
********************************** CONFIDENTIAL PATIENT INFORMATION -- 2/1/2006  9:05 AM  [MAW] **********************************
************************************* GUMP,FOREST E #989899    (ADULT REGULAR SUMMARY)  pg 1 *************************************

------------------------------------------------------- DEMOGRAPHIC DATA -------------------------------------------------------

GUMP,FOREST E                     DOB: OCT 17,1968 37 YRS  FEMALE  no blood type
CHEROKEE NATION OF OKLAHOMA       SSN: 555-04-0503
                                  MOTHER'S MAIDEN NAME: PRATT,SHARON
(H) 555-555-0503                  FATHER'S NAME: ADAMS,SAM
SPAVINAW (499 CIMARRON AVENUE, APPT 105,test,HUGO,OK,74366)  

LAST UPDATED: JAN 27,2006         ELIGIBILITY: CHS & DIRECT
VETERAN  AF (05/12/1992-02/06/1995)  CLAIM# 12345678

NOTICE OF PRIVACY PRACTICES REC'D BY PATIENT?  YES
                    DATE RECEIVED BY PATIENT:  May 08, 2005
                  WAS ACKNOWLEDGEMENT SIGNED?  YES
                                      REASON:  yo yo YO

HEALTH RECORD NUMBERS:  989899  CIMARRON HOSPITAL
                        989898  DELAWARE DHC
DESIGNATED PROVIDER: BEERS,SHANNON
REMARKS: This is just a test of additional registration info.  One more test.


ON CMS REGISTER(S):  IHS DIABETES REGISTER
                     MD NEW DIABETES REGISTER

----------------------------------------------------- INSURANCE INFORMATION -----------------------------------------------------

INSURANCE                NUMBER    SUFF COV       EL DATE   SIG DATE  END DATE
AK MEDICAID              123456789                01/25/06            
MEDICARE                 44444444  A    A         07/26/05            
BLUE CROSS                                                            
BLUE CROSS & BLUE SHIELD OF OK3232333             09/28/04            
ALLSTATE                 3238883                  11/06/04            
CIGNA                    123456778                10/26/05            
STATE FARM               9898989898               10/26/05            


------------------------------------------------- ALLERGIES (FROM PROBLEM LIST) -------------------------------------------------


                                                     ***** NONE RECORDED *****

----------------------------------------- MEASUREMENT PANELS (max 5 visits or 2 years) -----------------------------------------


           HT   WT      BP      BMI       %RW          VU             VC
10/06/05   68  172             26.2      120%                    
10/05/05   69  165             24.4      112%                    
03/30/04   68  178    144/88   27.1      124%                    


-------------------------------------------------------- ACTIVE PROBLEMS --------------------------------------------------------

             ENT.    MODIFIED
CIMH2       06/02/97 10/21/05 DIABETES TYPE 2  (onset 11/12/99)
CIMH2CIMH1                     10/21/05 -  TEST NOTE
CIMH5       12/08/97 10/21/05 CHRONIC ANTICOAGULATION DUE TO DVT  (onset 01/01/00)
CIMH5CIMH1                     PT EVERY MONTH
CIMH7       10/04/05 10/04/05 TEST DX  (onset 10/04/05)
CIMH7CIMH1                     10/04/05 -  TEST NOTE


------------------------------------------------------- INACTIVE PROBLEMS -------------------------------------------------------

             ENT.    MODIFIED
CIMH2.1     03/30/04 10/21/05 DIABETIC FOOT ULCER - LEFT  (onset 03/30/04)
CIMH4       09/14/97 10/21/05 DJD  (onset 10/21/05)

------------------------------------------------------ HISTORY OF SURGERY ------------------------------------------------------

03/30/04                  FINGERSTICK1
03/30/04                  FINGTERSTICK2
03/30/04                  BLOOD DRAW
07/27/02  NORTH,LEO       FINGERSTICK
07/09/02                  FINGERTSYICK
06/12/02                  FINGERSTICK
04/23/02                  FINGERSTICK
03/26/02  NORTH,LEO       FINGERSTICK
03/12/02                  FINGERSTICK
03/02/02                  RBS 332
02/05/02  TORREY,COLLEEN  ACCUCHECK 241
12/09/01  PEARSON,PAMELA  RBS 235
05/26/01                  RBS-125
05/30/01  BRIDGES,ELMER   RIGHT BELOW KNEE AMPUTATION
06/04/01  BRIDGES,ELMER   EGD WITH BIOPSY
05/19/01  TOWNSEND,RITA   AMPUTATION OF RIGHT BIG TOE
05/12/01                  RBS 387
04/30/01  CARMICHAEL,CHRI ANGIOPLASTY RIGHT ANTERIOR TIBIAL AND POPLITEAL ARTERY
12/31/00                  FINGERSTICK 263
06/18/00  BRIDGES,ELMER   LEFT BELOW KNEE AMPUTATION
06/11/00  BRIDGES,ELMER   CONVERSION OF LEFT TRANSMETATARSAL AMPUTATION
05/24/00  BRIDGES,ELMER   RAY AMPUTATION OF LEFT FIFTH TOE
03/19/00                  SURGICAL REMOVAL OF HYPEROSTOSIS FIFTH TOE (L) FOOT
02/10/99                  LAB: CHEM-7, DIGOXIN LEVEL, PROTIME
11/15/97  CARTER,ISAAC    EGD

-------------------------------------------------------- HEALTH FACTORS --------------------------------------------------------


~~ Tobacco use ~~
10/05/05  NON-TOBACCO USER
11/15/03  CURRENT SMOKER

~~ TB Treatment Status ~~
10/05/05  TB - TX COMPLETE


----------------------------------------------- CURRENT MEDICATIONS (max 2 years) -----------------------------------------------


Other Medications
Last Fill Date
11/02/05      ACETAMINOPHEN 325MG TAB U/D #30
                
                Most recent issue date:  4/5/2002
10/05/05      ALBUTEROL INHALER 6.8GM #1
                
                Most recent issue date:  4/5/2002
03/30/04      METFORMIN HCL 1000MG TAB
                
                Most recent issue date:  4/5/2002
03/30/04      ROSIGLITAZONE 4MG TAB #60 (30 days) 
                TAKE 1 TABLET 2 TIMES EACH DAY  2 refills left.
                Most recent issue date:  4/11/2002
                # times prev filled: 1   3/30/2004  
03/30/04      CHLORPROPAMIDE 250MG TAB #60 (60 days) 
                TAKE 1 TABLET EVERY MORNING FOR DIABETES *AVOID ALCOHOL WHI~  2 refills left.
                Most recent issue date:  4/11/2002

---------------------------------------- SCHEDULED ENCOUNTERS (max 10 visits or 90 days) ----------------------------------------


--------------------------------------- HOSPITALIZATION STAYS (max 5 visits or 10 years) ---------------------------------------

05/26/01-06/17/01 CIM HOSP       DIABETES MELLITUS, POORLY CONTROLLED WITH
                                 GANGRENE OF
                                 ULCER OF RIGHT HEEL WITH
                                 CELLULITIS OF RIGHT FOOT
                                 DIABETES MELLITUS, POORLY CONTROLLED SEE ABOVE
                                 CHRONIC RENAL FAILURE WITH HYPERTENSION
                                 ATRIAL FIBRILLATION
                                 ACUTE BLOOD LOSS ANEMIA
                                 GASTROINTESTINAL BLEEDING
                                 CONGESTIVE HEART FAILURE
                                 CORONARY ARTERY DISEASE
                                 ANTRAL GASTRITIS
                                 ARTERIOSCLEROTIC VASCULAR DISEASE
                                 HYPOTHYROIDISM
04/23/01-05/05/01 CIM HOSP       DIABETES MELLITUS, UNCONTROLLED WITH
                                 RIGHT FOOT ULCER, INFECTED
                                 RIGHT ANTERIOR TIBIAL AND POPLITEAL ARTERY STENOSIS
                                 DIABETES MELLITUS WITH
                                 PERIPHERAL VASCULAR DISEASE
                                 HYPERTENSION
                                 DIABETIC EDUCATION, NUTRITIION
01/07/01-01/17/01 CIM HOSP       DIABETES MELLITUS WITH
                                 INFECTED RIGHT BIG TOE WITH
                                 ULCER
                                 INGROWN RIGHT TOENAIL
                                 HYPERTENSION
06/10/00-06/26/00 CIM HOSP       DM WITH
                                 NONHEALING INFECTION WOUND OF LEFT FOOT OF AMPUTATION SITE
                                 ULCERATION WITH
                                 ACUTE CELLULITIS
                                 CHRONIC RENAL FAILURE WITH HYPERTENSION
                                 DM WITH
                                 GANGRENE
                                 HYPOTHYROIDISM
                                 ORGANIC HEART DS
                                 DJD
05/21/00-05/30/00 CIM HOSP       DM WITH 
                                 NON-HEALING ULCER WITH
                                 GANGRENE OF THE LEFT FIFTH TOE
                                 DM WITH
                                 ACUTE OSTEOMYELITIS, L. 5TH TOE
                                 ACUTE OSTEOMYELITIS IN DIABETES
                                 SEVERE CAD
                                 HYPOTHYROIDISM
                                 HTN
                                 DJD
                                 S/P ANGIOPLASTY, 1996

----------------------------------------- IN HOSPITAL VISITS (max 10 visits or 2 years) -----------------------------------------


--------------------------- OUTPATIENT/FIELD VISITS (Excludes CHR visits) (max 10 visits or 2 years) ---------------------------

10/17/05  CIM HOSP              <purpose of visit not yet entered>
03/30/04  CIM HOSP     OTHER    HTN
                       OTHER    DM MED REFILL
                                ISSUE REPEAT PRESCRIPT      ****ICD****
                       GEN      URI
                                UTI
                       GEN      HYPER THIS AND THAT
03/17/04  <13008>      MH       ALCOHOL ABUSE

------------------------------------------- REFERRED CARE (max 10 visits or 2 years) -------------------------------------------

                        <<<  RCIS ACTIVE REFERRALS  >>> 

No Referred Care Referral records on file.

------------------------------------ MOST RECENT PATIENT EDUCATION (max 5 visits or 2 years) ------------------------------------

11/02/05  CIM HOSP     DM-ACANTHOSIS NIGRICANS  
10/05/05  CIM HOSP     DM-COMPLICATIONS  - GOOD UNDERSTANDING
                       Behavior Code: GOAL SET    Objectives Met: 

----------------------------------- MOST RECENT RADIOLOGY STUDIES (max 10 visits or 5 years) -----------------------------------


CHEST 2 VIEW WITH FLUORO (11/02/05)  RESULT:  <none recorded>
   IMPRESSION:  
------------------------------------------- MOST RECENT LABORATORY DATA (max 2 years) -------------------------------------------

                                                       UNITS    REF RANGE
CREATININE                         10/17/05                                    A
HEMOGLOBIN A1C                     03/30/04  4.8                               
URINE PROTEIN                      03/30/04  TRACE                             
CHOLESTEROL                        11/02/05                                    

--------------------------------------------------- MOST RECENT EXAMINATIONS ---------------------------------------------------

DIABETIC EYE EXAM  (03/30/04)  
DENTAL EXAM        (03/30/04)  

--------------------------------------------------------- IMMUNIZATIONS ---------------------------------------------------------

   IMMUNIZATION FORECAST:



   IMMUNIZATION HISTORY:

   DT-PEDS            05-Oct-2005 36 YRS     Cimarron Hospital    

   INFLUENZA          02-Jun-1997 28 YRS     Cimarron Hospital    E2715HB
   INFLUENZA          23-Apr-2001 32 YRS     Cimarron Hospital    E24809GA
   INFLUENZA          13-Jul-2003 34 YRS     Cimarron Hospital    UO682AA
   INFLUENZA          30-Mar-2004 35 YRS     Cimarron Hospital    
   INFLUENZA          05-Oct-2005 36 YRS     Cimarron Hospital    

   PNEUM-CONJ         05-Oct-2005 36 YRS     Cimarron Hospital    

------------------------------------------------- HEALTH MAINTENANCE REMINDERS -------------------------------------------------

                          LAST        NEXT

BLOOD PRESSURE            03/30/04  MAY BE DUE NOW (WAS DUE 03/31/04)
WEIGHT                    10/06/05  10/06/06

PAP SMEAR                           MAY BE DUE NOW

INFLUENZA                 10/05/05  10/05/06

PNEUMOCCAL POLYSACCHARIDE 10/05/05  VACCINATION MAY BE DUE NOW
TD-ADULT                  10/05/05  10/03/15

SCREEN FOR ALCOHOL USE              MAY BE DUE NOW
SCREEN FOR TOBACCO USE    10/05/05  10/05/06

--------------------------------------------------- FLOWSHEETS (max 2 years) ---------------------------------------------------

DIABETIC FLOWSHEET
              GLU    A1C   CHOL    LDL    HDL   PROT   M/ALB  TRIG   CREAT
  -----------------------------------------------------------------------
  11/02/05  :      :      :n/r   :      :      :      :      :      :
  -----------------------------------------------------------------------
  10/17/05  :      :      :      :      :      :      :      :      :n/r
            :      :      :      :      :      :      :      :      :n/r
            :      :      :      :      :      :      :      :      :n/r
            :      :      :      :      :      :      :      :      :n/r
            :      :      :      :      :      :      :      :      :n/r
            :      :      :      :      :      :      :      :      :n/r
            :      :      :      :      :      :      :      :      :n/r
            :      :      :      :      :      :      :      :      :n/r
  -----------------------------------------------------------------------
  10/05/05  :      :      :NEGAT :      :      :      :      :      :
            :      :      :IVE   :      :      :      :      :      :
  -----------------------------------------------------------------------
  03/30/04  :      :4.8   :      :      :      :TRACE :      :      :
  -----------------------------------------------------------------------




DIABETES PATIENT CARE SUMMARY                 Report Date:  Feb 01, 2006
Patient Name:  GUMP,FOREST E    HRN: 989899
Age:  37      Sex:  F         Date of DM Onset: Nov 12, 1999 (Problem List)
Dob:  Oct 17, 1968            DM Problem #: CIMH2
                              Primary Care Provider: BEERS,SHANNON
Last Height:  68 inches       Oct 06, 2005
Last Weight:  172 lbs         Oct 06, 2005  BMI: 26.2
Tobacco Use:  NO, DOES NOT USE TOBACCO

HTN Diagnosed:  Yes
ON ACE Inhibitor/ARB in past 6 months: No
Aspirin Use (in past yr):  No

Last 3 BP:  144/88     Mar 30, 2004
            131/57     Nov 15, 2003
            122/72     Aug 06, 2003

In past 12 months:
Diabetic Foot Exam:   No    
Diabetic Eye Exam:    No    Mar 30, 2004
Dental Exam:          No    Mar 30, 2004
(Females Only)
Pap Smear: Date of Last Pap in PCC: 
           WH Cervical TX Need: 
Mammogram:   

Self Monitoring of Blood Glucose: No Strips Dispensed through Pharmacy

DM Education Provided (in past yr): 
   Last Dietitian Visit:   Jan 27, 2001  TYPE II DIABETIC-INSULIN REQUIRE
   DM-COMPLICATIONS        Oct 05, 2005

Immunizations:
Flu vaccine since August 1st:  Yes  Oct 05, 2005
Pneumovax ever:                Patient Refused PNEUMOCOCCAL POLYSACCARIDE VACCINE on Mar 30, 2004
Td in past 10 yrs:             Yes  Oct 05, 2005

PPD Status:  Known Positive PPD or Hx of TB (Health Factor recorded)
Last CHEST X-RAY:  Nov 02, 2005
Last TB Status Health Factor: TB - TX COMPLETE
EKG:                           Feb 05, 2002

Laboratory Results (most recent):
HbA1c:                    4.8            Mar 30, 2004  
Next most recent HbA1c:   7.0            Jul 13, 2003  
Nephropathy Assessment
  Urine Protein:          TRACE          Mar 30, 2004  
  Microalbuminuria:                                    
  Creatinine:             1.6            Nov 15, 2003  
Total Cholesterol:        NEGATIVE       Oct 05, 2005  
  LDL Cholesterol:                                     
  HDL Cholesterol:                                     
  Triglycerides:                                       

GUMP,FOREST E                     DOB: 10/17/1968     Chart #CIMH 989899
*** END *************************** CONFIDENTIAL PATIENT INFORMATION -- 2/1/2006  9:05 AM  [MAW] **********************************



