CPT Code 99091

Patient Name : Willis, Pamela

Gender : Female

Birth Date :   Female | 62 years old | 03/04/1960

RX History

OZEMPIC 0.25/0.5 PEN

VITAMIN D2 1.25MG(50,000 UNIT)

BD UF NANO PEN NEEDLE 4MMX32G

ACCU-CHEK GUIDE TEST STRIP

LANTUS SOLOSTAR 100 UNIT/ML

TIZANIDINE HCL 4 MG TABLET

TORSEMIDE 20 MG TABLET

GABAPENTIN 300MG CAP

ATORVASTATIN 10MG TAB

JARDIANCE 25MG TAB

FARXIGA 10MG TAB

HUMALOG KWIK 100U/ML PEN

METOPROLOL SUCC ER 50 MG TAB

SPIRONOLACTONE 25 MG TABLET

LISINOPRIL 40MG TAB

ACCU-CHEK SOFTCLIX LANCETS

INSULIN GLARGINE SOLOSTAR U100

GLIPIZIDE XL 10MG TAB

BD NANO 2 GEN PEN NDL 32GX4MM

JARDIANCE 10 MG TABLET

DOXYCYCLINE MONO 100 MG TABLET

ACCU-CHEK GUIDE MONITOR SYSTEM

METFORMIN HCL ER 500 MG TABLET

HYDROCODONE-ACETAMIN 5-325 MG

METFORMIN HCL 500 MG TABLET

CLINDAMYCIN HCL 300 MG CAPSULE

The patient is a 62-year-old female who presented with normotension. Patient advised to
make an appointment with the doctor and to check her fasting blood sugar to determine if she
is taking the appropriate dosage and taking her diabetic medications at the right time.
She has been diagnosed with Type 2 DM, and hypertension and is being controlled/treated by
her primary physician with the following medications along with healthy eating and lifestyle
changes.
Heart Rate
No readings found

Blood Pressure
No readings found

Glucose Reading
No readings found

September 1, 2022 (late entry)

No data was received for September, but the patient was advised to use her devices. Managed to
educate the patient by sending educational articles, and links patient was educated regarding proper
nutrition. The patient was educated on eating healthy foods such as fruits, and vegetables, low
sodium content in foods, and decreasing fatty food intake. The patient was encouraged to be
physically active such as walking daily to improve her endurance and activity tolerance.

Date: October 1 , 2022 (late entry)

Heart Rate
No readings found

Blood Pressure
No readings found

Glucose Reading
No readings found

Summary:
Reiterated the importance of using the devices to monitor her health. Sent a link of Research
done by Blacher et al. that explains how pulse pressure is a significant risk factor in the
development of heart disease. The patient was diagnosed with hypertension, diabetes, and
high cholesterol and thus needs maintenance medications to improve her health condition
which she is currently taking readings using his glucometer 2x/a day before breakfast and
dinner. The patient was also advised to make an appointment with the doctor to determine if
she is taking the right dosage and if she is taking it at the right time. Her blood pressure, heart
rate, glucose readings, and pulse pressure will continue to be monitored remotely while
educating patients regarding hypertension, diabetes, and hyperlipidemia

Date: November 1, 2022 (late entry)

No data was received for November, but the patient was advised to use her devices. Managed to
educate the patient by sending educational articles, and links patient was educated regarding proper
nutrition. The patient was educated on eating healthy foods such as fruits, and vegetables, low
sodium content in foods, and decreasing fatty food intake. The patient was encouraged to be
physically active such as walking daily to improve her endurance and activity tolerance.

The patient is a 62-year-old female who presented with normotension. Patient advised to
make an appointment with the doctor and to check her fasting blood sugar to determine if she
is taking the appropriate dosage and taking her diabetic medications at the right time.
She has been diagnosed with Type 2 DM, and hypertension and is being controlled/treated by
her primary physician with the following medications along with healthy eating and lifestyle
changes.

Heart Rate
No readings found
Blood Pressure
No readings found

Glucose Reading
No readings found

Reiterated the importance of using the devices to monitor her health. Sent a link of Research
done by Blacher et al. that explains how pulse pressure is a significant risk factor in the
development of heart disease. The patient was diagnosed with hypertension, diabetes, and
high cholesterol and thus needs maintenance medications to improve her health condition
which she is currently taking readings using his glucometer 2x/a day before breakfast and
dinner. The patient was also advised to make an appointment with the doctor to determine if
she is taking the right dosage and if she is taking it at the right time. Her blood pressure, heart
rate, glucose readings, and pulse pressure will continue to be monitored remotely while
educating patients regarding hypertension, diabetes, and hyperlipidemia

Date: December 1, 2022 (late entry)

The patient is a 62-year-old female who presented with normotension. The patient was
advised to make an appointment with the doctor and to check her fasting blood sugar to
determine if she is taking the appropriate dosage and taking her diabetic medications at the
right time.
She has been diagnosed with Type 2 DM and hypertension and is being controlled/treated by
her primary physician with the following medications, healthy eating, and lifestyle changes.

Heart Rate
No readings found

Blood Pressure
No readings found

Glucose Reading
No readings found
Reiterated the importance of using the devices to monitor her health. Sent a link of Research
done by Blacher et al. that explains how pulse pressure is a significant risk factor in the
development of heart disease. The patient was diagnosed with hypertension, diabetes, and
high cholesterol and thus needs maintenance medications to improve her health condition
which she is currently taking readings using his glucometer 2x/a day before breakfast and
dinner. The patient was also advised to make an appointment with the doctor to determine if
she is taking the right dosage and if she is taking it at the right time. Her blood pressure, heart
rate, glucose readings, and pulse pressure will continue to be monitored remotely while
educating patients regarding hypertension, diabetes, and hyperlipidemia

Heart Rate
No readings found

Blood Pressure
No readings found

Glucose Reading
No readings found

Summary:
Reiterated the importance of using the devices to monitor her health. Sent a link of Research
done by Blacher et al. that explains how pulse pressure is a significant risk factor in the
development of heart disease. The patient was diagnosed with hypertension, diabetes, and
high cholesterol and thus needs maintenance medications to improve her health condition
which she is currently taking readings using his glucometer 2x/a day before breakfast and
dinner. The patient was also advised to make an appointment with the doctor to determine if
she is taking the right dosage and if she is taking it at the right time. Her blood pressure, heart
rate, glucose readings, and pulse pressure will continue to be monitored remotely while
educating patients regarding hypertension, diabetes, and hyperlipidemia