aihilums / problem_assessment

  • Public
  • 8 runs
  • L40S
  • Prediction

    aihilums/problem_assessment:01b4c15370eeac74b770f6c127b2130185c70536269f6aaf81564555f44b0019
    ID
    573fxeb995rgj0cjenbt5844fc
    Status
    Succeeded
    Source
    Web
    Hardware
    A40 (Large)
    Total duration
    Created

    Input

    prompt
    Encounter Date: 11/09/2020 Patient Name [REDACTED] (68yo, F) ID# Appt. Date/Time 11/09/2020 12:00PM 3380 DOB 10/22/1952 Service Dept. ZANJABEE - WOBURN Provider BASMAA ALI, MD Insurance Med Primary: MEDICARE-MA (MEDICARE) Insurance # : 8GW0UU6FX24 Med Secondary: BCBS-MA Insurance # : XXM981796798 Policy/Group # : 991767925 Prescription: DST PHARMACY SOLUTIONS DIRECT - Member is eligible. details Chief Complaint fatigue, Pre prep visit discussed, Initial Visit diagnosed by 3 alternative doctors brain tape worm or parasite fatigue, poor sleep, low appetite, poor memory, numbness, terrible headaches, diagnosed with encephalitis This appointment is telehealth and was done with real audio despite multiple tries by Dr Ali to connect to the patient via video also. In the end, we decided to do phone call since pt could not figure out doxy or facetime. Amy Benison and/or Sarah Clancy helped set up the visit and did the pre-visit planning with the patient. Patient's Pharmacies WALGREENS DRUGSTORE #18415 (ERX): 15 BOLTON STREET, READING, MA 01867, Ph (781) 942-5810, Fax (781) 942-1457 Vitals None recorded. Allergies Reviewed Allergies NKDA sensitive to fragrances Medications Reviewed Medications[REDACTED] (id #3380, dob: 10/22/1952) Page 10/24 Ambien 11/09/20 entered nightly clonazePAM 1 mg tablet 10/29/20 filled 1-2 tablets at bedtime dextroamphetamine-amphetamine 10 mg tablet 10/27/20 filled TK 1 T PO BID Maxalt 10 mg tablet 09/01/20 entered Take 1 tablet(s) as needed by oral route. Internal Note: PRN ondansetron 4 mg disintegrating tablet 09/01/20 filled PRN oxyCODONE 5 mg tablet 11/06/20 filled 3-4 times a day Internal Note: typically morning, noon and night zolpidem 5 mg tablet 09/01/20 entered Take 1 tablet(s) every day by oral route. brain support vitamins Problems Reviewed Problems Chronic pain syndrome - Onset: 11/09/2020 Fatigue - Onset: 11/09/2020 Family History Reviewed Family History Maternal Grandmother - Family history of cancer Maternal Grandfather - Family history of cancer Paternal Grandmother - Family history of cancer Paternal Grandfather - Family history of cancer Father - Heart disease Mother - Family history of cancer - breast cancer Brother - Alcoholism Social History Reviewed Social History General IM Female Education: 12 Marital status: Divorced Diet: Gluten free (Notes: low sugar) Exercise level: Occasional Tobacco Smoking Status: Former smoker (Notes: quit late nineties) Alcohol intake: None Caffeine intake: Moderate Illicit drugs: none General stress level: High Significant life stressors: (Notes: health, family, chronic pain) Stress Management - How do you manage stress?: read, walks Quality of sleep: very poor (Notes: takes many things at night to try to help her sleep) Hobbies/Interests: chronic pain stops her Seat belts used routinely: N Sunscreen used routinely: N Smoke alarm in home: Y Pap Smear: around 2018 Mammogram: around 2018 Colon Cancer Screening: at 50 Living Situation - Lives with whom, nearby support, guage for loneliness: alone (Notes: feels safe) Hard of hearing or deaf in one or both ears?: N PHQ9 score: (Notes: no energy because of chronic pain) Do you have >6 drinks on any night of the week?: N[REDACTED] (id #3380, dob: 10/22/1952) Page 11/24 Do you have >6 drinks on any night of the week?: N Sexual orientation : Straight or heterosexual Surgical History Reviewed Surgical History breast implant in 1983, ruptured and removed 1992 GYN History Reviewed GYN History If Post Menopausal, Age at Menopause: 50. Current Birth Control Method: None (Notes: not s.a.). Menses Monthly: N. Age at Menarche: 13. Obstetric History Reviewed Obstetric History TOTALFULLPREAB. IAB. SECTOPICSMULTIPLELIVING 2 1 Past Medical History Reviewed Past Medical History other: Y - chronic fatigue chronic facial and head pain acupuncture - how many session, where, for what?: Y arthritis: Y asthma: Y back pain: Y cancer: Y - skin and L lung headache: Y heart murmur: Y hyperthyroidism: Y hypothyroidism: Y Screening None recorded. HPI 68 F has a long standing history of headaches which have now generalized to her entire body. She believes that her HA is caused by a brain parasite possibly a tape worm. She thinks she has had exposure to molds which have changed her immune system which then allowed her to get parasites into her brain. Pt has breast implants which burst and were subsequently removed and she thinks the implants did lasting damage to her body but is not able to specify it further. She wants a doctor who would do a lumbar puncture and look for parasites. She has already had a lumbar puncture which showed nl CSF. ROS Patient reports fatigue but reports no fever, no significant weight gain, no significant weight loss, no exercise intolerance, (normal) sleep, and (normal) appetite; pain all over the body.. She reports no dry eyes, no irritation, and no vision change. She reports no difficulty hearing and no ear pain. She reports no frequent nosebleeds and no nose/sinus problems. She reports no sore throat, no bleeding gums, no snoring, no dry mouth, no mouth ulcers, no oral abnormalities, and no teeth problems. She reports no chest pain, no arm pain on exertion, no shortness of breath when walking, no shortness of breath when lying down, no palpitations, and no known heart murmur. She reports no cough, no wheezing, no shortness of breath, and no coughing up blood. She reports no abdominal pain, no vomiting, no diarrhea, and not vomiting blood. She reports no incontinence, no difficulty urinating, no hematuria, and no increased frequency. She reports no muscle aches, no muscle weakness, no arthralgias/joint pain, no back pain, and no swelling in the extremities. She reports no abnormal mole, no jaundice, and no rashes. She reports no loss of consciousness, no weakness, no numbness, no seizures, no dizziness, and no headaches. She reports no depression, no sleep disturbances, feeling safe in relationship, and no alcohol abuse. She reports no swollen glands and no bruising. She reports no runny nose, no sinus pressure, no itching, no hives, and no frequent sneezing. Physical Exam Patient is a 68-year-old female. no exam done. this was a phone call. Assessment / Plan 68 F has a chronic pain syndrome as well as mental illness that does not allow her to have deeper insight into her illness. I spent 25 minutes trying to suggest that parasites as a cause of any disease in the US was very rare and would[REDACTED] (id #3380, dob: 10/22/1952) Page 12/24 I spent 25 minutes trying to suggest that parasites as a cause of any disease in the US was very rare and would have caught on the numerous tests pt has had done. I gave her names of alternative practitioners at Kripalu and the integrative medicine clinic at Canyon Ranch and wished her best of luck with her health Given that I could not be of further help in fiding a parasite inside her head, pt and I agreed that I could be of no further service to her. 1. Fatigue R53.83: Other fatigue 2. Chronic pain syndrome G89.4: Chronic pain syndrome Return to Office None recorded. Encounter Sign-Off

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