
Medical Record
2019
hematologic symptoms. No musculoskeletal symptoms. No neurological symptoms. No psychological symptoms. No skin

symptoms.
Reported History:
Medical: No previous hospitalizations. Past medical history was reported by the patient as noted above.
Surgical / procedural: Surgical / procedural history Ex Lap.
Reported prior tests: Prior tests were performed Ex lap, EGD.
Diagnosis History:
Personal history
Habits: Exercising regularly.
Family history
Review of systems
Gastrointestinal symptoms: No hematemesis and no hematemesis ('coffee grounds'). Abdominal pain. No flatus, no melena, no
hematochezia, no red blood on the surface of the stool, and no mucus in the stool. No constipation.
Physical findings
Vital signs:
General appearance:
° Alert. ° Well developed. ° Well nourished. ° Well hydrated. ° In no acute distress. ° Patient did not appear uncomfortable.
Neck:
Oral cavity:
Lymph Nodes:
Lungs:
Abdomen:
Palpation: ° Abdomen was soft. ° Abdominal muscle guarding was not demonstrated. ° Abdominal muscle rigidity was not
demonstrated. ° No direct tenderness in the abdomen. ° No rebound tenderness in the abdomen. ° Murphy's sign was
not observed. ° No mass was palpated in the abdomen.
Neurological:
° System: normal.
Psychiatric Exam:
° Normal.
Skin:
° Normal.
Therapy
A/P Written by SISK, CHAD M @ 23 Dec 2008 1108 EST

1. HELICOBACTER PYLORI (H. PYLORI) INFECTION
2. GASTRITIS DUE TO H. PYLORI: EGD findings from Dr. Mcguigan reviewed. Suspect h.pylori gastritis at the root of his GI
complaints and possibly a factor with the history of mesenteric adenitis. No evidence to support lymphoma on gastric biopsy or EX
2019
Medical Record
2019
Lap. Repeat CT in Nov negative with resolution of the adenitis. Will treat for 14 days with amoxil/biaxin/Prilosec, then continue
prilosec for next 3-6 months. Pt to f/u with me in few weeks to assess response.
Disposition Written by SISK, CHAD M @ 23 Dec 2008 1109 EST

Follow up: 3 week(s) in the GASTROENTEROLOGY CLINIC clinic or sooner if there are problems.
Discussed: Diagnosis, Medication(s)/Treatment(s), Alternatives, Potential Side Effects with Patient who indicated understanding. -
Comments: Patient counseled regarding diagnosis and medical therapy options. Written and verbal education completed.
Note Written by KAY, CHRISTOPHER MICHEAL @ 23 Dec 2008 1010 EST

Consult Order
Referring Provider: HINES, DAVID A
Date of Request: 01 Dec 2008
Priority: ASAP
abdominal pain
Reason for Request:
38yoBMAD with 1 year history of midepigastric abdominl pain, no EGD. Has had an extensive negative lab workup, and noted to
have meserentic adenitis on CT, and lap. Please evaluate and advise
Signed By SISK, CHAD M (Chief, Gastroenterology Service, Martin ACH, Fort Benning, GA) @ 23 Dec 2008 1109
2019
Medical Record
2019
02 Dec 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M
Encounter ID: CDR-50819461 Primary Dx: Abdominal pain
Patient: WAITERS, TOMMIE Date: 02 Dec 2008 1110 EST Appt Type: EST
ALAJANDRO
MARIER
Reason for Appointment: f/u and update profile

dvg
AutoCites Refreshed by GRACE, DAISY V @ 02 Dec 2008 1115 EST

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
Active Medications

Esomeprazole Magnesium Trihydrate 20mg, Active CD NR 26 Nov 2008
Capsule, Oral
Screening Written by GRACE, DAISY V @ 02 Dec 2008 1117 EST

Reason(s) For Visit (Chief Complaint): visit for: administrative purpose (New) ;
Vitals
Vitals Written by GRACE, DAISY V @ 02 Dec 2008 1117 EST
BP: 131/88, HR: 109, RR: 22, T: 98.8 °F, WT: 212.3 lbs, Tobacco Use: No, Alcohol Use: No, Pain Scale: 0 Pain Free
SO Note Written by MCGUIGAN,REBECCA MARIER @ 04 Dec 2008 0833 EST

Chief complaint
He reported: No heartburn, no nausea, and no vomiting. Abdominal pain epigastric for 3 years - pt had CT and MRI of
abdomen March 2008 showing abnormal mesentery - possible mesenteric sclerosis vs lymphoma - laparoscopic biopsy of
mesentery performed May 2008 - bx negative for mesenteric sclerosis and somewhat inconclusive on lymphoma question -
subsequent MRI/CT were done, see results below and in the LUQ. No bright red blood per rectum, no diarrhea, and no
constipation.
Reported History:
Physical trauma: No physical trauma.
Abdominal / peritoneal surgery - appendectomy
Personal history
Behavioral history: Not smoking and not chewing nicotine-containing substances.
Review of systems
2019
Medical Record
2019
Systemic symptoms: Night sweats. No recent weight loss and no recent weight gain.
Hematologic symptoms: No easy bleeding and no tendency for easy bruising.
Physical findings
• Patient was overweight.
General appearance:
° Well-appearing. ° Awake. ° Alert. ° Well developed. ° Not acutely ill.
Head:
Eyes:
General/bilateral:
Sclera: ° Normal.
Abdomen:
Palpation: • Direct epigastric tenderness. • Direct tenderness in the LUQ of the abdomen. ° Abdomen was soft. ° No rebound
tenderness in the abdomen.
Neurological:
Speech: ° Normal.
Skin:
° General appearance was normal. ° Color and pigmentation were normal.
Rad Result Cited by MCGUIGAN, REBECCA M @ 04 Dec 2008 0830 EST

********** MRI ABDOMEN W/WO CONTRAST,PG **********
Status: Complete
Procedure: MRI ABDOMEN W/WO CONTRAST,PG

Event Date: 04-Nov-2008 12:26:00
Reason for Order:
hx of abnormal appearing mesentery ? mesenteric sclerosis vs lymphoma - request
f/u MRI
Exam #: 08095993
SURGERY MARTIN ARMY COMMUNITY HOSPITAL
Status: COMPLETE
Report Text:
CAT scan of the the abdomen without and with IV contrast:
The study is compared to the previous exams. In the area of the previously
described increased attenuation of the mesentery and the lymph node enlargement
on the CAT scan there is no suspicious enhancement on today's MRI exam. There
is residual prominence of the mesentery lymph nodes. A CT imaging without and
with IV contrast would be helpful to be compared to the previous CAT scan dated
3/9/2008. The liver, and kidneys reveal no gross mass lesion.
2019
Medical Record
2019
Rad Result Cited by MCGUIGAN, REBECCA M @ 04 Dec 2008 0830 EST

********** CT ABD W/CONTRAST **********
Status: Complete
Procedure: CT ABD W/CONTRAST

Event Date: 26-Nov-2008 03:02:00
Reason for Order:
epigastric pain, had MRI today, recommended CT with IV contrast for
comparison to prior CT in Mar 08, pt presented to ED with acute worsening of
his epigastric and luq abd pain
Exam #: 08103243
Provider: TRICKEY, DAVID N
Status: COMPLETE
Report Text:
CT OF THE ABDOMEN WITH CONTRAST
PROCEDURE: Patient was prepared with 3 doses oral contrast. Following the
intravenous administration of 100 cc iodinated contrast material helically
acquired axial imaging of the abdomen was performed.
FINDINGS: Overall the nodal burden in the mesentery is diminished compared with
3/08. The appearance of a Misty mesentery is also nearly completely resolved.
The visualized liver, gallbladder, spleen, pancreas, adrenal glands and kidneys
are unremarkable. Incidental note is made of a small splenule.
IMPRESSION: Near-complete resolution of mesenteric adenitis and infiltration of

mesenteric fat. Would recommend follow-up scan in one year to insure continued
stability or sooner if clinically indicated.
A/P Written by MCGUIGAN, REBECCA M @ 04 Dec 2008 0836 EST

1. abdominal pain
Disposition Written by MCGUIGAN, REBECCA M @ 04 Dec 2008 0837 EST

Follow up: 1 day(s) in the endo clinic or sooner if there are problems. - Comments: previous mesenteric findings resolved in
imaging. was likely mesenteric adenitis - however still has pain - will do EGD 12/3 and if negative proceed with colonoscopy
2019
Medical Record
2019
Signed By MCGUIGAN, REBECCA M (Physician/Workstation, Martin ACH, Fort Benning, GA) @ 04 Dec 2008 0837
2019
Medical Record
2019
01 Dec 2008 at Martin ACH, Fort Benning, GA, FMC Red Clinic by HINES, DAVID A
Patient: WAITERS, TOMMIE Date: 01 Dec 2008 1530 EST Appt Type: EST
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: FMC STAFF CLINIC Provider: HINES,DAVID A
Reason for Appointment: f/u for stomach pain still in pain

mhz
AutoCites Refreshed by KELLIERROBERTS, KEREAN P @ 01 Dec 2008 1511 EST

Problems Allergies
• visit for: preoperative exam • No Known Allergies
• abdominal pain
• CERVICALGIA
• FOLLICULITIS
• BACKACHE
Active Medications

ESOMEPRAZOLE (NEXIUM)--PO 20MG CAP Active CD NR 26 Nov 2008
METHOCARBAMOL (ROBAXIN) 500MG--PO TAB Active T2 TAB QID #40 RF5 5 of 5 26 Jan 2008
Vitals
No Vitals Found.
Screening Written by KELLIERROBERTS, KEREAN P @ 01 Dec 2008 1511 EST

Reason For Appointment: f/u for stomach pain still in pain
Allergen information verified by KELLIERROBERTS,KEREAN P @ 01 Dec 2008 1511 EST
Vitals
Vitals Written by KELLIERROBERTS, KEREAN P @ 01 Dec 2008 1511 EST
BP: 137/80 Left Arm, Adult Cuff, HR: 86 Apical, Regular, RR: 20, T: 99.5 °F Oral, HT: 66 in Stated, With Shoes, WT: 204 lbs, BMI:
32.93, BSA: 2.017 square meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 7/10 Severe, Pain Scale Comments: abd
SO Note Written by HINES,DAVID A @ 01 Dec 2008 1537 EST

Chief complaint
The Chief Complaint is: GI Complaint.
Appetite not decreased. Nausea and vomiting. No diarrhea.
Visit is not deployment-related. No fever and no chills. No headache. No oliguria.
Reported History:
Medical: Previous hospitalizations, a previous emergency room visit, and prior medical history was reported by the patient.
Surgical / procedural: Surgical / procedural history Appy and Lap.
Reported medications: Not taking antibiotics recently.
2019
Medical Record
2019
Reported prior tests: Prior tests were performed Extensive work up.
Exposure: No exposure and no consumption of possibly contaminated, spoiled, or poisonous food.
Dietary: Reported dietary history.
Diagnosis History:
Personal history
Behavioral history: No caffeine use and no tobacco use.
Travel: No travel or residence in a foreign country.
Family history
Review of systems
Gastrointestinal symptoms: No hematemesis and no hematemesis ('coffee grounds'). Abdominal pain. No flatus, no melena, no
hematochezia, no red blood on the surface of the stool, and no mucus in the stool. No constipation.
Physical findings
Vital signs:
General appearance:
• In acute distress. • Patient appeared uncomfortable. ° Alert. ° Well developed. ° Well nourished. ° Well hydrated.
Neck:
Oral cavity:
Lymph Nodes:
Lungs:
Abdomen:
Palpation: • Abdomen was not soft. • Direct tenderness in the abdomen. ° Abdominal muscle guarding was not demonstrated.
° Abdominal muscle rigidity was not demonstrated. ° No rebound tenderness in the abdomen. ° Murphy's sign was not
observed. ° No mass was palpated in the abdomen.
Therapy
A/P Written by HINES,DAVID A @ 01 Dec 2008 1537 EST

1. abdominal pain
GASTROENTEROLOGY CLINIC Primary Diagnosis: abdominal pain
-Referred To: NUTRITION CONSULT (Routine) Specialty: Clinic: NUTRITION Primary Diagnosis:
abdominal pain
Disposition Last updated by HINES, DAVID A @ 01 Dec 2008 1553 EST

Follow up: as needed with PCM. - Comments: GI Consult placed, meds as directed, follow up after EGD
Signed By HINES, DAVID A (Physician/Workstation, Martin ACH, Fort Benning, GA) @ 01 Dec 2008 1554
_________________________________________________________________________________________________________
CHANGE HISTORY
The following Disposition Note Was Overwritten by HINES, DAVID A @ 01 Dec 2008 1553 EST:
The Disposition section was last updated by HINES, DAVID A @ 01 Dec 2008 1553 EST - see above.Previous Version of Disposition section was entered/updated by
HINES,DAVID A @ 01 Dec 2008 1540 EST.
2019
Medical Record
2019
Follow up: as needed with PCM. - Comments: GI Consult placed, meds as directed, follow up after EGD
The following Signature(s) No Longer Applies because this Encounter Was Opened for Amendment by HINES, DAVID A @ 01 Dec 2008 1553 EST:
Signed HINES,DAVID A (amedgamach01) @ 01 Dec 2008 1540
2019
Medical Record
2019
12 Nov 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M
Patient: WAITERS, TOMMIE A Date: 12 Nov 2008 1420 EST Appt Type: T-CON*
MARIER
Reason for Telephone Consult: MRI consult

Notes Entered by: BAKER, TIMOTHY A 12 Nov 2008 1420
------------------------------
PT needs MRI consult to be sent off post he has an appt for the 18th of NOV and needs to be seen before then.
AutoCites Refreshed by MCGUIGAN, REBECCA M @ 14 Nov 2008 1049 EST

• abdominal pain
Active Medications

A/P Written by MCGUIGAN, REBECCA M @ 14 Nov 2008 1050 EST

1. abdominal pain
Disposition Written by MCGUIGAN, REBECCA M @ 14 Nov 2008 1050 EST
Note Written by MCGUIGAN, REBECCA M @ 14 Nov 2008 1050 EST

pt originally scheduled for 18 DEC. Has been moved up to 25 Nov.
Signed By MCGUIGAN, REBECCA M (Physician/Workstation, Martin ACH, Fort Benning, GA) @ 14 Nov 2008 1050
2019
Medical Record
2019
04 Nov 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M
Patient: WAITERS, TOMMIE A Date: 04 Nov 2008 1150 EST Appt Type: EST
MARIER
Reason for Appointment: f/u appt

dvg
AutoCites Refreshed by BRYSON, CAROLYN E. @ 04 Nov 2008 1147 EST

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
Active Medications

TRAMADOL HCL, 50MG, TABLET, ORAL Active TAKE 1 TAB PO Q 4-6 H NR 02 Nov 2008
PRN FOR PAIN
Screening Written by BRYSON, CAROLYN E. @ 04 Nov 2008 1148 EST
Allergen information verified by BRYSON, CAROLYN E. @ 04 Nov 2008 1148 EST
Vitals
Vitals Written by BRYSON, CAROLYN E. @ 04 Nov 2008 1148 EST
BP: 139/80, HR: 77, T: 98.9 °F, WT: 214 lbs, SpO2: 95%, Pain Scale: 7/10 Severe, Pain Scale Comments: abdomen
SO Note Written by MCGUIGAN,REBECCA MARIER @ 05 Nov 2008 1015 EST

Chief complaint
He reported: No heartburn, no nausea, and no vomiting. RUQ abdominal pain. LUQ abdominal pain - pt s/p exploratory
laparosocpy/mesenteric bx by me May 2008 - inconlusive - per AFIP report lesions not typical of mesenteric sclerosis; lymphoma
not ruled out completely. Chronic/constant abdominal pain. No bright red blood per rectum, no diarrhea, and no constipation.
Reported History:
Physical trauma: No physical trauma.
Abdominal / peritoneal surgery s/p exploratory laparoscopy/mesenteric bx May 2008; s/p appendectomy (open)
Personal history
Family history
2019
Medical Record
2019
No malignant neoplasm of the large intestine.

Physical findings
General appearance:
° Well-appearing. ° Awake. ° Alert. ° In no acute distress.
Head:
Abnormality Of Appearance: ° Head normocephalic.
Neck:
Palpation: ° Of the neck revealed no crepitus.
Lymph Nodes:
° Cervical lymph nodes were not enlarged. ° Inguinal lymph nodes were not enlarged.
Lungs:
° No wheezing was heard. ° No rhonchi were heard.
Abdomen:
Palpation: • Abdominal tenderness. • Direct tenderness in the abdomen - diffuse, mild upper abdominal tenderness.
° Abdomen was soft. ° Abdominal muscle guarding was not demonstrated.
Hepatic Findings: ° Liver was not enlarged.
Splenic Findings: ° Spleen was not enlarged.
Skin:
° General appearance was normal. ° Color and pigmentation were normal.
Assessment Of Injury / Incision Site: • A scar well healed port sites and RLQ scar.
Rad Result Cited by MCGUIGAN, REBECCA M @ 05 Nov 2008 1019 EST
WAITERS, TOMMIE A 20/262-65-1757 38yo 18 Aug 1970 M

********** MRI ABDOMEN W/O CONTRAST **********
Status: Complete
Procedure: MRI ABDOMEN W/O CONTRAST

Event Date: 17-Mar-2008 12:34:00
Reason for Order:
Radiologist recommended to repeat sequences-suboptimal study secondary to
respiratory motion artifact.
Exam #: 08022237
Status: COMPLETE
Report Text:
MRI of the abdomen
HISTORY: Abnormal CT examination demonstrating increased density within the

mesentery and small lymph nodes along the mesenteric root.
2019
Medical Record
2019
TECHNIQUE: Axial T2-weighted fat-suppressed and nonsuppressed breath-hold

imaging of the abdomen was performed as well as coronal FIESTA. Correlation is
made with contrast-enhanced examination of 11 March 2008.
FINDINGS: There is a subtle decrease in the overall fatty signal within the
mesentery in the area of interest. However, this does not appear to represent
edema based on the fat-suppressed sequences. There is poor overall fat
saturation as well as chemical shift artifact.
IMPRESSION: 1. Very subtle decreased fatty signal along the root of mesentery.
Given the faint mild enhancement of this region of the abdomen on postcontrast
imaging, the previous differential considerations of mesenteric sclerosis,
underlying infection, or less likely neoplasia remain. The subtle halo of
normal appearing fat surrounding the veins of the mesentery on CT would favor
mesenteric sclerosis. A short interval follow-up with contrast-enhanced CT in 3
months could be obtained. Definitive diagnosis would require open surgical
biopsy.
A/P Written by MCGUIGAN, REBECCA M @ 05 Nov 2008 1021 EST

1. abdominal pain
Radiology(ies): -MRI ABDOMEN W/WO CONTRAST,PG (Routine) Ordered By: MCGUIGAN, REBECCA M Impression:
hx of abnormal appearing mesentery ? mesenteric sclerosis vs
Disposition Written by MCGUIGAN, REBECCA M @ 05 Nov 2008 1022 EST

Follow up: in the surgery clinic. - Comments: will repeat MRI - may need to do another laparoscopy/biopsy (previously not
amenable to percutaneous biopsy)
Signed By MCGUIGAN, REBECCA M (Physician/Workstation, Martin ACH, Fort Benning, GA) @ 05 Nov 2008 1022
2019
Medical Record
2019
19 Jun 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M
Patient: WAITERS, TOMMIE A Date: 19 Jun 2008 0814 EDT Appt Type: T-CON*
MARIER
Reason for Telephone Consult: Please call pt. ref results of surgery.
AutoCites Refreshed by MCGUIGAN, REBECCA M @ 23 Jun 2008 1406 EDT

• CERVICALGIA
• abdominal pain
• Aftercare Following Surgery Of Digestive
System
Active Medications

A/P Written by MCGUIGAN, REBECCA M @ 01 Aug 2008 1441 EDT

1. abdominal pain
Disposition Written by MCGUIGAN, REBECCA M @ 01 Aug 2008 1441 EDT
Note Written by MCGUIGAN, REBECCA M @ 01 Aug 2008 1441 EDT

duplicate t-con. spoke to patient about results.
Signed By MCGUIGAN, REBECCA M (Physician/Workstation, Martin ACH, Fort Benning, GA) @ 01 Aug 2008 1441
2019
Medical Record
2019
22 May 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M
Aftercare Following Surgery Of Digestive

System
Patient: WAITERS, TOMMIE A Date: 22 May 2008 1313 EDT Appt Type: EST
MARIER
Reason for Appointment: wound check
AutoCites Refreshed by MCGUIGAN, REBECCA M @ 22 May 2008 1326 EDT

• CERVICALGIA
• abdominal pain
Active Medications

Oxycodone Hydrochloride + Acetaminophen, Active T1-2 TABS Q4-6H PP NR 19 May 2008
Tablet, Oral
DOCUSATE SODIUM, 100MG, CAPSULE, ORAL Active T1 CAP BID NR 19 May 2008
SO Note Written by MCGUIGAN,REBECCA MARIER @ 22 May 2008 1326 EDT

Chief complaint
The Chief Complaint is: Post op follow up, s/p exploratory laparoscopy/biopsy of small bowel mesentery pod 3.
He reported: No erythema. A skin wound which oozes - pt c/o red/bloody drainage from umbilical port site/wound.
No severe pain in a wound.
Review of systems
Physical findings
General appearance:
° Awake. ° Alert. ° In no acute distress.
Skin:
Assessment Of Injury / Incision Site: • Assessment of injury/incision site supraumbilical port site: 2x2/tegaderm (still original
dressing) removed - there is old blood - no new bleeding from incision - no erythema - new dry gauze applied.
A/P Written by MCGUIGAN, REBECCA M @ 22 May 2008 1329 EDT

1. Aftercare Following Surgery Of Digestive System
Procedure(s): -Postoperative Visit, Without Charge x 1
Disposition Written by MCGUIGAN, REBECCA M @ 22 May 2008 1329 EDT

Follow up: 10 day(s) in the surgery clinic or sooner if there are problems. - Comments: no ongoing bleeding. pathology results
pending
2019
Medical Record
2019
Signed By MCGUIGAN, REBECCA M (Physician/Workstation, Martin ACH, Fort Benning, GA) @ 22 May 2008 1329
2019
Medical Record
2019
16 May 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M
Encounter ID: CDR-32949082 Primary Dx: Visit for: preoperative exam
ALAJANDRO
MARIER
Reason for Appointment: pre-op

jrj
AutoCites Refreshed by BRYSON, CAROLYN E. @ 16 May 2008 0937 EDT

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
Active Medications

Screening Written by BRYSON, CAROLYN E. @ 16 May 2008 0937 EDT
Allergen information verified by BRYSON, CAROLYN E. @ 16 May 2008 0937 EDT
Vitals
Vitals Written by BRYSON, CAROLYN E. @ 16 May 2008 0937 EDT
BP: 156/83, HR: 79, T: 98.9 °F, HT: 66 in, WT: 207 lbs, SpO2: 97%, BMI: 33.41, BSA: 2.03 square meters, Pain Scale: 5/10
Moderate
SO Note Written by BRYSON,CAROLYN E @ 16 May 2008 0940 EDT

Reason for Visit
Visit for: preop.
In the Army. Visit is not deployment-related.
Reported History:
Medical: A previous emergency room visit.
Surgical / procedural: Surgical / procedural history was reviewed and updated in patient problem list.
Reported medications: Medication history tramadol, percoset.
Reported prior tests: Prior tests were performed.
Personal history
2019
Medical Record
2019
SO Note Written by MCGUIGAN,REBECCA MARIER @ 16 May 2008 1029 EDT

Reason for Visit
Visit for: Pre-op. See CIS for H&P.
• Education and counseling - I have explained the diagnosis, nature/purpose of the proposed procedure, the risks, benefits,
alternatives, and expected outcome to the patient, who verbalizes understanding and agrees to proceed.
A/P Written by MCGUIGAN, REBECCA M @ 16 May 2008 1029 EDT

1. visit for: preoperative exam
Disposition Written by MCGUIGAN, REBECCA M @ 16 May 2008 1030 EDT

Follow up: in the OR clinic. - Comments: laparoscopic vs open biopsy 19 May mesenteric sclerosis vs lymphoma
Signed By MCGUIGAN, REBECCA M (Physician/Workstation, Martin ACH, Fort Benning, GA) @ 16 May 2008 1030
2019
Medical Record
2019
10 Apr 2008 at Martin ACH, Fort Benning, GA, CTMC Ambulatory Primary Clinic by LOYD,
CLIFTON D
Encounter ID: CDR-29994767 Primary Dx: Visit for: follow-up exam
Patient: WAITERS, TOMMIE Date: 10 Apr 2008 1330 EDT Appt Type: ROUT
ALAJANDRO
Treatment Facility: CTMC-FT. BENNING Clinic: CTMC AMBULATORY PRIMARY Provider: LOYD,CLIFTON DEWAYNE
CLINIC
Reason for Appointment: ULTRAL SOUND RESULTS

ACH
AutoCites Refreshed by LOYD, CLIFTON D @ 10 Apr 2008 1344 EDT

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
Active Medications

MELOXICAM, 7.5MG, TABLET, ORAL Active T1 TAB PO BID F 7 DAYS 1 of 1 16 Oct 2007
THEN 1 TAB PO QD
Vitals
Vitals Written by SMITH, JORDON N @ 10 Apr 2008 1332 EDT
Use: No, Pain Scale: 5/10 Moderate, Pain Scale Comments: Lower stomach
Comments: Not deployment related
Currently taking percocet
SO Note Written by LOYD,CLIFTON DEWAYNE @ 11 Apr 2008 0939 EDT

He reported: Encounter Background Information: AD/M F/U FOR TESTICLE U/S by civ. rad; pt w/o pain/ changes since last
seen before u/s for testicle mass.
Reported History:
Medical: No history of cancer.
Surgical / procedural: No surgical / procedural history.
Personal history
Behavioral history: Caffeine use drinks coffee each day. last this am. No tobacco use.
Family history
No cancer
Family medical history was unknown Reviewed.
Review of systems
Systemic symptoms: Not feeling tired or poorly. No fever and no recent weight change.
Head symptoms: No sinus pain.
Pulmonary symptoms: No dyspnea, no cough, and no wheezing.
2019
Medical Record
2019
Skin symptoms: No skin symptoms.

Physical findings
General appearance:
° Well-appearing. ° Alert. ° Oriented to time, place, and person. ° Well developed. ° Well nourished. ° Well hydrated. ° In no
acute distress.
Objective
Vss/nad/a&ox3; no exam done today.
Tests
Imaging studies:
Imaging studies test report revealed - rRt epididymis head cyst vs spermatocele.
A/P Written by LOYD, CLIFTON D @ 11 Apr 2008 0947 EDT

1. visit for: follow-up exam: f/u afetr rt testicle u/s- rt epididymis head cyst vs spermatocele; pt ed. and be aware of changes/pain
and testicle exams- f/u if worsen/changes/prn
Disposition Written by LOYD, CLIFTON D @ 11 Apr 2008 0947 EDT

Discussed: Diagnosis, Medication(s)/Treatment(s), Alternatives, Potential Side Effects with Patient who indicated understanding. -
Comments: testicle exam/results-info
Signed By LOYD, CLIFTON D (Physician Assistant, 65DM1/3) @ 11 Apr 2008 0947
2019
Medical Record
2019
08 Apr 2008 at Martin ACH, Fort Benning, GA, Surgery by MCGUIGAN, REBECCA M
ALAJANDRO
MARIER
Reason for Appointment: hernia

dvg
AutoCites Refreshed by GRACE, DAISY V @ 08 Apr 2008 1032 EDT

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
Active Medications

THEN 1 TAB PO QD
Vitals
Vitals Written by BAKER, TIMOTHY A @ 08 Apr 2008 1042 EDT
BP: 125/83, HR: 77, RR: 16, T: 98.6 °F, HT: 66 in, WT: 206 lbs, SpO2: 97%, BMI: 33.25, BSA: 2.025 square meters, Tobacco Use:
No, Alcohol Use: No, Pain Scale: 6/10 Moderate, Pain Scale Comments: ABD AREA
Comments: MEDICAL RECORDS AVAILABLE NOT OIF/OEF ELATED
NO MEDS
SO Note Written by BAKER,TIMOTHY A @ 08 Apr 2008 1043 EDT

Reason for Visit
Visit for: HERNIA. Visit for: follow-up exam and medication refill.
Referred here
referred here.
He reported: Past medical history reviewed and updated in patient problemlist.
Allergies
An allergy: Reviewed Allergy Information and updated as necessary.
Reported History:
Medical: No previous hospitalizations and no previous emergency room visit.
Surgical / procedural: Surgical / procedural history was reviewed and updated in patient problem list.
Reported medications: Medication history was reviewed and updated in patient medication list.
Reported prior tests: No prior tests were performed.
Personal history
Behavioral history: No tobacco use for _____ years.
2019
Medical Record
2019
SO Note Written by MCGUIGAN,REBECCA MARIER @ 11 Apr 2008 0223 EDT

Chief complaint
He reported: No nausea and no vomiting. Abdominal pain for 2 years diffuse, lower abdomen. No bright red blood per rectum,
no diarrhea, and no constipation.
Testicular lump in the right testis.
No abdominal / peritoneal surgery
Physical findings
Vital signs:
• Pain level (0-10).
General appearance:
° Well-appearing. ° Awake. ° Alert. ° Well developed. ° Well nourished.
Abdomen:
Palpation: • Abdominal tenderness mild TTP lower abdomen. ° Abdomen was soft.
Genitalia:
Testes: ° No tenderness. ° No swelling. ° No mass.
Rad Result Cited by MCGUIGAN, REBECCA M @ 11 Apr 2008 0222 EDT

********** MRI ABDOMEN W/O CONTRAST **********
Status: Complete
Procedure: MRI ABDOMEN W/O CONTRAST

Event Date: 17-Mar-2008 12:34:00
Reason for Order:
Radiologist recommended to repeat sequences-suboptimal study secondary to
respiratory motion artifact.
Exam #: 08022237
Status: COMPLETE
Report Text:
MRI of the abdomen
HISTORY: Abnormal CT examination demonstrating increased density within the

mesentery and small lymph nodes along the mesenteric root.
TECHNIQUE: Axial T2-weighted fat-suppressed and nonsuppressed breath-hold

imaging of the abdomen was performed as well as coronal FIESTA. Correlation is
made with contrast-enhanced examination of 11 March 2008.
2019
Medical Record
2019
FINDINGS: There is a subtle decrease in the overall fatty signal within the
mesentery in the area of interest. However, this does not appear to represent
edema based on the fat-suppressed sequences. There is poor overall fat
saturation as well as chemical shift artifact.
biopsy.
A/P Written by MCGUIGAN, REBECCA M @ 11 Apr 2008 0228 EDT

1. abdominal pain: Testicular ultrasound (done at Columbus Diagnostic) - no solid testicular mass.
Disposition Written by MCGUIGAN, REBECCA M @ 11 Apr 2008 0229 EDT

Follow up: in the surgery clinic. - Comments: needs laparoscopic vs open biopsy to rule out neoplasm vs mesenteric sclerosis.
surgery date pending.
Signed By MCGUIGAN, REBECCA M (Physician/Workstation, Martin ACH, Fort Benning, GA) @ 11 Apr 2008 0229
2019
Medical Record
2019
28 Mar 2008 at Martin ACH, Fort Benning, GA, CTMC Ambulatory Primary Clinic by
KITCHENS, JEFFERY A
Encounter ID: CDR-28785834 Primary Dx: Visit for: administrative purpose
ALAJANDRO
Treatment Facility: CTMC-FT. BENNING Clinic: CTMC AMBULATORY PRIMARY Provider: KITCHENS,JEFFERY A
CLINIC
Reason for Telephone Consult: requesting results of x-rays 877 377 1321
Notes Entered by: RAGIN, HARRISON 28 Mar 2008 1412
------------------------------
requesting results of x-rays
advised 72hr rule

877 377 1321
AutoCites Refreshed by KITCHENS, JEFFREY A @ 28 Mar 2008 1540 EDT

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
• abdominal pain
Active Medications

THEN 1 TAB PO QD
Vitals
No Vitals Found.
A/P Written by KITCHENS, JEFFREY A @ 28 Mar 2008 1546 EDT

1. visit for: administrative purpose
Disposition Written by KITCHENS, JEFFREY A @ 28 Mar 2008 1546 EDT
Note Written by KITCHENS, JEFFREY A @ 28 Mar 2008 1546 EDT

spoke w/ pt, who will con\me in on monday
Signed By KITCHENS, JEFFREY A (PA-C, Martin ACH, Fort Benning, GA) @ 28 Mar 2008 1547
2019
Medical Record
2019
20 Mar 2008 at Martin ACH, Fort Benning, GA, CTMC Ambulatory Primary Clinic by
KITCHENS, JEFFERY A
Patient: WAITERS, TOMMIE Date: 20 Mar 2008 1305 EDT Appt Type: ACUT
ALAJANDRO
Treatment Facility: CTMC-FT. BENNING Clinic: CTMC AMBULATORY PRIMARY Provider: KITCHENS,JEFFERY A
CLINIC
Reason for Appointment: EVAL ON (MRI) RESULTS F/UP /ER

ach
AutoCites Refreshed by KITCHENS, JEFFREY A @ 20 Mar 2008 1313 EDT

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
Active Medications

THEN 1 TAB PO QD
Vitals
No Vitals Found.
Vitals
Vitals Written by SMITH, JORDON N @ 20 Mar 2008 1308 EDT
Use: No, Pain Scale: 6/10 Moderate, Pain Scale Comments: Lower Stomach
Meds reconciled- Ibuprofen
SO Note Written by KITCHENS,JEFFERY A @ 20 Mar 2008 1402 EDT

Chief complaint
The Chief Complaint is: ABDOMINAL PAIN X 1 YEAR INCREASED OVER THE PAST 2 WEEKS.
Reason for Visit
Visit for: NO CHANGE IN SX SINCE LAST VISIT.
He reported: Past medical history reviewed, medication list reviewed, and surgical history reviewed APPENDECTOMY.
Nausea with vomiting. No abdominal swelling. Abdominal pain periumbilical which feels dull, boring, or aching. No diarrhea
and no constipation.
No urinary symptoms. Testicular lump in the right testis.
No fever and no chills. No headache, no sinus pain, and no sinus pressure. No ear symptoms, no nasal symptoms, and no
throat symptoms.
Personal history
Work: Work history.
Review of systems
Endocrine symptoms: Not feeling dehydrated, no temperature intolerance, and no excessive sweating.
Neurological symptoms: No dizziness and no fainting.
2019
Medical Record
2019
Psychological symptoms: No anxiety and no depression.

Physical findings
Vital signs:
° Current vital signs reviewed. ° Normal temperature. ° RR was normal. ° PR was normal. ° Blood pressure was normal.
° Normal. ° Weight was normal.
General appearance:
° Awake. ° Alert. ° Oriented to time, place, and person. ° In no acute distress. ° Patient did not appear uncomfortable.
Neck:
Pain Elicited By Motion: ° Neck pain was not elicited by motion.
Lymph Nodes:
° No adenopathy. ° Not tender.
Lungs:
° Normal breath sounds/voice sounds. ° No wheezing was heard. ° No rhonchi were heard.
Back:
° No tenderness on palpation. ° No costovertebral angle tenderness.
Abdomen:
Palpation: • Abdominal tenderness. • Direct tenderness in the abdomen. • Direct periumbilical tenderness. ° Abdomen was
soft. ° Abdominal muscle guarding was not demonstrated. ° Abdominal muscle rigidity was not demonstrated. ° No
rebound tenderness in the abdomen.
Genitalia:
Penis: ° Normal.
Scrotum: ° Normal.
Testes: • Abnormal. • Mass. • Mass in the right testis. ° No tenderness. ° No swelling. ° Not elevated.
Neurological:
Speech: ° Normal.
Motor: ° A motor exam demonstrated no dysfunction.
Skin:
° General appearance was normal. ° Color and pigmentation were normal. ° Temperature was normal.
Lab Result Cited by KITCHENS, JEFFREY A @ 20 Mar 2008 1319 EDT

MTF/Facility Units Ref Rng
Amylase Site/Specimen 09 Mar 2008 1520 Units Ref Rng
Amylase PLASMA 56 U/L (25-115)

Lipase Site/Specimen 09 Mar 2008 1520 Units Ref Rng
Lipase PLASMA 189 U/L (114-286)

Metabolic Panel Comprehensive Site/Specimen 09 Mar 2008 1520 Units Ref Rng
Total Protein PLASMA 7.2 g/dL (6.4-8.2)
CO2 PLASMA 33 (H) mmol/L (21-32)
2019
Medical Record
2019

Hemogram+Differential Auto Site/Specimen 09 Mar 2008 1520 Units Ref Rng
WBC BLOOD 4.4 (L) x10(3)/mcL (4.9-10.0)
RBC BLOOD 5.28 x10(6) (4.7-6.1)
MCHC BLOOD 35.5 % (32-36)
RDW-CV BLOOD 12.7 % (11.5-14.5)

Urinalysis Site/Specimen 09 Mar 2008 1632 Units Ref Rng
Color URINE YELLOW
pH URINE 7.0 (5.0-7.5)
Epithelial Cells Squamous URINE <1 /HPF (0-5)
Rad Result Cited by KITCHENS, JEFFREY A @ 20 Mar 2008 1317 EDT
biopsy.
In the area of interest along the root of the mesentery there is demonstration
of numerous small lymph nodes measure 5-6 mm in short axis dimension. There is
suggestion of subtle enhancement within the mesenteric fat on dynamic
postcontrast imaging. No definite precontrast correlate is seen for the area
of signal abnormality noted on postcontrast imaging. This is likely secondary to
2019
Medical Record
2019
image degradation from respiratory motion. The visualized portions of the

kidney, spleen, liver, and aorta are normal in appearance.
IMPRESSION: 1. The examination is suboptimal secondary to respiratory motion

artifact. Repeat imaging should be performed.
IMPRESSION: 1. No evidence of nephrolithiasis, hydroureter, or bladder calculus.

2. Subtly increased was attenuation in the mesenteric fat as described above.
Finding is nonspecific particularly on a noncontrast examination. Mesenteric
sclerosis is in the differential for a "misty mesentery." Other disease
processes such as lymphoma are also in the differential. MRI with contrast is
recommended. 3. Results were called to Dr. Kaplan at 1614 hours and read back
of critical results was performed.
A/P Written by KITCHENS, JEFFREY A @ 20 Mar 2008 1402 EDT

1. abdominal pain: CONTACT AT 877-377-3121
Medication(s): -TRAMADOL--PO 50MG TAB - T1-2 TABS PO Q6H PP #30 RF0 Qt: 30 Rf: 0 Ordered By: KITCHENS,
JEFFREY A
-METOCLOPRAMIDE--PO 10MG TAB - T1 TAB PO TID #15 RF0 Qt: 15 Rf: 0 Ordered By: KITCHENS,
JEFFREY A
Consult(s): -Referred To: GENERAL SURGERY CONSULT (Routine) Specialty: Clinic: SURGERY Primary
Diagnosis: abdominal pain Ordered By: KITCHENS, JEFFREY A
2. TESTICULAR NEOPLASM
Consult(s): -Referred To: RADIOLOGY NET (Routine) Specialty: Clinic: REFERRAL MANAGEMENT CLINIC
Primary Diagnosis: TESTICULAR NEOPLASM Ordered By: KITCHENS, JEFFREY A
Disposition Written by KITCHENS, JEFFREY A @ 20 Mar 2008 1407 EDT

Sick at Home / Quarters - for 48 Hours
Follow up: with PCM and/or in the CTMC AMBULATORY PRIMARY CLINIC clinic. - Comments: F/U AFTER COMPLETION OF
TESTICULAR U/S OR ASAP IF ANY INCREASE IN SX.
Note Written by KITCHENS, JEFFREY A @ 20 Mar 2008 1407 EDT

PT REVIEWED W/ DR PETERS.
Signed By KITCHENS, JEFFREY A (PA-C, Martin ACH, Fort Benning, GA) @ 20 Mar 2008 1408
2019
Medical Record
2019
05 Feb 2008 at Martin ACH, Fort Benning, GA, Physical Therapy by JAMES, KRYSTAL K
Encounter ID: CDR-23841218 Primary Dx: Other Physical Therapy
Patient: WAITERS, TOMMIE A Date: 05 Feb 2008 1300 EST Appt Type: PROC
Treatment Facility: MARTIN ACH Clinic: PHYSICAL THERAPY Provider: JAMES,KRYSTAL K
Reason for Appointment: R Shoulder

adb
AutoCites Refreshed by JAMES, KRYSTAL K @ 05 Feb 2008 1450 EST

Allergies
SO Note Written by JAMES,KRYSTAL K @ 05 Feb 2008 1450 EST

Reason for Visit
Visit for: Patient reported to this clinic for modality as directed per the patient's Physical Therapist treatment plan. The Patient
was advised to alert the staff of any significant changes in pain, swelling or edema. The treatment modality and any possible
adverse reaction were discussed with the patient. The patient was instructed to notify the staff if any of these adverse reactions
occur. The patient received the below listed modality for the prescribed time. The patient left this clinic after treatment without any
increases in pain, adverse reactions, and or complications. Patient verbalized understanding of next treatment appointment and or
follow up evaluation with the physical therapist.
The below indicated modality was applied to the patient's: R upper trap.
He reported: Visit is not deployment-related.

Physical findings
Vital signs:
Pain level (0-10) 5
General appearance:
° In no acute distress.
Therapy
• 2 physical therapy session segments, 15 minutes each.
• Ultrasound intensity 1.5 watts/cm2 x 8 mins.
A/P Written by JAMES, KRYSTAL K @ 05 Feb 2008 1502 EST

1. Other Physical Therapy
2. joint pain, localized in the shoulder
Procedure(s): -Physical Therapy: ___ Session Segments, 15 Minutes Each x 2
-Modalities Ultrasound x 1
Disposition Written by JAMES, KRYSTAL K @ 05 Feb 2008 1504 EST

Released w/ Work/Duty Limitations
Follow up: as needed in the PHYSICAL THERAPY clinic.
Signed By JAMES, KRYSTAL K (Physical Therapy Assistant, Martin ACH, FT BENNING, GA) @ 05 Feb 2008 1504
2019
Medical Record
2019
31 Jan 2008 at Martin ACH, Fort Benning, GA, Internal Med Benn by VAUGHN, VEETA M
Encounter ID: CDR-24101971 Primary Dx: Laboratory Studies
Patient: WAITERS, TOMMIE A Date: 31 Jan 2008 1412 EST Appt Type: T-CON*
Treatment Facility: MARTIN ACH Clinic: INTERNAL MED BENN Provider: VAUGHN,VEETA MISHAE
Reason for Telephone Consult: labwork results pls call with tests results
Notes Entered by: BEARDEN, TAMARA S 31 Jan 2008 1412
------------------------------
tsb
AutoCites Refreshed by RUDY, RUTH @ 03 Feb 2008 1422 EST

Problems Allergies
• FOLLICULITIS
• CERVICALGIA
Active Medications

IBUPROFEN, 800MG, TABLET, ORAL Active TT WF #30 NR 26 Jan 2008
THEN 1 TAB PO QD
Questionnaire AutoCites Refreshed by RUDY, RUTH @ 03 Feb 2008 1422 EST

Questionnaires
Lab Result Cited by VAUGHN, VEETA M @ 07 Feb 2008 1500 EST

WBC BLOOD 5.4 x10(3)/mcL (4.9-10.0)
RBC BLOOD 4.97 x10(6) (4.7-6.1)
MCHC BLOOD 35.3 % (32-36)
RDW-CV BLOOD 13.3 % (11.5-14.5)

2019
Medical Record
2019


Lab Result Cited by RUDY, RUTH @ 03 Feb 2008 1423 EST

Wound Culture
Status: Final
Ordering Provider: HOLST, KATHLEEN C
Priority: ROUTINE
Date Ordered: 09 Jan 2008 1617
Date Resulted: 12 Jan 2008 1407
COLLECT_SAMPLE: SWAB
Specimen: Wound
Collected: 09 Jan 2008 1625
Results:
Final report
Quantity: Staphylococcus aureus

MIC Sensitivity:
Ampicillin > 8 Resistant
Cefazolin <= 8 Susceptible
Chloramphenicol <= 8 Susceptible
Clindamycin <= 0.5 Susceptible
Cefotaxime <= 8 Susceptible
ERYTHROMYCIN BASE <= 0.5 Susceptible
Gentamicin <= 4 Susceptible
Oxacillin 1 Susceptible
PENICILLINS > 8 Resistant
Rifampin <= 1 Susceptible
Tetracycline <= 4 Susceptible
Trimethoprim+Sulfamethoxazole <= 2/38 Susceptible
Vancomycin <= 2 Susceptible
Ciprofloxacin <= 1 Susceptible
Ceftriaxone <= 8 Susceptible
Imipenem <= 4 Susceptible
Amoxicillin+Clavulanate <= 4/2 Susceptible
Ampicillin+Sulbactam <= 8/4 Susceptible
Azithromycin <= 2 Susceptible
Levofloxacin <= 2 Susceptible
2019
Medical Record
2019
Gatifloxacin <= 2 Susceptible

WBC BLOOD 5.4 x10(3)/mcL (4.9-10.0)
RBC BLOOD 4.97 x10(6) (4.7-6.1)
MCHC BLOOD 35.3 % (32-36)
RDW-CV BLOOD 13.3 % (11.5-14.5)


A/P Written by VAUGHN, VEETA M @ 07 Feb 2008 1502 EST

1. Laboratory Studies
Disposition Written by VAUGHN, VEETA M @ 07 Feb 2008 1502 EST
2019
Medical Record
2019
Note Written by VAUGHN, VEETA M @ 07 Feb 2008 1502 EST

notified of his results-normal.
Signed By VAUGHN, VEETA M (CPT,, MC) @ 07 Feb 2008 1502
2019
Medical Record
2019
31 Jan 2008 at Martin ACH, Fort Benning, GA, Physical Therapy by HUMPHRIES, SHAWN
E
Encounter ID: CDR-23432552 Primary Dx: CERVICALGIA
Patient: WAITERS, TOMMIE A Date: 31 Jan 2008 1330 EST Appt Type: SPEC
Treatment Facility: MARTIN ACH Clinic: PHYSICAL THERAPY Provider: HUMPHRIES,SHAWN
EDWARD
Reason for Appointment: Shoulder

adb
AutoCites Refreshed by HUMPHRIES, SHAWN E @ 31 Jan 2008 1343 EST
SO Note Written by HUMPHRIES,SHAWN EDWARD @ 31 Jan 2008 1358 EST

He reported: Visit is not deployment-related S/P MVA, OTHER DRIVER AT FAULT, ON 28JAN 08. PRESENTED TO ED AND
TREATED WITH TRIGGER POINT INJECTION. PNT STATES THIS REALLY HELPED. ALSO REFERRED FOR PT TO DO
MODALITIES FOR PAIN MODULATION. *X RAYS IN ED WERE INCONCLUSIVE RE: R SHOULDER. STATES THERE IS
EVIDENCE OF DEFECT IN ACROMIAN AND HUMERAL HEAD WHICH COULD REPRESENT AN OLD HILL SACHS LESION OR
A "RECENT FX." PNT HAS EXPECTATION THAT PHYSICIAN WANTED HIM TO GET AN MRI BUT STATES HE COULD NOT
GO ON THE DATE HE WAS CALLED. WILL ORDER MRI TODAY TO MORE CONCLUSIVELY IDENTIFY THE NOTED
ABNORMALITY. C SPINE X RAYS WERE READ AS NL. Neck pain does not radiate down the right arm. No numbness of the
limbs.
Reported History:
Past medical history REVIEWED.
Physical findings
General appearance:
° In no acute distress DOES NOT HOLD SHOULDER IN GUARDED POSTURE, MOVES IT NORMALLY WITH DON AND
DOFF OF SHIRT AND TUCKING SHIRT BEHIND BACK. *NL PASSIVE ELEV; ER; AND IR UP BACK. NEG
IMPINGEMENT NEER; HAWKINS; CROSS ARM; NEG O'BRIAN'S; *NO SIGNFICANT CX MM GUARDING ON EXAM,
FULL ROT AND SIDE BEND.* NL NEURO SCREEN **DOES NOT APPEAR TO BE A SIGNIFICANT AND NEW BONEY
INJURY TO THE RIGHT SHOULDER BASED ON TODAY'S EXAM.
Therapy
• Request lab results from x-ray department NOTED.
• Education and instructions: Barriers to Treatment (Age, Learning, Culutral, and Distance) were assessed and are appropriate
at this time.
• Physical therapy session segments, 15 minutes each TODAY SHOWED CX STRETCH FOR UPPER TRAPY AND
INTERSCAP MM. TOL WELL AND WITHOUT C/O SHOULDER PAIN. WILL ORDER MRI OF SHOULDER AS NOTED. WILL
SCHEDULE TIW X 2 WEEKS FOR US 1.5 W/CM 2 TO R TRAP, FOLLOW WITH THEREX AND PROGRESS AS TOLERATED: IR
UP BACK AND CX SIDE BEND; IR UP BACK AND CX SIDE BEND/ROT; SCAP PRO AND RETRACTION; AXIAL FLEX/EXT;
FINISH WITH UBE AS TOLERATED IN RETRO DIRECTION. LET ME KNOW IF UNABLE TO PERFORM THEREX.
• General physical therapy goals: independence in home exercise program x today. G: DEFINITIVE SHOULDER DX OF
ABNORMALITY WITH X RAY; NL ACTIVITIES WITH EASILY TOL SX X 4-6 WEEKS.
• Patient goals get rid of the pain and learn how to prevent in the future... : get rid of the pain and prevent pain in the future...
get rid of the pain and learn how to prevent in the future... : get rid of the pain and prevent pain in the future.
A/P Written by HUMPHRIES, SHAWN E @ 31 Jan 2008 1421 EST

1. CERVICALGIA
2. joint pain, localized in the shoulder: R/O NEW BONEY ABNORMALITY OF R SHOULDER; X RAYS INCONCLUSIVE
Procedure(s): -Physical Medicine Physical Therapy Evaluation x 1

Radiology(ies): -MRI SHOULDER RT W/O CONTRAST (Routine) Ordered By: HUMPHRIES, SHAWN E Impression:
R/O BONEY ABNORMALITY R SHOULDER; X RAYS INCONCLUSIVE; IDENTIFIED POSSIBLE OLD
2019
Medical Record
2019
HILL SACH'S LESION

Patient Instruction(s): -Plan Of Care Reviewed And Agreed To By Patient
Disposition Written by HUMPHRIES, SHAWN E @ 31 Jan 2008 1421 EST

Follow up: in the PHYSICAL THERAPY clinic. - Comments: SEE PLAN OF CARE IN CLINICAL NOTE
Note Written by HUMPHRIES, SHAWN E @ 31 Jan 2008 1343 EST

Consult Order
Referring Provider: KAPLAN, JOSEPH J
Date of Request: 28 Jan 2008
Priority: 72 Hours
Reason for Request:
s/p mvc with spasm and pain r trapezius. did trigger point injection withdecrease in sx/ please follow up and do modalities
Signed By HUMPHRIES, SHAWN E (MPT, OCS, CHE (PHYSICAL THERAPIST), Martin ACH, Fort Benning, GA) @ 31 Jan 2008
1422
2019
Medical Record
2019
09 Jan 2008 at Martin ACH, Fort Benning, GA, Internal Med Benn by HOLST, KATHLEEN
C
Encounter ID: CDR-22359089 Primary Dx: FOLLICULITIS
Patient: WAITERS, TOMMIE Date: 09 Jan 2008 1530 EST Appt Type: ACUT
ALAJANDRO
Treatment Facility: MARTIN ACH Clinic: INTERNAL MED BENN Provider: HOLST,KATHLEEN C
Reason for Appointment: poss Staph infection

ajj
AutoCites Refreshed by HOLST, KATHLEEN C @ 09 Jan 2008 1632 EST

• BACKACHE No Active Family History Found. • No Known Allergies
• visit for: refer patient without exam or
treatment
• headache
Active Medications

Cephalexin 250mg + Cephalexin Monohydrate, Active T1 CAP Q6H OR QID F10D NR 09 Jan 2008
Capsule, Oral
THEN 1 TAB PO QD
Screening Written by COGDELL, KIRT D. @ 09 Jan 2008 1529 EST
Allergen information verified by COGDELL, KIRT D. @ 09 Jan 2008 1529 EST
Vitals
Vitals Written by COGDELL, KIRT D. @ 09 Jan 2008 1529 EST
Use: No, Pain Scale: 5/10 Moderate, Pain Scale Comments: left thigh pain
SO Note Written by COGDELL,KIRT D @ 09 Jan 2008 1530 EST

Reason for Visit
Visit for: Patient here for medical evaluation for an infection on left thigh.
He reported: Visit is not deployment-related.

Allergies
An allergy: Reviewed Allergy Information and updated as necessary.
Reported History:
Medical: No previous hospitalizations and no previous emergency room visit.
SO Note Written by HOLST,KATHLEEN C @ 18 Jan 2008 1559 EST

Chief complaint
The Chief Complaint is: Left thigh lesion. States he's had these before, always in areas of hair growth. Was concerned when he
saw small amt green pus at site. Given his son's immunocompromised status, he didn't want to have an active infection and be in
contact with his son.
2019
Medical Record
2019
He reported: Past medical history reviewed.

Military service. Visit is not deployment-related.
Review of systems
Skin symptoms: Skin lesion(s): spot: single, erythematous, on the left thigh, circular in shape, and timing appeared over several
days.
Physical findings
Vital signs:
General appearance:
° Well-appearing. ° Awake. ° Alert. ° Oriented to time, place, and person. ° Well developed. ° Well nourished. ° In no acute
distress. ° Not acutely ill.
Skin:
• Skin: • Lesions: • Single skin lesion. • Clinical impressions 0.5cm erythematous, circular macule with pinpoint center
containing scant, green purulent drainage. Slightly tender over wound area, but no streaking of lower extremity, no
surrounding cellulitis. ° Normal except as noted.
Lab Result Cited by HOLST, KATHLEEN C @ 18 Jan 2008 1606 EST

Wound Culture
Status: Final
Ordering Provider: HOLST, KATHLEEN C
Priority: ROUTINE
Date Ordered: 09 Jan 2008 1617
Date Resulted: 12 Jan 2008 1407
COLLECT_SAMPLE: SWAB
Specimen: Wound
Collected: 09 Jan 2008 1625
Results:
Final report
Quantity: Staphylococcus aureus

MIC Sensitivity:
Ampicillin > 8 Resistant
Cefazolin <= 8 Susceptible
Chloramphenicol <= 8 Susceptible
Clindamycin <= 0.5 Susceptible
Cefotaxime <= 8 Susceptible
ERYTHROMYCIN BASE <= 0.5 Susceptible
Gentamicin <= 4 Susceptible
Oxacillin 1 Susceptible
PENICILLINS > 8 Resistant
Rifampin <= 1 Susceptible
Tetracycline <= 4 Susceptible
Trimethoprim+Sulfamethoxazole <= 2/38 Susceptible
Vancomycin <= 2 Susceptible
Ciprofloxacin <= 1 Susceptible
Ceftriaxone <= 8 Susceptible
Imipenem <= 4 Susceptible
Amoxicillin+Clavulanate <= 4/2 Susceptible
Ampicillin+Sulbactam <= 8/4 Susceptible
Azithromycin <= 2 Susceptible
Levofloxacin <= 2 Susceptible
Gatifloxacin <= 2 Susceptible
A/P Written by HOLST, KATHLEEN C @ 09 Jan 2008 1632 EST

1. FOLLICULITIS: Left thigh folliculitis. Lanced wound with culture taken. Given pt's history of folliculitis and pt's son being
immunocompromised (liver transplant), will give pt course of keflex. Understands to call if wound is not improving. Step daughter
2019
Medical Record
2019
also has had skin wounds - but found NOT to have MRSA.
Procedure(s): -Incision And Drainage Of Skin Abscess x 1
Medication(s): -CEPHALEXIN (KEFLEX) 250MG--PO CAP - T1 CAP Q6H OR QID F10D #40 RF0 Qt: 40 Rf: 0
Laboratory(ies): -WOUND CULTURE (Routine)
2. visit for: screening exam: Routine labs ordered for evaluation. Pt has strong family hx of DM, HTN, and early MI. Will f/u with
pt once labs complete.
No lipid panel for reference.
Laboratory(ies): -COMPREHENSIVE METABOLIC PANEL (Routine); HEMOGRAM AUTO+COMP AUTO DIFF
(Routine); LIPIDS (Routine)
Disposition Written by HOLST, KATHLEEN C @ 18 Jan 2008 1609 EST

Follow up: as needed . - Comments: After labs complete
Note Written by HOLST, KATHLEEN C @ 18 Jan 2008 1608 EST

Wound grew MSSA - sensitive to Cephalexin.
Signed By HOLST, KATHLEEN C (Physician/Workstation, Martin ACH, Fort Benning, GA) @ 18 Jan 2008 1609
2019
Medical Record
2019
VAILLANT, GEORGE R
Encounter ID: CDR-14688952 Primary Dx: BACKACHE
Patient: WAITERS, TOMMIE Date: 15 Oct 2007 0655 EDT Appt Type: ROUT
ALAJANDRO
Treatment Facility: CTMC-FT. BENNING Clinic: CTMC AMBULATORY PRIMARY Provider: VAILLANT,GEORGE R
CLINIC
Reason for Appointment: Need profile updated
AutoCites Refreshed by THOMAS, NORFLETT T @ 15 Oct 2007 0656 EDT

treatment
• headache
Active Medications
Screening Written by THOMAS, NORFLETT T @ 15 Oct 2007 0656 EDT
Allergen information verified by THOMAS, NORFLETT T @ 15 Oct 2007 0656 EDT
Vitals
Vitals Written by THOMAS, NORFLETT T @ 15 Oct 2007 0656 EDT
Med reconciliation.
SO Note Written by VAILLANT,GEORGE R @ 15 Oct 2007 0751 EDT

Chief complaint
The Chief Complaint is: 37 y/o male with 10 month hx of chronic, persitent LBP with pain to buttocks at times. Sustained during
MVA.
• Past medical history reviewed with patient • Problem list reviewed with patient • Medication list reviewed with patient ° ROS
unchanged
• Feeling as well as can be expected
• Pain controlled by rest • Pain controlled by medication
• Lower back pain on the right • On the left • Midline • Radiating to the buttocks • With muscle spasm bilaterally
Reported History:
Reported prior tests: No prior tests were performed.
Reported medications: Medication history.
Medical: Reported medical history.
past medical/surgical history [use for free text].
Personal history
Behavioral history: No caffeine use and no tobacco use.
Family history
Family in good health.
Review of systems
Otolaryngeal symptoms: No ear symptoms, no nasal symptoms, and no throat symptoms.
Neck symptoms: No neck pain, no neck muscle tightness, and no neck stiffness.
Cardiovascular symptoms: No chest pain or discomfort and no palpitations.
Pulmonary symptoms: Not feeling congested in the chest and no dyspnea.
2019
Medical Record
2019
Gastrointestinal symptoms: No nausea, no vomiting, no abdominal pain, and no diarrhea.

Genitourinary symptoms: No urinary symptoms and no genital lesion.
Skin symptoms: No dry skin and no pruritus.
Hematologic symptoms: No easy bleeding and no tendency for easy bruising.
Musculoskeletal symptoms: No arthralgias and no lightning pains.
Neurological symptoms: No lightheadedness, no dizziness, no focal disturbances, no motor disturbances, and no sensory
disturbances.
Physical findings
Vital signs:
• Vital signs:
° Current vital signs reviewed. ° Normal temperature. ° RR was normal. ° PR was normal. ° Blood pressure was normal.
° Weight was normal.
General appearance:
° Awake. ° Alert. ° Oriented to time, place, and person.
Neck:
° Appearance was normal. ° Palpation revealed no abnormalities. ° Demonstrated no decrease in suppleness. ° Thyroid
showed no abnormalities.
Lymph Nodes:
° No adenopathy. ° Not tender.
Lungs:
° Respiration rhythm and depth was normal. ° Respiratory movements were normal. ° Clear to auscultation.
Back:
• Lower back exhibited tenderness on palpation of the right paraspinal region. • Lower back exhibited tenderness on palpation
of the left paraspinal region. • Muscle spasm of the lower back in the right paraspinal region. • Muscle spasm of the lower
back in the left paraspinal region.
Abdomen:
Visual Inspection: ° Abdomen was normal on visual inspection.
Auscultation: ° Abdominal auscultation revealed no abnormalities.
Percussion: ° Abdominal percussion was normal.
Palpation: ° Abdominal palpation revealed no abnormalities.
Gallbladder: ° Normal to palpation.
General/bilateral: • A musculoskeletal exam was performed.
Cervical Spine:
General/bilateral: ° Cervical spine had a normal appearance. ° Cervical spine showed no tenderness on palpation.
° Cervical spine motion was normal.
Thoracic Spine:
General/bilateral: ° Thoracic spine had a normal appearance. ° Palpation of the thoracic spine revealed no abnormalities.
° Thoracic spine exhibited no spasm of the paraspinal muscles.
General/bilateral: • Lumbosacral spine exhibited tenderness on palpation of the spinous process at L l2-5. • Lumbosacral
spine exhibited spasms of the paraspinal muscles. • Active flexion of the lumbosacral spine 85-90 DEGREES.
• Lumbosacral spine pain was elicited by flexion. • Lumbosacral spine pain was elicited by extension. ° Lumbosacral
spine exhibited a normal appearance. ° A bilateral straight-leg raising test was negative. ° A bowstring test was
negative. ° Schober's index (finger-floor distance) was normal. ° Yeoman's test was negative.
Coccyx:
General/bilateral: ° Coccyx showed no abnormalities.
Neurological:
° Speech was normal.
Motor: ° A motor exam demonstrated no dysfunction.
Balance: ° Normal.
Reflexes: ° Normal.
A/P Written by VAILLANT, GEORGE R @ 15 Oct 2007 0751 EDT

1. BACKACHE: 10 mo. hx
2019
Medical Record
2019
Medication(s): -MOBIC 7.5MG TABLETS--PO 7.5MG TAB - 1 PO BID X 7 DAYS THEN 1 PO QD #30 RF1 Qt: 30 Rf: 1
Laboratory(ies): -HIV (Routine)
Radiology(ies): -L-S SPINE WITH OBLIQUES FOR RADICULAR PAIN ONLY (STAT) Impression: chronic LBP with
radicular complaints s/p MVA 1 year ago. R/
Disposition Written by VAILLANT, GEORGE R @ 15 Oct 2007 0755 EDT

Released w/ Work/Duty Limitations: Profile: BACKACHE 724.5 from 15 Oct 2007 to 10 Dec 2007; Comment: SEE da 3349
Follow up: as needed with PCM. - Comments: FOLLOW UP ON wEDNESDAY
Note Written by VAILLANT, GEORGE R @ 15 Oct 2007 0751 EDT

Additional A/P Information:
Discontinued KETOROLAC--INJ 60MG SYRN - 60 MG IM NOW #1 RF0
Signed By VAILLANT, GEORGE R (Physician Assistant, Certified, Martin ACH, Fort Benning, GA) @ 15 Oct 2007 0755
2019
Medical Record
2019
EASON, LINDA F
Encounter ID: CDR-15911422 Primary Dx: MIGRAINE HEADACHE
ALAJANDRO
Treatment Facility: CTMC-FT. BENNING Clinic: CTMC AMBULATORY PRIMARY Provider: EASON,LINDA FAYE
CLINIC
Reason for Appointment: headache

skp
AutoCites Refreshed by EASON, LINDA F @ 11 Oct 2007 1435 EDT

Problems Allergies
treatment
• headache
Active Medications
Vitals
Vitals Written by LEMKE,MICHAEL A @ 11 Oct 2007 1328 EDT
Use: No, Pain Scale: 7/10 Severe, Pain Scale Comments: headache
meds reconciled
Vitals
Vitals Written by EASON, LINDA F @ 11 Oct 2007 1443 EDT
Pain Scale: 7/10 Severe, Pain Scale Comments: headache
SO Note Written by EASON,LINDA FAYE @ 11 Oct 2007 1436 EDT

Chief complaint
The Chief Complaint is: 37 yo male presents with c/o migraine headache.
Physical findings
Vital signs:
General appearance:
• Patient appeared uncomfortable. ° Alert. ° Oriented to time, place, and person. ° Well developed. ° Well nourished. ° Well
hydrated. ° Healthy appearing. ° In no acute distress.
Head:
° Normocephalic.
Eyes:
General/bilateral:
Pupils: ° PERRLA.
External Eye: ° Showed no abnormalities. ° No discharge from the conjunctiva.
Sclera: ° Showed no icterus.
Lungs:
° Exaggerated use of accessory muscles for inspiration was not observed. ° Clear to auscultation. ° Normal breath
sounds/voice sounds: ° No wheezing was heard. ° No rales/crackles were heard.
Arterial Pulses: ° Normal.
Neurological:
Balance: ° Normal.
2019
Medical Record
2019
A/P Last updated by BELL, ROBERT A. @ 11 Oct 2007 1457 EDT

1. MIGRAINE HEADACHE
Procedure(s): -Dr. Supervised Injection Intramuscular x 1
-INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG x 4
Medication(s): -ACETAMINOPHEN (TYLENOL) 325MG--PO TAB - T1-2 TABS PO Q4-6H PRN **MAX OF 12 TABS
PER DAY** #24 RF0 Qt: 24 Rf: 0 Ordered By: EASON, LINDA F
-KETOROLAC--INJ 60MG SYRN - 60 MG IM NOW #1 RF0 Qt: 1 Rf: 0 Ordered By: EASON, LINDA F
Disposition Written by EASON, LINDA F @ 30 Oct 2007 0929 EDT

Follow up: as needed . - Comments: followup as needed
Signed By EASON, LINDA F (fnp, Martin ACH, Fort Benning, GA) @ 30 Oct 2007 0929
_________________________________________________________________________________________________________
CHANGE HISTORY
The following A/P Note Was Overwritten by BELL, ROBERT A. @ 11 Oct 2007 1457 EDT:
The A/P section was last updated by BELL, ROBERT A. @ 11 Oct 2007 1457 EDT - see above.Previous Version of A/P section was entered/updated by EASON, LINDA F @
11 Oct 2007 1443 EDT.
1. MIGRAINE HEADACHE
Medication(s): -KETOROLAC--INJ 60MG SYRN - 60 MG IM NOW #1 RF0 Qt: 1 Rf: 0 Ordered By: EASON, LINDA F
-ACETAMINOPHEN (TYLENOL) 325MG--PO TAB - T1-2 TABS PO Q4-6H PRN **MAX OF 12 TABS PER DAY** #24 RF0 Qt: 24 Rf: 0
Ordered By: EASON, LINDA F
2019
Medical Record
2019
GONZALEZ, RODNEY SHAWN
ALAJANDRO
Treatment Facility: TMC-2-FT. BENNING Clinic: CTMC AMBULATORY PRIMARY Provider: GONZALEZ,RODNEY SHAWN
CLINIC
Reason for Appointment: illness

ltj
AutoCites Refreshed by LEMKE, MICHAEL A. @ 11 Oct 2007 1328 EDT

treatment
• headache
Active Medications
Vitals
No Vitals Found.
Vitals
Vitals Written by LEMKE, MICHAEL A. @ 11 Oct 2007 1328 EDT
Use: No, Pain Scale: 7/10 Severe, Pain Scale Comments: headache
meds reconciled

Encounter Cancelled by DAVENPORT, TACCARRA R @ 11 Oct 2007 1612 EDT
2019
Medical Record
2019
08 Jul 2007 at 20th Medical Group, MAHC Immediate Care Clinic by PETERSON, JAMES L
Encounter ID: 47656075 Primary Dx: Headache
Patient: WAITERS, TOMMIE Date: 08 Jul 2007 1437 EDT Appt Type: EST$
ALAJANDRO
Treatment Facility: Moncrief ACH-Fort Clinic: MACH IMMEDIATE CARE CLINIC Provider: PETERSON,JAMES L
Jackson
Reason for Appointment: 36yo m co severe chx pains x 2days
AutoCites Refreshed by JORDAN, KATRINA R @ 08 Jul 2007 1450 EDT

treatment
Active Medications
Screening Written by BULLOCK, SHIRLEY @ 08 Jul 2007 1500 EDT
Allergen information verified by BULLOCK, SHIRLEY @ 08 Jul 2007 1500 EDT
Vitals
Vitals Written by SMITH, ASHLEY D @ 08 Jul 2007 1724 EDT
BP: 129/87, HR: 83, RR: 16, T: 98.1 °F, SpO2: 99%, Pain Scale: 6/10 Moderate, Pain Scale Comments: headache
Vitals Written by JORDAN,KATRINA R @ 08 Jul 2007 1448 EDT
Comments: vs and RST taken by JOSLYN>RST NEG
30cc Motrin given by JOSLYN @ 1400 per STEWART
Vitals Written by SMITH, ASHLEY D @ 08 Jul 2007 1400 EDT
SupBP: 125/79 , SupHR: 72 , StaBP: 134/84 , StaHR: 80 ,
SO Note Written by BULLOCK,SHIRLEY @ 08 Jul 2007 1500 EDT

C/o ha onset yesterday 7/10 pain level. c/o cx pain x 2 days. admits was in hosp for same c/o and is to be f/u. does not know dx.
states steady mild lt cx. to bed 6. report to ltr smith, rn.
Triage Category
Time:__1500_
By:_sb__
___ I Emergent
___ II Urgent
___x III Non-Urgent
___ IV Routine.
Therapy
• Transportation to an urgent care center Ambulatory on Arrival to Emergency Department and in a private vehicle.
SO Note Written by PETERSON,JAMES L @ 08 Jul 2007 1720 EDT

• Past medical history reviewed: Reviewed Autocite Content.
• Generalized pain: AD here for recruiter school with 5/10 left anterior chest pain, similar to last week when he was sent down
town for evaluation, normal TMST, neg Echo. Also with headache. Denies gastric complaints.
Allergies
No allergies: Reviewed Allergy Information in CHCS.
Reported History:
2019
Medical Record
2019
Reported medications: Medication history: Reviewed Autocite Content.

Review of systems
Musculoskeletal symptoms: No musculoskeletal symptoms.
Neurological symptoms: No neurological symptoms.
Physical findings
Vital signs:
• Pain level (0-10): Reviewed.
General appearance:
° Alert. ° Oriented to time, place, and person. ° Healthy appearing.
Head:
° Normocephalic.
Eyes:
General/bilateral:
External Eye: ° Showed no abnormalities. ° No discharge from the conjunctiva.
Neck:
° No tenderness.
Lymph Nodes:
Lungs:
° Clear to auscultation. ° Normal breath sounds/voice sounds:
Abdomen:
Palpation: ° Abdomen was soft. ° No abdominal tenderness.
Skin:
° Color and pigmentation were normal.
Neurological:
Balance: ° Normal.
Tests
Laboratory studies:
Electrocardiogram: Value
Ventricular rate 58
Normal sinus rhythm.
Lab Result Cited by PETERSON, JAMES L @ 08 Jul 2007 1722 EDT

Chem 7 Site/Specimen 08 Jul 2007 1612 Units Ref Rng
Glucose PLASMA 126.0 (H) mg/dL (70-110)
Urea Nitrogen PLASMA 9.0 mg/dL (7.1-19.5)
Potassium PLASMA NOT DONE <r> mmol/L (3.2-4.7)
Chloride PLASMA 103.0 mmol/L (99-111)
CO2 PLASMA 28.0 mmol/L (20-30)
Hemolysis Site/Specimen 08 Jul 2007 1612 Units Ref Rng

Hemolysis PLASMA MODERATE HEMOLYSIS VISIBLE (NONE)
CBC Site/Specimen 08 Jul 2007 1612 Units Ref Rng

WBC BLOOD 5.72 x10(3)/mcL (4.5-11.5)
RBC BLOOD 5.4 x10(6)/mcL (4.6-6.0)
Hemoglobin BLOOD 16.0 g/dL (14-18)
MCV BLOOD 81.3 fL (80-100)
MCHC BLOOD 36.4 (H) g/dL (32.0-36.0)
Platelets BLOOD 240.0 x10(3)/mcL (150-450)
Lymphocytes BLOOD 17.3 (L) % (20-50)
2019
Medical Record
2019

MPV BLOOD 11.1 fL (9.0-13.0)
RBC Distribution Width-SD BLOOD 38.1 fL (37-55)
A/P Last updated by PETERSON, JAMES L @ 08 Jul 2007 1723 EDT

1. headache: Motrin
Procedure(s): -ECG 12-Lead x 1
-Parenteral Fluids IV Infusion For Hydration x 1
-INFUSION, NORMAL SALINE SOLUTION , 1000 CC x 1
-INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG x 1 - 30mg IV administered at 1405. No
adverse reaction noted. Pt states pain of 6/10 headache.
-Dr. Supervised Injection Intravenous x 1
Laboratory(ies): -CBC MACH(SHAW NOT ALLOWED) (STAT); CHEM 7 MONCRIEF (STAT)
Disposition Written by PETERSON, JAMES L @ 08 Jul 2007 1724 EDT

Follow up: as needed with PCM and/or in the TMC AMBULATORY clinic.
Discussed: Diagnosis, Medication(s)/Treatment(s)
Note Written by SMITH, ASHLEY D @ 08 Jul 2007 1724 EDT

Nursing
Pt teaching r/t medication, tx plan and f/u. Pt verbalized understanding. Pt d/c'd from UCC without limitations with Motrin 800 mg. Pt
did not voice any questions or concerns at time of d/c.
Signed By PETERSON, JAMES L (Physician Assistant, Urgent Care Clinic, MACH, Ft. Jackson) @ 08 Jul 2007 1744
_________________________________________________________________________________________________________
CHANGE HISTORY
The following A/P Note Was Overwritten by PETERSON, JAMES L @ 08 Jul 2007 1723 EDT:
The A/P section was last updated by PETERSON, JAMES L @ 08 Jul 2007 1723 EDT - see above.Previous Version of A/P section was entered/updated by SMITH, ASHLEY D
@ 08 Jul 2007 1623 EDT.
1. headache
-INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG x 1 - 30mg IV administered at 1405. No adverse reaction noted. Pt states pain
of 6/10 headache.
The following A/P Note Was Overwritten by SMITH, ASHLEY D @ 08 Jul 2007 1623 EDT:
The A/P section was last updated by SMITH, ASHLEY D @ 08 Jul 2007 1623 EDT - see above.Previous Version of A/P section was entered/updated by PETERSON, JAMES L
@ 08 Jul 2007 1518 EDT.
1. headache
-INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG x 1 - 30mg IV
The following Vitals Entry Was Overwritten by JORDAN, KATRINA R @ 08 Jul 2007 1456 EDT:
Vitals Written by JORDAN, KATRINA R @ 08 Jul 2007 1448 EDT
BP: 121/75, HR: 105, RR: 18, T: 102.2 °F, SpO2: 99%, Tobacco Use: No, Alcohol Use: No, Pain Scale: 3/10 Mild, Pain Scale Comments: head
2019
Medical Record
2019
07 Jun 2007 at 20th Medical Group, TMC Physical Therapy by WARING, CHRISTOPHER A
Encounter ID: 46796950 Primary Dx: BACKACHE
Patient: WAITERS, TOMMIE Date: 07 Jun 2007 0919 EDT Appt Type: SPEC$
ALAJANDRO
Treatment Facility: TMC Consolidated (1- Clinic: TMC PHYSICAL THERAPY Provider: WARING,CHRISTOPHER
2-4)-Fort Jackson ANDREW
Reason for Appointment: Back
AutoCites Refreshed by WARING, CHRISTOPHER A @ 07 Jun 2007 0921 EDT

treatment
Active Medications
Vitals
Vitals Written by WARING, CHRISTOPHER A @ 07 Jun 2007 0922 EDT
Pain Scale: 6/10 Moderate, Pain Scale Comments: R side of mid and upper back
SO Note Written by WARING,CHRISTOPHER ANDREW @ 07 Jun 2007 0922 EDT

° Encounter Background Information: AGR NCO currently in recruiting school. Was hit by a car in FEB 06 in civilian job. Has
R side mid/upper back pain. AGG:fast walk, run. EASE: rest. Has had physical therapy doing stretches with little relief. GOAL:
decrease pain, increase fitness.
Physical findings
General/bilateral: • Musculoskeletal system: BACK: R lateral shift, hyper lordotic. FAROM with LBP on extension and B
rotation. Poor pelvic tilts. Tight gluts. 5/5 LE strength. TTP without spasm or guarding upper lumbar region. Popliteal
angle is 15? B. -Ely. - Patricks.
A/P Written by WARING, CHRISTOPHER A @ 07 Jun 2007 0934 EDT

1. BACKACHE
Procedure(s): -Exercises Assisted Exercises For ROM x 1
-Physical Medicine Physical Therapy Evaluation x 1
Disposition Written by WARING, CHRISTOPHER A @ 07 Jun 2007 0937 EDT

Released w/ Work/Duty Limitations: Profile: BACKACHE 724.5 from 07 Jun 2007 to 03 Jul 2007; Comment: No run or lift.
Follow up: 4 week(s) or sooner if there are problems. - Comments: HEP: pelvic tilts, bridging, trunk rotation, knee to opposite
shoulder. STG: Able to do 50 pelvic tilts by f/u visits. LTG: return to running in 8 wks.
Signed By WARING, CHRISTOPHER A (Chief, Physical Therapy, 20th Medical Group) @ 07 Jun 2007 0937
2019
Medical Record
2019
07 Jun 2007 at 20th Medical Group, TMC Ambulatory by LANE, HENDERSON M
Encounter ID: 46795679 Primary Dx: BACKACHE
Patient: WAITERS, TOMMIE Date: 07 Jun 2007 0800 EDT Appt Type: ACUT
ALAJANDRO
Treatment Facility: TMC Consolidated (1- Clinic: TMC AMBULATORY Provider: LANE,HENDERSON M
2-4)-Fort Jackson

ddl
AutoCites Refreshed by LANE, HENDERSON M @ 07 Jun 2007 0846 EDT

Problems Allergies
No Problems Found. • No Known Allergies
Active Medications
Vitals
No Vitals Found.
SO Note Written by LANE,HENDERSON M @ 07 Jun 2007 0857 EDT

Chief complaint
The Chief Complaint is: Chronic back pain x 5 months after being hit by vehicle. Pt states he was placed in Physical Therapy and
only went a couple times. Pt continues to have back pain. Discussed the possible benefits of physical therapy..
A/P Written by LANE, HENDERSON M @ 07 Jun 2007 0853 EDT

1. BACKACHE
2. visit for: refer patient without exam or treatment: To physical therapy
Disposition Written by LANE, HENDERSON M @ 07 Jun 2007 0916 EDT

Signed By LANE, HENDERSON M (Physician/Workstation, 20th Medical Group) @ 07 Jun 2007 0917
2019
Medical Record
2019
07 Jun 2007 at 20th Medical Group, TMC Ambulatory by LANE, HENDERSON M
Encounter ID: 46793505 Primary Dx:
Patient: WAITERS, TOMMIE Date: 07 Jun 2007 0736 EDT Appt Type: ACUT$
ALAJANDRO
Treatment Facility: TMC Consolidated (1- Clinic: TMC AMBULATORY Provider: LANE,HENDERSON M
2-4)-Fort Jackson
Vitals
Vitals Written by ELLISON, ELLA MARIE @ 07 Jun 2007 0739 EDT
BP: 135/81, HR: 65, RR: 20, T: 98.4 °F, Tobacco Use: No, Alcohol Use: No, Pain Scale: 6/10 Moderate, Pain Scale Comments:
lower and upper back

Encounter Cancelled by LANE, HENDERSON M @ 07 Jun 2007 0836 EDT
***** End of Previous Encounters *****
2019
Medical Record
2019
Clinical Notes
04 Sep 2019 1355 GMT at , Consultation by MCCAMBRIDGE, ERIN K
Title: PHYSICAL THERAPY Original Date: 04 Sep 2019 1355 GMT

CONSULT
Document Type: Consultation AHLTA Entry Date: 04 Sep 2019 1402 GMT
Facility: Document ID: 10653508183
Clinician: MCCAMBRIDGE, ERIN K
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Order Request for WAITERS, TOMMIE
Requesting HCP: AGUILAR, MICHAEL THOMAS

Requesting Location: AMHM02ASTRONG TEAM
Order ID number: 190809-02453
MCP Referral #: 20190241883
No. of Visits: 1
Referral Authorized Until: 08 Sep 2019
Reason for Consult:
48 y/o AAM, obese, HTN with chronic low back pain. Please evaluate and provide
stretching strengthening regimen +/- dry needling. Thank you.
Priority: ROUTINE
Low back pain
ACV:
Reviewed Date/Time: 09 Aug 2019@12:37:00
Appoint Status: APPOINT TO MTF
Appointment Review Comment:
Reviewer: MATTHEWS, ROYCE D
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 04 Sep 2019@08:55:00

Requesting HCP: AGUILAR, MICHAEL THOMAS
Clinic: PHYSICAL THERAPY
Consulting HCP: MCCAMBRIDGE, ERIN K.
HCDP: 315-TRICARE PRIME-RETIRED SPONSORS AND FAMILY MEMBERS

Problem List:
Note:
NOTE=Patient: WAITERS, TOMMIE ALAJANDRO
Date: 04 Sep 2019 0855 EDT
Appt Type: SPEC
Treatment Facility: ACH MARTIN-BENNING
Provider: MCCAMBRIDGE,ERIN K.
2019
Medical Record
2019

Clinic Phone: 544-2273
Autocites Refreshed by MCCAMBRIDGE,ERIN K @ 04 Sep 2019 0903 EDT
Allergies
No Known Allergies
Active Medications
Active Medications
Status
Sig
Refills Left
Last Filled
testosterone, 10 mg/0.5 gram per actuation (2 %), GEL MD PMP, TRANSDERM
Active
APPLY 4 PUMPS TO FRONT AND INNER THIGH EVERY MORNING *WASH HANDS AFTER USE* #1
RF3
3 of 3
23 Aug 2019
hydrochlorothiazide, 12.5 MG, CAPSULE, ORAL
Active
TAKE ONE CAPSULE BY MOUTH EVERY DAY #60 RF1
1 of 1
12 Aug 2019
sumatriptan succinate, 50 MG, TABLET, ORAL
Active
TAKE ONE TABLET BY MOUTH AT ONSET OF HEADACHE MAY REPEAT IN 2 HOURS AS NEEDED
FOR HEADACHE NO MORE THAN 4 TABLETS PER DAY #18 RF1
1 of 1
12 Aug 2019
lidocaine, 5 %, ADH. PATCH, TOPICAL
Active
APPLY 1 PATCH EVERY DAY (12 HOURS ON, 12 HOURS OFF) #1 RF10
10 of 10
12 Aug 2019
sildenafil citrate, 100 MG, TABLET, ORAL
Active
TAKE ONE TABLET BY MOUTH 1 HOUR BEFORE SEXUAL INTERCOURSE NO MORE THAN 1 A
DAY
#18 RF3
3 of 3
08 Aug 2019
Atorvastatin 10 mg oral tablet
Active
TAKE ONE TABLET BY MOUTH AT BEDTIME #90 RF3
3 of 3
07 Sep 2018
LIDOCAINE (lidocaine), 5 %, OINT. (G), TOPICAL, HI-TECH/AKORN C, 35.44 g TUBE
Active
0 of 3
28 Oct 2016
LIDOCAINE (lidocaine), 5 %, OINT. (G), TOPICAL, HI-TECH/AKORN C, 35.44 g TUBE
Active
1 of 3
28 Sep 2016
LIDOCAINE (lidocaine), 5 %, OINT. (G), TOPICAL, IGI LABS, INC./, 35.44 g TUBE
2019
Medical Record
2019
Active
3 of 3
18 Jul 2016
TRIAZOLAM (triazolam), 0.25 MG, TABLET, ORAL, GREENSTONE LLC., 10 ea. BOTTLE
Active
NR
03 May 2009
Low back pain
mon
Note Written by MCCAMBRIDGE,ERIN K @ 04 Sep 2019 0956 EDT
Lumbar Spine Physical Therapy Evaluation
Subjective
Patient was confirmed with correct full name and date of birth.
Pt verbally consented to today?s examination and treatment.
Date of Evaluation: Click here to enter a date.
Military Status: Retired
MOS/Occupation: CNA - GI clinic at BMACH
MRAT: N/A
History
Chief Complaint: low back pain
History/MOI: 49 y/o male with low back pain since 2008. He injured his back
in a vehicle accident in Iraq. He denies any recent injury or trauma to the
back. He reports his pain has been getting progressively worse. He has been
through therapy in the past (2009ish). His pain is primarily in the low back
but will have occasional pain into BLE that will last for a couple days and
then go away.
Patient Goals/Motivation: to reduce pain
Pain location: across low back
Pain presence: ?constant ?intermittent
VAS Score: 6/10
Numbness/tingling: ?No ?Yes:
Aggravating Factors: prolonged walking/sitting/standing
Mitigating Factors: changing position, pain medicine, pain patches
FABQ: 19+11=30
Functional Disability Score: Oswestry: 32%
Past Medical/Surgical History:
HTN
Low back pain
H pylori
Hypogonadism
Common Migraine
ED.
Appendectomy - 1991
Cyst removal left wrist - 2001 2002.
Medications: See active medication list in ALTHA
Medication reconciliation: Not indicated, no medications prescribed, no
medications changed
Imaging: See citation in ALTHA
Often bothered by feeling down, depressed or hopeless? ?No ?Yes:
Often bothered by little interest or pleasure in doing thing? ?No ?Yes:
2019
Medical Record
2019
Columbia Suicide Severity Rating Scale: N/A

Tobacco: ?No ?Yes:
-Requested assistance with cessation: ?No ?Yes:
Red Flags:
-Systemic: No fevers, chills, and no reported weight change; no reported
infections
-Head: No headache
-Cardiovascular: No chest pain or discomfort
-Pulmonary: No shortness of breath, no changes in cough or sputum
-Gastrointestinal: Normal appetite; No dysphagia, no nausea, no vomiting, no
fecal incontinence
-Genitourinary: No urinary loss of control, no urinary retention
-Endocrine: No excessive sweating
-Neurological: No dizziness, no tingling, no numbness; no reported dizziness
or vertigo
Examination
Affect: no apparent distress
Observation: No acute signs/symptoms of infection/DVT. No bruising, edema or
swelling noted.
Posture: Sitting: Poor; Standing: Poor
Correction of Posture: Same
Neurological
Motor Deficit: BLE myotomes 5/5
Sensory Deficit: Dermatomes (LE): WNL to crude touch (B)
Reflexes: Patellar tendon (2+) bilat, Achilles tendon (2+) bilat
Dural Signs: (-) B Slump, (-) B SLR
Functional Assessment
Squat: squat with pain
Movement Loss:
Lumbar Spine:
Direction
Movement Loss
Pain
Flexion
Fingertips to mid-thigh
pain during movement
Extension
Major
Right Lateral Side glide
Moderate
Left Lateral Side Glide
Moderate
Special Tests
(+) (B) Patrick?s/FABER
(-) (B) SLR
(+) (B) Prone Knee Flexion/Ely?s
Palpation
TTP
Repeated Movements
Movement
Symptoms During Testing
2019
Medical Record
2019
Symptoms After Testing

Extension in lying
Increase
No Worse
Repeated Extension in Lying
Increase
No Worse
Repeated Extension in Lying with wedge support
Increase
No Worse
Extension in standing
Increase
No Worse
Repeated extension in standing
Increase
No Worse
Instructed for HEP: repeated lumbar extension in lying with support under
abdomen or in standing 10x every 2-3 hours. Educated pt on use of lumbar
roll and posture corrections throughout the day. Educated pt to stop if loss
of ROM or peripheralization of symptoms, pt stated understanding
TREATMENT
Physical Therapy Evaluation (97162)
Therapeutic Exercise (97110): Patient instructed on and performed exercises
listed above x 15 minutes.
Patient educated on assessment, treatment options, risk, plan of care,
benefits/goals of skilled PT intervention, prognosis, and importance of
long-term self-management of condition.
Response to treatment: Pt tolerated evaluation and treatment without
complaint.
Learning needs were assessed. No Barriers to education noted.
The patient expressed and demonstrated understanding of all instruction and
has agreed to present POC.
Provisional Classification: Derangement or other
ASSESSMENT
Pt is a 49 y/o male who presents with chronic low back pain. His symptoms are
consistent with lumbar derangement or other to include chronic pain. The pt
will benefit from a trial of in clinic therapy for MDT, strengthening,
stretching, manual therapy and modalities as needed for pain relief.
Prognosis: Good if compliant with therapy
GOALS made in conjunction with patient at initial evaluation.
Short-term goal(s): 3-4 weeks
Pt will report 25% improvement in symptoms with daily and functional
activities.
Pt will be independence HEP
Long-term goal(s): 6-8 weeks
Pt will report 50% improvement in symptoms with daily and functional
activities.
Pt will be independent in long-term management of their condition.
PLAN
The pt will be seen 2x weeks and follow up in 4 weeks.
MARTIN ARMY PHYICAL THERAPY CLINIC
Daily Exercise/Procedure Flowsheet
Patient: Waiter, Tommie (20/1757)
DOB:18Aug1970
2019
Medical Record
2019
Diagnosis: LBP
Special Concerns:
Therapist: McCambridge
Frequency: 2x3 week
Follow-Up: 3-4 weeks
Exercise/Date:
Repeated lumbar extension in lying on wedge 3x10 (beginning and end of tx)
Bridge with TB around knees
Clamshells
Prone swimmer -> bird dog
TrA activation with:
-pelvic tilt 20x
-march 20x
-heel slide (heel contact with mat) 20x
-knee extension 20x
-arm lift/march 20x
Ice PRN
Time in Clinic
Pain Scale pre/post _/10
Provider Initials
DATE
Treatment Notes / Adverse Reactions / Complaints
Goals:
A/P Written by MCCAMBRIDGE,ERIN K @ 04 Sep 2019 0946 EDT
1. Low back pain M54.5
Procedure(s):
- (97162) Physical Therapy Service Evaluation Moderate Complexity
- (97110) Physical Therapy: ___ Session Segments, 15 Minutes Each
Disposition Written by MCCAMBRIDGE,ERIN K @ 04 Sep 2019 0949 EDT
Follow up: in the PHYSICAL THERAPY clinic.
Discussed: Diagnosis, Medication(s)/Treatment(s), Alternatives, Potential Side
Effects with Patient who indicated understanding.
Note Written by HOPKINS,TARA L @ 04 Sep 2019 0846 EDT
Consult Order
Referring Provider:AGUILAR,MICHAEL THOMAS
Date of Request:09 Aug 2019
Priority:Routine
Low back pain
Reason for Request:
48 y/o AAM, obese, HTN with chronic low back pain. Please evaluate and provide
stretching strengthening regimen +/- dry needling. Thank you.
Signed By MCCAMBRIDGE,ERIN K (PHYSICAL THERAPIST, BMACH, Ft. Benning, GA) @
04 Sep 2019 0956 EDT
Verified by: ERIN K. MCCAMBRIDGE, PT 04 Sep 2019@1002
2019
Medical Record
2019
26 Jul 2016 1600 GMT at , Consultation by
Title: Original Date: 26 Jul 2016 1600 GMT

GASTROENTEROLO
GY CONSULT
Document Type: Consultation AHLTA Entry Date: 18 Jul 2016 0101 GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: SALADYGA, ANNE TERESA

Requesting Location: SURGERY
No. of Visits: 1
Referral Authorized Until: 01 Jul 2016
Reason for Consult:
45-year-old male with a history of mesenteric panniculitis since 2008. Inconcl
usive biopsy at that time. Patient returns to the surgical clinic for consiste
nt left upper quadrant pain. The patient has not had recent EGD, and has never
had colonoscopy. Please evaluate and treat for mesenteric panniculitis, and p
erform EGD and colonoscopy to evaluate for other sources of the patient's pain
.
Priority: ROUTINE
Sclerosing mesenteritis
ACV:
Reviewed Date/Time: 02 Jun 2016@14:28:00
referral from Surgery to review
Reviewer: MCTIER, CORINNE A
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 26 Jul 2016@11:00:00

Requesting HCP: SALADYGA, ANNE TERESA
Clinic: GASTROENTEROLOGY CLINIC
Consulting HCP: MCP, PROVIDER
HCDP: 117-TRICARE PRIME FAMILY COVERAGE FOR RETIRED AND MEDAL OF HONOR
SPONSORS AND FAMILY MEMBERS
Problem List:
Note:
This referral/consult order has been administratively closed. It has been
45 days or greater since it was ordered, and has no related kept
appointment.
2019
Medical Record
2019
Administratively Closed on 17 Jul 2016
2019
Medical Record
2019
05 Jul 2016 1420 GMT at , Consultation by VEGA, JULIAN T
Title: FPC VASECTOMY Original Date: 05 Jul 2016 1420 GMT

Document Type: Consultation AHLTA Entry Date: 07 Jul 2016 0900 GMT
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: CALLAHAN, ROBERT CHARLES

Requesting Location: AMHM02BVICTORY TEAM
No. of Visits: 1
Reason for Consult:
45yo black male retiree who desires permenant sterilization. Please evaluate
and treat, thank you!! pt contact #: 706-326-4585
Priority: ROUTINE
ACV:
Reviewer: RAINA, ARWYN E
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 05 Jul 2016@09:20:00

Clinic: FMC SPECIALTY CLINIC
Consulting HCP: VEGA, JULIAN T
Problem List:
Note:
NOTE=Patient: WAITERS, TOMMIE ALAJANDRODate: 05 Jul 2016 0920 EDTAppt Type:
PROC
Treatment Facility: ACH MARTIN-BENNINGClinic: FMC SPECIALTY CLINICProvider:
VEGA,JULIAN T
Allergies
No Allergies Found.
Vitals
No Vitals Found.
2019
Medical Record
2019

vas pop
bjs
Vitals
Vitals Written by VEGA,JULIAN T @ 05 Jul 2016 1421 EDT
BP: 145/89, HR: 76, RR: 18, T: 98.1 F, Tobacco Use: No,
Alcohol Use: No, Pain Scale: 3/10 Mild
S/O Note Written by VEGA,JULIAN T @ 05 Jul 2016 1421 EDT
bodybodyChief complaint g1
The Chief Complaint is: Vasectomy post op.eg
ebody
ebody
Note Written by VEGA,JULIAN T @ 06 Jul 2016 0837 EDT
AHLTA down at the time of the encounter. The encouter was entered on 06July
2016.
SO: The patient's pain is 3/10. He reports being able to walk without
discomfort. No acute concerns. Denies fever, chills, swelling, bruising,
bleeding, hematuria. He states that he has not ejaculated since procedure.
vital signs reviewed
PE: penis - normal, scrotum - incision healing normally, no redness, or
swelling present.
A/P Written by VEGA,JULIAN T @ 06 Jul 2016 0841 EDT
1. Essential (primary) hypertension: follow up with PCM.
2. Vasectomy status: Pt is healing normally. Orders entered for post vasectomy
semenalysis. pending tissue exam of vas deferens. Pt to continue return to
activity, using scrotal support. Tylenol and motrin as needed for pain. pt
verbalized agreement.
Disposition Written by VEGA,JULIAN T @ 06 Jul 2016 0841 EDT
Signed By VEGA, JULIAN T (Captain, Physician DO PGY 3, Licensed Physician,
Family Medicine Resident, MACH) @ 06 Jul 2016 0841
Verified by: JULIAN T. VEGA, CPT, MC 07 Jul 2016@0500
2019
Medical Record
2019
27 Jun 2016 1420 GMT at , Consultation by VEGA, JULIAN T
Title: FPC VASECTOMY Original Date: 27 Jun 2016 1420 GMT

Document Type: Consultation AHLTA Entry Date: 27 Jun 2016 1423 GMT
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------

Requesting Location: AMHM02BVICTORY TEAM
No. of Visits: 1
Reason for Consult:
Priority: ROUTINE
ACV:
Reviewer: RAINA, ARWYN E
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 27 Jun 2016@09:20:00

Consulting HCP: VEGA, JULIAN T
Problem List:
Note:
NOTE=Patient: WAITERS, TOMMIE ALAJANDRODate: 27 Jun 2016 0920 EDTAppt Type:
PROC
Treatment Facility: ACH MARTIN-BENNINGClinic: FMC SPECIALTY CLINICProvider:
VEGA,JULIAN T
Allergies
No Allergies Found.
Vitals
2019
Medical Record
2019
BP: 126/80, HR: 88, RR: 18, T: 98.1 F, HT: 66 in, WT: 243 lbs, BMI: 39.22,
BSA: 2.173 square meters, Tobacco Use: No, Alcohol Use: No,
vas preop
bjs
Vitals
BP: 126/80, HR: 88, RR: 18, T: 98.1 F, HT: 66 in, WT:
243 lbs, BMI: 39.22, BSA: 2.173 square meters, Tobacco Use: No,
Alcohol Use: No,
bodybodyHistory of present illness g2
A 45 yr old AAM present today for referral for Vasectomy . Pt already have 5
children ranging from 3wks to 22yrs. Has discussed with spouse and both are
happy with their family and do not desire further children. In stable
monogomous relationship. Patient understands irreversability of procuedre
and would not desire further children under any circumstances. Pt has no
history of testicular trauma. No history of STDs.
Patient IS NOT currently in a situation where they are being verbally or
physically hurt, threatened, or made to feel afraid.
Pt was last seen urology. He will be referred to Gastro.eg
Allergies g24
.eg
Current medication g3
ASA 81 MG EVERY DAY
Updated 6/1/2016
.eg
Past medical/surgical history g4
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
2019
Medical Record
2019
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.eg
Personal history g5
Children: 3.
No - Do you have a learning disability, language barrier, hearing/vision
deficit?
Annual Questions Date: 11/04/2014.eg
Family history g7
CA- mother- bresat
father- DM.
.eg
Review of systems g16
Head: No headache.
Otolaryngeal: No earache, no nasal discharge, no nasal passage blockage
(stuffiness), and no sore throat.
Gastrointestinal: No nausea, no vomiting, no abdominal pain, no bright red
Genitourinary: No change in urinary frequency and no feelings of urinary
urgency. No dysuria.
The patient HAS NOT traveled outside of the country in the past 90 days.eg
Physical findings g8
Vital Signs:
? Temperature: Reviewed. ? RR: Reviewed. ? PR: Reviewed. ? Blood pressure:
Reviewed.
General Appearance:
2019
Medical Record
2019
Normal. Well developed. Well nourished. In no acute distress.

Lungs:
Respiration rhythm and depth was normal. Exaggerated use of accessory
muscles for inspiration was not observed. Clear to auscultation. No
wheezing was heard. No rhonchi were heard. No rales/crackles were
heard.
Genitalia:
Penis: Normal.
Scrotum: Normal.
Testes: Normal.
Neurological:
Oriented to time, place, and person.
Psychiatric:
Mood: Euthymic.
Affect: Normal.
Skin:
Showed no ecchymosis. Temperature was normal. No skin lesions.eg
Practice Management g17
Colonoscopy - n/a
.
Patient
's BMI >= 30. Screening Date:11/04/2014.eg
ebody
ebody
A/P Last updated by VEGA,JULIAN T @ 27 Jun 2016 1017 EDT
1. Encounter for sterilization: 45 yo male presents for pre-op vasectomy
appointment. He has 6 children and would like to have permanent
sterilization. He understands the risks and benefits of the elective
procedure. He signed the consent form. Patient given preop information packet
to review and instructions. Patient given prescription for Valium to use
before procedure and pain medication to use afterward. Patient will follow up
Thursday for his appointment. If he has any questions to call clinic. Patient
verbalizes agreement.
Medication(s): -OXYCODONE/APAP 5MG/325MG ORAL TAB--PO 5M - TAKE ONE EVERY
4-6 HOURS AS NEEDED #10 RF0 Ordered By: SMITH,AUSTIN M Ordering Provider:
VEGA, JULIAN T
PROCEDURE AND TAKE ANOTHER AT PROCEDURE TIME #2 RF0 Ordered By: SMITH,AUSTIN
M Ordering Provider: VEGA, JULIAN T
Disposition Last updated by VEGA,JULIAN T @ 27 Jun 2016 1017 EDT
Follow up: as needed in 3 with PCM or sooner if there are problems.
2019
Medical Record
2019
30 minutes face-to-face/floor time. >50% of appointment time spent counseling

and/or coordinating care.
Note Written by TAFT,ROBERT M @ 27 Jun 2016 0921 EDT
Consult Order
Referring Provider:CALLAHAN, ROBERT C
Date of Request:01 Jun 2016
Priority:Routine
Reason for Request:
Signed By VEGA, JULIAN T (Captain, Physician DO PGY 3, Licensed Physician,
Family Medicine Resident, MACH) @ 27 Jun 2016 1017
______________________________________________________________________________
___________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by VEGA,JULIAN T @ 27 Jun 2016 1017
EDT:
bodybodyHistory of present illness g2
A 45 yr old AAM present today for referral for Vasectomy . Pt already have 5
children ranging from 3wks to 22yrs. Has discussed with spouse and both are
happy with their family and do not desire further children. In stable
monogomous relationship. Patient understands irreversability of procuedre
and would not desire further children under any circumstances.
Patient IS NOT currently in a situation where they are being verbally or
physically hurt, threatened, or made to feel afraid.
Pt was last seen urology. He will be referred to Gastro.eg
Allergies g24
.eg
ASA 81 MG EVERY DAY
Updated 6/1/2016
.eg
Reported:
HTN
2019
Medical Record
2019
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
ABD LAPROSCOPY 2012
.eg
Personal history g5
Children: 3.
No - Do you have a learning disability, language barrier, hearing/vision
deficit?
Annual Questions Date: 11/04/2014.eg
Family history g7
CA- mother- bresat
father- DM.
.eg
Head: No headache.
The patient HAS NOT traveled outside of the country in the past 90 days.eg
2019
Medical Record
2019
Vital Signs:
? Temperature: Reviewed. ? RR: Reviewed. ? PR: Reviewed. ? Blood pressure:
Reviewed.
General Appearance:
Lungs:
heard.
Genitalia:
Penis: Normal.
Scrotum: Normal.
Testes: Normal.
Neurological:
Psychiatric:
Mood: Euthymic.
Affect: Normal.
Skin:
Showed no ecchymosis. Temperature was normal. No skin lesions.eg
Practice Management g17
Colonoscopy - n/a
.
Patient
's BMI >= 30. Screening Date:11/04/2014.eg
ebody
ebody
The following Disposition Note Was Overwritten by VEGA,JULIAN T @ 27 Jun 2016
1016 EDT:
Disposition section was last updated by VEGA,JULIAN T @ 27 Jun 2016 1016 EDT -
see above.Previous Version of Disposition section was entered/updated by
SMITH,AUSTIN M @ 27 Jun 2016 0945 EDT.
The following A/P Note Was Overwritten by VEGA,JULIAN T @ 27 Jun 2016 1015
EDT:
A/P section was last updated by VEGA,JULIAN T @ 27 Jun 2016 1015 EDT - see
above.Previous Version of A/P section was entered/updated by SMITH,AUSTIN M @
27 Jun 2016 0937 EDT.
2019
Medical Record
2019
1. Encounter for sterilization

Medication(s): -OXYCODONE/APAP 5MG/325MG ORAL TAB--PO 5M - TAKE ONE EVERY
4-6 HOURS AS NEEDED #10 RF0 Ordered By: SMITH,AUSTIN M Ordering Provider:
VEGA, JULIAN T
PROCEDURE AND TAKE ANOTHER AT PROCEDURE TIME #2 RF0 Ordered By: SMITH,AUSTIN
M Ordering Provider: VEGA, JULIAN T
Verified by: JULIAN T. VEGA, CPT, MC 27 Jun 2016@1023
2019
Medical Record
2019
31 May 2016 1930 GMT at , Consultation by SALADYGA, ANNE T
Title: GENERAL Original Date: 31 May 2016 1930

SURGERY CONSULT GMT
Document Type: Consultation AHLTA Entry Date: 01 Jun 2016 2140 GMT
Clinician: SALADYGA, ANNE T
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: LESTER, JOSEPH L

Requesting Location: EMERGENCY ROOM
No. of Visits: 10
Referral Authorized Until: 20 Jun 2016
Reason for Consult:
Priority: ROUTINE
ACV:
Reviewed Date/Time: 21 Apr 2016@14:58:00
Reviewer: SALADYGA, ANNE T
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 31 May 2016@14:30:00

Requesting HCP: LESTER, JOSEPH L
Clinic: SURGERY
Consulting HCP: SALADYGA, ANNE TERESA
Problem List:
Note:
NOTE=Patient: WAITERS, TOMMIE ALAJANDRODate: 31 May 2016 1430 EDTAppt Type:
SPEC
Treatment Facility: ACH MARTIN-BENNINGClinic: SURGERYProvider: SALADYGA,ANNE
TERESA
AutoCites Refreshed by SALADYGA,ANNE T @ 01 Jun 2016 1716 EDT
Allergies
No Allergies Found.
mesenteric panniculitus-letter sent
2019
Medical Record
2019
crp
S/O Note Written by SALADYGA,ANNE TERESA @ 01 Jun 2016 1719 EDT
The Chief Complaint is: LUQ pain.eg
History of present illness g2
LATE ENTRY: PATIENT SEEN 31May16. This is a 45-year-old male who presents to
the general surgery clinic for reevaluation of the left upper quadrant pain
and mesenteric panniculitis. The patient initially presented to the Gen.
surgery clinic in 2008 and was a patient of Dr. McGuigan. In 2008 she
completed an extensive workup to include abdominal CT scan and MRI. The
patient underwent mesenteric biopsy which was inconclusive but not suggestive
of lymphoma or a mesenteric sclerosis. EGD showed Helicobacter pylori
gastritis for which he was treated but did not resolve his left upper
quadrant pain. A subsequent MRI finding showed resolution of the inflammation
at the root of the mesentery. The patient then re- presented in 2013 with
continued complaints of left upper quadrant pain. The patient was given
referral for her EGD and colonoscopy for which never occurred, and the
patient was lost to followup.
The patient presents today complaining of increased consistency of his left
upper quadrant pain. He notes the pain is 6/10, and feels almost like a
runners cramp. The patient notes the pain has been consistent over the past
several months which concerns him. The patient has not been able to find any
aggravating her mitigating factors. Advil does not work for his pain. The
patient denies early satiety. The patient denies nausea, vomiting, fever,
chills. He notes that perhaps the pain became worse after eating oysters and
clamps and obtaining food poisoning in 2013.
.
Pain Severity 6 / 10.eg
Allergies g24
NKDA
.eg
None
.eg
Reported:
Medical: Reported medical history Helicobacter pylori gastritis treated in
2008, 2011 high blood pressure
.
Laparoscopic mesenteric biopsy of 2008
.eg
Personal history g5
Behavioral: No tobacco use history.
Alcohol: Not using alcohol AUDIT-C Date:eg
Family history g7
Dad DM.eg
2019
Medical Record
2019
Head: Headache.
Musculoskeletal: No back pain. Pain localized to one or more joints.
Neurological: No lightheadedness.eg
General Appearance:
Head:
Injuries: No evidence of a head injury.
Appearance: Head normocephalic.
Neck:
Appearance: Of the neck was normal.
Palpation: No tenderness of the neck.
Thyroid: Showed no abnormalities.
Eyes:
General/bilateral:
Pupils: Size of the pupil was normal. Pupil accommodation was not
impaired.
External: Eyelids showed no abnormalities. Conjunctiva exhibited no
abnormalities.
Sclera: Normal.
Ears:
General/bilateral:
Outer Ear: Normal.
Nose:
General/bilateral:
External Deformities: No external nose deformities.
Lymph Nodes:
Cervical lymph nodes were not enlarged. Submandibular lymph nodes were
not enlarged. Supraclavicular lymph nodes were not enlarged.
Lungs:
heard.
Cardiovascular:
Heart Rate And Rhythm: Normal.
Heart Sounds: Normal S1 and S2. No gallop was heard. No click was
heard. No pericardial friction rub heard.
Murmurs: No murmurs were heard.
Abdomen:
Visual Inspection: Abdomen was not distended.
Auscultation: Bowel sounds were not diminished or absent.
Palpation: ? Abdominal tenderness Mild tenderness to palpation of the left
upper quadrant without peritoneal signs. ? A mass was palpated in the
abdomen Slight fullness on the left upper corner and the abdomen. Abdomen
was soft. No abdominal guarding.
2019
Medical Record
2019
Liver: Normal to palpation.

Spleen: Normal to palpation.
Hernia: No hernia was discovered.
Functional Exam:
General/bilateral: Mobility was not limited.
Neurological:
Psychiatric:
Mood: Euthymic.
Affect: Normal.eg
Test conclusions g21
Medication list was updated at the beginning of the visit.eg
ebody
ebody
Rad Result Cited by SALADYGA,ANNE T @ 01 Jun 2016 1728 EDT
WAITERS, TOMMIE ALAJANDRO 20/1757 DoD ID: 1068397665 45yo 18 Aug
1970 M
********** CT ABDOMEN/PELVIS W/ CONTRAST **********
Status: Complete
Procedure: CT ABDOMEN/PELVIS W/ CONTRAST
Event Date: 20-Apr-2016 23:30:00
Exam #: 16040758
Exam Date/Time: 21-Apr-2016 01:25:00
Transcription Date/Time: 21-Apr-2016 09:00:00
Status: COMPLETE
Approved Date: 21-Apr-2016 09:17:00
Report Text:
TECHNIQUE: Axial images were obtained from the lung bases through the
pubic
symphysis after oral and intravenous contrast administration.
FINDINGS: The lung bases are unremarkable. The liver, spleen, pancreas,
gallbladder, kidneys and adrenal glands are normal. There are prominent
lymph
nodes seen within the root of the mesentery with mild inflammation in the
root
2019
Medical Record
2019
of the mesentery. Findings may represent mesenteric panniculitis.

Otherwise
there is no mesenteric, retroperitoneal or pelvic lymphadenopathy. There
is no
abdominal or pelvic ascites. The bowel is normal without evidence of
obstruction
or inflammation. There is no abscess or fluid collection. The urinary
bladder
and pelvic structures are unremarkable.
IMPRESSION: Mild inflammation in the root of the mesentery. Findings may
represent mesenteric panniculitis. Otherwise unremarkable CT of the
abdomen and
pelvis.
A/P Written by SALADYGA,ANNE T @ 01 Jun 2016 1733 EDT
1. Sclerosing mesenteritis K65.4: Patient with multiple imaging studies and
symptoms suggestive of mesenteric panniculitis, although etiology is unknown.
The patient is having increasing symptoms which warrant further evaluation. I
will begin with the last plans evaluation which is EGD and colonoscopy,
particularly since the patient has never had evaluation of his colon. In
placing a consult to gastroenterology for evaluation and treatment of
mesenteric panniculitis, but also for EGD and colonoscopy. Gastroenterology
may have more ideas on how to treat the patient's pain. I would like to see
the patient back, as I feel another mesentery biopsy is warranted to see if
there has been a declaration of the etiology. At this point I have no
treatment or surgery to help the patient's pain, as I discussed with the
patient, but the best plan is to continue with evaluation for a cause. The
patient will return to see me in approximately one week after EGD and
colonoscopy.
Consult(s): -Referred To: GASTROENTEROLOGY CONSULT (Routine) Specialty:
Clinic: GASTROENTEROLOGY CLINIC Provisional Diagnosis: Sclerosing
mesenteritis Order Date: 06/01/2016 17:32 Ordered By: SALADYGA,ANNE T
Ordering Provider: SALADYGA,ANNE TERESA
Disposition Written by SALADYGA,ANNE T @ 01 Jun 2016 1734 EDT
Follow up: 3 to 6 week(s) in the SURGERY clinic or sooner if there are
problems.
Note Written by PAUL,CORAZON R @ 31 May 2016 1403 EDT
Consult Order
Referring Provider:LESTER, JOSEPH L
Date of Request:21 Apr 2016
Priority:Routine
Reason for Request:
Signed By SALADYGA, ANNE T (Major, MC, MD, Martin AHC; Fort Benning, GA) @ 01
Jun 2016 1735
______________________________________________________________________________
___________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by SALADYGA,ANNE T @ 01 Jun 2016 1720
2019
Medical Record
2019
EDT:
S/O Note Written by HICE,LAURIE E @ 31 May 2016 1442 EDT
The Chief Complaint is: LUQ pain.eg
Pt states he has had discomfort in his LUQ for several years but has worsened
over the last several months. States it is a constant discomfort on a scale
of 6 - 7.
.eg
Allergies g24
NKDA
.eg
None
.eg
Reported:
Medical: Reported medical history H. Pylori 2011
Htn - trying to control with diet
.
.eg
Personal history g5
Social history reviewed Denies alcohol/tobacco use at present.eg
Family history g7
Dad DMeg
ebody
ebody
Verified by: ANNE T. SALADYGA, MAJ, MC 01 Jun 2016@1740
2019
Medical Record
2019
02 Mar 2016 1500 GMT at , Consultation by
Title: CARDIOLOGY 24 Original Date: 02 Mar 2016 1500

HR BP MONITOR GMT
Document Type: Consultation AHLTA Entry Date: 21 Feb 2016 0714 GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: MCCOMB, CLARA E

No. of Visits: 1
Referral Authorized Until: 04 Feb 2016
Reason for Consult:
Pt is a 45 y/o black M with PMHx of HTN and strong family hx of cardiac diseas
e - pt states he has some elevated blood pressures at home, though BP in clini
c 133/86. Please evaluate 24 hour blood pressure IOT determine if blood pressu
re medications need adjustment. Thank you. POC: 706-326-4585.
Priority: ROUTINE
ACV:
Reviewed Date/Time: 05 Jan 2016@10:32:00
Reviewer: SCOTT, GWENDA L
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 02 Mar 2016@09:00:00

Requesting HCP: MCCOMB, CLARA E
Clinic: CARDIOLOGY CLINIC
Problem List:
Note:
45 days or greater since it was ordered, and has no related kept
appointment.
Administratively Closed on 20 Feb 2016
2019
Medical Record
2019
12 Jan 2015 2154 GMT at , Consultation by
Title: PREV MED Original Date: 12 Jan 2015 2154 GMT

REPORTABLE MED
EVENTS
Document Type: Consultation AHLTA Entry Date: 13 Feb 2015 0201 GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: STARBUCK, AARON K

No. of Visits: 1
Referral Authorized Until: 11 Feb 2015
Reason for Consult:
44 yo ret SM had ppd done for potential employment with a 20 mm result. Also
chest x-ray negative. Please evaluate and treat. Available at 706-326-4585.
Priority: ROUTINE
Visit for: screening exam pulmonary tuberculosis
ACV:
Reviewer: MELENDEZ, ELY
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 12 Jan 2015@15:54:00

Clinic: PREVENTIVE MEDICINE
Problem List:
Note:
30 days or greater since it was ordered, and has no related appointment.
Administratively Closed on 12 Feb 2015
2019
Medical Record
2019
09 Jan 2015 1400 GMT at , Consultation by ANDREWS, JAMIE NATHAN
Title: Original Date: 09 Jan 2015 1400 GMT

OTORHINOLARYNG
OLOGY CONSULT
Document Type: Consultation AHLTA Entry Date: 28 Jan 2015 0005 GMT
Clinician: ANDREWS, JAMIE
NATHAN
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------

No. of Visits: 1
Referral Authorized Until: 07 Dec 2014
Reason for Consult:
44 yo with hearing loss and abnormal appearing TM, concern for significant mid
dle ear pathology.
Priority: ROUTINE
OTITIS EXTERNA
ACV:
Reviewed Date/Time: 10 Nov 2014@13:05:00
Reviewer: ANDREWS, JAMIE N
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 09 Jan 2015@08:00:00

Clinic: OTORHINOLARYNGOLOGY
Consulting HCP: ANDREWS, JAMIE NATHAN
Problem List:
Note:
NOTE=Patient: WAITERS, TOMMIE ALAJANDRODate: 09 Jan 2015 0800 ESTAppt Type:
SPEC
Treatment Facility: MARTIN ACHClinic: OTORHINOLARYNGOLOGYProvider:
ANDREWS,JAMIE NATHAN
OTITIS EXTERNA
2019
Medical Record
2019
cjbh
Vitals
RR: 12, HT: 66 in, WT: 227 lbs, SpO2: 99%, BMI: 36.64,
BSA: 2.111 square meters, Pain Scale: 4/10 Moderate
S/O Note Written by ANDREWS,JAMIE NATHAN @ 09 Jan 2015 1755 EST
The Chief Complaint is: Ear ache.eg
The Patient is a 44 year old male. Source of patient information was
patient.
Pt is a 44 yom who presents for eval of chronic RIGHT sided otalgia. This has
been present for several months, pt notes difficulty with chewing d/t pain.
He was treated with antibiotics w/o benefit for a presumed oe. +h/o
bruxism. hearing test - normal. no otorrhea, aural fullness, vertigo, occ
tinnitus, no prior ear surgeries.
Reliability of source of patient information.
Generalized pain.
Hearing loss and earache. No discharge from the ears and no watery nasal
discharge. No postnasal drip and no epistaxis. Nasal passage blockage
(stuffiness). No hoarseness, no sore throat, and no lump in the throat.
No sinus pressure. No neck pain and no swollen glands in the neck. No
dizziness, no vertigo, and no difficulty with balance.eg
Reported:
.
. Not taking dietary supplements, no vitamin supplements, and no
over-the-counter medications.
Diagnoses:
Hypertension.
No renal disease.
No stroke syndrome.
Surgical:
? No otolaryngologic surgery
? No myringotomy with ventilating tube insertion
? No sinus surgery
? No tonsillectomy with adenoidectomyeg
Personal history g5
2019
Medical Record
2019
.
Alcohol: Not using alcohol.eg
Family history g7
No congenital deafness.eg
Systemic: No systemic symptoms, no fever, no chills, no night sweats, and no
recent weight loss.
Skin: No skin symptoms.eg
Vital Signs:
? Temperature: Reviewed. ? RR: Reviewed. ? PR: Reviewed. ? SBP: Reviewed.
General Appearance:
Well developed. Well nourished. In no acute distress.
Neck:
Thyroid: Showed no abnormalities.
Cervical Mass: No cervical mass was seen.
Eyes:
General/bilateral:
Extraocular Movements: Normal.
Pupils: PERRL.
External: Conjunctiva exhibited no abnormalities.
Sclera: Normal.
Ears:
General/bilateral:
External Auditory Canal: Normal.
Tympanic Membrane: Normal. No retraction of tympanic membrane. Did not
have pressure equalization tubes. Mobility normal.
Hearing: Weber test normal. Rinne test normal.
Nose:
General/bilateral:
External Deformities: No external nose deformities.
Cavity: Nasal septum normal. Nasal mucosa normal. Nasal turbinate
normal.
Oral Cavity:
? Oral cavity: SEVERAL CLICKING WHICH IS AUDIBLE UPON JAW OPENING, TM/EAC
CLEAR INTACT AU.
Pharynx:
Oropharynx: Soft palate was normal. Uvula showed no abnormalities.
Tonsils showed no abnormalities.
Lymph Nodes:
Cervical lymph nodes were not enlarged. Submandibular lymph nodes were
2019
Medical Record
2019
not enlarged. Supraclavicular lymph nodes were not enlarged.

Neurological:
Oriented to time, place, and person. No learning disability was noted
(barriers to learning).
Cranial Nerves: Olfactory nerve was normal. Optic nerve was not impaired.
Oculomotor nerve was not impaired. Trochlear nerve was not impaired.
No trigeminal neuropathy. Abducens nerve was normal. No facial nerve
palsy was noted. Vestibulocochlear nerve was not impaired.
Glossopharyngeal nerve was not impaired. Vagus nerve was not impaired.
Cranial and spinal accessory nerves were normal. Hypoglossal nerve was not
impaired.
Psychiatric:
Mood: Euthymic.
Affect: Normal.
Skin:
Showed no ecchymosis. No skin lesions.eg
Therapy g12
? No herbal medicines.eg
Counseling/Education g22
Patient verbalized understanding and accepted instructions.eg
ebody
ebody
A/P Written by ANDREWS,JAMIE N @ 09 Jan 2015 1800 EST
1. TEMPOROMANDIBULAR JOINT-PAIN DYSFUNCTION SYNDROME: Sxs are c/w tmj
dysfunction, soft diet, nsaids, and mri tmj prescribed. Pt advised to trial
oral appliance, followup in 6-8 weeks.
Medication(s): -NAPROXEN 500MG (NAPROSYN)-ORAL TABLET--P - TAKE ONE TABLET
TWICE A DAY WITH FOOD #60 RF1 Ordered By: ANDREWS,JAMIE N Ordering Provider:
ANDREWS, JAMIE NATHAN
Radiology(ies): -MRI TMJ W/O CONTRAST (Routine) Ordered By: ANDREWS,JAMIE N
Ordering Provider: ANDREWS, JAMIE NATHAN Impression: 44 yom with right tmj
pain, please eval tmj joint, thanks
2. Earache
Disposition Written by ANDREWS,JAMIE N @ 09 Jan 2015 1801 EST
Follow up: in the OTORHINOLARYNGOLOGY clinic.
Signed By ANDREWS, JAMIE N (Physician) @ 09 Jan 2015 1801
______________________________________________________________________________
___________________________
CHANGE HISTORY
The following S/O Note Was Overwritten by ANDREWS,JAMIE N @ 09 Jan 2015 1704
EST:
S/O Note Written by MCNEARNEY,CODY M @ 09 Jan 2015 0822 EST
The Chief Complaint is: Ear ache.eg
The Patient is a 44 year old male. Source of patient information was
patient. Reliability of source of patient information.
Generalized pain.
Hearing loss, earache, and discharge from the ears. No watery nasal
discharge. No postnasal drip and no epistaxis. Nasal passage blockage
2019
Medical Record
2019
(stuffiness). No hoarseness, no sore throat, and no lump in the throat.

No dizziness and no vertigo. Difficulty with balance.
No sinus pressure. No neck pain and no swollen glands in the neck.eg
Reported:
.
. Not taking dietary supplements, no vitamin supplements, and no
over-the-counter medications.
Diagnoses:
Hypertension.
No renal disease.
No stroke syndrome.
Surgical:
? No otolaryngologic surgery
? No myringotomy with ventilating tube insertion
? No sinus surgery
? No tonsillectomy with adenoidectomyeg
Personal history g5
.
Alcohol: Not using alcohol.eg
Family history g7
No congenital deafness.eg
Systemic: No systemic symptoms, no fever, no chills, no night sweats, and no
recent weight loss.
Skin: No skin symptoms.eg
Neurological:
2019
Medical Record
2019
No learning disability was noted (barriers to learning).eg

Therapy g12
? No herbal medicines.eg
Counseling/Education g22
Patient verbalized understanding and accepted instructions.eg
ebody
ebody
Verified by: JAMIE N. ANDREWS, CPT, MC 27 Jan 2015@1904
2019
Medical Record
2019
20 Nov 2014 2000 GMT at , Consultation by
Title: AUDIOLOGY Original Date: 20 Nov 2014 2000

CONSULT GMT
Document Type: Consultation AHLTA Entry Date: 26 Nov 2014 1625
GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------

No. of Visits: 1
Reason for Consult:
44 yo with hearing loss and abnormal appearing TM, concern for significant mid
dle ear pathology.
Priority: ROUTINE
OTITIS EXTERNA
ACV:
Appoint Status: DEFER TO NETWORK
no audiologist
Reviewer: ANDREWS, JAMIE N
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 20 Nov 2014@14:00:00

Clinic: NETWORK
Problem List:
Note:
Consult results have been received from the Network Consulting Provider for
WAITERS,TOMMIE ALAJANDRO. Please refer to the hardcopy on file.
Administratively Closed on 26 Nov 2014
2019
Medical Record
2019
02 Nov 2013 1241 GMT at Martin ACH, Fort Benning, GA, Emergency Department
Encounter Note by BROWN, REGINA S
Title: ER VISIT 02 NOV 13 Original Date: 02 Nov 2013 1241

EKG GMT
Document Type: Emergency Department AHLTA Entry Date: 02 Nov 2013 1241
Encounter Note GMT
Facility: Martin ACH, Fort Document ID: 6085632730
Benning, GA
Clinician: BROWN, REGINA S
2019
Medical Record
2019
2019
Medical Record
2019
02 Nov 2013 1240 GMT at Martin ACH, Fort Benning, GA, Emergency Department
Encounter Note by BROWN, REGINA S
Title: Original Date: 02 Nov 2013 1240

GMT
Document Type: Emergency Department AHLTA Entry Date: 02 Nov 2013 1241
Encounter Note GMT
Benning, GA
Clinician: BROWN, REGINA S
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
31 May 2013 0431 GMT at Martin ACH, Fort Benning, GA, Emergency Department
Encounter Note by WILLIAMS, DANISE N
Title: Original Date: 31 May 2013 0431

GMT
Document Type: Emergency Department AHLTA Entry Date: 31 May 2013 0431
Encounter Note GMT
Benning, GA
Clinician: WILLIAMS, DANISE
N
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
31 Mar 2013 0721 GMT at Martin ACH, Fort Benning, GA, Emergency Department
Encounter Note by WILLIAMS, DANISE N
Title: Original Date: 31 Mar 2013 0721

GMT
Document Type: Emergency Department AHLTA Entry Date: 31 Mar 2013 0721
Encounter Note GMT
Benning, GA
Clinician: WILLIAMS, DANISE
N
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
29 Jan 2013 1814 GMT at Martin ACH, Fort Benning, GA, Study Report by MORRIS, TARA
C
Title: 01/15/2013 UGI Original Date: 29 Jan 2013 1814 GMT

W/AIR
Document Type: Study Report AHLTA Entry Date: 29 Jan 2013 1815 GMT
Benning, GA
Clinician: MORRIS, TARA C
2019
Medical Record
2019
2019
Medical Record
2019
18 Oct 2012 0858 GMT at , Consultation by
Title: Original Date: 18 Oct 2012 0858 GMT

Document Type: Consultation AHLTA Entry Date: 18 Oct 2012 0858 GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: ZAGORSKI, KIM JOSEPH

Requesting Location: AMHM02DYELLOW TEAM
No. of Visits: 2
Referral Authorized Until: 18 Nov 2012
Reason for Consult:
PLEASE EVALUATE AND TREAT. 42 Y/O AD SOLDIER WITH LEFT LATERAL HIP PAIN AT TH
E GREATER TROCHANTER. PLEASAE ASSIST WITH LOCAL STEROID INJECTION TO ASSIST W
ITH PT.. (706) 326-4585, (404) 421 - 3064
Priority: ROUTINE
ACV:
Reviewed Date/Time: 21 Sep 2012@13:24:00
clinic atc lm vm to schedule sports med clinic appt
Reviewer: IRWIN, MARY E
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 16 Oct 2012@09:25:00

Consulting HCP: NOEL, MARY
HCDP: 106-TRICARE PRIME INDIVIDUAL COVERAGE FOR ACTIVE DUTY SPONSORS

Problem List:
Note:
Patient: WAITERS, TOMMIE ALAJANDRO
Date: 16 Oct 2012 0925 EDT
Appt Type: PROC
Treatment Facility: MARTIN ACH
Provider: NOEL,MARY
AutoCites Refreshed by NEAL,CALVIN @ 16 Oct 2012 0915 EDT
Allergies
2019
Medical Record
2019
No Allergies Found.
jdm
Screening Written by NEAL,CALVIN @ 16 Oct 2012 0915 EDT
Reason For Appointment: BURSITIS TROCHANTERIC
Allergen information verified by NEAL, CALVIN @ 16 Oct 2012 0915 EDT
Vitals
Vitals Written by NEAL,CALVIN @ 16 Oct 2012 0914 EDT
BP: 124/84, HR: 72, RR: 18, T: 97.5 F, HT: 66 in, WT:
215 lbs, BMI: 34.7, BSA: 2.063 square meters
Chief complaint
42-year-old male who has had 3 weeks of left thigh pain. Pain is located on
the outer portion of L thigh. He states the pain is dull and 8/10. Hurts
worse with walking, it improves with rest. No history of trauma or
infection. Patient has tried stretches, ibuprofen, Flexeril without relief.
He states when he walks he feels like he is walking barefoot on concrete and
radiates up his leg. Patient denies fevers, chills, weight loss. No
numbness or tingling of extremities.
.
Medication list reviewed with patient, reconciliation completed, and list
given to patient.
Not currently on active duty and visit is not deployment-related. Not
thinking about suicide and no homicidal thoughts.
Pain assessment: The pain has been located in LT KNEE for a period of 4+
YRS. The patient describes the pain as DULL and has tried MED with relief
and reports MOVEMENT makes it worse.
.
Procedure: Possible limitations and risks include partial success requiring
repetition of procedure.
[ x ] Yes [ ] No Patient was identified using full name plus any
suffix and DOB.
[ x ] Yes [ ] No Patient was evaluated and medical record reviewed to
include medical history and laboratory findings, if ordered.
[ x ] Yes [ ] No [ ] N/A Radiographs are properly oriented and
correct laterality has been visually confirmed (if applicable).
[ x ] Yes [ ] No [ ] N/A Procedure and site/side matches the
2019
Medical Record
2019
consent form (if applicable).

[ x ] Yes [ ] No [ ] N/A Patient was involved in the site/side
marking (if applicable).
[ x ] Yes [ ] No Final Time Out - Physician paused (if alone) or
verbally confirmed with the procedure team that this is the correct patient,
procedure and site/side (if applicable). The patient has been positioned
correctly for the procedure. All necessary equipment and implants are
available.
Procedure: Possible limitations and risks include complications from
anesthesia.
Procedure: Peri-operative risks, benefits, and limitations discussed and
understood - Patient wished to proceed.
Allergies
NKDA.
Current medication
Levitra 20Mg-take one tablet by mouth 60 minutes prior to intercourse;no more
than 1 per day
Cyclobenzaprine HCL(Flexeril) 10Mg-take 1 tab by mouth three times daily as
needed for pain
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
.
T#3/darvocet
Environmental Exposure: No exposure to fumes and no secondhand cigarette
smoke exposure. No exposure to respiratory irritants.
Previous therapy
Personal history
Family of 5
3 children
2019
Medical Record
2019
Behavioral: No tobacco use in the last 10 years. Never a smoker / Never Used
Tobacco Products.
Alcohol: No consumption of alcohol and not using alcohol Screening Date: 2
nOVEMBER 2011.
Habits: Exercising regularly (Engaged in Routine / Regular Activity to
Improve Your Health)
.
What is your preferred method of learning? [ X] Verbal [ X ] Written
[ ] Visual [ ] Other (Specify):
Do you have a learning disability, language barrier, hearing/vision deficit?
[ ] Yes [ X ] No Specify:
Do you have any cultural or religious beliefs that may affect your care?
[ ] Yes [ X ] No
Family history
father- DM.
Review of systems
Musculoskeletal: No muscle aches, no localized joint pain, no localized joint
swelling, and no limb pain.
Skin: No pruritus.
Physical findings
General:
Physical examination -Positive Ober's test.
Vital Signs:
Temperature: Reviewed. RR: Reviewed. PR: Reviewed. Blood pressure:
Reviewed.
General Appearance:
Oriented to time, place, and person. Well developed. Well nourished.
In no acute distress.
Lungs:
Respiration rhythm and depth was normal.
Buttocks:
General/bilateral: Left buttock showed no tenderness on palpation.
Hips:
Left Hip: Hip was tender on palpation directly over greater trochanter.
Pain was elicited by motion with internal rotation of hip. No erythema.
No misalignment. Motion was normal. No instability was noted. No hip
tenderness was observed with ambulation.
Thigh:
Left Thigh: Thigh was tender on palpation over greater trochanter. No
swelling.
Neurological:
Sensation: No sensory exam abnormalities were noted.
Motor (Motor Strength): No weakness of the left hip was observed.
Balance: Normal.
2019
Medical Record
2019
Gait And Stance: Normal.

Psychiatric:
Mood: Euthymic.
Affect: Normal.
Tests
The skin overlying the L greater trochanteric bursa was prepped with
betadine. A 22 gauge needle was used to inject 4mL 1% Lidocaine, 4mL 0.5%
marcaine, and 1mL Kenalog 40 into L greater trochanteric bursa. The patient
tolerated the procedure well.
Practice Management
Colonoscopy - n/a
Influenza -?
Zoster - n/a
Pneumococcal -n/a
Men:
Rad Result Cited by NOEL,MARY @ 17 Oct 2012 1126 EDT
********** HIP LT **********
Status: Complete
Procedure: HIP LT
Event Date: 19-Sep-2012 11:25:00
Reason for Order:
42 Y/O MALE AD SOLDIER WITH LEFT LATERAL HIP PAIN AT THE GREATER
TROCHANTER.
Exam #: 12079198
Status: COMPLETE
Report Text:
FINDINGS:
No fracture-dislocation or definite stress related changes. No
degenerative
A/P Last Updated by NOEL,MARY @ 17 Oct 2012 1126 EDT
2019
Medical Record
2019
1. BURSITIS TROCHANTERIC 726.5: 42-year-old male with a three-week history of

left trochanteric bursitis. Radiology report reviewed that showed no acute
fracture or degeneration. Options for treatment were discussed with patient
include rest, medication, physical therapy, steroid injection, further
evaluation by orthopedic surgery. Patient elected to try corticosteroid
injection today. Risks and benefits of procedure were discussed with
patient. Procedure performed as stated above. Patient tolerated procedure
well. Instructed to limit activity for one week and given profile. Patient
to followup in 3-4 weeks or sooner if needed if pain persists. Patient also
being seen by physical therapy for back, instructed patient to continue hip
stretches at physical therapy.
Procedure(s):
-(20600) Corticosteroids Injection Intrabursal x 1 ADDITIONAL PROVIDER(S):
COBB,CLARK H.
-(J3301) INJECTION,TRIAMCINOLONE ACETONIDE,NOS,10 MG x 4 ADDITIONAL
PROVIDER(S): COBB,CLARK H.
Disposition Last Updated by NOEL,MARY @ 17 Oct 2012 1127 EDT
Discussed: Diagnosis, Medication(s)/Treatment(s), Alternatives, Potential
Side Effects with Patient who indicated understanding.
Note Written by COBB,CLARK H @ 17 Oct 2012 1138 EDT
Co-signer Note
Discussed with resident team. Performed independent exam. Supervised
procedure. Agree with plan.
Signed By NOEL, MARY (CPT, MC, USA, FMRP PGY-1) @ 17 Oct 2012 1129
Co-Signed By COBB, CLARK H (Physician, Martin ACH, Fort Benning, GA) @ 17
Oct 2012 1138
______________________________________________________________________________
___________________________
CHANGE HISTORY
Chief complaint
42-year-old male who has had 3 weeks of left hip pain. He states the pain is
dull and 8/10. Hurts worse with walking, it improves with rest. Patient has
tried stretches, ibuprofen, Flexeril without relief. He states when he walks
he feels like he is walking barefoot on concrete and radiates up his leg.
Patient denies fevers, chills, weight loss. No numbness or tingling of
extremities.
.
given to patient.
2019
Medical Record
2019
.
Procedure: Possible limitations and risks include complications from
anesthesia.
Procedure: Possible limitations and risks include partial success requiring
repetition of procedure.
Procedure: Peri-operative risks, benefits, and limitations discussed and
understood - Patient wished to proceed.
[ x ] Yes [ ] No Patient was identified using full name plus any
suffix and DOB.
[ x ] Yes [ ] No Patient was evaluated and medical record reviewed to
include medical history and laboratory findings, if ordered.
[ x ] Yes [ ] No [ ] N/A Radiographs are properly oriented and
correct laterality has been visually confirmed (if applicable).
[ x ] Yes [ ] No [ ] N/A Procedure and site/side matches the
consent form (if applicable).
[ x ] Yes [ ] No [ ] N/A Patient was involved in the site/side
marking (if applicable).
[ x ] Yes [ ] No Final Time Out - Physician paused (if alone) or
verbally confirmed with the procedure team that this is the correct patient,
procedure and site/side (if applicable). The patient has been positioned
correctly for the procedure. All necessary equipment and implants are
available.
Allergies
NKDA.
Current medication
Levitra 20Mg-take one tablet by mouth 60 minutes prior to intercourse;no more
than 1 per day
Cyclobenzaprine HCL(Flexeril) 10Mg-take 1 tab by mouth three times daily as
needed for pain
.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
2019
Medical Record
2019
.
APPENDECTOMY
.
T#3/darvocet
Previous therapy
Personal history
Family of 5
3 children
Tobacco Products.
nOVEMBER 2011.
.
[ ] Yes [ X ] No
Family history
father- DM.
Review of systems
Musculoskeletal: No muscle aches, no localized joint pain, no localized joint
swelling, and no limb pain.
Skin: No pruritus.
Physical findings
General:
Physical examination -Positive Ober's test.
Vital Signs:
Temperature: Reviewed. RR: Reviewed. PR: Reviewed. Blood pressure:
Reviewed.
General Appearance:
2019
Medical Record
2019
Oriented to time, place, and person. Well developed. Well nourished.

In no acute distress.
Lungs:
Respiration rhythm and depth was normal.
Buttocks:
General/bilateral: Left buttock showed no tenderness on palpation.
Hips:
Left Hip: Hip was tender on palpation directly over greater trochanter.
Pain was elicited by motion with internal rotation of hip. No erythema.
No misalignment. Motion was normal. No instability was noted. No hip
tenderness was observed with ambulation.
Thigh:
Left Thigh: Thigh was tender on palpation over greater trochanter. No
swelling.
Neurological:
Sensation: No sensory exam abnormalities were noted.
Motor (Motor Strength): No weakness of the left hip was observed.
Balance: Normal.
Gait And Stance: Normal.
Psychiatric:
Mood: Euthymic.
Affect: Normal.
Tests
The skin overlying the L greater trochanteric bursa was prepped with
betadine. A 22 gauge needle was used to inject 4mL 1% Lidocaine, 4mL 0.5%
marcaine, and 1mL Kenalog 40 into L greater trochanteric bursa. The patient
tolerated the procedure well.
Practice Management
Colonoscopy - n/a
Influenza -?
Zoster - n/a
Pneumococcal -n/a
Men:
The following Signature(s) No Longer Applies because this Encounter Was
Opened for Amendment by NOEL,MARY @ 17 Oct 2012 1128 EDT:
Signed NOEL, MARY (CPT, MC, USA, FMRP PGY-1) @ 17 Oct 2012 1127
SO Note Written by NEAL,CALVIN @ 16 Oct 2012 0859 EDT
Chief complaint
Patient states when they have these symptoms, they last ALL THE TIME and
occurs DAILY.
2019
Medical Record
2019
Patient states they have had these symptoms before

No change in symptoms.
.
given to patient.
.
Allergies
NKDA.
Current medication
(Levitra) 20Mg-take one table 60 minutes prior to intercourse;no more than 1
per day
Hydrocodone Bit/Acetaminophen 5Mg/500Mg-take 1 to 2 tabs by mouth every 4 to
6 hours as needed.
Reported:
HTN
DEPRESSION
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
.
T#3/darvocet
Previous therapy
Personal history
Family of 5
3 children
2019
Medical Record
2019
Tobacco Products.
nOVEMBER 2011.
.
[ ] Yes [ X ] No
Family history
father- DM.
Practice Management
Colonoscopy - n/a
Influenza -?
Zoster - n/a
Pneumococcal -n/a
Men:
The following SO Note Was Overwritten by NEAL,CALVIN @ 16 Oct 2012 0901 EDT:
SO Note Written by OSHEA,VALERIE W @ 15 Oct 2012 0944 EDT
Chief complaint
Allergies
NKDA.
Current medication
(Levitra) 20Mg-take one table 60 minutes prior to intercourse;no more than 1
per day
Hydrocodone Bit/Acetaminophen 5Mg/500Mg-take 1 to 2 tabs by mouth every 4 to
6 hours as needed.
Reported:
HTN
DEPRESSION
2019
Medical Record
2019
OVERWEIGHT
MECHANICAL LBP
OSA
SEASONAL ALLERGY
.
APPENDECTOMY
.
T#3/darvocet
Previous therapy
Personal history
Family of 5
3 children
Tobacco Products.
nOVEMBER 2011.
.
What is Your Preferred Method of Learning? [ x]Verbal [x ]Written [x
]Visual [ ]Other (Specify):
Patient Consented to Allow Shadowing Personnel into the Room for Observation?
[ ]Yes [ ] No [ x ]N/A
.
Family history
father- DM.
Practice Management
Colonoscopy - n/a
Influenza -?
Zoster - n/a
Pneumococcal -n/a
2019
Medical Record
2019
Men:
Verified by: MARY A. NOEL, CPT, MC 18 Oct 2012@0458
2019
Medical Record
2019
08 Sep 2012 0100 GMT at , Consultation by
Title: Original Date: 08 Sep 2012 0100 GMT

Document Type: Consultation AHLTA Entry Date: 08 Sep 2012 0100 GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: CALDWELL, JACQUELINE K

Requesting Location: FMC SPECIALTY CLINIC
No. of Visits: 9
Referral Authorized Until: 06 Nov 2012
Reason for Consult:
AD male being seen today for PHA completion admits to multiple daily
depressive symptoms. Has h/o anxiety. Was in counseling over 1 year ago and
on meds as well tha the cannot recall. He would like to start counseling
again. Please assist with scheduling. thank youl
Priority: ROUTINE
depression, anxiety, insomnia
ACV:
Reviewed Date/Time: 07 Sep 2012@21:00:00
Appoint Status: ADMIN CLOSURE - 90 DAY AUTO
This referral/consult order was Deferred to the Network and is being
administratively closed after 90 days.
Reviewer: POSTMASTER,
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date:
Requesting HCP: CALDWELL, JACQUELINE K
Clinic: NETWORK
Consulting HCP: ,

Problem List:
Note:
This referral/consult order was Deferred to the Network and is being
administratively closed after 90 days.
Administratively Closed on 07 Sep 2012
2019
Medical Record
2019
07 Aug 2012 1349 GMT at Martin ACH, Fort Benning, GA, Outpatient Consult by
MCCLAIN, RENEE K
Title: 06 AUG 2012 Original Date: 07 Aug 2012 1349

COUNSELING GMT
Document Type: Outpatient Consult AHLTA Entry Date: 07 Aug 2012 1350
GMT
Benning, GA
Clinician: MCCLAIN, RENEE K
2019
Medical Record
2019
2019
Medical Record
2019
01 Apr 2012 0901 GMT at , Consultation by
Title: Original Date: 01 Apr 2012 0901

GMT
Document Type: Consultation AHLTA Entry Date: 01 Apr 2012 0901
GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------

Requesting Location: FMC YELLOW CLINIC
No. of Visits: 12
Referral Authorized Until: 05 Apr 2013
Reason for Consult:
PLEASE EVALUATE AND TREAT. 41 Y/O AD MALE WITH EXACERBATION OF LUMBAR STRAIN.
PLEASE ASSIST WITH INCREASING ROM / CORE STRENGTHENING. OTHER MODALITIES TO
REDUCE PAIN. (706) 326 - 4585
Priority: ROUTINE
SPRAIN LUMBAR
ACV:
Reviewed Date/Time: 27 Mar 2012@09:05:00
Reviewer: JAMES, TERRANCE J
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT

Consulting HCP: HOUSER, JEREMY D

Problem List:
Note:
Date: 29 Mar 2012 0830 EDT
Appt Type: SPEC
Provider: HOUSER,JEREMY D
2019
Medical Record
2019
SAH
SO Note Written by HOUSER,JEREMY D @ 29 Mar 2012 0954 EDT
He reported: Lower back pain. No lower back pain radiating, not to the
buttocks, and not to the groin.
Visit is not deployment-related Pt is a 41yo male with chronic hx of LBP.
Pt states pain is progressively getting worse after MVA 2010. Pt states
constant pain of 6-7/10. However, pt does not appear to be in any acute
distress. Worse: unknown Better:Unknown - medication does not help. No
tingling of the limbs and no numbness of the limbs.
Allergies
Previous therapy
Physical findings
General appearance:
In acute distress.
Lumbar / Lumbosacral Spine (Motion):
General/bilateral: Lumbosacral spine motion was abnormal. Lumbosacral
spine flexion was abnormal. Lumbosacral spine extension was abnormal.
Flexion in standing maneuver with pain at the end range of movement.
Extension in standing maneuver with pain at the end range of movement.
Neurodynamic tests of the lumbosacral spine were not performed. A
straight-leg raising test was negative.
Posture:
General/bilateral: Standing posture was abnormal. Standing posture was
flexed.
Neurological:
Motor (Motor Strength): Dorsiflexion strength of the ankles was normal.
Plantar flexion strength of the ankles was normal. Eversion strength of
the ankles was normal. Extension strength of the first toes was normal.
Reflexes: Knee jerk was normal. Ankle jerk reflex was normal.
Therapy
No education and instructions: Barriers to Treatment (Age, Learning,
Cultural, and Distance) were assessed and are appropriate at this time.
Physical therapy session segments, 15 minutes each Pt was given HEP for
DKTC, HS stretch, Prone press ups, Standing Extension, Lumbar Rotation,
Pelvic Rotation, sitting lumbar flexion x 2 daily. Performed TENS unit today
but pt states min relief and did not like. Will f/u with me in 2 weeks.
Instructed pt on the importance of walking and exercise.
General physical therapy goals: independence in home exercise program x
today.
McKenzie extension.
Patient goals get rid of the pain and learn how to prevent in the future
A/P Written by HOUSER,JEREMY D @ 29 Mar 2012 1007 EDT
Procedure(s):
-Physical Medicine Physical Therapy Evaluation x 1
-Modalities Electrical Stimulation x 1
2019
Medical Record
2019
Disposition Written by HOUSER,JEREMY D @ 29 Mar 2012 1008 EDT

Follow up: in the PHYSICAL THERAPY clinic. - Comments: Will f/u with me in 2
weeks for reassessment.
Consult Order
Priority: Routine
SPRAIN LUMBAR
Reason for Request:
PLEASE EVALUATE AND TREAT. 41 Y/O AD MALE WITH EXACERBATION OF LUMBAR
STRAIN. PLEASE ASSIST WITH INCREASING ROM / CORE STRENGTHENING. OTHER
MODALITIES TO REDUCE PAIN. (706) 326 - 4585
Signed By HOUSER, JEREMY D (Physical Therapist/DPT) @ 29 Mar 2012 1008
Verified by: JEREMY D. HOUSER, PT 01 Apr 2012@0501
2019
Medical Record
2019
15 Dec 2011 1828 GMT at , Consultation by
Title: Original Date: 15 Dec 2011 1828

GMT
Document Type: Consultation AHLTA Entry Date: 15 Dec 2011 1828
GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------

No. of Visits: 1
Reason for Consult:
PLEASE EVALUATE AND TREAT. 41 Y/O ACTIVE DUTY SOLDIER WITH LOUD SNORING AND D
AYTIME SOMNOLENCE.
Priority: ROUTINE
Snoring
ACV:
Reviewer: CARTER, KEVIN A
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 15 Dec 2011@10:00:00

Clinic: INTERNAL MED SLEEP CLINIC
Consulting HCP: CARTER, KEVIN ALLEN

Problem List:
Note:
Date: 15 Dec 2011 1000 EST
Appt Type: SPEC
Clinic: INTERNAL MED SLEEP CLINIC
Provider: CARTER,KEVIN ALLEN
Reason for Appointment: Snoring
Appointment Comments: Written by SAMPSON,LINDA M @ 15 Dec 2011 0708 EST
2019
Medical Record
2019
LMS/PER DR. CARTER BOOK AFTER 28DAY

Remind pt
AutoCites Refreshed by CARTER,KEVIN A @ 15 Dec 2011 1029 EST
Allergies
No Allergies Found.
Active Medications
Active Medications
Status
Sig
Refills Left
Last Filled
Testosterone 1%, Gel/Jelly, Transdermal, 1.25g
Active
USE 1 PUMP IN EACH ARM EVERY DAY
5 of 5
02 Nov 2011
Triamterene 37.5mg + Hydrochlorothiazide 25mg, (Maxzide-25), Tablet, Oral
Active
TAKE ONE TABLET BY MOUTH EVERY DAY
1 of 1
02 Nov 2011
VARDENAFIL HCL, 20 MG, TABLET, ORAL
Active
TAKE 1 TABLET 60 MINUTES PRIOR TO INTERCOURSE; NO MORE THAN 1 PER DAY
7 of 11
13 Sep 2011
TRIAZOLAM (TRIAZOLAM), 0.25 MG, TABLET, ORAL, GREENSTONE LLC., 10 ea. BOTTLE
Active
NR
03 May 2009
Vitals
Vitals Written by THORNBURG,BRADLEY W @ 15 Dec 2011 1019 EST
BP: 142/82, HR: 66, RR: 18, HT: 66 in, WT: 212 lbs, SpO2: 98%, BMI: 34.22,
Questionnaire AutoCites Refreshed by CARTER,KEVIN A @ 15 Dec 2011 1029 EST
Questionnaires
SO Note Written by CARTER,KEVIN ALLEN @ 15 Dec 2011 1318 EST
Chief complaint
Reason for Visit
Visit for: 41 y.o. AD man with a long h/o snoring, nonrestorative sleep,
waking up with a dry mouth, and EDS.
He reported: Past medical history reviewed, medication list reviewed with
patient, and family history reviewed with patient.
Military service.
Feeling tired or poorly and lethargy. Recent weight change. No recent
weight loss. Recent 8 lbs weight gain.
No nasal discharge and no nasal passage blockage. Snoring loudly and has
been witnessed. No throat pain.
Genitourinary symptoms was three.
No fainting followed by prolonged sleepiness. Confusion not occurring upon
2019
Medical Record
2019
awakening and no transient limb weakness when falling asleep or awakening

(sleep paralysis). Restless movements during sleep. Involuntary movements
during sleep without vivid dream recall.
No anxiety, no persistent anxiety about insomnia, and depression not
accompanied by sleeping more. Daytime somnolence. Not suddenly falling
asleep during the day and no initial insomnia. Middle-night awakening. No
insomnia due to pain. Morning grogginess and nonrestorative sleep. No sleep
apnea.
No sinus pressure. No vision problems. No chest pain or discomfort. No
dyspnea and no cough. No heartburn at night in bed. No muscle weakness and
no loss of hair from the head or body. The legs do not feel restless. No
asthma nighttime symptoms.
Allergies
NKA.
Current medication
Levitra, vicodin.
Reported History:
- medical history reviewed No recent change in medical history and no prior
serious illness.
Reported medications: Medication history - medication list reviewed with
patient to include OTC and herbal medications. Medication reconciliation
completed.
Diagnosis History:
Hypertension.
No asthma.
No morbid obesity.
Personal history
Behavioral history: No caffeine use. No tobacco use in the last 10 years.
Not a current smoker.
Family history
Sleep apnea.
Review of systems
Head symptoms: No headache and headache not present upon awakening. No sinus
pain.
Otolaryngeal symptoms: No frequent breathing through the mouth, no
hoarseness, and no choking.
Endocrine symptoms: No temperature intolerance and no decreased libido. No
inadequacy of penile erection.
Neurological symptoms: No transient limb paralysis with intense emotions
(cataplexy).
2019
Medical Record
2019

Physical findings
Vital signs:
Current vital signs reviewed.
Weight was not within normal limits. Patient was observed to be obese.
Body build was mesomorphic.
General appearance:
Well-appearing. Awake. Alert. Oriented to time, place, and person.
Not ill-appearing. Patient did not appear acutely exhausted. Not
poorly hydrated.
Head:
Cranial Bruit: No cranial bruit.
Examination Of Face: No micrognathia was observed.
Neck:
Neck Appearance: Value
Neck circumference 17 in
Eyes:
General/bilateral:
Extraocular Movements: Normal.
Pupils: PERRL.
Nose:
General/bilateral:
Nasal Discharge: No nasal discharge seen.
External Nasal Deformities: No external nose deformities.
Cavity: Nasal mucosa normal. Nasal turbinate normal.
Erythema: No nasal erythema was noted.
Edema: No nasal edema was noted.
Upper Airway:
Flaring nasal alae were not observed. Mouth breathing was not seen.
No stridor was observed.
Oral cavity:
Teeth: Showed no malocclusion.
Pharynx:
Oropharynx: Mallampati class 4 airway Modified Mallampati Score: Uvula
was not enlarged. Tonsils were enlarged symmetrically.
Lymph Nodes:
Anterior cervical lymph nodes were not enlarged.
Chest:
Normal.
Lungs:
Respiration rhythm and depth was normal. Clear to auscultation.
Jugular Venous Distention: JVD not increased.
Arterial Pulses: Not normal.
Edema: Not present.
Abdomen:
Visual Inspection: Showed a scaphoid-shaped abdomen.
Neurological:
Level of consciousness was normal.
Speech: Voice was not hyponasal.
2019
Medical Record
2019
Cranial Nerves: Normal.

Objective
There were no barriers to learning. Patient's needs were assessed and patient
education was provided. Verbal teaching on the risk factors for sleep apnea,
associated diseases, diagnostic evaluation, and treatment options.
Conservative treatment options to include sleep position modification and
weight loss were recommended. Patient was strongly cautioned against driving
while sleepy or participating in other high risk activities until evaluation
and treatment are completed. Patient verbalized understanding of the
A/P Last updated by CARTER,KEVIN A @ 15 Dec 2011 1321 EST
1. Snoring: The patient has signs/symptoms consistent with Obstructive Sleep
Apnea (OSA), sending for an overnight Diagnostic Polysomnogram (Sleep Study),
the patient will follow-up with me to review the results.
There were no barriers to learning. Patient's needs were assessed and patient
education was provided. Verbal teaching on the risk factors for sleep apnea,
associated diseases, diagnostic evaluation, and treatment options.
Conservative treatment options to include sleep position modification and
weight loss were recommended. Patient was strongly cautioned against driving
while sleepy or participating in other high risk activities until evaluation
and treatment are completed. Patient verbalized understanding of the
Moderate-High PTP for OSA. Pt will f/u with me to review the results. appt
for PSG booked.
Patient Instruction(s):
-Abstinence From Alcohol
-Anticipatory Guidance: Concerns About Sleeping
-Anticipatory Guidance: Sleeping Position
-Circadian System Adjustment By Light / Dark Exposure
-Duration Of Encounter - Coordination Of Care (___ min)
-Duration Of Encounter - Counseling (___ min)
-Goals General - Improve Quality of Life
-Lose Weight
2. NONORGANIC SLEEP DISORDERS: ensure a TST = 7-8 hrs/night.
Procedure(s):
-Pulse Oximetry x 1
Disposition Written by CARTER,KEVIN A @ 15 Dec 2011 1322 EST
Note Written by BYRD,ANTONIO C @ 15 Dec 2011 0958 EST
Consult Order
Date of Request: 02 Nov 2011
Priority: Routine
Snoring
Reason for Request:
PLEASE EVALUATE AND TREAT. 41 Y/O ACTIVE DUTY SOLDIER WITH LOUD SNORING AND
DAYTIME SOMNOLENCE.
Signed By CARTER, KEVIN A (Director, The Sleep Medicine Center, BMACH) @ 15
2019
Medical Record
2019
Dec 2011 1322

______________________________________________________________________________
___________________________
CHANGE HISTORY
The following A/P Note Was Overwritten by CARTER,KEVIN A @ 15 Dec 2011 1321
EST:
The A/P section was last updated by CARTER,KEVIN A @ 15 Dec 2011 1321 EST -
see above.Previous Version of A/P section was entered/updated by
THORNBURG,BRADLEY W @ 15 Dec 2011 1022 EST.
Procedure(s):
-Pulse Oximetry x 1
The following SO Note Was Overwritten by CARTER,KEVIN A @ 15 Dec 2011 1030
EST:
SO Note Written by THORNBURG,BRADLEY W @ 15 Dec 2011 1020 EST
Chief complaint
Allergies
NKA.
Current medication
Levitra, vicodin.
Personal history
Verified by: KEVIN A. CARTER, CPT, MC 15 Dec 2011@1328
2019
Medical Record
2019

GMT
GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------

No. of Visits: 1
Reason for Consult:
PLEASE EVALUATE AND TREAT. 41 Y/O AD SOLDIER OVER WEIGHT WITH ELEVATED CHOOLE
STEROL. LOW FAT CARDIAC DIET.
Priority: ROUTINE
HYPERLIPIDEMIA
ACV:
Reviewed Date/Time: 04 Dec 2011@21:01:00
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date:
Clinic: NUTRITION
Consulting HCP: ,

Problem List:
Note:
Administratively Closed on 04 Dec 2011
2019
Medical Record
2019

GMT
GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------

No. of Visits: 1
Reason for Consult:
PLEASE EVALUATE AND TREAT. 41 Y/O AD MALE WITH BMI 35. PLEASE ASSIST WITH 12
00 CAL MEAL PLAN (706) 326 - 4585
Priority: ROUTINE
OVERWEIGHT
ACV:
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date:
Clinic: NUTRITION
Consulting HCP: ,

Problem List:
Note:
Administratively Closed on 03 Dec 2011
2019
Medical Record
2019

GMT
Document Type: Consultation AHLTA Entry Date: 18 Mar 2011 0101
GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------

No. of Visits: 1
Referral Authorized Until: 11 Mar 2011
Reason for Consult:
PLEASE EVALUATE AND TREAT. 40 Y/O AD SOLDIER WITH SNORING, DAYTIME SOMNOLENCE
. MALLAMPATI III.
Priority: ROUTINE
Snoring
ACV:
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date:
Clinic: INTERNAL MED BENN
Consulting HCP: HOFFMAN, MONICA ANN

Problem List:
Note:
Administratively Closed on 17 Mar 2011
2019
Medical Record
2019
29 Oct 2010 0101 GMT at , Consultation by
Title: Original Date: 29 Oct 2010 0101 GMT

Document Type: Consultation AHLTA Entry Date: 29 Oct 2010 0101 GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: RANDALL, WILLIAM LEWIS

Requesting Location: EMERGENCY ROOM
No. of Visits: 1
Referral Authorized Until: 29 Sep 2010
Reason for Consult:
40 y/o AA male with peri-umbilical pain for ten days. Recurrent for two
years.
pt phone # 706-326-4585
Priority: 72 HRS
Abdominal Pain
ACV:
Reviewed Date/Time: 28 Oct 2010@21:01:00
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date:
Requesting HCP: RANDALL, WILLIAM LEWIS
Consulting HCP: ,

Problem List:
Note:
Administratively Closed on 28 Oct 2010
2019
Medical Record
2019
25 Nov 2009 0202 GMT at , Consultation by

GMT
Document Type: Consultation AHLTA Entry Date: 25 Nov 2009 0206
GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: ,
No. of Visits: 3
Reason for Consult:
Please evaluate and treat. 39 y/o AD male requesting follow up w/ gastro as r
ecommended at last visit. Hx chronic undetermined abdominal pain. Laproscopy
last year, uneventfull. Not scopped to date. (706) 326-4585
Priority: ROUTINE
abdominal pain
ACV:
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date:
Requesting HCP: ,
Consulting HCP: ,

Problem List:
Note:
Administratively Closed on 24 Nov 2009
2019
Medical Record
2019
06 May 2009 0400 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by
AUGUSTIN, WUN C
Title: Original Date: 06 May 2009 0400

GMT
Document Type: Outpatient Report AHLTA Entry Date: 11 May 2009 1457
GMT
Benning, GA
Clinician: AUGUSTIN, WUN C
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
08 Apr 2009 0122 GMT at , Consultation by

GMT
Document Type: Consultation AHLTA Entry Date: 08 Apr 2009 0123
GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: HIGDON, MARK LOWELL

Requesting Location: FMC TEACHING CLINIC
No. of Visits: 6
Reason for Consult:
38 year old active duty SFC with some depression and extreme thoughts followin
g deployment experience in Iraq 2004-2005. Would like evaluation per recent d
iscussion during his PHA. Thank you.
Priority: ROUTINE
Eval for PTSD
ACV:
please schedule with next available provider
Reviewer: CANINO, EDNA
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT

Requesting HCP: HIGDON, MARK LOWELL
Clinic: COMMUNITY MENTAL HEALTH
Consulting HCP: LUPCHO, THERESA

Problem List:
Note:
Date: 11 Mar 2009 0900 EDT
Appt Type: SPEC
Clinic: COMMUNITY MENTAL HEALTH
Provider: LUPCHO,THERESA
2019
Medical Record
2019
Reason for Appointment: Eval for PTSD

zdb
AutoCites Refreshed by LUPCHO, THERESA D @ 11 Mar 2009 0910 EDT
Active Family History
Type II diabetes mellitus (Father)
Arteriosclerotic cardiovascular disease (ASCVD) (Mother)
No family history of malignant neoplasm of the large intestine
Allergies
No Known Allergies
Active Medications
SO Note Written by LUPCHO,THERESA @ 13 Mar 2009 1040 EDT
Chief complaint
The Chief Complaint is: Depression and anxiety. Referred by FMC Teaching
Clinic Provider.
He reported: Visit is deployment-related.
Reported History:
Medical: Past medical history was reported by the patient - H Pylori Bacter
in stomach and on Nexium, hap appt. for investigaton of stomach/GI problems
w/Sisk on 18 March at 1530. Psychiatric treatment without hospitalization -
none.
Reported medications: Not taking medication and no prior use of medications
(psychiartic).
Previous therapy
History of psychiatric therapy - previous marital counseling which he
thought was going well but his wife refused to continue - her objections are
about things he can't change such as being obligated to the military and not
having more money than he does
Personal history
Personal history: No recent legal problems.
Abuse / neglect: No abuse/neglect.
Education: - working on Ph D in Business Administration and Finance Has high
school diploma and bachelors degree completed.
Military: Military history - Joined the Army in 1990 at age 18 right out of
high school, MOS currently 79R - Recruiter, pervious MOS = MP, served AD 13
years then went to Army Reserves until reactivated in October 04, AD since
that time, almost 20 years TIS and has to serve 24 more months before he can
retire and draw a check. 1 peacekeeping deployment to Bosnia/Herzegovina, and
1 combat deployment to Iraq from October 2004 to December 2005 in previous
MOS of MP. Screened negative for PTSD and mTBI.
Work: Work history - worked as a cook while in high school and before joining
the Army at age 18. He worked as a Sheriff's Deputy in Florida from 2003
until November 2006, then Florida Army Reserves sent him to Physical Security
School then to Recruiter school in June 2006, after which he worked with the
FL Department of Families and Children as a Case Investigator until an AD
slot opened up in July 2007. No job problems or incidents.
Marital: Currently married - to his now 30-year-old wife for 2 years. She has
2019
Medical Record
2019
3 children, 2 of which she has physical custody of. Her children are ages 15,
11, and 7, and her 7-year-old son has cancer and is in a children's hospital
in Gainesville, FL. Her 11-year-old son lives with his (the child's) dad in
Gainesville. Wife has an apartment in Gainesville so she can be near the son
who is ill and near her 11-year-old son and previously married - for 13 years
and divorced.
Family: Family social history - born Gainesville, FL and raised in Daytona
Beach, FL. Parents never married and his father was not around. Has a brother
who is younger by 3 years. No developmental problems or delays, and all
milestones were reportedly met on time. Their mother moved the family around
several times and had several jobs over the years. Home life was not stable,
although denies any history of abuse.
Functional status: Psychosocial support is insufficient.
Family history
No alcoholism
No mental illness (not retardation).
Subjective
He feels his wife does appreciate him and he doesn't feel respected by her
for all he is trying to do for her and her kids. He feels like it was a
mistake to marry someone who doesn't understand the military. His wife is
angry with him about her perception of injustice - many petty things, such as
his son supposedly stealling her W-2. They fight frequently and she says his
approach is silly - he is action oriented and she takes little responsibility
for the tensions or difficulties within the marriage. He's trying to maintain
2 households and out of the 2 years they've been married she's spent 17
months by the side of her 7-year-old while he's been hospitalized for liver
transplant and now cancer. His wife has had dozens of jobs over the years and
is only 30 years old. He finds it difficult to be with someone with a history
of instability. She also has a history of having been physically abused by
her 2 previous husbands. He stated his tentative understanding that he stays
in the marriage because he doesn't want to be alone.
Review of systems
Systemic symptoms: Feeling tired (fatigue).
Endocrine symptoms: Libido has decreased.
Neurological symptoms: Decreased concentrating ability - especially at work.
Psychological symptoms: High irritability - says he's "too quick on the draw"
since his return from Iraq. Depression - he thinks things seem to bother him
more since his deployment to Iraq (returned in December 2005) - started not
sleeping well since return from deployment in December 2005, difficulty
falling asleep - takes about 2 hours to get to sleep, middle-night awakening
- wakes up 5-6 times during the night and gets an average of 3-4 hours of
sleep per night, and nonrestorative sleep. Nightmares. Apathy - about some
things. Says he's going along to get along. A desire to continue living and
no previous suicide attempt. Low self-esteem, feeling guilty and frustrated
about his wife living apart and his not being able to keep everybody happy.
Feels he would be letting her kids down if they got divorced. He feels
obligated to help take care of her children, being upset by problems at home
or work - home issues, and feeling emotionally detached - or blunted.
Marital problems.
Physical findings
General appearance:
Well-appearing. Alert. Oriented to time, place, and person. In no
acute distress. Patient did not appear uncomfortable.
Neurological:
2019
Medical Record
2019
No hallucinations. Recent memory was not impaired. Short term memory

normal.
Speech: Normal.
Psychiatric Exam:
Appearance: Not tired. Clothing was appropriate. Grooming was normal.
Demonstrated Behavior: Behavior demonstrated psychomotor restlessness.
No psychomotor retardation. Behavior demonstrated no psychomotor
agitation.
Attitude: Cooperative.
Mood: Dysthymic. Frustrated. Concerned. Calm.
Affect: Restricted. Congruent with the mood.
Thought Processes: Not impaired.
Thought Content: Revealed no impairment . Insight was intact - however
insight is limited regarding his wife's behaviour and his own reasons for
staying in the marriage. No obsessions. No paranoid ideations. No
delusions. No suicidal ideation. No homicidal ideations.
Spiritual assessment:
Spiritual assessment - no issues.
Objective
He is working as a recruiter in Columbus, GA. He cooks and cleans house, has
his 2 children, sons ages 15 and7 who live with him, and his 5-year-old
daughter who lives with his mother. He gets up in the morning to be with the
kids, takes them to school, then after school he goes by the house to check
on them. Sometimes he cooks dinner while he's there then he will go back to
work for a while. He is home around 1930 to 2000 each night, then starts
getting self and surroundings ready for the next day. His job is stressful,
and no matter how many recruits he gets, it's never enough.
A/P Written by LUPCHO, THERESA D @ 11 Mar 2009 1003 EDT
1. MAJOR DEPRESSION, SINGLE EPISODE: Mild to Moderate
Procedure(s):
-Psychiatric Evaluation Comprehensive Examination x 1
-Psychiatric Evaluation Review of Records and Reports x 1
-Psychiatric Therapy Preparation of Psychiatric Status Report x 1
2. ANXIETY DISORDER NOS: Residual combat-induced sx and significant life
stressors
3. MARITAL PROBLEM
4. ASSESS PATIENT CONDITION WORK-RELATED OCCUPATIONAL DISEASE(POST-
DEPLOYMENT
EXAMINATION)
Disposition Written by LUPCHO, THERESA D @ 13 Mar 2009 1033 EDT
Follow up: as needed with PCM and/or in the OUTPATIENT PSYCHIATRY clinic. -
Comments: has appt. w/LTC (PNP) Streeter on 27 March at 0830 for an
evaluation for medication to treat his anxiety/depression, and has follow-up
with Dr. Lupcho on 1 April at 1400.
Note Written by LUPCHO, THERESA D @ 13 Mar 2009 1043 EDT
What he wants from coming to OMHS:
1. Open to idea of meds and is scheduled to see LTC (PNP) Streeter on 27
March at 0830 for medication
2. Will follow up for sessions of therapy - he wants a better understanding
2019
Medical Record
2019
of his issues - he wants an unbiased opinion - he wants to see if he's

avoiding any long-term issues which will come back to cause difficulty later
in life such as on his health and ability to sleep restfully. He is scheduled
to follow-up w/Dr. Lupcho for therapy on 1 April at 1400 to address issues of
depression, exploring his past and reasons for staying in an unsatisfying
marriage with a demanding woman with a history of being a victim of domestic
abuse and a history of job instability, self-care, stress management, sleep
hygiene, coping skills, and any other issues which need to be addressed, via
CBT or other interventions, as appropriate.
Note Written by LUPCHO, THERESA D @ 13 Mar 2009 1033 EDT
Note Written by CAZEAU, ALEX @ 11 Mar 2009 0841 EDT
Consult Order
Referring Provider: HIGDON, MARK L
Date of Request: 26 Jan 2009
Priority: Routine
Eval for PTSD
Reason for Request:
please schedule with next available provider38 year old active duty SFC with
some depression and extreme thoughts following deployment experience in Iraq
2004-2005. Would like evaluation per recent discussion during his PHA.
Thank you.
Signed By LUPCHO,THERESA (Psy. D., Clinical Psychologist) @ 13 Mar 2009 1045
Note Written by LUPCHO, THERESA D @ 07 Apr 2009 1446 EDT
Attempted to contact this SM at his cell phone number, regarding his missed
appt. with this writer today at 1500. No answer. A message was left reminding
him of the availability of emergency services during business hours and after
hours and on weekends. He was requested to make a follow-up appt. with this
writer, or come in to see same on Fridays as a walk-in. He was also reminded
to keep his schedule appointments for follow-up medication checks with LTC
(PNP) Streeter.
Verified by: THERESA D. LUPCHO, PHD 07 Apr 2009@2122
2019
Medical Record
2019
03 Mar 2009 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by RANDALL,
WILLIAM L

GMT
Document Type: Outpatient Report AHLTA Entry Date: 12 Mar 2009 1332
GMT
Benning, GA
Clinician: RANDALL, WILLIAM
L
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
13 Jan 2009 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by TAMBE,
MOSES A

Document Type: Outpatient Report AHLTA Entry Date: 26 Jan 2009 1538 GMT
Benning, GA
Clinician: TAMBE, MOSES A
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
02 Jan 2009 0201 GMT at , Consultation by

Document Type: Consultation AHLTA Entry Date: 02 Jan 2009 0201 GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: HINES, DAVID A

Requesting Location: FMC STAFF CLINIC
No. of Visits: 1
Reason for Consult:
Please evaluate and advise for weight loss.
Priority: ROUTINE
abdominal pain
ACV:
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date:
Clinic: NUTRITION
Consulting HCP: ,

Problem List:
Note:
Administratively Closed on 01 Jan 2009
2019
Medical Record
2019

GMT
GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------

Requesting Location: FMC STAFF CLINIC
No. of Visits: 1
Reason for Consult:
38yoBMAD with 1 year history of midepigastric abdominl pain, no EGD. Has had
an extensive negative lab workup, and noted to have meserentic adenitis on CT,
and lap. Please evaluate and advise
Priority: ASAP
abdominal pain
ACV:
Reviewer: SISK, CHAD M
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT
Appointment Date: 23 Dec 2008@10:00:00

Consulting HCP: SISK, CHAD MICHAEL

Problem List:
Note:
Date: 23 Dec 2008 1000 EST
Appt Type: SPEC
Provider: SISK,CHAD MICHAEL
Reason for Appointment: abdominal pain
2019
Medical Record
2019
kfc/mailout4dec.08
AutoCites Refreshed by KAY, CHRISTOPHER MICHEAL @ 23 Dec 2008 1010 EST
Problems
BACKACHE
MIGRAINE HEADACHE
FOLLICULITIS
visit for: screening exam
CERVICALGIA
joint pain, localized in the shoulder
Other Physical Therapy
Laboratory Studies
abdominal pain
TESTICULAR NEOPLASM
visit for: administrative purpose
visit for: follow-up exam
visit for: preoperative exam
Active Family History
Type II diabetes mellitus (Father)
Arteriosclerotic cardiovascular disease (ASCVD) (Mother)
No family history of malignant neoplasm of the large intestine
Allergies
No Known Allergies
Active Medications
Active Medications
Status
Sig
Refills Left
Last Filled
Omeprazole 20mg, Extended release capsule, Oral
Active
TAKE 1 CAP PO BID FOR 14 DAYS #28 RF0
NR
12 Dec 2008
Esomeprazole Magnesium Trihydrate 40mg, Capsule, Oral
Active
CHS
NR
03 Dec 2008
Esomeprazole Magnesium Trihydrate 20mg, Capsule, Oral
Active
CD
NR
26 Nov 2008
METHOCARBAMOL, 500MG, TABLET, ORAL
Active
T2 TAB QID #40 RF5
5 of 5
26 Jan 2008
Screening Written by KAY, CHRISTOPHER MICHEAL @ 23 Dec 2008 1012 EST
Allergen information verified by KAY, CHRISTOPHER MICHEAL @ 23 Dec 2008 1012
EST
Vitals
2019
Medical Record
2019
BP: 128/60, HR: 67, RR: 16, HT: 66 in, WT: 202 lbs, BMI: 32.6, BSA: 2.009
square meters, Tobacco Use: No, Alcohol Use: No, Pain Scale: 7/10 Severe,
Pain Scale Comments: Pt states he currently has a headache 6/10 and ULQ
abdominal pain 6/10.
Comments: cmk
SO Note Written by SISK,CHAD MICHAEL @ 23 Dec 2008 1105 EST
Chief complaint
The Chief Complaint is: GI Complaint: eval upper abdominal pain.
He reported: Past medical history reviewed and medication list reviewed with
patient.
Gastrointestinal symptoms. Appetite not decreased. No dysphagia.
Heartburn. No nausea and no vomiting. Bloating and epigastric pain. No
radiating abdominal pain. Dull, boring, or aching abdominal pain which is
chronic/recurring frequently which is intermittent. No regurgitation, no
jaundice, no bowel urgency, and no diarrhea.
Visit is not deployment-related. No systemic symptoms, no fever, and no
chills. No headache. No otolaryngeal symptoms. No cardiovascular symptoms.
No pulmonary symptoms. No genitourinary symptoms and no oliguria. No
endocrine symptoms. No hematologic symptoms. No musculoskeletal symptoms.
No neurological symptoms. No psychological symptoms. No skin symptoms.
Reported History:
Medical: No previous hospitalizations. Past medical history was reported by
the patient as noted above.
Surgical / procedural: Surgical / procedural history Ex Lap.
Reported prior tests: Prior tests were performed Ex lap, EGD.
Diagnosis History:
Personal history
Habits: Exercising regularly.
Family history
Review of systems
Gastrointestinal symptoms: No hematemesis and no hematemesis ('coffee
grounds'). Abdominal pain. No flatus, no melena, no hematochezia, no red
blood on the surface of the stool, and no mucus in the stool. No
constipation.
Genitourinary symptoms: Urine is not dark or cloudy. No dysuria and no pain
in the flank.
Physical findings
Vital signs:
Current vital signs reviewed.
2019
Medical Record
2019
General appearance:
Alert. Well developed. Well nourished. Well hydrated. In no
acute distress. Patient did not appear uncomfortable.
Neck:
Suppleness: Neck demonstrated no decrease in suppleness.
Oral cavity:
Buccal Mucosa: Moist.
Lymph Nodes:
Cervical lymph nodes were not enlarged.
Lungs:
Chest did not demonstrate dullness to percussion. Clear to auscultation.
Abdomen:
Auscultation: Bowel sounds were normal.
Palpation: Abdomen was soft. Abdominal muscle guarding was not
demonstrated. Abdominal muscle rigidity was not demonstrated. No direct
tenderness in the abdomen. No rebound tenderness in the abdomen.
Murphy's sign was not observed. No mass was palpated in the abdomen.
Hepatic Findings: Liver was not enlarged. Liver was not tender.
Splenic Findings: Spleen was not enlarged. Spleen was not tender.
General/bilateral: Musculoskeletal system: normal.
Neurological:
System: normal.
Psychiatric Exam:
Normal.
Skin:
Normal.
Therapy
No herbal medicines.
A/P Written by SISK, CHAD M @ 23 Dec 2008 1108 EST
1. HELICOBACTER PYLORI (H. PYLORI) INFECTION
2. GASTRITIS DUE TO H. PYLORI: EGD findings from Dr. Mcguigan reviewed.
Suspect h.pylori gastritis at the root of his GI complaints and possibly a
factor with the history of mesenteric adenitis. No evidence to support
lymphoma on gastric biopsy or EX Lap. Repeat CT in Nov negative with
resolution of the adenitis. Will treat for 14 days with
amoxil/biaxin/Prilosec, then continue prilosec for next 3-6 months. Pt to f/u
with me in few weeks to assess response.
Disposition Written by SISK, CHAD M @ 23 Dec 2008 1109 EST
Follow up: 3 week(s) in the GASTROENTEROLOGY CLINIC clinic or sooner if there
are problems.
Side Effects with Patient who indicated understanding. - Comments: Patient
counseled regarding diagnosis and medical therapy options. Written and verbal
education completed.
Note Written by KAY, CHRISTOPHER MICHEAL @ 23 Dec 2008 1010 EST
Consult Order
2019
Medical Record
2019
Referring Provider: HINES, DAVID A

Date of Request: 01 Dec 2008
Priority: ASAP
abdominal pain
Reason for Request:
38yoBMAD with 1 year history of midepigastric abdominl pain, no EGD. Has had
an extensive negative lab workup, and noted to have meserentic adenitis on
CT, and lap. Please evaluate and advise
Signed By SISK, CHAD M (Chief, Gastroenterology Service, Martin ACH, Fort
Benning, GA) @ 23 Dec 2008 1109
Verified by: CHAD M. SISK, DO. 23 Dec 2008@1114
2019
Medical Record
2019
25 Nov 2008 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by TRICKEY,
DAVID N

GMT
Document Type: Outpatient Report AHLTA Entry Date: 09 Dec 2008 1813
GMT
Benning, GA
Clinician: TRICKEY, DAVID N
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
20 Nov 2008 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by KAPLAN,
JOSEPH J

GMT
GMT
Benning, GA
Clinician: KAPLAN, JOSEPH J
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
13 Nov 2008 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by CASS,
DAVID A

GMT
Document Type: Outpatient Report AHLTA Entry Date: 18 Nov 2008 1904
GMT
Benning, GA
Clinician: CASS, DAVID A
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
07 Nov 2008 0500 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by KAPLAN,
JOSEPH J

GMT
Document Type: Outpatient Report AHLTA Entry Date: 18 Nov 2008 1857
GMT
Benning, GA
Clinician: KAPLAN, JOSEPH J
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
01 Nov 2008 0400 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by REEDY,
GARY W

GMT
GMT
Benning, GA
Clinician: REEDY, GARY W
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
16 Jun 2008 0400 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by HINES,
DAVID A
Title: Original Date: 16 Jun 2008 0400 GMT

Document Type: Outpatient Report AHLTA Entry Date: 19 Feb 2009 1346 GMT
Benning, GA
Clinician: HINES, DAVID A
2019
Medical Record
2019
2019
Medical Record
2019
2019
Medical Record
2019
01 Apr 2008 0400 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by
FOXWORTH, KIMBERLY L

GMT
Document Type: Outpatient Report AHLTA Entry Date: 01 Apr 2008 1320
GMT
Benning, GA
Clinician: FOXWORTH,
KIMBERLY L
2019
Medical Record
2019
01 Apr 2008 0400 GMT at Martin ACH, Fort Benning, GA, Outpatient Report by
FOXWORTH, KIMBERLY L

GMT
Document Type: Outpatient Report AHLTA Entry Date: 01 Apr 2008 1321
GMT
Benning, GA
Clinician: FOXWORTH,
KIMBERLY L
2019
Medical Record
2019

GMT
Document Type: Consultation AHLTA Entry Date: 27 Mar 2008 1326
GMT
Clinician:
CONSULT REPORT
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
Requesting HCP: KITCHENS, JEFFERY A

Requesting Location: CTMC FLIGHT MED
No. of Visits: 1
Referral Authorized Until: 19 Apr 2008
Reason for Consult:
PLEASE EVAL 37 YO MALE W/ LESION SUPERIOR ASPECT OF RIGHT TESTICLE. PT CAN BE
CONTACTED AT 877-377-3121. THANKS
Priority: ROUTINE
TESTICULAR NEOPLASM
ACV:
Appoint Status: DEFERRED - RESULTS RECEIVED
Note: Consult result has been received from the Network Consulting Provider
for this patient. Please refer to the hardcopy on file: the original has been
sent to the patient s records room, a copy has been sent to the requesting
physician and/or PCM.
Reviewer: LESTRONGE, RITA L
--------------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------
CONSULT RESULT

Requesting HCP: KITCHENS, JEFFERY A
Clinic: NETWORK
Consulting HCP: CIV, PROVIDER
HCDP: 001-DIRECT CARE FOR ACTIVE DUTY SPONSORS

Problem List:
Note:
Consult results have been received from the Network Consulting Provider for
WAITERS,TOMMIE A. Please refer to the hardcopy on file.
Administratively Closed on 27 Mar 2008
2019
Medical Record
2019
***** End of Clinical Notes *****
2019
Medical Record
2019
Vitals
Date: 13 Nov 2019 Facility: Martin ACH, Fort Benning, GA Clinician: CARR, VANESSA
Type Value Units
Pain Scale 0/10 Adult
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 11 Sep 2019 Facility: Martin ACH, Fort Benning, GA Clinician: NESMITH, KAREN A
Type Value Units
Pain Scale Comments BACK AND LEFT SHOULDER Adult
Comments:
Date: 11 Sep 2019 Facility: Martin ACH, Fort Benning, GA Clinician: NESMITH, KAREN A
Type Value Units
SBP 124 mmHg
DBP 79 mmHg
HR 88 beats/min
Pain Scale Comments BAKC AND LEFT SHOULDER Adult
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 08 Aug 2019 Facility: Martin ACH, Fort Benning, GA Clinician: GHOLSON, RACHEL J
Type Value Units
SBP 148 mmHg
DBP 86 mmHg
HR 92 beats/min
RR 20 breaths/min
T 97.6 Fahrenheit
HT 66 Inches
WT 250.2 Pounds
BMI 40.38 kg/mm
BSA 2.200 square meters
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 28 Mar 2019 Facility: Martin ACH, Fort Benning, GA Clinician: GRAY, MARION T
Type Value Units
SBP 129 mmHg
DBP 86 mmHg
HR 81 beats/min
HT 66 Inches
WT 233 Pounds
BMI 37.61 kg/mm
Tobacco Use No None
2019
Medical Record
2019
Comments:
Date: 15 Mar 2019 Facility: Martin ACH, Fort Benning, GA Clinician: BOWLING, ELSIE L
Type Value Units
SBP 153 mmHg
DBP 99 mmHg
HR 79 beats/min
RR 16 breaths/min
T 98.1 Fahrenheit
HT 66 Inches
WT 249 Pounds
BMI 40.19 kg/mm
Comments:
Date: 16 Jul 2018 Facility: Martin ACH, Fort Benning, GA Clinician: JONES, JESSICA
Type Value Units
SBP 131 mmHg
DBP 83 mmHg
HR 87 beats/min
RR 18 breaths/min
T 98.6 Fahrenheit
HT 66 Inches
WT 245.8 Pounds
BMI 39.67 kg/mm
Pain Scale Comments lower back pai Adult
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 23 Apr 2018 Facility: Martin ACH, Fort Benning, GA Clinician: CLAYTON, MARNIE D
Type Value Units
SBP 120 mmHg
DBP 82 mmHg
HR 75 beats/min
HT 66 Inches
WT 247.4 Pounds
BMI 39.93 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 20 Apr 2018 Facility: Martin ACH, Fort Benning, GA Clinician: CLAYTON, MARNIE D
Type Value Units
SBP 154 mmHg
DBP 79 mmHg
HR 87 beats/min
HT 66 Inches
WT 247 Pounds
BMI 39.87 kg/mm
2019
Medical Record
2019

Tobacco Use No None
Alcohol Use No None
Comments:
Date: 18 Jan 2018 Facility: Martin ACH, Fort Benning, GA Clinician: ROBERSON, PATRICIA A
Type Value Units
SBP 134 mmHg
DBP 80 mmHg
HR 78 beats/min
HT 66 Inches
WT 232 Pounds
BMI 37.44 kg/mm
Oxygen Saturation 99 Percent Saturation
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 27 Nov 2017 Facility: Martin ACH, Fort Benning, GA Clinician: ROBERSON, PATRICIA A
Type Value Units
SBP 137 mmHg
DBP 75 mmHg
HR 78 beats/min
HT 66 Inches
WT 232 Pounds
BMI 37.44 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 16 Nov 2017 Facility: Martin ACH, Fort Benning, GA Clinician: NESMITH, KAREN A
Type Value Units
SBP 132 mmHg
DBP 78 mmHg
HR 70 beats/min
HT 66 Inches
WT 232 Pounds
BMI 37.44 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 05 Jul 2016 Facility: Martin ACH, Fort Benning, GA Clinician: VEGA, JULIAN T
Type Value Units
SBP 145 mmHg
DBP 89 mmHg
HR 76 beats/min
2019
Medical Record
2019
RR 18 breaths/min
T 98.1 Fahrenheit
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 30 Jun 2016 Facility: Martin ACH, Fort Benning, GA Clinician: SMITH, AUSTIN M
Type Value Units
SBP 127 mmHg
DBP 87 mmHg
HR 85 beats/min
RR 18 breaths/min
T 98.8 Fahrenheit
HT 66 Inches
WT 243 Pounds
BMI 39.22 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 27 Jun 2016 Facility: Martin ACH, Fort Benning, GA Clinician: SMITH, AUSTIN M
Type Value Units
SBP 126 mmHg
DBP 80 mmHg
HR 88 beats/min
RR 18 breaths/min
T 98.1 Fahrenheit
HT 66 Inches
WT 243 Pounds
BMI 39.22 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 01 Jun 2016 Facility: Martin ACH, Fort Benning, GA Clinician: BATTLES, YVETTE D.
Type Value Units
SBP 127 mmHg
DBP 88 mmHg
HR 87 beats/min
RR 16 breaths/min
T 97.9 Fahrenheit
HT 66 Inches
WT 243.2 Pounds
BMI 39.25 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments:
2019
Medical Record
2019
Date: 05 Jan 2016 Facility: Martin ACH, Fort Benning, GA Clinician: HERRON, CATHERINE
Type Value Units
SBP 133 mmHg
DBP 83 mmHg
HR 91 beats/min
RR 16 breaths/min
T 98.4 Fahrenheit
HT 66 Inches
WT 242 Pounds
BMI 39.06 kg/mm
Pain Scale Comments lt shoulder/lower back...7/10/Lt Adult
side....5/10
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 18 Mar 2015 Facility: Martin ACH, Fort Benning, GA Clinician: MELENDEZ, ELY J
Type Value Units
SBP 147 mmHg
DBP 95 mmHg
HR 103 beats/min
RR 18 breaths/min
HT 66 Inches
WT 237 Pounds
BMI 38.25 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 18 Feb 2015 Facility: Martin ACH, Fort Benning, GA Clinician: MELENDEZ, ELY J
Type Value Units
SBP 149 mmHg
DBP 79 mmHg
HR 74 beats/min
RR 16 breaths/min
HT 66 Inches
WT 241 Pounds
BMI 38.90 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 15 Jan 2015 Facility: Martin ACH, Fort Benning, GA Clinician: FORD, VANESSA R
Type Value Units
SBP 144 mmHg
DBP 87 mmHg
HR 78 beats/min
2019
Medical Record
2019
RR 20 breaths/min
T 98 Fahrenheit
HT 66 Inches
WT 226 Pounds
BMI 36.48 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments: Medication reconciliation performed. Denies any OTC meds/supplements. Takes Naprosyn as
prescribed for back pain.
Date: 14 Jan 2015 Facility: Martin ACH, Fort Benning, GA Clinician: MELENDEZ, ELY J
Type Value Units
SBP 165 mmHg
DBP 92 mmHg
HR 78 beats/min
RR 18 breaths/min
HT 66 Inches
WT 226 Pounds
BMI 36.48 kg/mm
Pain Scale Comments Head ache Adult
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 09 Jan 2015 Facility: Martin ACH, Fort Benning, GA Clinician: MCNEARNEY, CODY M
Type Value Units
RR 12 breaths/min
HT 66 Inches
WT 227 Pounds
BMI 36.64 kg/mm
Comments:
Date: 07 Nov 2014 Facility: Martin ACH, Fort Benning, GA Clinician: OSHEA, VALERIE W
Type Value Units
SBP 134 mmHg
DBP 84 mmHg
HR 70 beats/min
RR 20 breaths/min
T 96.7 Fahrenheit
HT 66 Inches
WT 229 Pounds
BMI 36.96 kg/mm
Pain Scale Comments bilateral knees/ lower back Adult
Tobacco Use No None
2019
Medical Record
2019
Alcohol Use No None

Comments:
Date: 04 Nov 2014 Facility: Martin ACH, Fort Benning, GA Clinician: CAMPBELL, KELLY R
Type Value Units
SBP 136 mmHg
DBP 83 mmHg
HR 90 beats/min
RR 18 breaths/min
T 98.2 Fahrenheit
HT 66 Inches
WT 232.2 Pounds
BMI 37.48 kg/mm
Pain Scale Comments head and lower back Adult
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 20 Oct 2014 Facility: Martin ACH, Fort Benning, GA Clinician: PARK, MICHELLE D
Type Value Units
SBP 127 mmHg
DBP 82 mmHg
HR 69 beats/min
RR 16 breaths/min
T 97.7 Fahrenheit
WT 242 Pounds
Comments:
Date: 04 Jun 2013 Facility: Martin ACH, Fort Benning, GA Clinician: OWENS, CHRISTEN A
Type Value Units
SBP 153 mmHg
DBP 95 mmHg
HR 80 beats/min
T 98.1 Fahrenheit
Pain Scale Comments Left upper quandrant of abdomen Adult
Tobacco Use No None
Alcohol Use No None
Comments: 508 pulled
nondeployment related
#706-326-4585
Date: 03 May 2013 Facility: Martin ACH, Fort Benning, GA Clinician: GRILLO, ALLENA C
Type Value Units
SBP 122 mmHg
DBP 78 mmHg
HR 72 beats/min
RR 16 breaths/min
T 97 Fahrenheit
HT 66 Inches
WT 229.8 Pounds
2019
Medical Record
2019
BMI 37.09 kg/mm

Comments:
Date: 29 Jan 2013 Facility: Martin ACH, Fort Benning, GA Clinician: MORRIS, TARA C
Type Value Units
SBP 141 mmHg
DBP 91 mmHg
HR 90 beats/min
RR 20 breaths/min
T 98.3 Fahrenheit
HT 66 Inches
WT 226 Pounds
BMI 36.48 kg/mm
Comments:
Date: 27 Nov 2012 Facility: Martin ACH, Fort Benning, GA Clinician: CAIN, LOIS R
Type Value Units
SBP 130 mmHg
DBP 75 mmHg
HR 92 beats/min
HT 66.5 Inches
WT 220 Pounds
BMI 34.98 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 16 Nov 2012 Facility: Martin ACH, Fort Benning, GA Clinician: CAIN, LOIS R
Type Value Units
SBP 129 mmHg
DBP 77 mmHg
HR 89 beats/min
HT 66.5 Inches
WT 220 Pounds
BMI 34.98 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 31 Oct 2012 Facility: Martin ACH, Fort Benning, GA Clinician: HOLLIS, GEORGE S
Type Value Units
SBP 123 mmHg
DBP 81 mmHg
HR 76 beats/min
RR 18 breaths/min
T 98.7 Fahrenheit
HT 66 Inches
2019
Medical Record
2019
WT 226.2 Pounds
BMI 36.51 kg/mm
Comments:
Date: 16 Oct 2012 Facility: Martin ACH, Fort Benning, GA Clinician: NEAL, CALVIN
Type Value Units
SBP 124 mmHg
DBP 84 mmHg
HR 72 beats/min
RR 18 breaths/min
T 97.5 Fahrenheit
HT 66 Inches
WT 215 Pounds
BMI 34.70 kg/mm
Comments:
Date: 19 Sep 2012 Facility: Martin ACH, Fort Benning, GA Clinician: HOLLIS, GEORGE S
Type Value Units
SBP 147 mmHg
DBP 83 mmHg
HR 84 beats/min
RR 18 breaths/min
T 98.4 Fahrenheit
HT 66 Inches
WT 227.8 Pounds
BMI 36.77 kg/mm
Comments:
Date: 09 Jul 2012 Facility: Reynolds Army Community Hospital Ft. Sill, OK Clinician: ROSA, JUAN L
Type Value Units
Vision Uncorrected Right Eye 20 None
Vision Uncorrected Left Eye 20 None
Comments:
Date: 09 May 2012 Facility: Martin ACH, Fort Benning, GA Clinician: MELENDEZ, ELY J
Type Value Units
SBP 116 mmHg
DBP 70 mmHg
HR 94 beats/min
RR 16 breaths/min
HT 66 Inches
WT 211 Pounds
BMI 34.06 kg/mm
Pain Scale Comments LBP, Seen physical therapy and Adult
taken muscle relaxer
Tobacco Use No None
2019
Medical Record
2019
Alcohol Use No None

Comments: Medication reconcilliation reviwed
Date: 03 Apr 2012 Facility: Martin ACH, Fort Benning, GA Clinician: PATEL, DHRUVANG J
Type Value Units
SBP 147 mmHg
DBP 89 mmHg
HR 98 beats/min
RR 20 breaths/min
T 98.1 Fahrenheit
HT 66 Inches
WT 220 Pounds
BMI 35.51 kg/mm
Pain Scale Comments lower back Adult
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 26 Mar 2012 Facility: Martin ACH, Fort Benning, GA Clinician: HOLLIS, GEORGE S
Type Value Units
SBP 133 mmHg
DBP 80 mmHg
HR 74 beats/min
RR 18 breaths/min
T 99.9 Fahrenheit
HT 66 Inches
WT 220 Pounds
BMI 35.51 kg/mm
Comments:
Date: 15 Dec 2011 Facility: Martin ACH, Fort Benning, GA Clinician: THORNBURG, BRADLEY WADE
Type Value Units
SBP 142 mmHg
DBP 82 mmHg
HR 66 beats/min
RR 18 breaths/min
HT 66 Inches
WT 212 Pounds
BMI 34.22 kg/mm
Date: 02 Nov 2011 Facility: Martin ACH, Fort Benning, GA Clinician: HOLLIS, GEORGE S
Type Value Units
SBP 134 mmHg
DBP 88 mmHg
HR 84 beats/min
RR 18 breaths/min
2019
Medical Record
2019
T 98.1 Fahrenheit
HT 66 Inches
WT 220.2 Pounds
BMI 35.54 kg/mm
Comments:
Date: 24 Feb 2011 Facility: Martin ACH, Fort Benning, GA Clinician: KELLIER, KEREAN P
Type Value Units
SBP 134 mmHg
DBP 85 mmHg
HR 103 beats/min
RR 20 breaths/min
T 98.2 Fahrenheit
HT 66 Inches
WT 211.8 Pounds
BMI 34.18 kg/mm
Comments:
Date: 09 Feb 2011 Facility: Martin ACH, Fort Benning, GA Clinician: FLETCHER, LITITIA K
Type Value Units
SBP 146 mmHg
DBP 86 mmHg
HR 80 beats/min
RR 18 breaths/min
T 99.4 Fahrenheit
HT 66 Inches
WT 209 Pounds
BMI 33.73 kg/mm
Comments:
Date: 15 Nov 2010 Facility: Martin ACH, Fort Benning, GA Clinician: FLETCHER, LITITIA K
Type Value Units
HT 66 Inches
WT 228.4 Pounds
BMI 36.86 kg/mm
Comments:
Date: 15 Nov 2010 Facility: Martin ACH, Fort Benning, GA Clinician: FLETCHER, LITITIA K
Type Value Units
SBP 144 mmHg
DBP 81 mmHg
HR 91 beats/min
RR 20 breaths/min
T 97.4 Fahrenheit
Comments:
Date: 04 Oct 2010 Facility: Martin ACH, Fort Benning, GA Clinician: MCFADDEN, WANDA L
2019
Medical Record
2019
Type Value Units

SBP 126 mmHg
DBP 87 mmHg
HR 74 beats/min
RR 18 breaths/min
T 97.8 Fahrenheit
HT 66 Inches
WT 228.4 Pounds
BMI 36.86 kg/mm
Comments:
Date: 28 Sep 2010 Facility: 20th Medical Group Clinician: SWEATT, CAROLYN M
Type Value Units
SBP 139 mmHg
DBP 88 mmHg
HR 71 beats/min
RR 20 breaths/min
T 97.9 Fahrenheit
Pain Scale Comments abd pain Adult
Comments:
Date: 28 Sep 2010 Facility: 20th Medical Group Clinician: REED, TAMMY O
Type Value Units
SBP 127 mmHg
DBP 89 mmHg
HR 65 beats/min
Last Menstrual Date 0 None
Comments: Recheck of BP
Date: 27 Sep 2010 Facility: 20th Medical Group Clinician: BULLOCK, SHIRLEY
Type Value Units
SBP 140 mmHg
DBP 88 mmHg
HR 80 beats/min
RR 18 breaths/min
T 98.7 Fahrenheit
Pain Scale Comments lt side of abd Adult
Comments:
Date: 20 May 2010 Facility: Martin ACH, Fort Benning, GA Clinician: JOHNSON, SYRA K
Type Value Units
SBP 130 mmHg
DBP 82 mmHg
HR 77 beats/min
RR 16 breaths/min
T 98.5 Fahrenheit
HT 66 Inches
WT 214 Pounds
BMI 34.54 kg/mm
2019
Medical Record
2019

Comments:
Date: 25 Feb 2010 Facility: Martin ACH, Fort Benning, GA Clinician: MCFADDEN, WANDA L
Type Value Units
SBP 126 mmHg
DBP 84 mmHg
HR 81 beats/min
RR 18 breaths/min
T 97.2 Fahrenheit
HT 66 Inches
WT 208 Pounds
BMI 33.57 kg/mm
Tobacco Use No None
Alcohol Use No None
Comments: non-deployed related
Date: 25 Feb 2010 Facility: Martin ACH, Fort Benning, GA Clinician: WICKER-ARMOLT, JENNIFER C
Type Value Units
HT 66 Inches
WT 228.3 Pounds
BMI 36.85 kg/mm
Pain Scale 0/10
Tobacco Use No None
Alcohol Use No None
Comments: Weight taken in uniform and boots.
Date: 22 Oct 2009 Facility: Martin ACH, Fort Benning, GA Clinician: MORRIS, TARA C
Type Value Units
SBP 134 mmHg
DBP 83 mmHg
HR 73 beats/min
RR 20 breaths/min
T 99.5 Fahrenheit
HT 66 Inches
WT 210 Pounds
BMI 33.89 kg/mm
Pain Scale Comments Left side of abdomen Adult
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 13 Oct 2009 Facility: Martin ACH, Fort Benning, GA Clinician: HANKERSON, BENJAMIN
Type Value Units
Supine SBP 129 mmHg
Supine DBP 82 mmHg
2019
Medical Record
2019
Supine HR 67 beats/min
Sitting SBP 124 mmHg
Sitting DBP 83 mmHg
Sitting HR 76 beats/min
Standing SBP 117 mmHg
Standing DBP 82 mmHg
Standing HR 76 beats/min
T 98.2 Fahrenheit
HT 66 Inches
WT 200 Pounds
BMI 32.28 kg/mm
Pain Scale 2/10
Pain Scale Comments lower abdomen
Tobacco Use No None
Alcohol Use No None
meds reviewed
Date: 13 Oct 2009 Facility: Martin ACH, Fort Benning, GA Clinician: HANKERSON, BENJAMIN
Type Value Units
Supine SBP 129 mmHg
Supine DBP 82 mmHg
Sitting SBP 124 mmHg
Sitting DBP 83 mmHg
Sitting HR 76 beats/min
T 98.2 Fahrenheit
HT 66 Inches
WT 200 Pounds
BMI 32.28 kg/mm
Pain Scale 2/10
Pain Scale Comments lower abdomen
Tobacco Use No None
Alcohol Use No None
meds reviewed
Date: 03 Apr 2009 Facility: Martin ACH, Fort Benning, GA Clinician: ZARWOLO, ANGELA L
Type Value Units
SBP 148 mmHg
DBP 85 mmHg
HR 85 beats/min
RR 18 breaths/min
2019
Medical Record
2019
T 100.2 Fahrenheit
HT 66 Inches
WT 208.4 Pounds
BMI 33.64 kg/mm
Pain Scale Comments stomach Adult
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 18 Mar 2009 Facility: Martin ACH, Fort Benning, GA Clinician: KAY, CHRISTOPHER M
Type Value Units
SBP 134 mmHg
DBP 79 mmHg
HR 78 beats/min
RR 17 breaths/min
T 98.1 Fahrenheit
HT 66 Inches
WT 200 Pounds
BMI 32.28 kg/mm
Pain Scale 7/10
Pain Scale Comments Pt states he currently has pain in
his ULQ 7.5/10.
Tobacco Use No None
Alcohol Use No None
Comments: cmk
Date: 26 Jan 2009 Facility: Martin ACH, Fort Benning, GA Clinician: HIGDON, MARK L
Type Value Units
Comments: Med Reconciliation Completed
Date: 26 Jan 2009 Facility: Martin ACH, Fort Benning, GA Clinician: HIGDON, MARK L
Type Value Units
SBP 144 mmHg
DBP 83 mmHg
HR 73 beats/min
RR 14 breaths/min
T 98.3 Fahrenheit
Pain Scale 5/10
Pain Scale Comments Abdomen
Tobacco Use No None

Alcohol Use No None
Comments:
Date: 21 Jan 2009 Facility: Martin ACH, Fort Benning, GA Clinician: EDMONDS, TONIA T
Type Value Units
SBP 122 mmHg
DBP 83 mmHg
2019
Medical Record
2019
HR 74 beats/min
RR 20 breaths/min
T 97.8 Fahrenheit
HT 66 Inches
WT 211 Pounds
BMI 34.06 kg/mm
Pain Scale 7/10
Pain Scale Comments abdomen
Tobacco Use No None
Alcohol Use No None
Date: 14 Jan 2009 Facility: Martin ACH, Fort Benning, GA Clinician: WICKER-ARMOLT, JENNIFER C
Type Value Units
HT 66.5 Inches
WT 217.5 Pounds
BMI 34.58 kg/mm
Pain Scale 0/10
Tobacco Use No None
Alcohol Use No None
Date: 23 Dec 2008 Facility: Martin ACH, Fort Benning, GA Clinician: KAY, CHRISTOPHER M
Type Value Units
SBP 128 mmHg
DBP 60 mmHg
HR 67 beats/min
RR 16 breaths/min
HT 66 Inches
WT 202 Pounds
BMI 32.60 kg/mm
Pain Scale 7/10
Pain Scale Comments Pt states he currently has a
headache 6/10 and ULQ
abdominal pain 6/10.
Tobacco Use No None
Alcohol Use No None
Comments: cmk
Date: 02 Dec 2008 Facility: Martin ACH, Fort Benning, GA Clinician: GRACE, DAISY V
Type Value Units
SBP 131 mmHg
DBP 88 mmHg
HR 109 beats/min
RR 22 breaths/min
T 98.8 Fahrenheit
2019
Medical Record
2019
WT 212.3 Pounds
Pain Scale 0/10
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 01 Dec 2008 Facility: Martin ACH, Fort Benning, GA Clinician: KELLIER, KEREAN P
Type Value Units
SBP 137 mmHg
DBP 80 mmHg
HR 86 beats/min
RR 20 breaths/min
T 99.5 Fahrenheit
HT 66 Inches
WT 204 Pounds
BMI 32.93 kg/mm
Pain Scale 7/10
Pain Scale Comments abd
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 01 Dec 2008 Facility: Martin ACH, Fort Benning, GA Clinician: KELLIER, KEREAN P
Type Value Units
SBP 137 mmHg
DBP 80 mmHg
HR 86 beats/min
RR 20 breaths/min
T 99.5 Fahrenheit
HT 66 Inches
WT 204 Pounds
BMI 32.93 kg/mm
Pain Scale 7/10
Pain Scale Comments abd
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 04 Nov 2008 Facility: Martin ACH, Fort Benning, GA Clinician: JOHNSON, CAROLYN E
Type Value Units
SBP 139 mmHg
DBP 80 mmHg
HR 77 beats/min
T 98.9 Fahrenheit
WT 214 Pounds
Pain Scale 7/10
Pain Scale Comments abdomen
2019
Medical Record
2019
Date: 16 May 2008 Facility: Martin ACH, Fort Benning, GA Clinician: JOHNSON, CAROLYN E
Type Value Units
SBP 156 mmHg
DBP 83 mmHg
HR 79 beats/min
T 98.9 Fahrenheit
HT 66 Inches
WT 207 Pounds
BMI 33.41 kg/mm
Pain Scale 5/10
Date: 10 Apr 2008 Facility: Martin ACH, Fort Benning, GA Clinician: SMITH, JORDON N
Type Value Units
SBP 119 mmHg
DBP 81 mmHg
HR 76 beats/min
RR 16 breaths/min
T 98.9 Fahrenheit
HT 66 Inches
WT 192 Pounds
BMI 30.99 kg/mm
Pain Scale 5/10
Pain Scale Comments Lower stomach
Tobacco Use No None
Alcohol Use No None
Currently taking percocet
Date: 08 Apr 2008 Facility: Martin ACH, Fort Benning, GA Clinician: BAKER, TIMOTHY A
Type Value Units
SBP 125 mmHg
DBP 83 mmHg
HR 77 beats/min
RR 16 breaths/min
T 98.6 Fahrenheit
HT 66 Inches
WT 206 Pounds
BMI 33.25 kg/mm
Pain Scale 6/10
Pain Scale Comments ABD AREA
Tobacco Use No None
Alcohol Use No None
Comments: MEDICAL RECORDS AVAILABLE NOT OIF/OEF ELATED
2019
Medical Record
2019
NO MEDS
Date: 20 Mar 2008 Facility: Martin ACH, Fort Benning, GA Clinician: SMITH, JORDON N
Type Value Units
SBP 114 mmHg
DBP 76 mmHg
HR 68 beats/min
RR 16 breaths/min
T 98.5 Fahrenheit
HT 66 Inches
WT 195 Pounds
BMI 31.47 kg/mm
Pain Scale 6/10
Pain Scale Comments Lower Stomach
Tobacco Use No None
Alcohol Use No None
Meds reconciled- Ibuprofen
Date: 09 Jan 2008 Facility: Martin ACH, Fort Benning, GA Clinician: COGDELL, KIRT D
Type Value Units
SBP 128 mmHg
DBP 68 mmHg
HR 71 beats/min
RR 16 breaths/min
T 98.7 Fahrenheit
HT 66 Inches
WT 203 Pounds
BMI 32.76 kg/mm
Pain Scale 5/10
Pain Scale Comments left thigh pain
Tobacco Use No None
Alcohol Use No None
Comments:
Date: 15 Oct 2007 Facility: Martin ACH, Fort Benning, GA Clinician: THOMAS, NORFLETT T
Type Value Units
SBP 130 mmHg
DBP 76 mmHg
HR 61 beats/min
RR 18 breaths/min
T 98.5 Fahrenheit
HT 66 Inches
WT 190 Pounds
BMI 30.67 kg/mm
Pain Scale 0/10
Tobacco Use No None
Alcohol Use No None
2019
Medical Record
2019

Med reconciliation.
Date: 11 Oct 2007 Facility: Martin ACH, Fort Benning, GA Clinician: EASON, LINDA F
Type Value Units
Pain Scale 7/10
Pain Scale Comments headache
Comments:
Date: 11 Oct 2007 Facility: Martin ACH, Fort Benning, GA Clinician: LEMKE, MICHAEL A.
Type Value Units
SBP 124 mmHg
DBP 71 mmHg
HR 69 beats/min
RR 16 breaths/min
T 99.5 Fahrenheit
HT 66 Inches
WT 180 Pounds
BMI 29.05 kg/mm
Pain Scale 7/10
Tobacco Use No None
Alcohol Use No None
meds reconciled
Date: 08 Jul 2007 Facility: 20th Medical Group Clinician: SMITH, ASHLEY D
Type Value Units
SBP 129 mmHg
DBP 87 mmHg
HR 83 beats/min
RR 16 breaths/min
T 98.1 Fahrenheit
Pain Scale 6/10
Comments:
Date: 08 Jul 2007 Facility: 20th Medical Group Clinician: JORDAN, KATRINA R
Type Value Units
Pain Scale 0/10
Date: 08 Jul 2007 Facility: 20th Medical Group Clinician: SMITH, ASHLEY D
Type Value Units
Supine SBP 125 mmHg
2019
Medical Record
2019
Supine DBP 79 mmHg

Comments:
Date: 07 Jun 2007 Facility: 20th Medical Group Clinician: WARING, CHRISTOPHER A
Type Value Units
Pain Scale 6/10
Pain Scale Comments R side of mid and upper back
Comments:
Date: 07 Jun 2007 Facility: 20th Medical Group Clinician: ELLISON, ELLA MARIE
Type Value Units
SBP 135 mmHg
DBP 81 mmHg
HR 65 beats/min
RR 20 breaths/min
T 98.4 Fahrenheit
Pain Scale 6/10
Pain Scale Comments lower and upper back
Tobacco Use No None
Alcohol Use No None
Comments:
***** End of Vitals *****
2019

Waiters Tommie Alajandro 1757 1068397665 Awp PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Waiters Tommie Alajandro 1757 1068397665 Awp PDF

Uploaded by

Copyright:

Available Formats

Medical Record

From: 18 Aug 1970 To: 27 Dec 2019

Non-Sensitive Information Report: Requested

Sections Domain Requested Record Counts Warnings

*Report generated with no warnings.

Abdominal pain on 20 Mar 2008 ........................................................................................................................19

Family history of nonorganic sleep apnea on 25 Jan 2012 .................................................................................55

Chlamydia+Gonococcus DNA Probe on 04 Nov 2014 ......................................................................................77

Lipids on 28 Mar 2012 ......................................................................................................................................102

Urea Nitrogen on 13 Nov 2008 .........................................................................................................................123

CT Abdomen/Pelvis With Contrast Report on 08 Nov 2012............................................................................151

***** End of Demographics *****

***** End of Allergies *****

Male erectile disorder on 29 Jul 2019

MESENTERIC PANNICULITIS on 04 Jun 2013

Patient Counseling: on 16 Nov 2012

BURSITIS TROCHANTERIC on 19 Sep 2012

Visit for: military services physical accession on 09 Jul 2012

Counseling About Travel on 09 May 2012

GASTRITIS on 28 Apr 2012

HYPERGLYCEMIA on 03 Apr 2012

MCKENZIE POSTERIOR DERANGEMENT SYNDROME on 29 Mar 2012

Patient Counseling Medical Management Five To Eight Patients on 27 Jan

NONORGANIC SLEEP APNEA OBSTRUCTIVE on 25 Jan 2012

NONORGANIC SLEEP DISORDERS on 15 Dec 2011

HYPERLIPIDEMIA on 03 Nov 2011

OVERWEIGHT on 02 Nov 2011

HYPERTENSION (SYSTEMIC) on 02 Nov 2011

HYPOGONADISM on 24 Feb 2011

ASTIGMATISM on 10 Feb 2011

MALE ERECTILE DISORDER on 09 Feb 2011

Snoring on 09 Feb 2011

Visit for: vasectomy status on 15 Nov 2010

Abdominal pain in the left upper belly (LUQ) on 28 Sep 2010

LUMBAGO on 22 Oct 2009

MAJOR DEPRESSION, RECURRENT IN PARTIAL REMISSION on 27 Apr

ADJUSTMENT DISORDER WITH DEPRESSED MOOD on 08 Apr 2009

REFRACTIVE ERROR - HYPERMETROPIA on 01 Apr 2009

GENERALIZED ANXIETY DISORDER on 27 Mar 2009

MAJOR DEPRESSION, SINGLE EPISODE MODERATE on 27 Mar 2009

Abdominal pain around the belly button (periumbilical) on 18 Mar 2009

ASSESS PATIENT CONDITION WORK-RELATED OCCUPATIONAL

ANXIETY DISORDER NOS on 11 Mar 2009

MAJOR DEPRESSION, SINGLE EPISODE on 11 Mar 2009

Blood Pressure Isolated Elevated on 26 Jan 2009

Visit for: military services physical on 26 Jan 2009

Visit for: occupational health / fitness exam on 21 Jan 2009

Body Mass Index on 14 Jan 2009

Patient Education - Dietary on 14 Jan 2009

GASTRITIS DUE TO H. PYLORI on 23 Dec 2008

HELICOBACTER PYLORI (H. PYLORI) INFECTION on 23 Dec 2008

Visit for: preoperative exam on 16 May 2008

Visit for: follow-up exam on 11 Apr 2008

TESTICULAR NEOPLASM on 20 Mar 2008

Abdominal pain on 20 Mar 2008

Other Physical Therapy on 05 Feb 2008

Joint pain, localized in the shoulder on 31 Jan 2008

CERVICALGIA on 31 Jan 2008

Visit for: screening exam on 09 Jan 2008

FOLLICULITIS on 09 Jan 2008

MIGRAINE HEADACHE on 11 Oct 2007

BACKACHE on 07 Jun 2007

PROBLEM CONCERNING BEHAVIOR OF CHILD on 13 Nov 2013

* End of Demographics *

* End of Allergies *

* End of Problems *