Co venant Co mmunity Care • 57 16 MICHIGAN AVE, DETROIT MI 48 210 -30 39

CRUZ, RUT H EST HER (id #56280, do b: 06/11/1976)

COVENANT COMMUNITY CARE, INC

5716 MICHIGAN AVE
DETROIT, MI 48210-3039
Phone: (313) 554-1095, Fax: (313) 899-3560

Date: 04/26/2021

Dear Ruth Cruz,

The following is a summary of your visit today. If you have any questions, please contact our office.

Sincerely,

Electronically Signed by: R CHASE THEBAULT, MD

Patient Care Summary for Ruth Esther Cruz

Most Recent Encount er

04/26/2021 R Chase Thebault: 5716 Michigan Ave, Detroit, MI 48210- 3039, Ph. tel:+1- 313- 5541095

Reason f or Visit
DM2;HTN
Assessment and Plan
The following list includes any diagnoses that were discussed at your visit.
1. Type 2 diabetes mellitus in obese
• Basaglar KwikPen U- 100 Insulin 100 unit/mL (3 mL) subcutaneous
• Levemir FlexTouch U- 100 Insulin 100 unit/mL (3 mL) subcutaneous pen

2. Essential hypertension

3. Endometrial intraepithelial neoplasia

4. Body mass index 40+ - severely obese

Discussion Note: None recorded.

Patient educational handouts: No information available.

Plan of Care
Re m inde rs Pro vide r
Appointments Return 15 on or around 05/26/2021 R Chase Thebault, MD

Lab None recorded.

Referral None recorded.

Procedures None recorded.

Surgeries None recorded.

Imaging None recorded.

Current Medicat ions
Your medical record indicates you are on the following medicine. If this list is not consistent with the medications
you are currently taking, or if you are taking additional over-the-counter medicines, please inform your provider.
Nam e Pre scribe d Dat e St art Dat e
alcohol swabs
Use with each glucometer check and insulin administration (7/day)

allopurinol 100 mg tablet

Take 1 tablet every day by oral route.

Banophen 25 mg capsule
Take 50 mg every day by oral route in the evening.

Basaglar KwikPen U- 100 Insulin 100 unit/mL (3 mL) subcutaneous 04/26/2021

Inject 50 units every day by subcutaneous route.

benz oyl peroxide 5 % topical cleanser

betamethasone, augmented 0.05 % topical cream

Calmoseptine 0.44 %- 20.6 % topical ointment

clindamycin phosphate 1 % topical solution

cyclobenz aprine 10 mg tablet

Take 1 tablet every day by oral route in the evening.

FeroSul 325 mg (65 mg iron) tablet

Take 1 tablet every day by oral route.

fluoxetine 20 mg capsule
Take 1 capsule every day by oral route.

fluticasone propionate 50 mcg/actuation nasal spray,suspension

Spray 2 sprays every day by intranasal route.

Humalog KwikPen (U- 100) Insulin 100 unit/mL subcutaneous

10 Units with breakfast, 10 Units with Lunch, 20 Units with Dinner

ibuprofen 400 mg tablet

Januvia 100 mg tablet

Take 1 tablet every day by oral route.

Levemir FlexTouch U- 100 Insulin 100 unit/mL (3 mL) subcutaneous pen 04/26/2021
Inject 30 units twice a day by subcutaneous route.

lisinopril 5 mg tablet
Take 1 tablet every day by oral route.

loratadine 10 mg tablet
Take 1 tablet every day by oral route.

megestrol 40 mg tablet

metformin 1,000 mg tablet

Take 1 tablet twice a day by oral route.

montelukast 10 mg tablet
Take 1 tablet every day by oral route.

mupirocin 2 % topical ointment

omepraz ole 20 mg capsule,delayed release

Take 1 capsule by oral route.

polyethylene glycol 3350 17 gram/dose oral powder

Take 17 g every day by oral route.

rosuvastatin 10 mg tablet
Take 1 tablet every day by oral route in the evening.
tacrolimus 0.1 % topical ointment

TechLITE Pen Needle 31 gauge x 3/16"

triamcinolone acetonide 0.1 % topical ointment

True Metrix Glucose Meter

True Metrix Glucose Test Strip

Use with each glucometer check (3/day)

TRUEplus Lancets 30 gauge

Medicat ions Administ ered

None recorded.

Vit als
He ight We ight BMI Blo o d Pre ssure O2 Sat urat io n T e m pe rat ure He art Bo dy Surf ace
Rat e Are a
5 ft 2.89 329 lbs 5 58.5 (1) 160/90 98% Room Air at 98.5 F° oral (1) 112 2.57 m²
in oz kg/m2 mm[Hg] Rest (2) 96
(2) 146/76
mm[Hg]

Result s
Lab Re sult s

None recorded.

Allergies
Please review your allergy list for accuracy. Contact your provider if this list needs to be updated.
Co de Co de Syst e m Nam e Re act io n Se ve rit y Onse t
253157 RxNorm Bee Pollen

Grass Pollen

House Dust Mite

Insulins Respiratory Distress Severe

Wheez ing Severe

261551 RxNorm Lantus U- 100 Insulin Respiratory Distress Severe

Wheez ing Severe

Pollen Extracts
Notes: Some allergies listed in Documents: #1224339, #715065 could not be added to this patient's chart. Please
review these documents and add these allergies to the patient's chart manually as needed.
Problems
Nam e St at us Onse t Dat e So urce
Gout Active 11/08/2019

Anemia Active 11/08/2019

Insomnia Active 11/08/2019

Obstructive Sleep Apnea of Adult Active 11/08/2019

Cataract Active 11/08/2019

Essential Hypertension Active 11/08/2019

Allergic Rhinitis Active 11/08/2019

Gastritis Active 11/08/2019

Hernia of Anterior Abdominal Wall Active 11/08/2019

Contact Dermatitis Due to Solar Radiation Active 11/08/2019

Cervical Disc Disorder Active 11/08/2019

Chronic Low Back Pain Active 11/08/2019

Body Mass Index 40+ - Severely Obese Active 11/08/2019

Type 2 Diabetes Mellitus in Obese Active 11/08/2019

Mass of Uterus Active 11/08/2019

Pain of Right Shoulder Joint Active 11/08/2019

Atypical Squamous Cells of Undetermined Significance on Cervical Papanicolaou Smear Active 12/06/2019

Elevated Liver Enz ymes Level Active 02/03/2020

Hidradenitis Suppurativa Active 02/24/2020

Adult Atopic Dermatitis Active 06/24/2020

Type II Diabetes Mellitus Uncontrolled Active 10/20/2020

Hyperlipidemia Active 10/20/2020

Headache Active 12/21/2020

Complex Endometrial Hyperplasia Active 01/21/2021

Intrauterine Contraceptive Device in Situ Active 02/17/2021

Endometrial Intraepithelial Neoplasia Active 04/08/2021

Procedures
Dat e Nam e Pe rf o rm e d by
02/15/2021 Hysteroscopy Remove Myoma Information not available
Notes: Dr. Annmarie Vilkins, MD at Henry Ford Hospital

03/28/2019 Tonsillectomy and Adenoidectomy Information not available

Notes: Dr. Danny Kewson- Beaumont hospital, Dearborn, MI

Incision and Drainage Information not available

Notes: abscess; date unknown
Notes: Dilatation and curettage- date unknown
 Vaccine List
Here is a copy of your most up-to-date vaccination list.
Vaccine T ype
COVID- 19 vaccine, vector- nr, rS- Ad26, PF, 0.5 mL
03/22/2021 0.5 mL

Influenz a, injectable, MDCK, quadrivalent

09/25/2020 0.5 mL

influenz a, injectable, quadrivalent

11/08/2019 0.5 mL

Tobacco Smoking St at us
Tobacco Smoking Status Never Smoker

Past Encount ers

04/26/2021
Type 2 Diabetes Mellitus in Obese; Essential Hypertension; Endometrial Intraepithelial Neoplasia; Body Mass Index
40+ - Severely Obese
R Chase Thebault, MD: 5716 Michigan Ave, Detroit, MI 48210- 3039, Ph. (313) 554- 1095
Demographics
Sex: Female Ethnicity: Hispanic or Latino/Spanish
DOB: 06/11/1976 Race: White
Preferred language: English Marital status: Never Married

Contact: 4059 N Campbell St, Detroit, MI 48210, Ph. tel:+1- 313- 3209661

Care Team Members

Primary Care Provider
R Chase Thebault MD 5716 Michigan Ave, Detroit, MI 48210, Ph. tel:+1- 313- 5541095

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