Ryan S Gomez "Ryan"

Patient Health Summary, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Allergies
No known active allergies

Medications
triamcinolone (KENALOG) 0.1 % paste (Started 11/22/2022)
Use 1 Application in the mouth or throat 2 (two) times daily for 7 days.
sertraline (ZOLOFT) 50 MG tablet (Started 2/28/2023)
Take 1 tablet by mouth daily.
3 refills by 2/28/2024
lisinopril (PRINIVIL) 20 MG tablet (Started 3/13/2023)
Take 1 tablet by mouth daily.
1 refill by 3/12/2024
methocarbamol (ROBAXIN) 750 MG tablet (Started 7/10/2023)
Take 1 tablet by mouth 3 (three) times daily as needed (back pain).
2 refills by 7/9/2024
lisdexamfetamine (VYVANSE) 60 MG capsule (Started 7/11/2023)
Take 1 capsule by mouth every morning ** last refill: patient needs to see his doctor before further refills are needed **. Max
Daily Amount: 60 mg
hydrOXYzine (ATARAX) 25 MG tablet (Started 9/5/2023)
Take 1 tablet by mouth daily as needed for anxiety/sleep.
2 refills by 9/4/2024
naproxen (NAPROSYN) 500 MG tablet (Started 9/19/2023)
Take 1 tablet by mouth twice daily as needed for mild headache.

Ended Medications
naproxen (NAPROSYN) 500 MG tablet (Started 3/2/2023) (Discontinued)
Take 1 tablet by mouth twice daily as needed for mild headache.
1 refill by 3/1/2024
hydrOXYzine (ATARAX) 25 MG tablet (Started 5/8/2023) (Discontinued)
Take 1 tablet by mouth daily as needed for anxiety (sleep).
3 refills by 5/7/2024
Active Problems
Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems
Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations
COVID-19 MODERNA MONOVALENT AGES 12 AND OLDER (Given 4/19/2021, 3/18/2021)

Social History
Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Tobacco Cessation: Counseling Given: Yes

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 4 01/23/2023

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

Last Filed Vital Signs

Vital Sign Reading Time Taken Comments
Blood Pressure 128/76 01/23/2023 9:47 AM EST
Pulse 89 01/23/2023 9:47 AM EST
Temperature 36.8 °C (98.2 °F) 01/23/2023 9:47 AM EST
Respiratory Rate 18 01/18/2021 11:13 PM EST
Oxygen Saturation 98% 01/23/2023 9:47 AM EST
Inhaled Oxygen Concentration - -
Weight 97.1 kg (214 lb 1.1 oz) 01/23/2023 9:47 AM EST
Height 185.4 cm (6' 1") 01/23/2023 9:47 AM EST
Body Mass Index 28.24 01/23/2023 9:47 AM EST
Results
MICROALBUMIN, RANDOM URINE - Final result (11/22/2021 11:37 AM EST)
Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Microalbumin-Urine 1.4 0.0 - 11/24/2021 Norton
Conc 19.9 mg/ 7:20 AM Medical
dL EST Group
Central Lab
Creatinine-Urine 153.1 15 - 500 11/24/2021 Norton
Concentration mg/dL 7:20 AM Medical
EST Group
Central Lab
Microalb/Creat Ratio 9 <20 mg/ 11/24/2021 Norton
g 7:20 AM Medical
EST Group
Central Lab

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Urine (Urine) 11/22/2021 11:37 AM 11/24/2021 7:18 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant URINE ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217

(ABNORMAL) HEMOGLOBIN A1C - Final result (11/22/2021 11:37 AM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Hemoglobin A1C 6.0 (H) 4.3 - 5.6 11/24/2021 Norton
% 7:20 AM Medical
EST Group
Central Lab
Estimated Average 126 mg/dL 11/24/2021 Norton
Glucose 7:20 AM Medical
EST Group
Central Lab

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Whole Blood (Blood) 11/22/2021 11:37 AM 11/24/2021 7:19 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Performing
Organization Address City/State/ZIP Code Phone Number
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217

(ABNORMAL) LIPID PANEL - Final result (11/22/2021 11:37 AM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Triglycerides 183 (H) 0 - 149 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
Cholesterol 193 0 - 199 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
HDL Cholesterol 42 >39 mg/ 11/24/2021 Norton
dL 7:19 AM Medical
EST Group
Central Lab
LDL Cholesterol- 106 (H) 0 - 100 11/24/2021 Norton
Calculated mg/dL 7:19 AM Medical
EST Group
Central Lab
VLDL 38 5 - 40 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
CHOL/HDL Ratio 4.6 RATIO 11/24/2021 Norton
7:19 AM Medical
EST Group
Central Lab
Is patient fasting? Yes (arb'U) 11/22/2021 NPS NCMA
11:14 AM OBC 410
EST

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/22/2021 11:37 AM 11/24/2021 7:19 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NPS NCMA OBC 410 9880 Angie's Way Suite LOUISVILLE, KY 40241, 502-636-8095
410 USA
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217
NPS NCMA OBC 410 9800 ANGIES WAY LOUISVILLE, KY 40241
STE 410

(ABNORMAL) COMPREHENSIVE METABOLIC PANEL (CMP) - Final result (11/22/2021 11:37 AM EST)
 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Sodium 137 137 - 11/24/2021 Norton
145 7:19 AM Medical
mmol/L EST Group
Central Lab
Potassium 4.2 3.5 - 5.1 11/24/2021 Norton
mmol/L 7:19 AM Medical
EST Group
Central Lab
Chloride 99 98 - 107 11/24/2021 Norton
mmol/L 7:19 AM Medical
EST Group
Central Lab
Carbon Dioxide 21 (L) 22 - 30 11/24/2021 Norton
mmol/L 7:19 AM Medical
EST Group
Central Lab
Glucose 97 74 - 99 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
Blood Urea Nitrogen 14 7 - 20 11/24/2021 Norton
(BUN) mg/dL 7:19 AM Medical
EST Group
Central Lab
Creatinine-Blood 0.6 (L) 0.7 - 1.5 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
BUN/Creatinine Ratio 23.0 (H) 10.0 - 11/24/2021 Norton
20.0 7:19 AM Medical
RATIO EST Group
Central Lab
Estimated GFR >60 >60 / 11/24/2021 Norton
1.73 m2 7:19 AM Medical
EST Group
Central Lab
Total Protein 7.9 6.3 - 8.2 11/24/2021 Norton
g/dL 7:19 AM Medical
EST Group
Central Lab
Albumin 4.5 3.5 - 5.0 11/24/2021 Norton
g/dL 7:19 AM Medical
EST Group
Central Lab
Globulin 3.5 1.5 - 4.5 11/24/2021 Norton
g/dL 7:19 AM Medical
EST Group
Central Lab
Albumin/Globulin Ratio 1.3 1.1 - 2.5 11/24/2021 Norton
RATIO 7:19 AM Medical
EST Group
Central Lab
Calcium 9.8 8.4 - 11/24/2021 Norton
10.2 mg/ 7:19 AM Medical
dL EST Group
Central Lab
Total Bilirubin 0.3 0.2 - 1.3 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
AST/SGOT 28 15 - 46 11/24/2021 Norton
U/L 7:19 AM Medical
EST Group
Central Lab
ALT/SGPT 57 13 - 69 11/24/2021 Norton
U/L 7:19 AM Medical
EST Group
Central Lab
Alkaline Phosphatase 101 38 - 126 11/24/2021 Norton
U/L 7:19 AM Medical
EST Group
Central Lab
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/22/2021 11:37 AM 11/24/2021 7:19 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217

XR L SPINE COMP W OBLIQUES - Final result (01/18/2021 9:44 PM EST)

Anatomical Region Laterality Modality
Spine, L-spine NHC Radiographic Imaging

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
01/18/2021 9:45 PM EST

Narrative
01/18/2021 9:48 PM EST
Narrative
RADIOLOGY REPORT

FACILITY: NORTON BROWNSBORO HOSPITAL

UNIT/AGE/GENDER: J.ED ER AGE:37 Y SEX:M
PATIENT NAME/DOB: GOMEZ, RYAN, S 11/11/1983
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10101326692
ACCESSION NUMBER: EPJ21RAD43798

DATE: 01/18/2021

HISTORY: bilateral back pain.

COMPARISON: none

EXAMINATION: LUMBAR SPINE 5 VIEWS INCLUDING OBLIQUES

FINDINGS: Normal alignment maintained. No compression deformity, vertebral body subluxation, or

fracture is detected. No spondylolysis or spondylolisthesis is identified. The sacroiliac joints have a
normal appearance.

CONCLUSION: Negative examination.

Dictated by: Greg Walton, M.D.

Images and Report reviewed and interpreted by: Greg Walton, M.D.

<PS><Electronically signed by: Greg Walton, M.D.>

01/18/2021 2147

D: 01/18/2021 2145
T: 01/18/2021 2145

Procedure Note
Greg S Walton - 01/18/2021
Formatting of this note might be different from the original.
RADIOLOGY REPORT

FACILITY: NORTON BROWNSBORO HOSPITAL

UNIT/AGE/GENDER: J.ED ER AGE:37 Y SEX:M
PATIENT NAME/DOB: GOMEZ, RYAN, S 11/11/1983
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10101326692
ACCESSION NUMBER: EPJ21RAD43798

DATE: 01/18/2021

HISTORY: bilateral back pain.

COMPARISON: none

EXAMINATION: LUMBAR SPINE 5 VIEWS INCLUDING OBLIQUES

FINDINGS: Normal alignment maintained. No compression deformity, vertebral body subluxation, or fracture is detected. No
spondylolysis or spondylolisthesis is identified. The sacroiliac joints have a normal appearance.

CONCLUSION: Negative examination.

Dictated by: Greg Walton, M.D.

Images and Report reviewed and interpreted by: Greg Walton, M.D.

<PS><Electronically signed by: Greg Walton, M.D.>

01/18/2021 2147

D: 01/18/2021 2145
T: 01/18/2021 2145

Authorizing Provider Result Type

Melanie M Pleiss IMG DIAGNOSTIC IMAGING ORDERABLES
TRANSTHORACIC ECHO 2D MMODE SPECTRAL COLOR, COMPLETE (ECHO DOPPLER 2D MMODE SPECT COLOR
COMPLETE) - Final result (01/07/2021 7:19 AM EST)
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
01/07/2021 6:53 AM
EST

Narrative
NH MCKCPACS - 01/07/2021 12:06 PM EST
CARDIOLOGY REPORT
FACILITY: NORTON CARDIOVASCULAR DIAGNOSTIC CENTER - SPRINGS

PATIENT NAME/DOB: GOMEZ, RYAN S 11/11/1983

UNIT/AGE/GENDER: AGE: 37 YR GENDER: M
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10100505266
ACCESSION NUMBER: EPSC21ECHO9625

DATE OF EXAM: 01/07/2021 06:53

EXAMINATION(S): ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE

FINAL REPORT

Procedure
Type of Study

TTE procedure:ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE.

Clinical Indications:Abnormal ECG.Screening for ischemic heart disease.

Height: 185 cmWeight: 100 kgBSA: 2.24 m^2 BMI: 29.22 kg/m^2

BP: 138/80 mmHg

Conclusions

Summary
Normal left ventricular structure and systolic function.
The LVEF is 55-60%.
No significant valvular abnormalities.
Normal right ventricular size and function.

Any valve disease noted in the report is non-rheumatic unless otherwise

specifically noted.

Findings

Left Ventricle
The left ventricular chamber size, wall thickness, and systolic function are
within normal limits. There are no regional wall motion abnormalities
observed.
The estimated ejection fraction is 55-60%.
Normal diastolic filling pattern.

Left Atrium
The left atrial chamber size appears normal.

Right Ventricle
The right ventricular chamber size and systolic function are within normal
limits.

Right Atrium
The right atrial chamber size appears normal.

Aortic Valve
The aortic valve is trileaflet. The leaflets are thin with normal excursion.
There is no aortic stenosis or regurgitation present.

Mitral Valve
Structurally normal mitral valve.
Trace mitral regurgitation is present
No mitral stenosis.

Tricuspid Valve
Tricuspid valve is structurally normal.
Trace tricuspid regurgitation
There is inadequate tricuspid insufficiency to calculate accurate right
ventricular systolic pressure.

Pulmonic Valve
Trace pulmonic insufficiency
Narrative
The pulmonic valve was not well visualized.

Pericardium
There is no evidence of pericardial effusion.

Great Vessels
The aortic root appears normal. There is no dilatation of the ascending
aorta. IVC appears normal.

Pleural Effusion
No evidence of pleural effusion.

M-Mode/2D Measurements & Calculations

LV Diastolic Dimension: LV Systolic Dimension: LA Dimension: 3.9 cmAO

4.41 cm 2.64 cm Root Dimension: 3.5 cm
LV PW Diastolic: 1.04 cm LV Volume Diastolic: 122
Septum Diastolic: 1.15 ml
cm LV Volume Systolic: 52
ml RV Diastolic Dimension:
LV EDV/LV EDV Index: 122 3.7 cm
ml/54 m^2LV ESV/LV ESV
LV Area Diastolic: 41.9 Index: 52 ml/23 m^2 LA/Aorta: 1.11
cm^2 EF Calculated: 57.4 % Ascending Aorta: 3.5 cm
LV Area Systolic: 24 LA volume: 52ml
cm^2 LV Length: 10.1 cm LA volume/Index: 23ml/m^2
RA Area: 18.2 cm^2
LVOT: 2.3 cm RA volume: 50 ml
RA volume index: 22.3
ml/m2

Doppler Measurements & Calculations

MV Peak E-Wave: 0.63 m/s

MV Peak A-Wave: 0.61 m/s
MV E/A Ratio: 1.04

TV TAPSE:26 mm

MV E' Septal Velocity: 0.08 m/s

MV E' Lateral Velocity: 0.14 m/s
MV E/E' septal: 7.72
MV E/E' lateral: 4.68

Signature

Electronically signed by Jason Hopper, M.D. (Interpreting Physician) on

01/07/2021 at 12:06 PM

Procedure Note
Jason A Hopper - 01/07/2021
Formatting of this note might be different from the original.
CARDIOLOGY REPORT
FACILITY: NORTON CARDIOVASCULAR DIAGNOSTIC CENTER - SPRINGS

PATIENT NAME/DOB: GOMEZ, RYAN S 11/11/1983

UNIT/AGE/GENDER: AGE: 37 YR GENDER: M
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10100505266
ACCESSION NUMBER: EPSC21ECHO9625

DATE OF EXAM: 01/07/2021 06:53

EXAMINATION(S): ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE

FINAL REPORT

Procedure
Type of Study

TTE procedure:ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE.

Clinical Indications:Abnormal ECG.Screening for ischemic heart disease.

Height: 185 cmWeight: 100 kgBSA: 2.24 m^2 BMI: 29.22 kg/m^2
Procedure Note
BP: 138/80 mmHg

Conclusions

Summary
Normal left ventricular structure and systolic function.
The LVEF is 55-60%.
No significant valvular abnormalities.
Normal right ventricular size and function.

Any valve disease noted in the report is non-rheumatic unless otherwise

specifically noted.

Findings

Left Ventricle
The left ventricular chamber size, wall thickness, and systolic function are
within normal limits. There are no regional wall motion abnormalities
observed.
The estimated ejection fraction is 55-60%.
Normal diastolic filling pattern.

Left Atrium
The left atrial chamber size appears normal.

Right Ventricle
The right ventricular chamber size and systolic function are within normal
limits.

Right Atrium
The right atrial chamber size appears normal.

Aortic Valve
The aortic valve is trileaflet. The leaflets are thin with normal excursion.
There is no aortic stenosis or regurgitation present.

Mitral Valve
Structurally normal mitral valve.
Trace mitral regurgitation is present
No mitral stenosis.

Tricuspid Valve
Tricuspid valve is structurally normal.
Trace tricuspid regurgitation
There is inadequate tricuspid insufficiency to calculate accurate right
ventricular systolic pressure.

Pulmonic Valve
Trace pulmonic insufficiency
The pulmonic valve was not well visualized.

Pericardium
There is no evidence of pericardial effusion.

Great Vessels
The aortic root appears normal. There is no dilatation of the ascending
aorta. IVC appears normal.

Pleural Effusion
No evidence of pleural effusion.

M-Mode/2D Measurements & Calculations

LV Diastolic Dimension: LV Systolic Dimension: LA Dimension: 3.9 cmAO

4.41 cm 2.64 cm Root Dimension: 3.5 cm
LV PW Diastolic: 1.04 cm LV Volume Diastolic: 122
Septum Diastolic: 1.15 ml
cm LV Volume Systolic: 52
Procedure Note
ml RV Diastolic Dimension:
LV EDV/LV EDV Index: 122 3.7 cm
ml/54 m^2LV ESV/LV ESV
LV Area Diastolic: 41.9 Index: 52 ml/23 m^2 LA/Aorta: 1.11
cm^2 EF Calculated: 57.4 % Ascending Aorta: 3.5 cm
LV Area Systolic: 24 LA volume: 52ml
cm^2 LV Length: 10.1 cm LA volume/Index: 23ml/m^2
RA Area: 18.2 cm^2
LVOT: 2.3 cm RA volume: 50 ml
RA volume index: 22.3
ml/m2

Doppler Measurements & Calculations

MV Peak E-Wave: 0.63 m/s

MV Peak A-Wave: 0.61 m/s
MV E/A Ratio: 1.04

TV TAPSE:26 mm

MV E' Septal Velocity: 0.08 m/s

MV E' Lateral Velocity: 0.14 m/s
MV E/E' septal: 7.72
MV E/E' lateral: 4.68

Signature

Electronically signed by Jason Hopper, M.D. (Interpreting Physician) on

01/07/2021 at 12:06 PM

Authorizing Provider Result Type

Jason A Hopper CV ECHO ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NH MCKCPACS

POCT URINE DRUG TEST - Final result (01/04/2021 11:55 AM EST)

Ref Analysis
Component Value Range Test Method Time Performed At Pathologist Signature
BZO Benzodiazepine Negative Negative NORTON
Screen-Urine COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
BAR Barbiturate-Urine Negative Negative NORTON
Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
COC Cocaine-Urine Negative Negative NORTON
Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
THC Cannabinoids- Negative Negative NORTON
Urine Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
 Ref Analysis
Component Value Range Test Method Time Performed At Pathologist Signature
MET Methamphetamine Negative Negative NORTON
Screen Urine COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
MOP Opiates-Urine Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
MTD Methadone Negative Negative NORTON
Screen-Urine COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
BUP Buprenorphine- Negative Negative NORTON
Urine Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
OXY Oxycodone-Urine Negative Negative NORTON
Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
MDMA-Urine Screen Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
PCP-Urine Screen Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
AMP Amphetamine Negative Negative NORTON
-Urine Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Internal QC Yes NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Lot Number w51200528 NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Urine 01/04/2021 11:55 AM
EST
Narrative

Authorizing Provider Result Type

Jing Bryant POINT OF CARE TEST ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON COMMUNITY 9880 Angie's Way Suite LOUISVILLE, KY 40241, 502-636-8095
MEDICAL ASSOCIATES- 410 USA
BROWNSBORO 410

HEPATIC FUNCTION PANEL - Final result (01/04/2021 11:45 AM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Total Protein 7.7 6.3 - 8.2 01/04/2021 Norton
g/dL 3:54 PM Medical
EST Group
Central Lab
Albumin 4.4 3.5 - 5.0 01/04/2021 Norton
g/dL 3:54 PM Medical
EST Group
Central Lab
Globulin 3.3 1.5 - 4.5 01/04/2021 Norton
g/dL 3:54 PM Medical
EST Group
Central Lab
Albumin/Globulin Ratio 1.3 1.1 - 2.5 01/04/2021 Norton
RATIO 3:54 PM Medical
EST Group
Central Lab
Total Bilirubin 0.2 0.2 - 1.3 01/04/2021 Norton
mg/dL 3:54 PM Medical
EST Group
Central Lab
Conjugated Bilirubin <0.2 0.0 - 0.3 01/04/2021 Norton
mg/dL 3:54 PM Medical
EST Group
Central Lab
Unconjugated Bilirubin UNABLE TO 0.1 - 0.8 01/04/2021 Norton
CALCULATE mg/dL 3:54 PM Medical
EST Group
Central Lab
AST/SGOT 27 15 - 46 01/04/2021 Norton
U/L 3:54 PM Medical
EST Group
Central Lab
ALT/SGPT 62 13 - 69 01/04/2021 Norton
U/L 3:54 PM Medical
EST Group
Central Lab
Alkaline Phosphatase 108 38 - 126 01/04/2021 Norton
U/L 3:54 PM Medical
EST Group
Central Lab

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 01/04/2021 11:45 AM 01/04/2021 11:55 AM
EST EST

Narrative
Authorizing Provider Result Type
Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2

(ABNORMAL) POCT URINALYSIS, DIPSTICK - Final result (11/25/2020 3:01 PM EST)

Ref Analysis
Component Value Range Test Method Time Performed At Pathologist Signature
Spec Grav, UA 1.020 1.000 - NORTON
1.030 COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
pH-Urine Dipstick 8 5-8 NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Leukocytes-POCT Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Nitrite-Urine Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
PROTEIN-POCT Negative Negative, NORTON
Trace COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
GLUCOSE-POCT Normal Normal NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Urine Ketone, POCT Negative Negative, NORTON
Small, COMMUNITY
Trace MEDICAL
ASSOCIATES-
BROWNSBORO
410
Urobilinogen-UA 1 mg/dL (A) Normal NORTON
mg/dL COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
 Ref Analysis
Component Value Range Test Method Time Performed At Pathologist Signature
UA BILIRUBIN- POCT Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Blood Negative Negative, NORTON
Trace COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Urine 11/25/2020 3:01 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant POINT OF CARE TEST ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON COMMUNITY 9880 Angie's Way Suite LOUISVILLE, KY 40241, 502-636-8095
MEDICAL ASSOCIATES- 410 USA
BROWNSBORO 410

MICROALBUMIN, RANDOM URINE - Final result (11/25/2020 2:17 PM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Microalbumin-Urine 1.2 0.0 - 11/25/2020 Norton
Conc 19.9 mg/ 9:47 PM Medical
dL EST Group
Central Lab
Creatinine-Urine 291.9 15 - 500 11/25/2020 Norton
Concentration mg/dL 9:47 PM Medical
EST Group
Central Lab
Microalb/Creat Ratio 4 <20 mg/ 11/25/2020 Norton
g 9:47 PM Medical
EST Group
Central Lab

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Urine (Urine) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant URINE ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2
(ABNORMAL) CBC W/DIFF - Final result (11/25/2020 2:17 PM EST)
Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
White Blood Count 7.27 4.5 - 11.0 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
Red Blood Count 5.27 4.5 - 5.9 11/25/2020 NWC
10*6/uL 7:52 PM Hospital
EST
Hemoglobin 15.8 13.5 - 11/25/2020 NWC
17.5 g/dL 7:52 PM Hospital
EST
Hematocrit 47.4 41.0 - 11/25/2020 NWC
53.0 % 7:52 PM Hospital
EST
Mean Corpuscular 89.9 80.0 - 11/25/2020 NWC
Volume 100.0 fL 7:52 PM Hospital
EST
Mean Corpuscular 30.0 26.0 - 11/25/2020 NWC
Hemoglobin 34.0 pg 7:52 PM Hospital
EST
Mean Corpuscular HGB 33.3 31.0 - 11/25/2020 NWC
Conc 37.0 g/dL 7:52 PM Hospital
EST
Red Cell Distribution 12.5 12.0 - 11/25/2020 NWC
Width-CV 16.8 % 7:52 PM Hospital
EST
Platelet Count 336 140 - 440 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
Mean Platelet Volume 12.0 8.4 - 12.4 11/25/2020 NWC
fL 7:52 PM Hospital
EST
Diff Type Hospital CBC (arb'U) 11/25/2020 NWC
w/AutoDiff 7:52 PM Hospital
EST
Neutrophils % 41.9 (L) 45 - 80 % 11/25/2020 NWC
7:52 PM Hospital
EST
Lymphocyte % 45.0 15 - 50 % 11/25/2020 NWC
7:52 PM Hospital
EST
Monocyte % 8.9 0 - 15 % 11/25/2020 NWC
7:52 PM Hospital
EST
Eosinophil% 2.2 0-7% 11/25/2020 NWC
7:52 PM Hospital
EST
BASO% 1.4 0-2% 11/25/2020 NWC
7:52 PM Hospital
EST
Immature Granulocyte% 0.6 0.0 - 1.0 11/25/2020 NWC
% 7:52 PM Hospital
EST
Nucleated RBC % 0 0/ 11/25/2020 NWC
100(WBC) 7:52 PM Hospital
EST
Neutrophil Abs 3.05 2.0 - 8.8 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
Lymphocyte-Absolute 3.27 0.7 - 5.5 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Monocyte Absolute 0.65 0.0 - 1.7 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
EOS-Absolute 0.16 0.0 - 0.8 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
Basophil Abs 0.10 0.0 - 0.2 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
Immature Granulocyte 0.04 0.00 - 11/25/2020 NWC
Abs 0.10 7:52 PM Hospital
10*3/uL EST
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Whole Blood (Blood) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON WOMEN AND 4001 DUTCHMAN'S Louisville, KY 40207 502-893-1000
CHILDRENS HOSPITAL LANE
NWC Hospital 4001 Dutchmans Lane Louisville, KY 40207

THYROID STIMULATING HORMONE(TSH) - Final result (11/25/2020 2:17 PM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Thyroid Stimulating 1.030 0.27 - 11/27/2020 Norton
Hormone (TSH)3rd Gen 4.20 9:40 AM Medical
u(iU)/mL EST Group
Central Lab

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2

T4.FREE - Final result (11/25/2020 2:17 PM EST)

 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Free T4 1.22 0.93 - 11/27/2020 Norton
1.70 ng/ 9:40 AM Medical
dL EST Group
Central Lab
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Serum (Blood) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2

(ABNORMAL) LIPID PANEL - Final result (11/25/2020 2:17 PM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Triglycerides 158 (H) 0 - 149 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
Cholesterol 180 0 - 199 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
HDL Cholesterol 37 (L) >39 mg/ 11/25/2020 Norton
dL 8:19 PM Medical
EST Group
Central Lab
LDL Cholesterol- 111 (H) 0 - 100 11/25/2020 Norton
Calculated mg/dL 8:19 PM Medical
EST Group
Central Lab
VLDL 32 5 - 40 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
CHOL/HDL Ratio 4.9 RATIO 11/25/2020 Norton
8:19 PM Medical
EST Group
Central Lab
Is patient fasting? Yes (arb'U) 11/25/2020 Brownsboro
2:16 PM MA
EST

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES
Performing
Organization Address City/State/ZIP Code Phone Number
BROWNSBORO MA 9880 ANGIE'S WAY LOUISVILLE, KY 40241 502-394-6237
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2
Brownsboro MA 4950 Norton Healthcare Louisville, KY 40241
Blvd
Norton Medical Plaza,
Ste 100

(ABNORMAL) COMPREHENSIVE METABOLIC PANEL (CMP) - Final result (11/25/2020 2:17 PM EST)
Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Sodium 139 137 - 11/25/2020 Norton
145 8:19 PM Medical
mmol/L EST Group
Central Lab
Potassium 4.5 3.5 - 5.1 11/25/2020 Norton
mmol/L 8:19 PM Medical
EST Group
Central Lab
Chloride 102 98 - 107 11/25/2020 Norton
mmol/L 8:19 PM Medical
EST Group
Central Lab
Carbon Dioxide 25 22 - 30 11/25/2020 Norton
mmol/L 8:19 PM Medical
EST Group
Central Lab
Glucose 95 74 - 99 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
Blood Urea Nitrogen 16 7 - 20 11/25/2020 Norton
(BUN) mg/dL 8:19 PM Medical
EST Group
Central Lab
Creatinine-Blood 0.7 0.7 - 1.5 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
BUN/Creatinine Ratio 24.0 (H) 10.0 - 11/25/2020 Norton
20.0 8:19 PM Medical
RATIO EST Group
Central Lab
Estimated GFR >60 >60 / 11/25/2020 Norton
1.73 m2 8:19 PM Medical
EST Group
Central Lab
Total Protein 8.2 6.3 - 8.2 11/25/2020 Norton
g/dL 8:19 PM Medical
EST Group
Central Lab
Albumin 4.5 3.5 - 5.0 11/25/2020 Norton
g/dL 8:19 PM Medical
EST Group
Central Lab
Globulin 3.7 1.5 - 4.5 11/25/2020 Norton
g/dL 8:19 PM Medical
EST Group
Central Lab
 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Albumin/Globulin Ratio 1.2 1.1 - 2.5 11/25/2020 Norton
RATIO 8:19 PM Medical
EST Group
Central Lab
Calcium 10.1 8.4 - 11/25/2020 Norton
10.2 mg/ 8:19 PM Medical
dL EST Group
Central Lab
Total Bilirubin 0.4 0.2 - 1.3 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
AST/SGOT 40 15 - 46 11/25/2020 Norton
U/L 8:19 PM Medical
EST Group
Central Lab
ALT/SGPT 77 (H) 13 - 69 11/25/2020 Norton
U/L 8:19 PM Medical
EST Group
Central Lab
Alkaline Phosphatase 131 (H) 38 - 126 11/25/2020 Norton
U/L 8:19 PM Medical
EST Group
Central Lab
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2

POCT RAPID STREP A - Final result (09/14/2014 1:00 PM EDT)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Rapid Strep A Screen Negative Negative

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Throat 09/14/2014 1:00 PM
EDT

Narrative

Authorizing Provider Result Type

Mandy J Whitt POINT OF CARE TEST ORDERABLES

POCT RAPID STREP A - Final result (07/27/2014 1:33 PM EDT)

 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Rapid Strep A Screen Negative Negative
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Throat 07/27/2014 1:33 PM
EDT

Narrative

Authorizing Provider Result Type

Michael Merrick POINT OF CARE TEST ORDERABLES

Care Teams
Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Nov. 11, 1983 - Sep. 29, 2023
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Legal Authenticator
Director H

If you take your Lucy record on a thumb drive to a different doctor, he or she might be able to use his computer to read the
file electronically. Your downloaded, machine-readable Personal Health Summary document is in a format called "CDA." If
your doctor has a computer that understands CDA, your information is a folder on your thumb drive called
MachineReadable_XDMFormat. You might need to enter a password before your doctor can use this file.

Copyright ©2023 Epic

Ryan S Gomez "Ryan"
Continuity of Care Document, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.
Encounters - from 06/29/2019 to 09/29/2023
Date Type Department Care Team Description
01/23/2023 Office Visit Norton Community Medical Jing Bryant
9:40 AM Associates - Brownsboro
EST 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600
10/17/2022 Office Visit Norton Community Medical Jing Bryant
10:40 AM Associates - Brownsboro
EDT 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600
07/14/2022 Office Visit Norton Community Medical Jing Bryant
10:00 AM Associates - Brownsboro
EDT 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600
04/14/2022 Office Visit Norton Community Medical Jing Bryant
8:20 AM Associates - Brownsboro
EDT 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600
02/02/2022 Office Visit Norton Community Medical Jing Bryant
11:00 AM Associates - Brownsboro
EST 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600
02/02/2022 Office Visit Norton Neuroscience Institute Sara Seifert
9:15 AM 4915 Norton Healthcare Blvd
EST Suite 301
Louisville, KY 40241-2860
502-394-6390
01/04/2022 Office Visit Norton Neuroscience Institute Sara Seifert
10:30 AM 4915 Norton Healthcare Blvd
EST Suite 301
Louisville, KY 40241-2860
502-394-6390
11/22/2021 Office Visit Norton Community Medical Jing Bryant
10:40 AM Associates - Brownsboro
EST 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600
08/17/2021 Office Visit Norton Community Medical Jing Bryant
1:40 PM Associates - Brownsboro
EDT 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600
05/03/2021 Office Visit Norton Community Medical Jing Bryant
8:20 AM Associates - Brownsboro
EDT 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600
02/22/2021 Office Visit Norton Community Medical Jing Bryant
1:40 PM Associates - Brownsboro
EST 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600
Date Type Department Care Team Description
01/19/2021 Telemedicine Norton Community Medical Jing Bryant
11:00 AM Associates - Brownsboro
EST 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600
01/18/2021 Emergency NBH Emergency Department Charlotte Crowley Discharge Disposition: Home
8:40 PM 4960 Norton Healthcare Blvd or Self Care
EST - Louisville, KY 40241-2831
01/18/2021 502-446-8125
11:23 PM
EST
01/07/2021 Hospital SCC Cardiology Jason A Hopper Discharge Disposition: Home
6:50 AM Encounter 6420 Dutchmans Parkway or Self Care
EST - Suite 75 Lower Level
01/07/2021 Louisville, KY 40205-3373
11:59 PM 502-891-8577
EST
01/05/2021 Office Visit Norton Heart Specialists Jason A Hopper
1:00 PM 6420 Dutchmans Pkwy
EST Suite 200
Louisville, KY 40205-3373
502-891-8300
01/04/2021 Office Visit Norton Community Medical Jing Bryant
10:40 AM Associates - Brownsboro
EST 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600
11/25/2020 Office Visit Norton Community Medical Jing Bryant
1:40 PM Associates - Brownsboro
EST 9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600

Allergies - from 06/29/2019 to 09/29/2023

No known active allergies
Medications - from 06/29/2019 to 09/29/2023
Medication Sig Dispensed Refills Start Date End Date Status
triamcinolone (KENALOG) 0.1 Use 1 Application in the 5g 0 11/22/2022 Active
% paste mouth or throat 2 (two)
times daily for 7 days.
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 3 02/28/2023 02/28/2024 Active
tablet daily.
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth 90 tablet 1 03/13/2023 Active
tablet daily.
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 2 07/10/2023 Active
750 MG tablet (three) times daily as
needed (back pain).
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 07/11/2023 Active
60 MG capsule every morning ** last
refill: patient needs to
see his doctor before
further refills are needed
**. Max Daily Amount: 60
mg
hydrOXYzine (ATARAX) 25 MG Take 1 tablet by mouth 30 tablet 2 09/05/2023 Active
tablet daily as needed for
anxiety/sleep.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 90 tablet 0 09/19/2023 Active
MG tablet twice daily as needed for
mild headache.
acetaminophen (TYLENOL) 500 Take 500 mg by mouth 0 11/25/2020 Discontinued
MG tablet every 6 (six) hours as (Therapy
needed for Pain completed)
ibuprofen (ADVIL,MOTRIN) 600 Take 600 mg by mouth 0 01/04/2021 Discontinued
MG tablet every 6 (six) hours as (Formulary
needed for Pain change)
loperamide (IMODIUM A-D) 2 Take 1 tablet by mouth 30 tablet 0 01/24/2015 11/25/2020 Discontinued
MG tablet four times daily as (Therapy
needed for Diarrhea for completed)
up to 7 days
Aspirin-Acetaminophen- Take by mouth as 0 01/04/2021 Discontinued
Caffeine (EXCEDRIN PO) needed . (Formulary
change)
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 0 01/04/2021 02/04/2021 Discontinued
MG tablet (two) times daily as
needed (mild headache)
for up to 10 days Take
with food.
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 01/11/2021 01/12/2021 Discontinued
30 MG capsule every morning. Max Daily (Cost of
Amount: 30 mg medication)
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 01/12/2021 02/09/2021 Discontinued
ER) 36 MG ER tablet every morning. Max Daily (Reorder)
Amount: 54 mg
methylPREDNISolone follow package 21 tablet 0 01/18/2021 01/18/2021 Expired
(MEDROL DOSPACK) 4 MG directions.
tablet
methocarbamol (ROBAXIN) Take 1 tablet by mouth 4 20 tablet 0 01/18/2021 04/21/2021 Discontinued
750 MG tablet (four) times daily. (Reorder)
lidocaine (LIDODERM) 5 % Place 1 patch onto the 6 patch 0 01/18/2021 05/03/2021 Discontinued
skin daily Remove & (Patient
Discard patch within 12 Choice)
hours or as directed by
MD.
Medication Sig Dispensed Refills Start Date End Date Status
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 1 02/04/2021 05/21/2021 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 02/09/2021 02/22/2021 Discontinued
ER) 36 MG ER tablet every morning. Max Daily (Reorder)
Amount: 54 mg
methylPREDNISolone TAKE 6 TABLETS ON DAY 0 01/19/2021 02/22/2021 Discontinued
(MEDROL DOSPACK) 4 MG 1 AS DIRECTED ON
tablet PACKAGE AND
DECREASE BY 1 TAB
EACH DAY FOR A TOTAL
OF 6 DAYS
VYVANSE 30 MG capsule 0 01/14/2021 02/22/2021 Discontinued
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 02/22/2021 03/25/2021 Discontinued
ER) 54 MG ER tablet every morning. Max Daily (Reorder)
Amount: 54 mg
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 03/25/2021 05/03/2021 Discontinued
ER) 54 MG ER tablet every morning. Max Daily (Alternate
Amount: 54 mg therapy)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 04/21/2021 10/20/2021 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
diazePAM (VALIUM) 10 MG Take 1 tablet by mouth 1 0 04/07/2021 08/10/2021 Discontinued
tablet hour prior to procedure (Therapy
completed)
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 05/03/2021 06/01/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 15 MG tablet Daily Amount: 30 mg
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 1 05/21/2021 10/20/2021 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 06/01/2021 06/30/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 20 MG tablet Daily Amount: 40 mg
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 06/30/2021 08/12/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 20 MG tablet Daily Amount: 40 mg
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 08/12/2021 09/13/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 20 MG tablet Daily Amount: 40 mg
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 09/13/2021 10/15/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 20 MG tablet Daily Amount: 40 mg
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 10/15/2021 11/19/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 20 MG tablet Daily Amount: 40 mg
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 10/21/2021 04/01/2022 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 1 10/21/2021 12/28/2021 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 11/19/2021 11/22/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 20 MG tablet Daily Amount: 40 mg
sertraline (ZOLOFT) 25 MG daily. 0 01/04/2022 Discontinued
tablet
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 11/22/2021 12/24/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 12/27/2021 02/02/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
Medication Sig Dispensed Refills Start Date End Date Status
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 3 12/29/2021 03/02/2022 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 30 tablet 1 02/02/2022 02/28/2022 Discontinued
tablet daily. (Reorder)
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 02/02/2022 02/28/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 02/28/2022 03/25/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 1 02/28/2022 09/07/2022 Discontinued
tablet daily.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 90 tablet 1 03/02/2022 05/31/2022 Discontinued
MG tablet (two) times daily as
needed (mild headache).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 03/25/2022 05/03/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 04/01/2022 04/14/2022 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth 90 tablet 0 04/14/2022 06/28/2022 Discontinued
tablet daily.
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 04/14/2022 04/18/2022 Discontinued
750 MG tablet (three) times daily as
needed (back pain).
methocarbamol (ROBAXIN) Take 1 tablet by mouth 30 tablet 3 04/18/2022 07/10/2023 Discontinued
750 MG tablet three times daily as
needed for back pain.
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 05/03/2022 06/07/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 90 tablet 1 05/31/2022 12/21/2022 Discontinued
MG tablet twice daily as needed for (Reorder)
mild headache.
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 06/07/2022 07/07/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth 90 tablet 0 06/28/2022 09/07/2022 Discontinued
tablet daily.
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 07/08/2022 07/14/2022 Discontinued
dextroamphetamine (two) times daily. Max (Formulary
(ADDERALL) 30 MG tablet Daily Amount: 60 mg change)
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 07/14/2022 08/08/2022 Discontinued
50 MG capsule every morning. Max Daily (Reorder)
Amount: 50 mg
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 08/09/2022 08/15/2022 Discontinued
50 MG capsule every morning. Max Daily (Reorder)
Amount: 50 mg
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 08/15/2022 09/13/2022 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 0 09/07/2022 11/23/2022 Discontinued
tablet daily.
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth 90 tablet 1 09/07/2022 03/13/2023 Discontinued
tablet daily.
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 09/13/2022 10/17/2022 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
triamcinolone (KENALOG) 0.1 Use 1 Application in the 5g 0 10/17/2022 11/20/2022 Discontinued
% paste mouth or throat 2 (two) (Reorder)
times daily for 7 days.
Medication Sig Dispensed Refills Start Date End Date Status
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 10/17/2022 11/20/2022 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 11/22/2022 12/21/2022 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 0 11/23/2022 02/28/2023 Discontinued
tablet daily.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 60 tablet 0 12/21/2022 03/02/2023 Discontinued
MG tablet (two) times daily as
needed (mild headache)
Take with food.
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 12/21/2022 01/26/2023 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
hydrOXYzine (ATARAX) 25 MG Take 1 tablet by mouth 30 tablet 3 01/23/2023 05/08/2023 Discontinued
tablet daily as needed for
Anxiety (sleep).
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 01/26/2023 02/28/2023 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 03/01/2023 03/29/2023 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 90 tablet 1 03/02/2023 09/19/2023 Discontinued
MG tablet twice daily as needed for
mild headache.
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 03/29/2023 04/27/2023 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 04/29/2023 06/06/2023 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
hydrOXYzine (ATARAX) 25 MG Take 1 tablet by mouth 30 tablet 3 05/08/2023 09/05/2023 Discontinued
tablet daily as needed for
anxiety (sleep).
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 06/06/2023 07/04/2023 Discontinued
60 MG capsule every morning ** last (Reorder)
refill: patient needs to
see his doctor before
further refills are needed
**. Max Daily Amount: 60
mg
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 07/05/2023 07/11/2023 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg

Active Problems - from 06/29/2019 to 09/29/2023

Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - from 06/29/2019 to 09/29/2023

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021
Immunizations - from 06/29/2019 to 09/29/2023
Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - from 06/29/2019 to 09/29/2023

Smoking Status as of 01/23/2023
Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Smoking Status as of 08/17/2021

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use as of 01/23/2023

Alcohol Use Standard Drinks/Week
Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 4 01/23/2023

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last 10 days, have you been in contact with someone No / Unsure 7/14/2022 10:07 AM EDT
who was confirmed or suspected to have Coronavirus/
COVID-19?

Last Filed Vital Signs - from 06/29/2019 to 09/29/2023

Vital Sign Reading Time Taken Comments
Blood Pressure 128/76 01/23/2023 9:47 AM EST
Pulse 89 01/23/2023 9:47 AM EST
Temperature 36.8 °C (98.2 °F) 01/23/2023 9:47 AM EST
Respiratory Rate 18 01/18/2021 11:13 PM EST
Oxygen Saturation 98% 01/23/2023 9:47 AM EST
Inhaled Oxygen Concentration - -
Weight 97.1 kg (214 lb 1.1 oz) 01/23/2023 9:47 AM EST
Height 185.4 cm (6' 1") 01/23/2023 9:47 AM EST
Body Mass Index 28.24 01/23/2023 9:47 AM EST

Plan of Treatment - from 06/29/2019 to 09/29/2023

Not on file
Results - from 06/29/2019 to 09/29/2023
MICROALBUMIN, RANDOM URINE - Final result (11/22/2021 11:37 AM EST)
Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Microalbumin-Urine 1.4 0.0 - 11/24/2021 Norton
Conc 19.9 mg/ 7:20 AM Medical
dL EST Group
Central Lab
Creatinine-Urine 153.1 15 - 500 11/24/2021 Norton
Concentration mg/dL 7:20 AM Medical
EST Group
Central Lab
Microalb/Creat Ratio 9 <20 mg/ 11/24/2021 Norton
g 7:20 AM Medical
EST Group
Central Lab

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Urine (Urine) 11/22/2021 11:37 AM 11/24/2021 7:18 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant URINE ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217

(ABNORMAL) HEMOGLOBIN A1C - Final result (11/22/2021 11:37 AM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Hemoglobin A1C 6.0 (H) 4.3 - 5.6 11/24/2021 Norton
% 7:20 AM Medical
EST Group
Central Lab
Estimated Average 126 mg/dL 11/24/2021 Norton
Glucose 7:20 AM Medical
EST Group
Central Lab

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Whole Blood (Blood) 11/22/2021 11:37 AM 11/24/2021 7:19 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Performing
Organization Address City/State/ZIP Code Phone Number
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217

(ABNORMAL) LIPID PANEL - Final result (11/22/2021 11:37 AM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Triglycerides 183 (H) 0 - 149 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
Cholesterol 193 0 - 199 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
HDL Cholesterol 42 >39 mg/ 11/24/2021 Norton
dL 7:19 AM Medical
EST Group
Central Lab
LDL Cholesterol- 106 (H) 0 - 100 11/24/2021 Norton
Calculated mg/dL 7:19 AM Medical
EST Group
Central Lab
VLDL 38 5 - 40 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
CHOL/HDL Ratio 4.6 RATIO 11/24/2021 Norton
7:19 AM Medical
EST Group
Central Lab
Is patient fasting? Yes (arb'U) 11/22/2021 NPS NCMA
11:14 AM OBC 410
EST

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/22/2021 11:37 AM 11/24/2021 7:19 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NPS NCMA OBC 410 9880 Angie's Way Suite LOUISVILLE, KY 40241, 502-636-8095
410 USA
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217
NPS NCMA OBC 410 9800 ANGIES WAY LOUISVILLE, KY 40241
STE 410

(ABNORMAL) COMPREHENSIVE METABOLIC PANEL (CMP) - Final result (11/22/2021 11:37 AM EST)
 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Sodium 137 137 - 11/24/2021 Norton
145 7:19 AM Medical
mmol/L EST Group
Central Lab
Potassium 4.2 3.5 - 5.1 11/24/2021 Norton
mmol/L 7:19 AM Medical
EST Group
Central Lab
Chloride 99 98 - 107 11/24/2021 Norton
mmol/L 7:19 AM Medical
EST Group
Central Lab
Carbon Dioxide 21 (L) 22 - 30 11/24/2021 Norton
mmol/L 7:19 AM Medical
EST Group
Central Lab
Glucose 97 74 - 99 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
Blood Urea Nitrogen 14 7 - 20 11/24/2021 Norton
(BUN) mg/dL 7:19 AM Medical
EST Group
Central Lab
Creatinine-Blood 0.6 (L) 0.7 - 1.5 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
BUN/Creatinine Ratio 23.0 (H) 10.0 - 11/24/2021 Norton
20.0 7:19 AM Medical
RATIO EST Group
Central Lab
Estimated GFR >60 >60 / 11/24/2021 Norton
1.73 m2 7:19 AM Medical
EST Group
Central Lab
Total Protein 7.9 6.3 - 8.2 11/24/2021 Norton
g/dL 7:19 AM Medical
EST Group
Central Lab
Albumin 4.5 3.5 - 5.0 11/24/2021 Norton
g/dL 7:19 AM Medical
EST Group
Central Lab
Globulin 3.5 1.5 - 4.5 11/24/2021 Norton
g/dL 7:19 AM Medical
EST Group
Central Lab
Albumin/Globulin Ratio 1.3 1.1 - 2.5 11/24/2021 Norton
RATIO 7:19 AM Medical
EST Group
Central Lab
Calcium 9.8 8.4 - 11/24/2021 Norton
10.2 mg/ 7:19 AM Medical
dL EST Group
Central Lab
Total Bilirubin 0.3 0.2 - 1.3 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
AST/SGOT 28 15 - 46 11/24/2021 Norton
U/L 7:19 AM Medical
EST Group
Central Lab
ALT/SGPT 57 13 - 69 11/24/2021 Norton
U/L 7:19 AM Medical
EST Group
Central Lab
Alkaline Phosphatase 101 38 - 126 11/24/2021 Norton
U/L 7:19 AM Medical
EST Group
Central Lab
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/22/2021 11:37 AM 11/24/2021 7:19 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217

XR L SPINE COMP W OBLIQUES - Final result (01/18/2021 9:44 PM EST)

Anatomical Region Laterality Modality
Spine, L-spine NHC Radiographic Imaging

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
01/18/2021 9:45 PM EST

Narrative
01/18/2021 9:48 PM EST
Narrative
RADIOLOGY REPORT

FACILITY: NORTON BROWNSBORO HOSPITAL

UNIT/AGE/GENDER: J.ED ER AGE:37 Y SEX:M
PATIENT NAME/DOB: GOMEZ, RYAN, S 11/11/1983
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10101326692
ACCESSION NUMBER: EPJ21RAD43798

DATE: 01/18/2021

HISTORY: bilateral back pain.

COMPARISON: none

EXAMINATION: LUMBAR SPINE 5 VIEWS INCLUDING OBLIQUES

FINDINGS: Normal alignment maintained. No compression deformity, vertebral body subluxation, or

fracture is detected. No spondylolysis or spondylolisthesis is identified. The sacroiliac joints have a
normal appearance.

CONCLUSION: Negative examination.

Dictated by: Greg Walton, M.D.

Images and Report reviewed and interpreted by: Greg Walton, M.D.

<PS><Electronically signed by: Greg Walton, M.D.>

01/18/2021 2147

D: 01/18/2021 2145
T: 01/18/2021 2145

Procedure Note
Greg S Walton - 01/18/2021
Formatting of this note might be different from the original.
RADIOLOGY REPORT

FACILITY: NORTON BROWNSBORO HOSPITAL

UNIT/AGE/GENDER: J.ED ER AGE:37 Y SEX:M
PATIENT NAME/DOB: GOMEZ, RYAN, S 11/11/1983
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10101326692
ACCESSION NUMBER: EPJ21RAD43798

DATE: 01/18/2021

HISTORY: bilateral back pain.

COMPARISON: none

EXAMINATION: LUMBAR SPINE 5 VIEWS INCLUDING OBLIQUES

FINDINGS: Normal alignment maintained. No compression deformity, vertebral body subluxation, or fracture is detected. No
spondylolysis or spondylolisthesis is identified. The sacroiliac joints have a normal appearance.

CONCLUSION: Negative examination.

Dictated by: Greg Walton, M.D.

Images and Report reviewed and interpreted by: Greg Walton, M.D.

<PS><Electronically signed by: Greg Walton, M.D.>

01/18/2021 2147

D: 01/18/2021 2145
T: 01/18/2021 2145

Authorizing Provider Result Type

Melanie M Pleiss IMG DIAGNOSTIC IMAGING ORDERABLES
TRANSTHORACIC ECHO 2D MMODE SPECTRAL COLOR, COMPLETE (ECHO DOPPLER 2D MMODE SPECT COLOR
COMPLETE) - Final result (01/07/2021 7:19 AM EST)
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
01/07/2021 6:53 AM
EST

Narrative
NH MCKCPACS - 01/07/2021 12:06 PM EST
CARDIOLOGY REPORT
FACILITY: NORTON CARDIOVASCULAR DIAGNOSTIC CENTER - SPRINGS

PATIENT NAME/DOB: GOMEZ, RYAN S 11/11/1983

UNIT/AGE/GENDER: AGE: 37 YR GENDER: M
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10100505266
ACCESSION NUMBER: EPSC21ECHO9625

DATE OF EXAM: 01/07/2021 06:53

EXAMINATION(S): ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE

FINAL REPORT

Procedure
Type of Study

TTE procedure:ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE.

Clinical Indications:Abnormal ECG.Screening for ischemic heart disease.

Height: 185 cmWeight: 100 kgBSA: 2.24 m^2 BMI: 29.22 kg/m^2

BP: 138/80 mmHg

Conclusions

Summary
Normal left ventricular structure and systolic function.
The LVEF is 55-60%.
No significant valvular abnormalities.
Normal right ventricular size and function.

Any valve disease noted in the report is non-rheumatic unless otherwise

specifically noted.

Findings

Left Ventricle
The left ventricular chamber size, wall thickness, and systolic function are
within normal limits. There are no regional wall motion abnormalities
observed.
The estimated ejection fraction is 55-60%.
Normal diastolic filling pattern.

Left Atrium
The left atrial chamber size appears normal.

Right Ventricle
The right ventricular chamber size and systolic function are within normal
limits.

Right Atrium
The right atrial chamber size appears normal.

Aortic Valve
The aortic valve is trileaflet. The leaflets are thin with normal excursion.
There is no aortic stenosis or regurgitation present.

Mitral Valve
Structurally normal mitral valve.
Trace mitral regurgitation is present
No mitral stenosis.

Tricuspid Valve
Tricuspid valve is structurally normal.
Trace tricuspid regurgitation
There is inadequate tricuspid insufficiency to calculate accurate right
ventricular systolic pressure.

Pulmonic Valve
Trace pulmonic insufficiency
Narrative
The pulmonic valve was not well visualized.

Pericardium
There is no evidence of pericardial effusion.

Great Vessels
The aortic root appears normal. There is no dilatation of the ascending
aorta. IVC appears normal.

Pleural Effusion
No evidence of pleural effusion.

M-Mode/2D Measurements & Calculations

LV Diastolic Dimension: LV Systolic Dimension: LA Dimension: 3.9 cmAO

4.41 cm 2.64 cm Root Dimension: 3.5 cm
LV PW Diastolic: 1.04 cm LV Volume Diastolic: 122
Septum Diastolic: 1.15 ml
cm LV Volume Systolic: 52
ml RV Diastolic Dimension:
LV EDV/LV EDV Index: 122 3.7 cm
ml/54 m^2LV ESV/LV ESV
LV Area Diastolic: 41.9 Index: 52 ml/23 m^2 LA/Aorta: 1.11
cm^2 EF Calculated: 57.4 % Ascending Aorta: 3.5 cm
LV Area Systolic: 24 LA volume: 52ml
cm^2 LV Length: 10.1 cm LA volume/Index: 23ml/m^2
RA Area: 18.2 cm^2
LVOT: 2.3 cm RA volume: 50 ml
RA volume index: 22.3
ml/m2

Doppler Measurements & Calculations

MV Peak E-Wave: 0.63 m/s

MV Peak A-Wave: 0.61 m/s
MV E/A Ratio: 1.04

TV TAPSE:26 mm

MV E' Septal Velocity: 0.08 m/s

MV E' Lateral Velocity: 0.14 m/s
MV E/E' septal: 7.72
MV E/E' lateral: 4.68

Signature

Electronically signed by Jason Hopper, M.D. (Interpreting Physician) on

01/07/2021 at 12:06 PM

Procedure Note
Jason A Hopper - 01/07/2021
Formatting of this note might be different from the original.
CARDIOLOGY REPORT
FACILITY: NORTON CARDIOVASCULAR DIAGNOSTIC CENTER - SPRINGS

PATIENT NAME/DOB: GOMEZ, RYAN S 11/11/1983

UNIT/AGE/GENDER: AGE: 37 YR GENDER: M
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10100505266
ACCESSION NUMBER: EPSC21ECHO9625

DATE OF EXAM: 01/07/2021 06:53

EXAMINATION(S): ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE

FINAL REPORT

Procedure
Type of Study

TTE procedure:ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE.

Clinical Indications:Abnormal ECG.Screening for ischemic heart disease.

Height: 185 cmWeight: 100 kgBSA: 2.24 m^2 BMI: 29.22 kg/m^2
Procedure Note
BP: 138/80 mmHg

Conclusions

Summary
Normal left ventricular structure and systolic function.
The LVEF is 55-60%.
No significant valvular abnormalities.
Normal right ventricular size and function.

Any valve disease noted in the report is non-rheumatic unless otherwise

specifically noted.

Findings

Left Ventricle
The left ventricular chamber size, wall thickness, and systolic function are
within normal limits. There are no regional wall motion abnormalities
observed.
The estimated ejection fraction is 55-60%.
Normal diastolic filling pattern.

Left Atrium
The left atrial chamber size appears normal.

Right Ventricle
The right ventricular chamber size and systolic function are within normal
limits.

Right Atrium
The right atrial chamber size appears normal.

Aortic Valve
The aortic valve is trileaflet. The leaflets are thin with normal excursion.
There is no aortic stenosis or regurgitation present.

Mitral Valve
Structurally normal mitral valve.
Trace mitral regurgitation is present
No mitral stenosis.

Tricuspid Valve
Tricuspid valve is structurally normal.
Trace tricuspid regurgitation
There is inadequate tricuspid insufficiency to calculate accurate right
ventricular systolic pressure.

Pulmonic Valve
Trace pulmonic insufficiency
The pulmonic valve was not well visualized.

Pericardium
There is no evidence of pericardial effusion.

Great Vessels
The aortic root appears normal. There is no dilatation of the ascending
aorta. IVC appears normal.

Pleural Effusion
No evidence of pleural effusion.

M-Mode/2D Measurements & Calculations

LV Diastolic Dimension: LV Systolic Dimension: LA Dimension: 3.9 cmAO

4.41 cm 2.64 cm Root Dimension: 3.5 cm
LV PW Diastolic: 1.04 cm LV Volume Diastolic: 122
Septum Diastolic: 1.15 ml
cm LV Volume Systolic: 52
Procedure Note
ml RV Diastolic Dimension:
LV EDV/LV EDV Index: 122 3.7 cm
ml/54 m^2LV ESV/LV ESV
LV Area Diastolic: 41.9 Index: 52 ml/23 m^2 LA/Aorta: 1.11
cm^2 EF Calculated: 57.4 % Ascending Aorta: 3.5 cm
LV Area Systolic: 24 LA volume: 52ml
cm^2 LV Length: 10.1 cm LA volume/Index: 23ml/m^2
RA Area: 18.2 cm^2
LVOT: 2.3 cm RA volume: 50 ml
RA volume index: 22.3
ml/m2

Doppler Measurements & Calculations

MV Peak E-Wave: 0.63 m/s

MV Peak A-Wave: 0.61 m/s
MV E/A Ratio: 1.04

TV TAPSE:26 mm

MV E' Septal Velocity: 0.08 m/s

MV E' Lateral Velocity: 0.14 m/s
MV E/E' septal: 7.72
MV E/E' lateral: 4.68

Signature

Electronically signed by Jason Hopper, M.D. (Interpreting Physician) on

01/07/2021 at 12:06 PM

Authorizing Provider Result Type

Jason A Hopper CV ECHO ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NH MCKCPACS

POCT URINE DRUG TEST - Final result (01/04/2021 11:55 AM EST)

Ref Analysis
Component Value Range Test Method Time Performed At Pathologist Signature
BZO Benzodiazepine Negative Negative NORTON
Screen-Urine COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
BAR Barbiturate-Urine Negative Negative NORTON
Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
COC Cocaine-Urine Negative Negative NORTON
Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
THC Cannabinoids- Negative Negative NORTON
Urine Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
 Ref Analysis
Component Value Range Test Method Time Performed At Pathologist Signature
MET Methamphetamine Negative Negative NORTON
Screen Urine COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
MOP Opiates-Urine Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
MTD Methadone Negative Negative NORTON
Screen-Urine COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
BUP Buprenorphine- Negative Negative NORTON
Urine Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
OXY Oxycodone-Urine Negative Negative NORTON
Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
MDMA-Urine Screen Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
PCP-Urine Screen Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
AMP Amphetamine Negative Negative NORTON
-Urine Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Internal QC Yes NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Lot Number w51200528 NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Urine 01/04/2021 11:55 AM
EST
Narrative

Authorizing Provider Result Type

Jing Bryant POINT OF CARE TEST ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON COMMUNITY 9880 Angie's Way Suite LOUISVILLE, KY 40241, 502-636-8095
MEDICAL ASSOCIATES- 410 USA
BROWNSBORO 410

HEPATIC FUNCTION PANEL - Final result (01/04/2021 11:45 AM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Total Protein 7.7 6.3 - 8.2 01/04/2021 Norton
g/dL 3:54 PM Medical
EST Group
Central Lab
Albumin 4.4 3.5 - 5.0 01/04/2021 Norton
g/dL 3:54 PM Medical
EST Group
Central Lab
Globulin 3.3 1.5 - 4.5 01/04/2021 Norton
g/dL 3:54 PM Medical
EST Group
Central Lab
Albumin/Globulin Ratio 1.3 1.1 - 2.5 01/04/2021 Norton
RATIO 3:54 PM Medical
EST Group
Central Lab
Total Bilirubin 0.2 0.2 - 1.3 01/04/2021 Norton
mg/dL 3:54 PM Medical
EST Group
Central Lab
Conjugated Bilirubin <0.2 0.0 - 0.3 01/04/2021 Norton
mg/dL 3:54 PM Medical
EST Group
Central Lab
Unconjugated Bilirubin UNABLE TO 0.1 - 0.8 01/04/2021 Norton
CALCULATE mg/dL 3:54 PM Medical
EST Group
Central Lab
AST/SGOT 27 15 - 46 01/04/2021 Norton
U/L 3:54 PM Medical
EST Group
Central Lab
ALT/SGPT 62 13 - 69 01/04/2021 Norton
U/L 3:54 PM Medical
EST Group
Central Lab
Alkaline Phosphatase 108 38 - 126 01/04/2021 Norton
U/L 3:54 PM Medical
EST Group
Central Lab

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 01/04/2021 11:45 AM 01/04/2021 11:55 AM
EST EST

Narrative
Authorizing Provider Result Type
Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2

(ABNORMAL) POCT URINALYSIS, DIPSTICK - Final result (11/25/2020 3:01 PM EST)

Ref Analysis
Component Value Range Test Method Time Performed At Pathologist Signature
Spec Grav, UA 1.020 1.000 - NORTON
1.030 COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
pH-Urine Dipstick 8 5-8 NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Leukocytes-POCT Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Nitrite-Urine Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
PROTEIN-POCT Negative Negative, NORTON
Trace COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
GLUCOSE-POCT Normal Normal NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Urine Ketone, POCT Negative Negative, NORTON
Small, COMMUNITY
Trace MEDICAL
ASSOCIATES-
BROWNSBORO
410
Urobilinogen-UA 1 mg/dL (A) Normal NORTON
mg/dL COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
 Ref Analysis
Component Value Range Test Method Time Performed At Pathologist Signature
UA BILIRUBIN- POCT Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Blood Negative Negative, NORTON
Trace COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Urine 11/25/2020 3:01 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant POINT OF CARE TEST ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON COMMUNITY 9880 Angie's Way Suite LOUISVILLE, KY 40241, 502-636-8095
MEDICAL ASSOCIATES- 410 USA
BROWNSBORO 410

MICROALBUMIN, RANDOM URINE - Final result (11/25/2020 2:17 PM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Microalbumin-Urine 1.2 0.0 - 11/25/2020 Norton
Conc 19.9 mg/ 9:47 PM Medical
dL EST Group
Central Lab
Creatinine-Urine 291.9 15 - 500 11/25/2020 Norton
Concentration mg/dL 9:47 PM Medical
EST Group
Central Lab
Microalb/Creat Ratio 4 <20 mg/ 11/25/2020 Norton
g 9:47 PM Medical
EST Group
Central Lab

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Urine (Urine) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant URINE ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2
(ABNORMAL) CBC W/DIFF - Final result (11/25/2020 2:17 PM EST)
Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
White Blood Count 7.27 4.5 - 11.0 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
Red Blood Count 5.27 4.5 - 5.9 11/25/2020 NWC
10*6/uL 7:52 PM Hospital
EST
Hemoglobin 15.8 13.5 - 11/25/2020 NWC
17.5 g/dL 7:52 PM Hospital
EST
Hematocrit 47.4 41.0 - 11/25/2020 NWC
53.0 % 7:52 PM Hospital
EST
Mean Corpuscular 89.9 80.0 - 11/25/2020 NWC
Volume 100.0 fL 7:52 PM Hospital
EST
Mean Corpuscular 30.0 26.0 - 11/25/2020 NWC
Hemoglobin 34.0 pg 7:52 PM Hospital
EST
Mean Corpuscular HGB 33.3 31.0 - 11/25/2020 NWC
Conc 37.0 g/dL 7:52 PM Hospital
EST
Red Cell Distribution 12.5 12.0 - 11/25/2020 NWC
Width-CV 16.8 % 7:52 PM Hospital
EST
Platelet Count 336 140 - 440 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
Mean Platelet Volume 12.0 8.4 - 12.4 11/25/2020 NWC
fL 7:52 PM Hospital
EST
Diff Type Hospital CBC (arb'U) 11/25/2020 NWC
w/AutoDiff 7:52 PM Hospital
EST
Neutrophils % 41.9 (L) 45 - 80 % 11/25/2020 NWC
7:52 PM Hospital
EST
Lymphocyte % 45.0 15 - 50 % 11/25/2020 NWC
7:52 PM Hospital
EST
Monocyte % 8.9 0 - 15 % 11/25/2020 NWC
7:52 PM Hospital
EST
Eosinophil% 2.2 0-7% 11/25/2020 NWC
7:52 PM Hospital
EST
BASO% 1.4 0-2% 11/25/2020 NWC
7:52 PM Hospital
EST
Immature Granulocyte% 0.6 0.0 - 1.0 11/25/2020 NWC
% 7:52 PM Hospital
EST
Nucleated RBC % 0 0/ 11/25/2020 NWC
100(WBC) 7:52 PM Hospital
EST
Neutrophil Abs 3.05 2.0 - 8.8 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
Lymphocyte-Absolute 3.27 0.7 - 5.5 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Monocyte Absolute 0.65 0.0 - 1.7 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
EOS-Absolute 0.16 0.0 - 0.8 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
Basophil Abs 0.10 0.0 - 0.2 11/25/2020 NWC
10*3/uL 7:52 PM Hospital
EST
Immature Granulocyte 0.04 0.00 - 11/25/2020 NWC
Abs 0.10 7:52 PM Hospital
10*3/uL EST
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Whole Blood (Blood) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON WOMEN AND 4001 DUTCHMAN'S Louisville, KY 40207 502-893-1000
CHILDRENS HOSPITAL LANE
NWC Hospital 4001 Dutchmans Lane Louisville, KY 40207

THYROID STIMULATING HORMONE(TSH) - Final result (11/25/2020 2:17 PM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Thyroid Stimulating 1.030 0.27 - 11/27/2020 Norton
Hormone (TSH)3rd Gen 4.20 9:40 AM Medical
u(iU)/mL EST Group
Central Lab

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2

T4.FREE - Final result (11/25/2020 2:17 PM EST)

 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Free T4 1.22 0.93 - 11/27/2020 Norton
1.70 ng/ 9:40 AM Medical
dL EST Group
Central Lab
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Serum (Blood) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2

(ABNORMAL) LIPID PANEL - Final result (11/25/2020 2:17 PM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Triglycerides 158 (H) 0 - 149 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
Cholesterol 180 0 - 199 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
HDL Cholesterol 37 (L) >39 mg/ 11/25/2020 Norton
dL 8:19 PM Medical
EST Group
Central Lab
LDL Cholesterol- 111 (H) 0 - 100 11/25/2020 Norton
Calculated mg/dL 8:19 PM Medical
EST Group
Central Lab
VLDL 32 5 - 40 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
CHOL/HDL Ratio 4.9 RATIO 11/25/2020 Norton
8:19 PM Medical
EST Group
Central Lab
Is patient fasting? Yes (arb'U) 11/25/2020 Brownsboro
2:16 PM MA
EST

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES
Performing
Organization Address City/State/ZIP Code Phone Number
BROWNSBORO MA 9880 ANGIE'S WAY LOUISVILLE, KY 40241 502-394-6237
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2
Brownsboro MA 4950 Norton Healthcare Louisville, KY 40241
Blvd
Norton Medical Plaza,
Ste 100

(ABNORMAL) COMPREHENSIVE METABOLIC PANEL (CMP) - Final result (11/25/2020 2:17 PM EST)
Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Sodium 139 137 - 11/25/2020 Norton
145 8:19 PM Medical
mmol/L EST Group
Central Lab
Potassium 4.5 3.5 - 5.1 11/25/2020 Norton
mmol/L 8:19 PM Medical
EST Group
Central Lab
Chloride 102 98 - 107 11/25/2020 Norton
mmol/L 8:19 PM Medical
EST Group
Central Lab
Carbon Dioxide 25 22 - 30 11/25/2020 Norton
mmol/L 8:19 PM Medical
EST Group
Central Lab
Glucose 95 74 - 99 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
Blood Urea Nitrogen 16 7 - 20 11/25/2020 Norton
(BUN) mg/dL 8:19 PM Medical
EST Group
Central Lab
Creatinine-Blood 0.7 0.7 - 1.5 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
BUN/Creatinine Ratio 24.0 (H) 10.0 - 11/25/2020 Norton
20.0 8:19 PM Medical
RATIO EST Group
Central Lab
Estimated GFR >60 >60 / 11/25/2020 Norton
1.73 m2 8:19 PM Medical
EST Group
Central Lab
Total Protein 8.2 6.3 - 8.2 11/25/2020 Norton
g/dL 8:19 PM Medical
EST Group
Central Lab
Albumin 4.5 3.5 - 5.0 11/25/2020 Norton
g/dL 8:19 PM Medical
EST Group
Central Lab
Globulin 3.7 1.5 - 4.5 11/25/2020 Norton
g/dL 8:19 PM Medical
EST Group
Central Lab
 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Albumin/Globulin Ratio 1.2 1.1 - 2.5 11/25/2020 Norton
RATIO 8:19 PM Medical
EST Group
Central Lab
Calcium 10.1 8.4 - 11/25/2020 Norton
10.2 mg/ 8:19 PM Medical
dL EST Group
Central Lab
Total Bilirubin 0.4 0.2 - 1.3 11/25/2020 Norton
mg/dL 8:19 PM Medical
EST Group
Central Lab
AST/SGOT 40 15 - 46 11/25/2020 Norton
U/L 8:19 PM Medical
EST Group
Central Lab
ALT/SGPT 77 (H) 13 - 69 11/25/2020 Norton
U/L 8:19 PM Medical
EST Group
Central Lab
Alkaline Phosphatase 131 (H) 38 - 126 11/25/2020 Norton
U/L 8:19 PM Medical
EST Group
Central Lab
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/25/2020 2:17 PM EST 11/25/2020 2:18 PM EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2
Visit Diagnoses - from 06/29/2019 to 09/29/2023
Diagnosis Start Date
Encounter for annual physical exam 11/25/2020
Elevated blood pressure reading without diagnosis of hypertension 11/25/2020
Screening for deficiency anemia 11/25/2020
Screening for cholesterol level 11/25/2020
Screening for diabetes mellitus 11/25/2020
High risk medications (not anticoagulants) long-term use 1/4/2021
Elevated blood pressure reading without diagnosis of hypertension 1/4/2021
Abnormal EKG 1/4/2021
Elevated LFTs 1/4/2021
Headache disorder 1/4/2021
Screening for ischemic heart disease 1/5/2021
Abnormal EKG 1/5/2021
Screening for ischemic heart disease 1/7/2021
Abnormal EKG 1/7/2021
Acute bilateral low back pain without sciatica 1/18/2021
Chronic right-sided low back pain without sciatica 1/19/2021
Vasectomy evaluation 1/19/2021
Elevated blood pressure reading without diagnosis of hypertension 2/22/2021
Elevated blood pressure reading without diagnosis of hypertension 5/3/2021
Elevated blood pressure reading without diagnosis of hypertension 8/17/2021
Microalbuminuria absent 8/17/2021
Encounter for annual physical exam 11/22/2021
Elevated blood pressure reading without diagnosis of hypertension 11/22/2021
Microalbuminuria absent 11/22/2021
Dyslipidemia 11/22/2021
Neck pain 11/22/2021
Chronic bilateral low back pain, unspecified whether sciatica present 11/22/2021
Screening for diabetes mellitus 11/22/2021
Screening for cholesterol level 11/22/2021
Chronic neck pain 1/4/2022
Chronic bilateral low back pain without sciatica 1/4/2022
Elevated blood pressure reading without diagnosis of hypertension 2/2/2022
Microalbuminuria absent 2/2/2022
Chronic bilateral low back pain without sciatica 2/2/2022
Chronic neck pain 2/2/2022
HTN, goal below 130/80 4/14/2022
Microalbuminuria absent 4/14/2022
High risk medications (not anticoagulants) long-term use 4/14/2022
Chronic right-sided low back pain without sciatica 4/14/2022
HTN, goal below 130/80 7/14/2022
Microalbuminuria absent 7/14/2022
Right ear pain 7/14/2022
Canker sore 10/17/2022
Encounter for annual physical exam 1/23/2023
HTN, goal below 130/80 1/23/2023
Microalbuminuria absent 1/23/2023
High risk medications (not anticoagulants) long-term use 1/23/2023
Chronic bilateral low back pain without sciatica 1/23/2023
Chronic neck pain 1/23/2023
Dyslipidemia 1/23/2023
Prediabetes 1/23/2023
Screening for diabetes mellitus 1/23/2023
Screening for deficiency anemia 1/23/2023
Screening for cholesterol level 1/23/2023
Care Teams - from 06/29/2019 to 09/29/2023
Team Member Relationship Specialty Start Date End Date
629-1234 for Adult or 629- PCP - General 5/21/14 11/24/20
KIDS for Pediatric to est
Norton Primary Care
Provider
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
629-1234 for Adult or 629-KIDS for Pediatric to est Jason A Hopper Jun. 29, 2019 - Sep. 29, 2023
Norton Primary Care Provider (May 21, 2014 - Nov. 24, NPI: 1548605108
2020) 502-891-8300 (Work)
General Practice Physician 502-891-8338 (Fax)
Norton Healthcare 6420 Dutchmans Parkway
Louisville, KY 40202 Suite 200
Louisville, KY 40205-3373
Jing Bryant (Nov. 25, 2020 - Present) Cardiology
NPI: 1023317880 Norton Healthcare
502-394-6000 (Work) Louisville, KY 40202
502-394-3689 (Fax)
Family Medicine Henry N Meiers
Norton Healthcare NPI: 1245297217
Louisville, KY 40202 502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason Onset Date
Medication Refill 07/10/2023

Encounter Details
Date Type Department Care Team Description
07/10/2023 Telephone Norton Community Medical Jing Bryant
Associates - Brownsboro 9880 Angie's Way
9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
triamcinolone (KENALOG) 0.1 Use 1 Application in the 5g 0 11/22/2022 Active
% paste mouth or throat 2 (two)
times daily for 7 days.
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 3 02/28/2023 02/28/2024 Active
tablet daily.
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth 90 tablet 1 03/13/2023 Active
tablet daily.
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 2 07/10/2023 Active
750 MG tablet (three) times daily as
needed (back pain).
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 07/11/2023 Active
60 MG capsule every morning ** last
refill: patient needs to
see his doctor before
further refills are needed
**. Max Daily Amount: 60
mg
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 90 tablet 1 03/02/2023 09/19/2023 Discontinued
MG tablet twice daily as needed for
mild headache.
hydrOXYzine (ATARAX) 25 MG Take 1 tablet by mouth 30 tablet 3 05/08/2023 09/05/2023 Discontinued
tablet daily as needed for
anxiety (sleep).
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 07/05/2023 07/11/2023 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 4 01/23/2023

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

Last Filed Vital Signs - documented in this encounter

Not on file

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth every 30 capsule 0 07/11/2023
60 MG capsule morning ** last refill: patient
needs to see his doctor before
further refills are needed **.
Max Daily Amount: 60 mg

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file
Care Teams - documented as of this encounter
Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Jul. 10, 2023
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Jul. 10, 2023
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason Onset Date
Written Rx 06/06/2023

Encounter Details
Date Type Department Care Team Description
06/06/2023 Telephone Norton Community Medical Jing Bryant
Associates - Brownsboro 9880 Angie's Way
9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
triamcinolone (KENALOG) 0.1 Use 1 Application in the 5g 0 11/22/2022 Active
% paste mouth or throat 2 (two)
times daily for 7 days.
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 3 02/28/2023 02/28/2024 Active
tablet daily.
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth 90 tablet 1 03/13/2023 Active
tablet daily.
methocarbamol (ROBAXIN) Take 1 tablet by mouth 30 tablet 3 04/18/2022 07/10/2023 Discontinued
750 MG tablet three times daily as
needed for back pain.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 90 tablet 1 03/02/2023 09/19/2023 Discontinued
MG tablet twice daily as needed for
mild headache.
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 04/29/2023 06/06/2023 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
hydrOXYzine (ATARAX) 25 MG Take 1 tablet by mouth 30 tablet 3 05/08/2023 09/05/2023 Discontinued
tablet daily as needed for
anxiety (sleep).
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 4 01/23/2023

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

Last Filed Vital Signs - documented in this encounter

Not on file

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file
Care Teams - documented as of this encounter
Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Jun. 06, 2023
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Jun. 06, 2023
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
Annual Exam

Encounter Details
Date Type Department Care Team Description
01/23/2023 Office Visit Norton Community Medical Jing Bryant
9:40 AM Associates - Brownsboro 9880 Angie's Way
EST 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
triamcinolone (KENALOG) 0.1 Use 1 Application in the 5g 0 11/22/2022 Active
% paste mouth or throat 2 (two)
times daily for 7 days.
methocarbamol (ROBAXIN) Take 1 tablet by mouth 30 tablet 3 04/18/2022 07/10/2023 Discontinued
750 MG tablet three times daily as
needed for back pain.
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth 90 tablet 1 09/07/2022 03/13/2023 Discontinued
tablet daily.
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 0 11/23/2022 02/28/2023 Discontinued
tablet daily.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 60 tablet 0 12/21/2022 03/02/2023 Discontinued
MG tablet (two) times daily as
needed (mild headache)
Take with food.
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 12/21/2022 01/26/2023 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
hydrOXYzine (ATARAX) 25 MG Take 1 tablet by mouth 30 tablet 3 01/23/2023 05/08/2023 Discontinued
tablet daily as needed for
Anxiety (sleep).
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Tobacco Cessation: Counseling Given: Yes

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 4 01/23/2023

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 128/76 01/23/2023 9:47 AM EST
Pulse 89 01/23/2023 9:47 AM EST
Temperature 36.8 °C (98.2 °F) 01/23/2023 9:47 AM EST
Respiratory Rate - -
Oxygen Saturation 98% 01/23/2023 9:47 AM EST
Inhaled Oxygen Concentration - -
Weight 97.1 kg (214 lb 1.1 oz) 01/23/2023 9:47 AM EST
Height 185.4 cm (6' 1") 01/23/2023 9:47 AM EST
Body Mass Index 28.24 01/23/2023 9:47 AM EST

Patient Instructions - documented in this encounter

Patient Instructions
Jing Bryant - 01/23/2023 10:57 AM EST
Formatting of this note is different from the original.

It was nice seeing you today! I hope that your visit today was a positive one. I'd appreciate any feedback you may have through
our online feedback form/survey, so that I can do my best to continue to provide the best care.
------------------------------------------------------------------------
I will inform you of your lab results through Mychart once they are all back.

Please take your blood pressure medication(s) as directed.

Please monitor your blood pressure and heart rate (pulse) 3-4 times a week, and record your readings. Your goal is to have your
blood pressure below 140/90, and your heart rate (pulse) in between 60 - 90.

You may download the free app called "Blood Pressure Journal" to your smart device for your blood pressure log.

For colds and congestion, be careful about using over the counter medications. It is safe to use medication from the
CoricidinHBP line.
See coricidinhbp.com.

Follow up in 4 months for blood pressure check.

Continue to follow up with your specialist(s) as scheduled/needed.

For general health educational information, may check out familydoctor.org.

Return to our office in a year to review your health. We need to see you annually to prescribe any medications. If you have other
medical problems you may need to be seen sooner.

Maintain healthy life style, including: keep a healthy diet; exercise regularly (2 hours/week minimum); normalize your weight (BMI
less than 30), adequate sleep (7-8 hours per day). Remember: Eat healthy food, mostly vegetables, drink water, and exercise
more.

- Alcohol: consider holding Alcohol intake to less than 10 drinks a week. A drink is one 12 oz beer, a 4 oz glass of wine, or 1.5 oz
of liquor. Some patients should consider avoiding Alcohol entirely.

- Nutrition: "Eat healthy food, less of it, mostly vegetables". Avoid sweetened drinks and concentrated sugars. Limit "white" foods
like rice, bread and pasta.

Pain medications sold over-the-counter like ibuprofen (Motrin/Advil) and naproxen (Aleve) should be limited, they can cause
bleeding and kidney damage.

Pain & Cold medications sold over-the-counter that contain acetaminophen (Tylenol) can cause serious harm if not taken as
directed, particulalry to your liver.

Vaccinations: Make sure you get your Flu shot every year, if not contraindicated. Flu shots annually protect you AND our
community.

Vaccinations: Pneumonia shots usually happen at age 65. Smokers, diabetics, and people with heart, lung or immune disease
may need them earlier.

Vaccinations: Shingles immunization usually happens at age 60. You may want to check your insurance coverage.

Vaccinations: Tetanus shots are needed every 10 years, and once as an adult you should get a Tetanus shot that boosts Pertussis
("whooping cough").

Please consider/ continue life style modifications including daily calcium (recommended 1200 mg dietary calcium daily) and
vitamin D (recommended 800 IU daily), with weight bearing exercise for your bone health.

Target Heart Rate: Google "Target Heart Rate" and click on the American Heart Association Link (likely first or second option).
That is where chart below was obtained from.

Age Target HR Zone 50-85% Average Maximum Heart Rate, 100%

20 years 100-170 beats per minute 200 beats per minute
30 years 95-162 beats per minute 190 beats per minute
35 years 93-157 beats per minute 185 beats per minute
40 years 90-153 beats per minute 180 beats per minute
45 years 88-149 beats per minute 175 beats per minute
50 years 85-145 beats per minute 170 beats per minute
55 years 83-140 beats per minute 165 beats per minute
60 years 80-136 beats per minute 160 beats per minute
65 years 78-132 beats per minute 155 beats per minute
70 years 75-128 beats per minute 150 beats per minute

Avoid all tobacco products and exposure to them both at home and at work.

Wear seatbelts whenever riding in a car or truck. Safety Belts used regularly save lives.
Apply sunscreen 30 minutes before exposure to the sun. Choose a sunscreen that screens out both UVA and UVB rays, with a sun
protection factor (SPF) of 15 or greater. Avoid tanning salons.

Twice yearly routine dental care is recommended. Brush and floss your teeth at least twice daily.

See the eye doctor every two years after you turn 40.

Follow up as needed for acute issues.

From 12 pm - 1 pm, no patients will be placed in exam rooms for appointments. This will ensure that providers and nurses/
medical assistants are able to eat lunch and catch up on any work from that morning. If you have an appointment at 11:40 am,
we ask that you arrive on or before your appointment time if possible. We understand that unforeseen circumstances occur. If at
all possible if you could call the office and inform the front desk, in which case we will try our best to accommodate you as much
as possible. (Please note that all phone lines will be open during this time)

Blood Pressure Tracking Chart

Date Systolic Diastolic Pulse (heart rate) Date Systolic Diastolic Pulse (heart rate)

Hypertension
GENERAL INFORMATION:
What is hypertension? Hypertension is high blood pressure (BP). Your BP is the force of your blood moving against the walls of
your arteries. Normal BP is less than 120/80. Prehypertension is between 120/80 and 139/89. Hypertension is 140/90 or higher.
Hypertension causes your BP to get so high that your heart has to work much harder than normal. This can cause damage to
your heart. Hypertension is a long-term condition that you will need to control with a healthy lifestyle or medicines. A controlled
blood pressure helps protect your organs, such as your heart, lungs, brain, and kidneys.
What causes hypertension? The cause of hypertension may not be known. This type of hypertension is called essential or
primary hypertension. Hypertension can sometimes be caused by other medical conditions, such as kidney disease. This type of
hypertension is called secondary hypertension.
What increases my risk for hypertension?
For men, being older than 55 years, and for women, being older than 65 years

Family history of hypertension or heart disease

Obesity or lack of exercise

Too many high-sodium foods

Stress

Use of tobacco, alcohol, or illegal drugs

Medical conditions, such as diabetes, high cholesterol, kidney disease, thyroid disease, or adrenal gland disorder

Certain medicines, such as steroids or birth control pills

What are the signs and symptoms of hypertension? You may have no signs or symptoms, or you may have any of the following:
Headache

Blurred vision

Chest pain

Dizziness or weakness

Trouble breathing

Nosebleeds
How is hypertension diagnosed? Your healthcare provider will ask about your symptoms and the medicines you take. He will also
ask if you have a family history of hypertension and about any health conditions you have. He will check your BP and weight and
examine your heart, lungs, and eyes. You may need any of the following tests:
Blood tests may help healthcare providers find the cause of your hypertension. Blood tests can also help find other health
problems caused by hypertension.

Urine tests will be done to check your kidneys.

An EKG records the electrical activity of your heart. It is used to check your heart rhythm or other problems caused by
hypertension.
How is hypertension treated? Your healthcare provider will recommend lifestyle changes to lower your BP. You may also need the
following medicines:
Blood pressure medicine helps lower your blood pressure. You may need more than one type of blood pressure medicine. Take
your blood pressure medicine exactly as directed.

Diuretics help decrease extra fluid that collects in your body. This will help lower your BP. You may urinate more often while you
take this medicine.
How do I check my BP at home? Sit and rest for 5 minutes before you take your BP. Extend your arm and support it on a flat
surface. Your arm should be at the same level as your heart. Follow the directions that came with your BP monitor. If possible,
take at least 2 BP readings each time. Take your BP at least twice a day at the same times each day, such as morning and
evening. Keep a log of your BP readings and bring it to your follow-up visits. Ask your healthcare provider what your BP should
be.
How can I manage my hypertension? Talk with your healthcare provider about these and other lifestyle changes you can make to
manage your hypertension:
Eat less sodium (salt). Do not add salt to your food. Limit foods that are high in sodium, such as canned foods, potato chips, and
cold cuts. Your healthcare provider may suggest that you follow the DASH Eating Plan. The plan is low in sodium, unhealthy fats,
and total fat. It is high in potassium, calcium, and fiber. You get these nutrients by eating more fruits, vegetables, and whole
grains. Ask your healthcare provider or dietitian which meal plan you should follow.

Exercise to maintain a healthy weight. Exercise at least 30 minutes per day, on most days of the week. This will help decrease
your BP. Ask your healthcare provider about the best exercise plan for you.

Limit alcohol. Women should limit alcohol to 1 drink a day. Men should limit alcohol to 2 drinks a day. A drink of alcohol is 12
ounces of beer, 5 ounces of wine, or 1½ ounces of liquor.

Do not smoke. If you smoke, it is never too late to quit. Smoking can increase your BP. Smoking also worsens other health
conditions you may have that can increase your risk for hypertension. Ask your healthcare provider for information if you need
help quitting.

Manage any other health conditions you have. Health conditions such as diabetes can increase your risk for hypertension. Follow
your healthcare provider's instructions and take all your medicines as directed.

Decrease stress. This may help lower your BP. Learn ways to relax, such as deep breathing or listening to music.
What are the risks of hypertension? Without treatment, you may develop other health problems over time. You may lose vision
in one or both eyes. You may develop heart and blood vessel disease. This increases your risk of a heart attack, stroke, heart
failure, or kidney disease and can be life-threatening.
When should I contact my healthcare provider?
You feel faint, dizzy, confused, or drowsy.

You have been taking your BP medicine and your BP is still higher than your healthcare provider says it should be.

You have questions or concerns about your condition or care.

When should I seek immediate care or call 911?
You have a severe headache or vision loss.

You have weakness in an arm or leg.

You become confused or have difficulty speaking.

You have discomfort in your chest that feels like squeezing, pressure, fullness, or pain.

You suddenly feel lightheaded or have trouble breathing.

You have pain or discomfort in your back, neck, jaw, stomach, or arm.
CARE AGREEMENT:
You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment
options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. The above
information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your
doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.
© 2014 Truven Health Analytics Inc. Information is for End User's use only and may not be sold, redistributed or otherwise used
for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or
Truven Health Analytics.

Electronically signed by Jing Bryant at 01/23/2023 10:57 AM EST

Ordered Prescriptions - documented in this encounter
Prescription Sig Dispensed Refills Start Date End Date
hydrOXYzine (ATARAX) 25 MG Take 1 tablet by mouth daily as 30 tablet 3 01/23/2023 05/08/2023
tablet needed for Anxiety (sleep).

Progress Notes - documented in this encounter

Jing Bryant - 01/23/2023 9:56 AM EST
Formatting of this note is different from the original.
Subjective:

Ryan S Gomez is a 39 yr/o male and is here for a comprehensive physical exam. The patient reports problems - anxiety.

He has HTN without microalbuminuria, doing well on 20 mg lisinopril. No CP/SOA/palpitations.

He was evaluated by Robert Watson, Psy. D, in 12/2020. Dr. Watson thinks that his untreated ADD might have caused his anxiety
and depression to certain degree. Dr. Watson recommended that patient should be treated for his ADD.

He was started on 36 mg Concerta with moderate response. He stated that the effects weans off after 8-9 hours. He was started
on 54 mg Concerta in 2/2021, then 72 mg; however, it didn't last long enough. We changed his Concerta to 20 mg Adderall
bid in 5/2021. Patient was doing well till late last year due to holiday hectic work schedule. We increased his Adderall from 20
mg bid to 30 mg bid. He does have depression and anxiety, was on 50 mg Zoloft in the past. We switched his Adderall to
Vyvanse in 7/2022 for both ADD and depression/anxiety. He reports doing well. Controlling symptoms, staying focused,
organized skills, well. No side effects noted. Denies tremor, palpitations, chest pain, sleeping trouble. Appetite normal. No weight
loss. Patient is adherent with follow up visits with being on a controlled medication. No drug holidays. Last refill was on
12/21/2022.

He has depression for years. He has been on 50 mg Zoloft since 2/2022 with good response. He has intermittent worsening
anxiety due to stressors in life (work, family, etc).

He has intermittent neck and back pain issues, on Robaxin PRN.

He has preDM, on life style modifications. His

Hemoglobin A1C (%)

Date Value
11/22/2021 6.0 (H)

He has HLD, on life style modifications. His

Triglycerides (mg/dL)
Date Value
11/22/2021 183 (H)

Cholesterol (mg/dL)
Date Value
11/22/2021 193

HDL Cholesterol (mg/dL)

Date Value
11/22/2021 42

No results found for: LDLCHOLM

LDL Cholesterol-Calculated (mg/dL)
Date Value
11/22/2021 106 (H)

He is a manager for Amazon. He lives with his wife and two daughters. He walks often at work; otherwise, he doesn't do regular
exercise.

Do you take any herbs or supplements that were not prescribed by a doctor? no
Are you taking calcium supplements? no
Are you taking aspirin daily? no

The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past
family history, past medical history, past social history, past surgical history and problem list.
Review of Systems
Do you have pain that bothers you in your daily life? no

Review of Systems
Constitutional: negative for chills, fevers, fatigue
Respiratory: negative for cough and wheezing
Cardiovascular: negative for chest pain and irregular heart beat
Gastrointestinal: negative for abdominal pain, constipation and diarrhea
Genitourinary:negative for dysuria, frequency and hematuria
Musculoskeletal: positive for arthralgias, back pain and myalgias
Neurological: negative for dizziness and headaches
Behavioral/Psych: positive for anxiety and sleep disturbance

The following portions of the patient's history were reviewed and updated as appropriate:
He has a past medical history of ADD (attention deficit disorder) and Elevated LFTs (11/28/2020).
He does not have any pertinent problems on file.
He has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).
His family history includes ADD / ADHD in his daughter; Heart disease in his father, maternal grandfather, maternal grandmother,
and maternal uncle; Hypertension in his father, maternal grandfather, maternal grandmother, and maternal uncle; Thyroid disease
in his sister.
He reports that he quit smoking about 4 years ago. His smoking use included cigars and cigarettes. He smoked an average of .25
packs per day. He has never used smokeless tobacco. He reports current alcohol use of about 1.0 standard drink per week. He
reports that he does not use drugs.
He has No Known Allergies..

Health Maintenance Summary |

Overdue - Hepatitis B (HepB) Vaccine (1 of 3 - 3-dose series) Overdue - never done
No completion history exists for this topic.

Postponed - Influenza Vaccine (1) Postponed until 6/30/2023

11/25/2020 Declined

Tdap/Td Vaccine >11 yo (2 - Td or Tdap) Next due on 9/1/2028

09/01/2018 Done at another facility - due to having left arm Fx.

Pneumococcal Vaccines 6-64 yo Risk (Series Information) Aged Out

No completion history exists for this topic.

Haemophilus Influenzae Type B (Hib) Vaccine (Series Information) Aged Out

No completion history exists for this topic.

Polio (IPV) (Series Information) Aged Out

No completion history exists for this topic.

Hepatitis A (HepA) Vaccine (Series Information) Aged Out

No completion history exists for this topic.

Meningococcal ACWY (Series Information) Aged Out

No completion history exists for this topic.

Rotavirus (RV) Vaccine (Series Information) Aged Out

No completion history exists for this topic.

Health Maintenance Plans

Haemophilus Influenzae Type B (Hib) Vaccine
Hepatitis A (HepA) Vaccine
Hepatitis B (HepB) Vaccine
Inactivated Poliovirus (IPV) Vaccine
Influenza Vaccine Sequential
Meningococcal ACWY
Pneumococcal Vaccines 6-64 yo Risk
Rotavirus (RV) Vaccine
Tdap/Td Vaccine >11yo

Outpatient Medications Marked as Taking for the 1/23/23 encounter (Office Visit) with Bryant, Jing, MD
Medication Sig Dispense Refill
• lisdexamfetamine (VYVANSE) 60 MG capsule Take 1 capsule by mouth every morning. Max Daily Amount: 60 mg 30 capsule 0
• lisinopril (PRINIVIL) 20 MG tablet Take 1 tablet by mouth daily. 90 tablet 1
• methocarbamol (ROBAXIN) 750 MG tablet Take 1 tablet by mouth three times daily as needed for back pain. (Patient taking
differently: 3 (three) times daily as needed.) 30 tablet 3
• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth 2 (two) times daily as needed (mild headache) Take with food. 60
tablet 0
• sertraline (ZOLOFT) 50 MG tablet Take 1 tablet by mouth daily. 90 tablet 0

Immunization History
Name Date
COVID-19 Moderna 100 mcg/0.5 mL 04/19/2021
COVID-19 Moderna 100 mcg/0.5 mL 03/18/2021

Patient Care Team:

Bryant, Jing, MD as PCP - General (Family Medicine)
Hopper, Jason A, MD (Cardiology)
Meiers, Henry N, MD (Urology)

Objective:

Vitals:
01/23/23 0947
BP: 128/76
Pulse: 89
Temp: 98.2 °F (36.8 °C)
TempSrc: Temporal
SpO2: 98%
Weight: 97.1 kg (214 lb 1.1 oz)
Height: 6' 1" (185.4 cm)

Physical Exam

Constitutional: Oriented to person, place, and time. Appears well-developed and well-nourished. No distress.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: Tympanic membrane normal.
Left Ear: Tympanic membrane normal.
Mouth/Throat: Oropharynx is clear and moist.
Eyes: Conjunctivae and EOM are normal.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. No low extremity edema.
Pulmonary/Chest: Effort normal and breath sounds normal. No accessory muscle usage.
Abdominal: Soft. There is no tenderness. There is no guarding.
Musculoskeletal: Normal range of motion. Exhibits no edema. Normal gait.
Lymphadenopathy:
No cervical adenopathy.
Right: No supraclavicular adenopathy present.
Left: No supraclavicular adenopathy present.
Neurological: Alert and oriented to person, place, and time. Normal strength.
Skin: Skin is warm.
Psychiatric: Normal mood and affect. Behavior is normal.

PHQ 9
Little interest or pleasure in doing things?: (!) More than half the days
Feeling down, depressed or hopeless?: (!) More than half the days
Trouble falling or staying asleep, or too much sleep?: (!) More than half the days
Feeling tired or having little energy?: (!) More than half the days
Poor appetite or overeating?: Several days
Feeling bad about yourself?: Several days
Trouble concentrating on things?: (!) More than half the days
Moving or speaking slowly?: (!) More than half the days
Thoughts that you would be better off dead?: Not at all
PHQ9 Score: 14
Score interpretation: Moderate

GAD 7
Feeling nervous, anxious, or on edge: Nearly every day
Not being able to stop or control worrying: Over half the days
Worrying too much about different things: Over half the days
Trouble relaxing: Over half the days
Being so restless that it's hard to sit still: Over half the days
Becoming easily annoyed or irritable: None
Feeling afraid as if something awful might happen: None
GAD-7 Total Score: 11
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get
along with other people?: Very difficult

Recent Results (from the past 24 hour(s))

POCT Urine Drug Test
Collection Time: 01/23/23 9:56 AM
Result Value Ref Range
AMP Amphetamine -Urine Screen Positive (A) Negative
BAR Barbiturate-Urine Screen Negative Negative
BUP Buprenorphine-Urine Screen Negative Negative
BZO Benzodiazepine Screen-Urine Negative Negative
COC Cocaine-Urine Screen Negative Negative
MDMA-Urine Screen Negative Negative
MET Methamphetamine Screen Urine Negative Negative
MOP Opiates-Urine Negative Negative
MTD Methadone Screen-Urine Negative Negative
OXY Oxycodone-Urine Screen Negative Negative
PCP-Urine Screen Negative Negative
THC Cannabinoids-Urine Screen Negative Negative
Internal QC Yes
Lot Number w51210316
Expiration Date 2023/03/14
Comment-POCT

Assessment:

1. Annual physical exam

2. HTN, goal below 130/80 Microalbumin, random urine

Microalbumin, random urine

3. Microalbuminuria absent

4. Attention deficit disorder, unspecified hyperactivity presence

5. High risk medications (not anticoagulants) long-term use POCT Urine Drug Test

6. Depression with anxiety hydrOXYzine (ATARAX) 25 MG tablet

7. Chronic bilateral low back pain without sciatica

8. Chronic neck pain

9. Dyslipidemia

10. Prediabetes

11. Screening for diabetes mellitus

12. Screening for deficiency anemia

13. Screening for cholesterol level

Plan:

Maintain healthy life style, including diet, exercise and weight control.
Patient Counseling (available also in after visit summary):
--Nutrition: Stressed importance of moderation in sodium/caffeine intake, saturated fat and cholesterol, caloric balance,
sufficient intake of fresh fruits, vegetables, etc.
--Exercise: Stressed the importance of regular exercise.
--Substance Abuse: Discussed cessation/primary prevention of tobacco, alcohol, or other drug use.
--Dental health: Discussed importance of regular dental visits.
--Immunizations reviewed.
--Discussed benefits of screening colonoscopy.
--After hours service

Discussed the patient's BMI with him. The BMI is above average range. Patient is advised to adapt life style modificaitons
including diet, exercise to lose weight.

Follow up as needed for acute issues.

Routine labs when fasting; Caucasian.

Follow up in 1 year for annual physical.

HTN without microalbuminuria: doing well on 20 mg lisinopril; continue.

Will check labs when fasting.
Hypertension educational materials and blood pressure tracker are printed out and handed to the patient today if requested;
also available in after visit summary.
Continue life style modifications including diet (low-fat, low sodium), exercise and weight control.

ADD: doing well on 60 mg Vyvanse.

Discussed diagnosis, treatment options, risks and benefits, alternate therapies. Patient agreeable to treatment and understands
risks and benefits of treatment plan. Informed consent was obtained and in file. Patient's signed contract is in file; his UDS was
consistent with history today; KASPER (from Appriss) showed no irregularity. Patient is advised not to drive or operate
machinery under the influence of sedating medications, and to avoid alcohol and illicit drug use.
May call for 4 more refills.

Depression with anxiety: on 50 mg Zoloft.

Intermittent worsening anxiety due to stressors in life.
After discussion, he'd like to try hydroxyzine PRN.

Lower back pain, neck pain: on Robaxin PRN.

HLD: on life style modifications now.

Will check labs when fasting.

PreDM: on life style modifications.

Will check lab when fasting.

Screening & Prevention:

Age-appropriate Screening & Interventions recommended by USPSTF were reviewed with the patient, and Health Maintenance
was updated in Epic.

Medical Problems & Treatment Plans:

For details, see Problem List, Medications, and Orders sections in Epic, and AVS related to this day-of-service.
Electronically signed by Jing Bryant at 01/23/2023 12:01 PM EST

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file
Visit Diagnoses - documented in this encounter
Diagnosis
Encounter for annual physical exam - Primary
HTN, goal below 130/80
Microalbuminuria absent
High risk medications (not anticoagulants) long-term use
Chronic bilateral low back pain without sciatica
Chronic neck pain
Dyslipidemia
Prediabetes
Screening for diabetes mellitus
Screening for deficiency anemia
Screening for cholesterol level

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Jan. 23, 2023
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Jan. 23, 2023
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
Medication Refill

Encounter Details
Date Type Department Care Team Description
10/17/2022 Office Visit Norton Community Medical Jing Bryant
10:40 AM Associates - Brownsboro 9880 Angie's Way
EDT 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 30 tablet 3 04/18/2022 07/10/2023 Discontinued
750 MG tablet three times daily as
needed for back pain.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 90 tablet 1 05/31/2022 12/21/2022 Discontinued
MG tablet twice daily as needed for (Reorder)
mild headache.
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 0 09/07/2022 11/23/2022 Discontinued
tablet daily.
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth 90 tablet 1 09/07/2022 03/13/2023 Discontinued
tablet daily.
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 09/13/2022 10/17/2022 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
triamcinolone (KENALOG) 0.1 Use 1 Application in the 5g 0 10/17/2022 11/20/2022 Discontinued
% paste mouth or throat 2 (two) (Reorder)
times daily for 7 days.
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 10/17/2022 11/20/2022 Discontinued
60 MG capsule every morning. Max Daily (Reorder)
Amount: 60 mg
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Tobacco Cessation: Counseling Given: Yes

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 3 04/14/2022

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 144/76 10/17/2022 10:55 AM EDT
Pulse 99 10/17/2022 10:55 AM EDT
Temperature 37.3 °C (99.1 °F) 10/17/2022 10:55 AM EDT
Respiratory Rate - -
Oxygen Saturation 98% 10/17/2022 10:55 AM EDT
Inhaled Oxygen Concentration - -
Weight 97.8 kg (215 lb 9.8 oz) 10/17/2022 10:55 AM EDT
Height 185.4 cm (6' 1") 10/17/2022 10:55 AM EDT
Body Mass Index 28.45 10/17/2022 10:55 AM EDT

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth every 30 capsule 0 10/17/2022 11/20/2022
60 MG capsule morning. Max Daily Amount:
60 mg
triamcinolone (KENALOG) 0.1 Use 1 Application in the mouth 5 g 0 10/17/2022 11/20/2022
% paste or throat 2 (two) times daily for
7 days.
Progress Notes - documented in this encounter
Jing Bryant - 10/17/2022 1:46 PM EDT
Formatting of this note is different from the original.
Images from the original note were not included.
Subjective:

Patient ID: Ryan S Gomez is a 38 yr/o male.

Chief Complaint
Patient presents with
• Medication Refill
ADHD medicine refill

HPI

He was evaluated by Robert Watson, Psy. D, in 12/2020. Dr. Watson thinks that his untreated ADD might have caused his anxiety
and depression to certain degree. Dr. Watson recommended that patient should be treated for his ADD.

He was started on 36 mg Concerta with moderate response. He stated that the effects weans off after 8-9 hours. He was started
on 54 mg Concerta in 2/2021, then 72 mg; however, it didn't last long enough. We changed his Concerta to 20 mg Adderall
bid in 5/2021. Patient was doing well till late last year due to holiday hectic work schedule. We increased his Adderall from 20
mg bid to 30 mg bid. He does have depression and anxiety, was on 50 mg Zoloft in the past. We switched his Adderall to
Vyvanse in 7/2022 for both ADD and depression/anxiety. He reports doing well. Controlling symptoms, staying focused,
organized skills, well. No side effects noted. Denies tremor, palpitations, chest pain, sleeping trouble. Appetite normal. No weight
loss. Patient is adherent with follow up visits with being on a controlled medication. No drug holidays. Last refill was on
9/13/2022.

He has been having canker sore on his tongue for the past 1 month, painful. He drinks caffeine containing drinks (including diet
soda, unsweetened tea, coffee, etc), and lemonade during the day.

The following portions of the patient's history were reviewed and updated as appropriate:
He has a past medical history of ADD (attention deficit disorder) and Elevated LFTs (11/28/2020).
He does not have any pertinent problems on file.
He has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).
His family history includes ADD / ADHD in his daughter; Heart disease in his father, maternal grandfather, maternal grandmother,
and maternal uncle; Hypertension in his father, maternal grandfather, maternal grandmother, and maternal uncle; Thyroid disease
in his sister.
He reports that he quit smoking about 3 years ago. His smoking use included cigars. He smoked 0.25 packs per day. He has
never used smokeless tobacco. He reports current alcohol use of about 1.0 standard drink of alcohol per week. He reports that
he does not use drugs.
He has No Known Allergies..

Review of Systems
Constitutional: Negative for chills, fatigue, fever and unexpected weight change.
HENT: Positive for mouth sores (on tongue).
Cardiovascular: Negative for chest pain and palpitations.
Neurological: Positive for headaches (today). Negative for dizziness.
Psychiatric/Behavioral: Positive for decreased concentration. Negative for sleep disturbance. The patient is not nervous/anxious.

Outpatient Medications Marked as Taking for the 10/17/22 encounter (Office Visit) with Bryant, Jing, MD
Medication Sig Dispense Refill
• lisdexamfetamine (VYVANSE) 60 MG capsule Take 1 capsule by mouth every morning. Max Daily Amount: 60 mg 30 capsule 0
• lisinopril (PRINIVIL) 20 MG tablet Take 1 tablet by mouth daily. 90 tablet 1
• methocarbamol (ROBAXIN) 750 MG tablet Take 1 tablet by mouth three times daily as needed for back pain. (Patient taking
differently: 3 (three) times daily as needed.) 30 tablet 3
• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth twice daily as needed for mild headache. (Patient taking
differently: daily as needed.) 90 tablet 1
• sertraline (ZOLOFT) 50 MG tablet Take 1 tablet by mouth daily. 90 tablet 0
• triamcinolone (KENALOG) 0.1 % paste Use 1 Application in the mouth or throat 2 (two) times daily for 7 days. 5 g 0

Patient Care Team:

Bryant, Jing, MD as PCP - General (Family Medicine)
Hopper, Jason A, MD (Cardiology)
Meiers, Henry N, MD (Urology)

Objective:

Vitals:
10/17/22 1055
BP: (!) 144/76
Pulse: 99
Temp: 99.1 °F (37.3 °C)
TempSrc: Temporal
SpO2: 98%
Weight: 97.8 kg (215 lb 9.8 oz)
Height: 6' 1" (185.4 cm)

Physical Exam
Vitals and nursing note reviewed.
Constitutional:
General: He is not in acute distress.
Appearance: He is well-developed.
HENT:
Head: Normocephalic and atraumatic.
Mouth/Throat:

Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds.
Neurological:
Mental Status: He is alert and oriented to person, place, and time.
Psychiatric:
Mood and Affect: Mood normal.
Behavior: Behavior normal.
Thought Content: Thought content normal.
Judgment: Judgment normal.

Assessment and Plan:

Ryan was seen today for medication refill.

Diagnoses and all orders for this visit:

Attention deficit disorder, unspecified hyperactivity presence

- lisdexamfetamine (VYVANSE) 60 MG capsule; Take 1 capsule by mouth every morning. Max Daily Amount: 60 mg

Depression with anxiety

- lisdexamfetamine (VYVANSE) 60 MG capsule; Take 1 capsule by mouth every morning. Max Daily Amount: 60 mg

Canker sores oral

- triamcinolone (KENALOG) 0.1 % paste; Use 1 Application in the mouth or throat 2 (two) times daily for 7 days.

ADD: he was on 30 mg Adderall bid, and Zoloft in the past for both ADD, depression/anxiety.
Currently, he is doing well on 60 mg Vyvanse.
Discussed diagnosis, treatment options, risks and benefits, alternate therapies. Patient agreeable to treatment and understands
risks and benefits of treatment plan. Informed consent was obtained and in file. Patient's signed contract is in file; his UDS was
consistent with history today; KASPER (from Appriss) showed no irregularity. Patient is advised not to drive or operate
machinery under the influence of sedating medications, and to avoid alcohol and illicit drug use.
May call for 2 more refills.

Canker sores: will try dental paste.

Hydrate, reduce irritants intake.

Return in about 3 months (around 1/17/2023) for annual physical, ADHD med refill, HTN, come in fasting.
Electronically signed by Jing Bryant at 10/17/2022 1:54 PM EDT

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk
Results - documented in this encounter
Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
Canker sore

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Oct. 17, 2022
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Oct. 17, 2022
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason Onset Date
Medication Refill 08/08/2022

Encounter Details
Date Type Department Care Team Description
08/08/2022 Refill Norton Community Medical Jing Bryant
Associates - Brownsboro 9880 Angie's Way
9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 1 02/28/2022 09/07/2022 Discontinued
tablet daily.
methocarbamol (ROBAXIN) Take 1 tablet by mouth 30 tablet 3 04/18/2022 07/10/2023 Discontinued
750 MG tablet three times daily as
needed for back pain.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 90 tablet 1 05/31/2022 12/21/2022 Discontinued
MG tablet twice daily as needed for (Reorder)
mild headache.
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth 90 tablet 0 06/28/2022 09/07/2022 Discontinued
tablet daily.
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 07/14/2022 08/08/2022 Discontinued
50 MG capsule every morning. Max (Reorder)
Daily Amount: 50 mg
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 08/09/2022 08/15/2022 Discontinued
50 MG capsule every morning. Max (Reorder)
Daily Amount: 50 mg
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 08/15/2022 09/13/2022 Discontinued
60 MG capsule every morning. Max (Reorder)
Daily Amount: 60 mg
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 3 04/14/2022

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last 10 days, have you been in contact with someone No / Unsure 7/14/2022 10:07 AM EDT
who was confirmed or suspected to have Coronavirus/
COVID-19?

Last Filed Vital Signs - documented in this encounter

Not on file

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth every 30 capsule 0 08/15/2022 09/13/2022
60 MG capsule morning. Max Daily Amount:
60 mg
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth every 30 capsule 0 08/09/2022 08/15/2022
50 MG capsule morning. Max Daily Amount:
50 mg
Plan of Treatment - documented as of this encounter
Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Aug. 08, 2022 - Aug. 15, 2022
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Aug. 08, 2022
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
Office Visit
Medication Refill
HTN

Encounter Details
Date Type Department Care Team Description
07/14/2022 Office Visit Norton Community Medical Jing Bryant
10:00 AM Associates - Brownsboro 9880 Angie's Way
EDT 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 1 02/28/2022 09/07/2022 Discontinued
tablet daily.
methocarbamol (ROBAXIN) Take 1 tablet by mouth 30 tablet 3 04/18/2022 07/10/2023 Discontinued
750 MG tablet three times daily as
needed for back pain.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 90 tablet 1 05/31/2022 12/21/2022 Discontinued
MG tablet twice daily as needed for (Reorder)
mild headache.
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth 90 tablet 0 06/28/2022 09/07/2022 Discontinued
tablet daily.
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 07/08/2022 07/14/2022 Discontinued
dextroamphetamine (two) times daily. Max (Formulary
(ADDERALL) 30 MG tablet Daily Amount: 60 mg change)
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 07/14/2022 08/08/2022 Discontinued
50 MG capsule every morning. Max (Reorder)
Daily Amount: 50 mg
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Tobacco Cessation: Counseling Given: Yes

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 3 04/14/2022

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last 10 days, have you been in contact with someone No / Unsure 7/14/2022 10:07 AM EDT
who was confirmed or suspected to have Coronavirus/
COVID-19?

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 128/78 07/14/2022 10:14 AM EDT
Pulse 100 07/14/2022 10:14 AM EDT
Temperature 36.6 °C (97.8 °F) 07/14/2022 10:14 AM EDT
Respiratory Rate - -
Oxygen Saturation 97% 07/14/2022 10:14 AM EDT
Inhaled Oxygen Concentration - -
Weight 99.4 kg (219 lb 2.2 oz) 07/14/2022 10:14 AM EDT
Height 185.4 cm (6' 1") 07/14/2022 10:14 AM EDT
Body Mass Index 28.91 07/14/2022 10:14 AM EDT
Ordered Prescriptions - documented in this encounter
Prescription Sig Dispensed Refills Start Date End Date
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth every 30 capsule 0 07/14/2022 08/08/2022
50 MG capsule morning. Max Daily Amount:
50 mg

Progress Notes - documented in this encounter

Jing Bryant - 07/14/2022 10:19 AM EDT
Formatting of this note is different from the original.
Subjective:

Patient ID: Ryan S Gomez is a 38 yr/o male.

Chief Complaint
Patient presents with
• Office Visit
• Medication Refill
• HTN
Not fasting

HPI

He has HTN without microalbuminuria, doing well on 20 mg lisinopril. He monitors his BP at home, with readings in 120-130s/
70-80s.

He was evaluated by Robert Watson, Psy. D, in 12/2020. Dr. Watson thinks that his untreated ADD might have caused his anxiety
and depression to certain degree. Dr. Watson recommended that patient should be treated for his ADD.

He was started on 36 mg Concerta with moderate response. He stated that the effects weans off after 8-9 hours. He was started
on 54 mg Concerta in 2/2021, then 72 mg; however, it didn't last long enough. We changed his Concerta to 20 mg Adderall
bid in 5/2021. Patient was doing well till late last year due to holiday hectic work schedule. We increased his Adderall from 20
mg bid to 30 mg bid. He reports doing much better now. Denies tremor, palpitations, chest pain, sleeping trouble. Appetite
normal. No weight loss. However, he wonders whether he may try Vyvanse as he was noticed to have short temper. He does
have depression and anxiety, on 50 mg Zoloft.

His last refill of Adderall was on 7/8/2022.

He has intermittent right ear, right jaw pain. He does grind teeth at night.

The following portions of the patient's history were reviewed and updated as appropriate:
He has a past medical history of ADD (attention deficit disorder) and Elevated LFTs (11/28/2020).
He does not have any pertinent problems on file.
He has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).
His family history includes ADD / ADHD in his daughter; Heart disease in his father, maternal grandfather, maternal grandmother,
and maternal uncle; Hypertension in his father, maternal grandfather, maternal grandmother, and maternal uncle; Thyroid disease
in his sister.
He reports that he quit smoking about 3 years ago. His smoking use included cigars. He smoked 0.25 packs per day. He has
never used smokeless tobacco. He reports current alcohol use of about 1.0 standard drink of alcohol per week. He reports that
he does not use drugs.
He has No Known Allergies..

Review of Systems
Constitutional: Negative for chills, fatigue, fever and unexpected weight change.
HENT: Positive for ear pain (right).
Cardiovascular: Negative for chest pain and palpitations.
Neurological: Negative for dizziness and headaches.
Psychiatric/Behavioral: Positive for agitation and decreased concentration. Negative for sleep disturbance. The patient is not
nervous/anxious.

Outpatient Medications Marked as Taking for the 7/14/22 encounter (Office Visit) with Bryant, Jing, MD
Medication Sig Dispense Refill
• amphetamine-dextroamphetamine (ADDERALL) 30 MG tablet Take 1 tablet by mouth 2 (two) times daily. Max Daily Amount: 60
mg 60 tablet 0
• lisinopril (PRINIVIL) 20 MG tablet Take 1 tablet by mouth daily. 90 tablet 0
• methocarbamol (ROBAXIN) 750 MG tablet Take 1 tablet by mouth three times daily as needed for back pain. 30 tablet 3
• Multiple Vitamin (MULTIVITAMIN PO) Take by mouth.
• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth twice daily as needed for mild headache. 90 tablet 1
• sertraline (ZOLOFT) 50 MG tablet Take 1 tablet by mouth daily. 90 tablet 1
Patient Care Team:
Bryant, Jing, MD as PCP - General (Family Medicine)
Hopper, Jason A, MD (Cardiology)
Meiers, Henry N, MD (Urology)

Objective:

Vitals:
07/14/22 1014
BP: 128/78
Pulse: 100
Temp: 97.8 °F (36.6 °C)
TempSrc: Temporal
SpO2: 97%
Weight: 99.4 kg (219 lb 2.2 oz)
Height: 6' 1" (185.4 cm)

Physical Exam
Vitals and nursing note reviewed.
Constitutional:
General: He is not in acute distress.
Appearance: He is well-developed.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: Tympanic membrane normal.
Left Ear: Tympanic membrane normal.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds.
Neurological:
Mental Status: He is alert and oriented to person, place, and time.

Assessment and Plan:

Ryan was seen today for office visit, medication refill and htn.

Diagnoses and all orders for this visit:

HTN, goal below 130/80

Microalbuminuria absent

Attention deficit disorder, unspecified hyperactivity presence

- lisdexamfetamine (VYVANSE) 50 MG capsule; Take 1 capsule by mouth every morning. Max Daily Amount: 50 mg

Depression with anxiety

- lisdexamfetamine (VYVANSE) 50 MG capsule; Take 1 capsule by mouth every morning. Max Daily Amount: 50 mg

Right ear pain

HTN without microalbuminuria: doing well on 20 mg lisinopril; continue.

Continue life style modifications including diet (low-fat, low sodium), exercise and weight control.

ADD: on 30 mg Adderall bid.

He reports having short temper.
He has depression/anxiety, on Zoloft.
Will see whether his insurance covers Vyvanse.
Discussed diagnosis, treatment options, risks and benefits, alternate therapies. Patient agreeable to treatment and understands
risks and benefits of treatment plan. Informed consent was obtained and in file. Patient's signed contract is in file; his UDS was
consistent with history today; KASPER (from Appriss) showed no irregularity. Patient is advised not to drive or operate machinery
under the influence of sedating medications, and to avoid alcohol and illicit drug use.
May call for 3 refills.

Right ear pain: likely TMJ.

He is advised to consider mouth guard.
Return in about 3 months (around 10/14/2022) for ADHD med refill.
Electronically signed by Jing Bryant at 07/14/2022 10:59 AM EDT

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
HTN, goal below 130/80 - Primary
Microalbuminuria absent
Right ear pain

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Jul. 14, 2022
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Jul. 14, 2022
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
Office Visit

Encounter Details
Date Type Department Care Team Description
04/14/2022 Office Visit Norton Community Medical Jing Bryant
8:20 AM Associates - Brownsboro 9880 Angie's Way
EDT 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 1 02/28/2022 09/07/2022 Discontinued
tablet daily.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 90 tablet 1 03/02/2022 05/31/2022 Discontinued
MG tablet (two) times daily as
needed (mild headache).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 03/25/2022 05/03/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 04/01/2022 04/14/2022 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth 90 tablet 0 04/14/2022 06/28/2022 Discontinued
tablet daily.
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 04/14/2022 04/18/2022 Discontinued
750 MG tablet (three) times daily as
needed (back pain).
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Tobacco Cessation: Counseling Given: Yes

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 3 04/14/2022

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 4/14/2022 8:32 AM EDT
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 130/90 04/14/2022 8:43 AM EDT
Pulse 108 04/14/2022 8:43 AM EDT
Temperature 36.6 °C (97.8 °F) 04/14/2022 8:43 AM EDT
Respiratory Rate - -
Oxygen Saturation 97% 04/14/2022 8:43 AM EDT
Inhaled Oxygen Concentration - -
Weight 102.5 kg (225 lb 15.5 oz) 04/14/2022 8:43 AM EDT
Height 185.4 cm (6' 1") 04/14/2022 8:43 AM EDT
Body Mass Index 29.81 04/14/2022 8:43 AM EDT

Patient Instructions - documented in this encounter

Patient Instructions
Jing Bryant - 04/14/2022 1:31 PM EDT
Formatting of this note is different from the original.

Please take your blood pressure medication(s) as directed.

Please monitor your blood pressure and heart rate (pulse) 3-4 times a week, and record your readings. Your goal is to have your
blood pressure below 130/80, and your heart rate (pulse) in between 60 - 90.

You may download the free app called "Blood Pressure Journal" to your smart device for your blood pressure log.

For colds and congestion, be careful about using over the counter medications. It is safe to use medication from the
CoricidinHBP line.
See coricidinhbp.com.

Follow up in 3 months for blood pressure check.

Blood Pressure Tracking Chart

Date Systolic Diastolic Pulse (heart rate) Date Systolic Diastolic Pulse (heart rate)

Hypertension
GENERAL INFORMATION:
What is hypertension? Hypertension is high blood pressure (BP). Your BP is the force of your blood moving against the walls of
your arteries. Normal BP is less than 120/80. Prehypertension is between 120/80 and 139/89. Hypertension is 140/90 or higher.
Hypertension causes your BP to get so high that your heart has to work much harder than normal. This can cause damage to
your heart. Hypertension is a long-term condition that you will need to control with a healthy lifestyle or medicines. A controlled
blood pressure helps protect your organs, such as your heart, lungs, brain, and kidneys.
What causes hypertension? The cause of hypertension may not be known. This type of hypertension is called essential or
primary hypertension. Hypertension can sometimes be caused by other medical conditions, such as kidney disease. This type of
hypertension is called secondary hypertension.
What increases my risk for hypertension?
· For men, being older than 55 years, and for women, being older than 65 years

· Family history of hypertension or heart disease

· Obesity or lack of exercise

· Too many high-sodium foods

· Stress

· Use of tobacco, alcohol, or illegal drugs

· Medical conditions, such as diabetes, high cholesterol, kidney disease, thyroid disease, or adrenal gland disorder

· Certain medicines, such as steroids or birth control pills

What are the signs and symptoms of hypertension? You may have no signs or symptoms, or you may have any of the following:
· Headache

· Blurred vision

· Chest pain

· Dizziness or weakness

· Trouble breathing

· Nosebleeds
How is hypertension diagnosed? Your healthcare provider will ask about your symptoms and the medicines you take. He will also
ask if you have a family history of hypertension and about any health conditions you have. He will check your BP and weight and
examine your heart, lungs, and eyes. You may need any of the following tests:
· Blood tests may help healthcare providers find the cause of your hypertension. Blood tests can also help find other health
problems caused by hypertension.

· Urine tests will be done to check your kidneys.

· An EKG records the electrical activity of your heart. It is used to check your heart rhythm or other problems caused by
hypertension.
How is hypertension treated? Your healthcare provider will recommend lifestyle changes to lower your BP. You may also need the
following medicines:
· Blood pressure medicine helps lower your blood pressure. You may need more than one type of blood pressure medicine. Take
your blood pressure medicine exactly as directed.

· Diuretics help decrease extra fluid that collects in your body. This will help lower your BP. You may urinate more often while you
take this medicine.
How do I check my BP at home? Sit and rest for 5 minutes before you take your BP. Extend your arm and support it on a flat
surface. Your arm should be at the same level as your heart. Follow the directions that came with your BP monitor. If possible,
take at least 2 BP readings each time. Take your BP at least twice a day at the same times each day, such as morning and
evening. Keep a log of your BP readings and bring it to your follow-up visits. Ask your healthcare provider what your BP should
be.
How can I manage my hypertension? Talk with your healthcare provider about these and other lifestyle changes you can make to
manage your hypertension:
· Eat less sodium (salt). Do not add salt to your food. Limit foods that are high in sodium, such as canned foods, potato chips,
and cold cuts. Your healthcare provider may suggest that you follow the DASH Eating Plan. The plan is low in sodium, unhealthy
fats, and total fat. It is high in potassium, calcium, and fiber. You get these nutrients by eating more fruits, vegetables, and whole
grains. Ask your healthcare provider or dietitian which meal plan you should follow.

· Exercise to maintain a healthy weight. Exercise at least 30 minutes per day, on most days of the week. This will help decrease
your BP. Ask your healthcare provider about the best exercise plan for you.

· Limit alcohol. Women should limit alcohol to 1 drink a day. Men should limit alcohol to 2 drinks a day. A drink of alcohol is 12
ounces of beer, 5 ounces of wine, or 1½ ounces of liquor.

· Do not smoke. If you smoke, it is never too late to quit. Smoking can increase your BP. Smoking also worsens other health
conditions you may have that can increase your risk for hypertension. Ask your healthcare provider for information if you need
help quitting.

· Manage any other health conditions you have. Health conditions such as diabetes can increase your risk for hypertension.
Follow your healthcare provider's instructions and take all your medicines as directed.

· Decrease stress. This may help lower your BP. Learn ways to relax, such as deep breathing or listening to music.
What are the risks of hypertension? Without treatment, you may develop other health problems over time. You may lose vision
in one or both eyes. You may develop heart and blood vessel disease. This increases your risk of a heart attack, stroke, heart
failure, or kidney disease and can be life-threatening.
When should I contact my healthcare provider?
· You feel faint, dizzy, confused, or drowsy.

· You have been taking your BP medicine and your BP is still higher than your healthcare provider says it should be.

· You have questions or concerns about your condition or care.

When should I seek immediate care or call 911?
· You have a severe headache or vision loss.

· You have weakness in an arm or leg.

· You become confused or have difficulty speaking.

· You have discomfort in your chest that feels like squeezing, pressure, fullness, or pain.

· You suddenly feel lightheaded or have trouble breathing.

· You have pain or discomfort in your back, neck, jaw, stomach, or arm.
CARE AGREEMENT:
You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment
options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. The above
information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your
doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.
© 2014 Truven Health Analytics Inc. Information is for End User's use only and may not be sold, redistributed or otherwise used
for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or
Truven Health Analytics.

Electronically signed by Jing Bryant at 04/14/2022 1:31 PM EDT

Ordered Prescriptions - documented in this encounter
Prescription Sig Dispensed Refills Start Date End Date
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 04/14/2022 04/18/2022
750 MG tablet (three) times daily as needed
(back pain).
lisinopril (PRINIVIL) 20 MG Take 1 tablet by mouth daily. 90 tablet 0 04/14/2022 06/28/2022
tablet

Progress Notes - documented in this encounter

Jing Bryant - 04/14/2022 8:53 AM EDT
Formatting of this note is different from the original.
Subjective:

Patient ID: Ryan S Gomez is a 38 yr/o male.

Chief Complaint
Patient presents with
• Office Visit

HPI

He has been having elevated BP without microalbuminuria since 11/2020. He was on lisinopril in the past. He reports having
some HA. No CP.

He was evaluated by Robert Watson, Psy. D, in 12/2020. Dr. Watson thinks that his untreated ADD might have caused his anxiety
and depression to certain degree. Dr. Watson recommended that patient should be treated for his ADD.

He was started on 36 mg Concerta with moderate response. He stated that the effects weans off after 8-9 hours. He was started
on 54 mg Concerta in 2/2021, then 72 mg; however, it didn't last long enough. We changed his Concerta to 20 mg Adderall
bid in 5/2021. Patient was doing well till late last year due to holiday hectic work schedule. We increased his Adderall from 20
mg bid to 30 mg bid. He reports doing much better now. Denies tremor, palpitations, chest pain, sleeping trouble. Appetite
normal. No weight loss. Last refill 3/30/2022.

He reports having depression for years. He has been on 50 mg Zoloft since 2/2022 with good response. His anxiety got worse
from his recent spring break vacation. He desires to continue current dose at this time.

He has been having neck and back pain issues, on Robaxin PRN.

The following portions of the patient's history were reviewed and updated as appropriate:
He has a past medical history of ADD (attention deficit disorder) and Elevated LFTs (11/28/2020).
He does not have any pertinent problems on file.
He has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).
His family history includes ADD / ADHD in his daughter; Heart disease in his father, maternal grandfather, maternal grandmother,
and maternal uncle; Hypertension in his father, maternal grandfather, maternal grandmother, and maternal uncle; Thyroid disease
in his sister.
He reports that he quit smoking about 3 years ago. His smoking use included cigars. He smoked 0.25 packs per day. He has
never used smokeless tobacco. He reports current alcohol use of about 1.0 standard drink of alcohol per week. He reports that
he does not use drugs.
He has No Known Allergies..

Review of Systems
Constitutional: Negative for chills, fatigue, fever and unexpected weight change.
Cardiovascular: Negative for chest pain and palpitations.
Neurological: Positive for headaches. Negative for dizziness.
Psychiatric/Behavioral: Positive for decreased concentration and dysphoric mood. Negative for sleep disturbance. The patient is
nervous/anxious.

Outpatient Medications Marked as Taking for the 4/14/22 encounter (Office Visit) with Bryant, Jing, MD
Medication Sig Dispense Refill
• amphetamine-dextroamphetamine (ADDERALL) 30 MG tablet Take 1 tablet by mouth 2 (two) times daily. Max Daily Amount: 60
mg 60 tablet 0
• methocarbamol (ROBAXIN) 750 MG tablet Take 1 tablet by mouth 3 (three) times daily as needed (back pain). 30 tablet 1
• Multiple Vitamin (MULTIVITAMIN PO) Take by mouth.
• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth 2 (two) times daily as needed (mild headache). 90 tablet 1
• sertraline (ZOLOFT) 50 MG tablet Take 1 tablet by mouth daily. 90 tablet 1

Patient Care Team:

Bryant, Jing, MD as PCP - General (Family Medicine)
Hopper, Jason A, MD (Cardiology)
Meiers, Henry N, MD (Urology)

Objective:

Vitals:
04/14/22 0843
BP: (!) 130/90
Pulse: (!) 108
Temp: 97.8 °F (36.6 °C)
TempSrc: Temporal
SpO2: 97%
Weight: 102.5 kg (225 lb 15.5 oz)
Height: 6' 1" (185.4 cm)

Physical Exam
Vitals and nursing note reviewed.
Constitutional:
General: He is not in acute distress.
Appearance: Normal appearance.
Cardiovascular:
Rate and Rhythm: Regular rhythm.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal. No respiratory distress.
Breath sounds: Normal breath sounds.
Neurological:
Mental Status: He is alert and oriented to person, place, and time.
Psychiatric:
Mood and Affect: Mood normal.
Behavior: Behavior normal.
Thought Content: Thought content normal.
Judgment: Judgment normal.

Recent Results (from the past 24 hour(s))

POCT Urine Drug Test
Collection Time: 04/14/22 8:50 AM
Result Value Ref Range
AMP Amphetamine -Urine Screen Positive (A) Negative
BAR Barbiturate-Urine Screen Negative Negative
BUP Buprenorphine-Urine Screen Negative Negative
BZO Benzodiazepine Screen-Urine Negative Negative
COC Cocaine-Urine Screen Negative Negative
MDMA-Urine Screen Negative Negative
MET Methamphetamine Screen Urine Negative Negative
MOP Opiates-Urine Negative Negative
MTD Methadone Screen-Urine Negative Negative
OXY Oxycodone-Urine Screen Negative Negative
PCP-Urine Screen Negative Negative
THC Cannabinoids-Urine Screen Negative Negative
Internal QC Yes
Lot Number w51210507

PHQ 9
Little interest or pleasure in doing things?: (!) More than half the days
Feeling down, depressed or hopeless?: Several days
Trouble falling or staying asleep, or too much sleep?: (!) More than half the days
Feeling tired or having little energy?: (!) More than half the days
Poor appetite or overeating?: (!) More than half the days
Feeling bad about yourself?: (!) More than half the days
Trouble concentrating on things?: Several days
Moving or speaking slowly?: (!) More than half the days
Thoughts that you would be better off dead?: Several days
PHQ9 Score: 15
Score interpretation: Moderately Severe

GAD 7
Feeling nervous, anxious, or on edge: Over half the days
Not being able to stop or control worrying: Several days
Worrying too much about different things: Over half the days
Trouble relaxing: Several days
Being so restless that it's hard to sit still: Over half the days
Becoming easily annoyed or irritable: Over half the days
Feeling afraid as if something awful might happen: Several days
GAD-7 Total Score: 11
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get
along with other people?: Very difficult

His PHQ-9 was 13, GAD was 14 in 2/2022

Assessment and Plan:

Ryan was seen today for office visit.

Diagnoses and all orders for this visit:

HTN, goal below 130/80

- lisinopril (PRINIVIL) 20 MG tablet; Take 1 tablet by mouth daily.

Microalbuminuria absent

Attention deficit disorder, unspecified hyperactivity presence

High risk medications (not anticoagulants) long-term use

- POCT Urine Drug Test

Depression with anxiety

Chronic right-sided low back pain without sciatica

- methocarbamol (ROBAXIN) 750 MG tablet; Take 1 tablet by mouth 3 (three) times daily as needed (back pain).

HTN without microalbuminuria: will start 20 mg lisinopril.

Hypertension educational materials and blood pressure tracker are printed out and handed to the patient today if requested;
also available in after visit summary.
Continue life style modifications including diet (low-fat, low sodium), exercise and weight control.

ADD: doing well on 30 mg Adderall bid; continue.

Discussed diagnosis, treatment options, risks and benefits, alternate therapies. Patient agreeable to treatment and understands
risks and benefits of treatment plan. Informed consent was obtained and in file. Patient's signed contract is in file; his UDS was
consistent with history today; KASPER (from Appriss) showed no irregularity. Patient is advised not to drive or operate machinery
under the influence of sedating medications, and to avoid alcohol and illicit drug use.
May call for 3 refills.

Depression with anxiety: he reports doing well on 50 mg Zoloft and would like to stay on this dose at this time.

Lower back pain: refilled Robaxin.

Return in about 3 months (around 7/14/2022) for HTN, ADHD med refill, bring your blood pressure cuff and reading log.
Electronically signed by Jing Bryant at 04/14/2022 1:31 PM EDT

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
HTN, goal below 130/80 - Primary
Microalbuminuria absent
High risk medications (not anticoagulants) long-term use
Chronic right-sided low back pain without sciatica
Care Teams - documented as of this encounter
Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Apr. 14, 2022
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Apr. 14, 2022
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason Onset Date
Medication Refill 04/01/2022

Encounter Details
Date Type Department Care Team Description
04/01/2022 Refill Norton Community Medical Melanie C
Associates - Brownsboro
9880 Angie's Way
Suite 410
LOUISVILLE, KY 40241-2850
502-394-6600

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 10/21/2021 04/01/2022 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 1 02/28/2022 09/07/2022 Discontinued
tablet daily.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 90 tablet 1 03/02/2022 05/31/2022 Discontinued
MG tablet (two) times daily as
needed (mild headache).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 03/25/2022 05/03/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 04/01/2022 04/14/2022 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 3 02/02/2022

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

Last Filed Vital Signs - documented in this encounter

Not on file

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 04/01/2022 04/14/2022
750 MG tablet (three) times daily as needed
(back pain).

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
Chronic right-sided low back pain without sciatica
Care Teams - documented as of this encounter
Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Apr. 01, 2022 - Apr. 04, 2022
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Melanie C (Attending) Apr. 01, 2022

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason Onset Date
Medication Questions 04/01/2022

Encounter Details
Date Type Department Care Team Description
04/01/2022 Telephone Norton Community Medical Jing Bryant
Associates - Brownsboro 9880 Angie's Way
9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 10/21/2021 04/01/2022 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 1 02/28/2022 09/07/2022 Discontinued
tablet daily.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 90 tablet 1 03/02/2022 05/31/2022 Discontinued
MG tablet (two) times daily as
needed (mild headache).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 03/25/2022 05/03/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020
Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)
Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 3 02/02/2022

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

Last Filed Vital Signs - documented in this encounter

Not on file

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)
Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Apr. 01, 2022
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Apr. 01, 2022
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason Onset Date
Medication Questions 03/02/2022

Encounter Details
Date Type Department Care Team Description
03/02/2022 Telephone Norton Community Medical Jing Bryant
Associates - Brownsboro 9880 Angie's Way
9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 10/21/2021 04/01/2022 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 3 12/29/2021 03/02/2022 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 02/28/2022 03/25/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 90 tablet 1 02/28/2022 09/07/2022 Discontinued
tablet daily.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 90 tablet 1 03/02/2022 05/31/2022 Discontinued
MG tablet (two) times daily as
needed (mild headache).
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 3 02/02/2022

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who Yes 2/2/2022 9:18 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Not on file

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 (two) 90 tablet 1 03/02/2022 05/31/2022
MG tablet times daily as needed (mild
headache).

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file
Visit Diagnoses - documented in this encounter
Diagnosis
Headache disorder

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Mar. 02, 2022
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Mar. 02, 2022
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
Office Visit

Encounter Details
Date Type Department Care Team Description
02/02/2022 Office Visit Norton Community Medical Jing Bryant
11:00 AM Associates - Brownsboro 9880 Angie's Way
EST 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 10/21/2021 04/01/2022 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 12/27/2021 02/02/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 3 12/29/2021 03/02/2022 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth 30 tablet 1 02/02/2022 02/28/2022 Discontinued
tablet daily. (Reorder)
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 02/02/2022 02/28/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Tobacco Cessation: Counseling Given: Yes

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 3 02/02/2022

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who Yes 2/2/2022 9:18 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 144/94 02/02/2022 11:10 AM EST
Pulse 77 02/02/2022 11:10 AM EST
Temperature 36.4 °C (97.6 °F) 02/02/2022 11:10 AM EST
Respiratory Rate - -
Oxygen Saturation 99% 02/02/2022 11:10 AM EST
Inhaled Oxygen Concentration - -
Weight 101.3 kg (223 lb 5.2 oz) 02/02/2022 11:10 AM EST
Height 185.4 cm (6' 1") 02/02/2022 11:10 AM EST
Body Mass Index 29.46 02/02/2022 11:10 AM EST

Patient Instructions - documented in this encounter

Patient Instructions
Jing Bryant - 02/02/2022 11:22 AM EST
Formatting of this note is different from the original.

It was nice seeing you today! I hope that your visit today was a positive one. I'd appreciate any feedback you may have through
our online feedback form/survey, so that I can do my best to continue to provide the best care.
------------------------------------------------------------------------

Please take your ADHD medication as directed.

Please call our office 7 days ahead for your refills.

Follow up in 3 months for ADHD medication refill.

Please monitor your blood pressure and heart rate (pulse) 3-4 times a week, and record your readings. Your goal is to have your
blood pressure below 140/90, and your heart rate (pulse) in between 60 - 90.

You may download the free app called "Blood Pressure Journal" to your smart device for your blood pressure log.

For colds and congestion, be careful about using over the counter medications. It is safe to use medication from the
CoricidinHBP line.
See coricidinhbp.com.

Follow up in 3 months for blood pressure check.

Blood Pressure Tracking Chart

Date Systolic Diastolic Pulse (heart rate) Date Systolic Diastolic Pulse (heart rate)

Hypertension
GENERAL INFORMATION:
What is hypertension? Hypertension is high blood pressure (BP). Your BP is the force of your blood moving against the walls of
your arteries. Normal BP is less than 120/80. Prehypertension is between 120/80 and 139/89. Hypertension is 140/90 or higher.
Hypertension causes your BP to get so high that your heart has to work much harder than normal. This can cause damage to
your heart. Hypertension is a long-term condition that you will need to control with a healthy lifestyle or medicines. A controlled
blood pressure helps protect your organs, such as your heart, lungs, brain, and kidneys.
What causes hypertension? The cause of hypertension may not be known. This type of hypertension is called essential or
primary hypertension. Hypertension can sometimes be caused by other medical conditions, such as kidney disease. This type of
hypertension is called secondary hypertension.
What increases my risk for hypertension?
· For men, being older than 55 years, and for women, being older than 65 years

· Family history of hypertension or heart disease

· Obesity or lack of exercise

· Too many high-sodium foods

· Stress

· Use of tobacco, alcohol, or illegal drugs

· Medical conditions, such as diabetes, high cholesterol, kidney disease, thyroid disease, or adrenal gland disorder

· Certain medicines, such as steroids or birth control pills

What are the signs and symptoms of hypertension? You may have no signs or symptoms, or you may have any of the following:
· Headache

· Blurred vision

· Chest pain

· Dizziness or weakness

· Trouble breathing
· Nosebleeds
How is hypertension diagnosed? Your healthcare provider will ask about your symptoms and the medicines you take. He will also
ask if you have a family history of hypertension and about any health conditions you have. He will check your BP and weight and
examine your heart, lungs, and eyes. You may need any of the following tests:
· Blood tests may help healthcare providers find the cause of your hypertension. Blood tests can also help find other health
problems caused by hypertension.

· Urine tests will be done to check your kidneys.

· An EKG records the electrical activity of your heart. It is used to check your heart rhythm or other problems caused by
hypertension.
How is hypertension treated? Your healthcare provider will recommend lifestyle changes to lower your BP. You may also need the
following medicines:
· Blood pressure medicine helps lower your blood pressure. You may need more than one type of blood pressure medicine. Take
your blood pressure medicine exactly as directed.

· Diuretics help decrease extra fluid that collects in your body. This will help lower your BP. You may urinate more often while you
take this medicine.
How do I check my BP at home? Sit and rest for 5 minutes before you take your BP. Extend your arm and support it on a flat
surface. Your arm should be at the same level as your heart. Follow the directions that came with your BP monitor. If possible,
take at least 2 BP readings each time. Take your BP at least twice a day at the same times each day, such as morning and
evening. Keep a log of your BP readings and bring it to your follow-up visits. Ask your healthcare provider what your BP should
be.
How can I manage my hypertension? Talk with your healthcare provider about these and other lifestyle changes you can make to
manage your hypertension:
· Eat less sodium (salt). Do not add salt to your food. Limit foods that are high in sodium, such as canned foods, potato chips,
and cold cuts. Your healthcare provider may suggest that you follow the DASH Eating Plan. The plan is low in sodium, unhealthy
fats, and total fat. It is high in potassium, calcium, and fiber. You get these nutrients by eating more fruits, vegetables, and whole
grains. Ask your healthcare provider or dietitian which meal plan you should follow.

· Exercise to maintain a healthy weight. Exercise at least 30 minutes per day, on most days of the week. This will help decrease
your BP. Ask your healthcare provider about the best exercise plan for you.

· Limit alcohol. Women should limit alcohol to 1 drink a day. Men should limit alcohol to 2 drinks a day. A drink of alcohol is 12
ounces of beer, 5 ounces of wine, or 1½ ounces of liquor.

· Do not smoke. If you smoke, it is never too late to quit. Smoking can increase your BP. Smoking also worsens other health
conditions you may have that can increase your risk for hypertension. Ask your healthcare provider for information if you need
help quitting.

· Manage any other health conditions you have. Health conditions such as diabetes can increase your risk for hypertension.
Follow your healthcare provider's instructions and take all your medicines as directed.

· Decrease stress. This may help lower your BP. Learn ways to relax, such as deep breathing or listening to music.
What are the risks of hypertension? Without treatment, you may develop other health problems over time. You may lose vision
in one or both eyes. You may develop heart and blood vessel disease. This increases your risk of a heart attack, stroke, heart
failure, or kidney disease and can be life-threatening.
When should I contact my healthcare provider?
· You feel faint, dizzy, confused, or drowsy.

· You have been taking your BP medicine and your BP is still higher than your healthcare provider says it should be.

· You have questions or concerns about your condition or care.

When should I seek immediate care or call 911?
· You have a severe headache or vision loss.

· You have weakness in an arm or leg.

· You become confused or have difficulty speaking.

· You have discomfort in your chest that feels like squeezing, pressure, fullness, or pain.

· You suddenly feel lightheaded or have trouble breathing.

· You have pain or discomfort in your back, neck, jaw, stomach, or arm.
CARE AGREEMENT:
You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment
options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. The above
information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your
doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.
© 2014 Truven Health Analytics Inc. Information is for End User's use only and may not be sold, redistributed or otherwise used
for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or
Truven Health Analytics.

Electronically signed by Jing Bryant at 02/02/2022 5:06 PM EST

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
amphetamine- Take 1 tablet by mouth 2 (two) 60 tablet 0 02/02/2022 02/28/2022
dextroamphetamine times daily. Max Daily Amount:
(ADDERALL) 30 MG tablet 60 mg
sertraline (ZOLOFT) 50 MG Take 1 tablet by mouth daily. 30 tablet 1 02/02/2022 02/28/2022
tablet

Progress Notes - documented in this encounter

Jing Bryant - 02/02/2022 11:14 AM EST
Formatting of this note is different from the original.
Subjective:

Patient ID: Ryan S Gomez is a 38 yr/o male.

Chief Complaint
Patient presents with
• Office Visit

HPI

He was evaluated by Robert Watson, Psy. D, in 12/2020. Dr. Watson thinks that his untreated ADD might have caused his anxiety
and depression to certain degree. Dr. Watson recommended that patient should be treated for his ADD.

He was started on 36 mg Concerta with moderate response. He stated that the effects weans off after 8-9 hours. He was started
on 54 mg Concerta in 2/2021, then 72 mg; however, it didn't last long enough. We changed his Concerta to 20 mg Adderall bid
in 5/2021. Patient was doing well till late last year due to holiday hectic work schedule. We increased his Adderall from 20 mg
bid to 30 mg bid. He reports doing much better now. Denies tremor, palpitations, chest pain, sleeping trouble, headache.
Appetite normal. No weight loss. Patient is adherent with follow up visits with being on a controlled medication. He does take
occational drug holidays. Last refill 12/27/2021.

He was found to have elevated BP of 148/100 in 11/2020. He has no microalbuminuria. His

Thyroid Stimulating Hormone (TSH)3rd Gen (u(iU)/mL)

Date Value
11/25/2020 1.030

Free T4 (ng/dL)
Date Value
11/25/2020 1.22

He has been having neck and back pain issues, managed by his specialist now.

He reports having depression for years. His wife thinks that he should take "Prozac". Denies SI/HI. He is OK to start a medication
at this time.

The following portions of the patient's history were reviewed and updated as appropriate:
He has a past medical history of ADD (attention deficit disorder) and Elevated LFTs (11/28/2020).
He does not have any pertinent problems on file.
He has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).
His family history includes ADD / ADHD in his daughter; Heart disease in his father, maternal grandfather, maternal grandmother,
and maternal uncle; Hypertension in his father, maternal grandfather, maternal grandmother, and maternal uncle; Thyroid disease
in his sister.
He reports that he quit smoking about 3 years ago. His smoking use included cigars. He smoked 0.25 packs per day. He has
never used smokeless tobacco. He reports current alcohol use of about 1.0 standard drink of alcohol per week. He reports that
he does not use drugs.
He has No Known Allergies..

Review of Systems
Constitutional: Negative for chills, fatigue, fever and unexpected weight change.
Cardiovascular: Negative for chest pain and palpitations.
Neurological: Negative for dizziness and headaches.
Psychiatric/Behavioral: Positive for decreased concentration, dysphoric mood and sleep disturbance. Negative for suicidal ideas.
The patient is nervous/anxious.

Outpatient Medications Marked as Taking for the 2/2/22 encounter (Office Visit) with Bryant, Jing, MD
Medication Sig Dispense Refill
• amphetamine-dextroamphetamine (ADDERALL) 30 MG tablet Take 1 tablet by mouth 2 (two) times daily. Max Daily Amount: 60
mg 60 tablet 0
• methocarbamol (ROBAXIN) 750 MG tablet Take 1 tablet by mouth 3 (three) times daily as needed (back pain). 30 tablet 1
• Multiple Vitamin (MULTIVITAMIN PO) Take by mouth.
• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth 2 (two) times daily as needed (mild headache). 30 tablet 3

Patient Care Team:

Bryant, Jing, MD as PCP - General (Family Medicine)
Hopper, Jason A, MD (Cardiology)
Meiers, Henry N, MD (Urology)

Objective:

Vitals:
02/02/22 1110
BP: (!) 144/94
Pulse: 77
Temp: 97.6 °F (36.4 °C)
TempSrc: Temporal
SpO2: 99%
Weight: 101.3 kg (223 lb 5.2 oz)
Height: 6' 1" (185.4 cm)

Physical Exam
Vitals and nursing note reviewed.
Constitutional:
General: He is not in acute distress.
Appearance: He is well-developed.
HENT:
Head: Normocephalic and atraumatic.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Pulmonary:
Effort: Pulmonary effort is normal. No respiratory distress.
Neurological:
Mental Status: He is alert and oriented to person, place, and time.
Psychiatric:
Mood and Affect: Mood normal.
Behavior: Behavior normal.
Thought Content: Thought content normal.
Judgment: Judgment normal.

PHQ 9
Little interest or pleasure in doing things?: Several days
Feeling down, depressed or hopeless?: (!) More than half the days
Trouble falling or staying asleep, or too much sleep?: (!) More than half the days
Feeling tired or having little energy?: (!) More than half the days
Poor appetite or overeating?: (!) Nearly every day
Feeling bad about yourself?: (!) More than half the days
Trouble concentrating on things?: Several days
Moving or speaking slowly?: Not at all
Thoughts that you would be better off dead?: Not at all
PHQ9 Score: 13
Score interpretation: Moderate

GAD 7
Feeling nervous, anxious, or on edge: Nearly every day
Not being able to stop or control worrying: Over half the days
Worrying too much about different things: Over half the days
Trouble relaxing: Nearly every day
Being so restless that it's hard to sit still: Over half the days
Becoming easily annoyed or irritable: Several days
Feeling afraid as if something awful might happen: Several days
GAD-7 Total Score: 14
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get
along with other people?: Somewhat difficult

Assessment and Plan:

Ryan was seen today for office visit.

Diagnoses and all orders for this visit:

Attention deficit disorder, unspecified hyperactivity presence

- amphetamine-dextroamphetamine (ADDERALL) 30 MG tablet; Take 1 tablet by mouth 2 (two) times daily. Max Daily Amount:
60 mg

Elevated blood pressure reading without diagnosis of hypertension

Microalbuminuria absent

Depression with anxiety

- sertraline (ZOLOFT) 50 MG tablet; Take 1 tablet by mouth daily.

ADD: doing well on 30 mg Adderall bid; continue.

Discussed diagnosis, treatment options, risks and benefits, alternate therapies. Patient agreeable to treatment and understands
risks and benefits of treatment plan. Informed consent was obtained and in file. Patient's signed contract is in file; his UDS was
consistent with history today; KASPER (from Appriss) showed no irregularity. Patient is advised not to drive or operate machinery
under the influence of sedating medications, and to avoid alcohol and illicit drug use.

Elevated BP without microalbuminuria: BP is elevated today.

He does have back pain that is being managed by specialist.
Monitor for now.

Depression with anxiety: for years.

Will try 50 mg Zoloft and titrate up as needed.

Return in about 10 weeks (around 4/13/2022) for ADHD med refill, HTN, depression.
Electronically signed by Jing Bryant at 02/02/2022 5:06 PM EST

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
Elevated blood pressure reading without diagnosis of hypertension
Microalbuminuria absent
Care Teams - documented as of this encounter
Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Feb. 02, 2022
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Feb. 02, 2022
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
Office Visit

Encounter Details
Date Type Department Care Team Description
02/02/2022 Office Visit Norton Neuroscience Institute Sara Seifert
9:15 AM 4915 Norton Healthcare Blvd 4915 Norton Healthcare Blvd
EST Suite 301 #301
Louisville, KY 40241-2860 Louisville, KY 40241
502-394-6390 502-394-6390 (Work)
502-394-6388 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 10/21/2021 04/01/2022 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 12/27/2021 02/02/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 3 12/29/2021 03/02/2022 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Chronic neck pain 02/02/2022
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020
Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)
Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

PHQ-2 Answer Date Recorded

PHQ2 (SDOH) SCORE 3 02/02/2022

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who Yes 2/2/2022 9:18 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 148/92 02/02/2022 9:30 AM EST
Pulse - -
Temperature - -
Respiratory Rate - -
Oxygen Saturation - -
Inhaled Oxygen Concentration - -
Weight 101 kg (222 lb 10.6 oz) 02/02/2022 9:30 AM EST
Height 185.4 cm (6' 1") 02/02/2022 9:30 AM EST
Body Mass Index 29.38 02/02/2022 9:30 AM EST

Progress Notes - documented in this encounter

Sara Seifert - 02/02/2022 9:55 AM EST
Formatting of this note is different from the original.
Images from the original note were not included.

NEUROSURGERY OFFICE FOLLOW-UP VISIT

Patient Identification:
Ryan S Gomez
11/11/1983, 38 yr/o
EP01611383
Bryant, Jing, MD
No att. providers found

PCP: Bryant, Jing, MD

CHIEF COMPLAINT: Follow up after PT.
Chief Complaint
Patient presents with
• Office Visit
f/u 1 month

HPI:
Ryan S Gomez is a 38 yr/o male who came back today to follow up after referral to PT for neck and back pain.

PAST MEDICAL HISTORY

Past Medical History:
Diagnosis Date
• ADD (attention deficit disorder)
when he was a kid, on Ritalin but "made worse"
• Elevated LFTs 11/28/2020
11/2020: ALT 77, alk phos 131.

PAST SURGICAL HISTORY

has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).

ALLERGIES
Allergies as of 2/2/2022 Review status set to Review Complete by Seifert, Sara, PA-C on 2/2/2022
No Known Allergies

MEDICATIONS
Current Outpatient Medications
Medication Sig Dispense Refill
• amphetamine-dextroamphetamine (ADDERALL) 30 MG tablet Take 1 tablet by mouth 2 (two) times daily. Max Daily Amount: 60
mg 60 tablet 0
• methocarbamol (ROBAXIN) 750 MG tablet Take 1 tablet by mouth 3 (three) times daily as needed (back pain). 30 tablet 1
• Multiple Vitamin (MULTIVITAMIN PO) Take by mouth.
• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth 2 (two) times daily as needed (mild headache). 30 tablet 3

No current facility-administered medications for this visit.

FAMILY HISTORY
Family History
Problem Relation Age of Onset
• Heart disease Father
• Hypertension Father
• Heart disease Maternal Grandmother
• Hypertension Maternal Grandmother
• Heart disease Maternal Grandfather
• Hypertension Maternal Grandfather
• ADD / ADHD Daughter
• Heart disease Maternal Uncle
• Hypertension Maternal Uncle
• Thyroid disease Sister
hyperthyroid
• Cancer, Other or Unknown Type Neg Hx
• Diabetes Neg Hx

SOCIAL HISTORY
Social History

Tobacco Use
Smoking Status Former Smoker
• Packs/day: 0.25
• Types: Cigars
• Quit date: 01/2019
• Years since quitting: 3.0
Smokeless Tobacco Never Used
Tobacco Comment
cigars infrequently: more social

Social History

Substance and Sexual Activity

Alcohol Use Yes
• Alcohol/week: 1.0 standard drink
• Types: 1 Glasses of wine per week
Comment: every other day

REVIEW OF SYSTEMS

The following systems were reviewed with the patient: constitutional; eyes; ears, nose mouth and throat; respiratory; cardiac and
vascular; GI; GU; musculoskeletal; skin; psychiatric; neurological; hematological and lymphatic. Other than as noted above and as
will follow, all systems are negative.

PHYSICAL EXAMINATION:
Constitutional: 38yo male in no apparent distress. Well-nourished, well-groomed, appears stated age.

VITAL SIGNS: BP (!) 148/92 (BP Location: Right arm, Orthostatic Position: Sitting) | Ht 6' 1" (185.4 cm) | Wt 101 kg (222 lb 10.6 oz)
| BMI 29.38 kg/m²

Head: normocephalic, atraumatic

Eyes: no scleral icterus, conjunctiva clear, PERRL, EOMI

Neurological Examination:

Orientation: The patient is awake, alert, oriented to person, place, and time.
Attention Span and Concentration: Can follow complex multi-stepped commands.

Cranial Nerve II: The pupils are equal, round and reactive to light.
Cranial Nerves III, IV, VI: EOM intact
Cranial Nerve VIII: Hearing is intact
Cranial Nerve XI: Shoulder shrug is equal and symmetric

Musculoskeletal:
Motor: Tone was normal in all four extremities. There were no abnormal movements. Strength was 5/5 in bilateral upper and
lower extremities

Sensory: Intact to light touch throughout bilateral upper and lower extremities

Respiratory: normal effort, no use of accessory muscles, speaks in full sentences without pause

Cardiovascular: Dorsalis Pedal pulses 2+ and symmetric

Skin: no obvious skin lesions, warm, dry

RADIOGRAPHIC IMAGING: none

ASSESSMENT/PLAN
Ryan was seen today for office visit.

Diagnoses and all orders for this visit:

Chronic bilateral low back pain without sciatica

Chronic neck pain

Mr. Gomez is a 38yo male on no AC/AP medication who was referred to us by Dr. Bryant for chronic neck and back pain that
began 9 yrs ago after trying to move a heavy object up some stairs. The pain has been worse the past 2 yrs. The pain will come
and go but he has had a severe episode every few weeks to one month. The pain improves with muscle relaxers and pain
medications. The pain is localized to the posterior neck and R side of the low back. He denies any significant radicular pain. He
does notice some improvement with naprosyn and robaxin.

No deficits on exam.

Last time he was here I referred him to physical therapy. Unfortunately he has only been able to complete 3 sessions of PT due
to a recent Covid infection. He is hopeful that therapy will help and understands that he needs to give it more time. He will
complete a full 4 to 6-week course of PT and call if the pain does not improve. At that point we would order a cervical and
lumbar spine MRI and have him return thereafter. He will also call sooner with questions or concerns.

Electronically signed by:

Sara Seifert, PA-C
2/2/2022
9:57 AM
Electronically signed by Sara Seifert at 02/02/2022 9:59 AM EST

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
Chronic bilateral low back pain without sciatica - Primary
Chronic neck pain

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Feb. 02, 2022
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Sara Seifert (Attending) Feb. 02, 2022
NPI: 1790776102
502-394-6390 (Work)
502-394-6388 (Fax)
4915 Norton Healthcare Blvd #301
Louisville, KY 40241
Physician Assistant-Surgery

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
New Patient

Consultation (Routine) - Closed

Specialty Diagnoses / Procedures Referred By Contact Referred To Contact
Physician Assistant-Surgery / Diagnoses Jing Bryant Nps Nnik Obc
Neurosurgery Neck pain 9880 Angie's Way 4950 Norton Healthcare Blvd
Chronic bilateral low back STE 410 Suite 205
pain, unspecified whether Louisville, KY 40241 Louisville, KY 40241-2847
sciatica present Phone: 502-394-6000 Phone: 502-394-6390
Fax: 502-394-3689 Fax: 502-394-6388

Expiration Visits Visits

Referral ID Status Reason Start Date Date Requested Authorized
30938112 Closed 11/22/2021 12/23/2022 1 1

Encounter Details
Date Type Department Care Team Description
01/04/2022 Office Visit Norton Neuroscience Institute Sara Seifert
10:30 AM 4915 Norton Healthcare Blvd 4915 Norton Healthcare Blvd
EST Suite 301 #301
Louisville, KY 40241-2860 Louisville, KY 40241
502-394-6390 502-394-6390 (Work)
502-394-6388 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies
Medications - documented as of this encounter (statuses as of 09/29/2023)
Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 10/21/2021 04/01/2022 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
sertraline (ZOLOFT) 25 MG daily. 0 01/04/2022 Discontinued
tablet
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 12/27/2021 02/02/2022 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 3 12/29/2021 03/02/2022 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Prediabetes 11/24/2021
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 1/4/2022 10:40 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?
Last Filed Vital Signs - documented in this encounter
Vital Sign Reading Time Taken Comments
Blood Pressure 154/92 01/04/2022 10:45 AM EST
Pulse - -
Temperature - -
Respiratory Rate - -
Oxygen Saturation - -
Inhaled Oxygen Concentration - -
Weight 103.3 kg (227 lb 11.8 oz) 01/04/2022 10:45 AM EST
Height 185.4 cm (6' 1") 01/04/2022 10:45 AM EST
Body Mass Index 30.05 01/04/2022 10:45 AM EST

Progress Notes - documented in this encounter

Sara Seifert - 01/04/2022 11:02 AM EST
Formatting of this note is different from the original.
NEUROSURGERY OFFICE NOTE
Patient Identification:
Ryan S Gomez
11/11/1983, 38 yr/o
EP01611383
Bryant, Jing, MD
No att. providers found

CHIEF COMPLAINT
Chief Complaint
Patient presents with
• New Patient
neck pain/ bilateral low back pain
CC: Chronic neck and back pain

HISTORY OF PRESENT ILLNESS

It was a pleasure visiting with Ryan S Gomez in my Neurosurgery clinic today, as you know Ryan S Gomez is a very pleasant 38
yr/o male who presents to my clinic with neck and low back pain. Location: posterior C spine, R side of low lumbar region, Onset:
9 yrs, Duration:same, Timing:intermittent, Severity:moderate to severe, Alleviating/Exacerbating Factors: none.

PAST MEDICAL HISTORY

Past Medical History:
Diagnosis Date
• ADD (attention deficit disorder)
when he was a kid, on Ritalin but "made worse"
• Elevated LFTs 11/28/2020
11/2020: ALT 77, alk phos 131.

PAST SURGICAL HISTORY

has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).

ALLERGIES
Allergies as of 1/4/2022 Review status set to Review Complete by Seifert, Sara, PA-C on 1/4/2022
No Known Allergies

MEDICATIONS
Current Outpatient Medications
Medication Sig Dispense Refill
• amphetamine-dextroamphetamine (ADDERALL) 30 MG tablet Take 1 tablet by mouth 2 (two) times daily. Max Daily Amount: 60
mg 60 tablet 0
• methocarbamol (ROBAXIN) 750 MG tablet Take 1 tablet by mouth 3 (three) times daily as needed (back pain). 30 tablet 1
• Multiple Vitamin (MULTIVITAMIN PO) Take by mouth.
• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth 2 (two) times daily as needed (mild headache). 30 tablet 3

No current facility-administered medications for this visit.

IMMUNIZATIONS
Immunization History
See Immunization Record
FAMILY HISTORY
Family History
Problem Relation Age of Onset
• Heart disease Father
• Hypertension Father
• Heart disease Maternal Grandmother
• Hypertension Maternal Grandmother
• Heart disease Maternal Grandfather
• Hypertension Maternal Grandfather
• ADD / ADHD Daughter
• Heart disease Maternal Uncle
• Hypertension Maternal Uncle
• Thyroid disease Sister
hyperthyroid
• Cancer, Other or Unknown Type Neg Hx
• Diabetes Neg Hx

SOCIAL HISTORY
Social History

Tobacco Use
Smoking Status Former Smoker
• Packs/day: 0.25
• Types: Cigars
• Quit date: 01/2019
• Years since quitting: 3.0
Smokeless Tobacco Never Used
Tobacco Comment
cigars infrequently: more social

Social History

Substance and Sexual Activity

Alcohol Use Yes
• Alcohol/week: 1.0 standard drink
• Types: 1 Glasses of wine per week
Comment: every other day

REVIEW OF SYSTEMS
The following systems were reviewed with the patient: constitutional; eyes; ears, nose mouth and throat; respiratory; cardiac and
vascular; GI; GU; musculoskeletal; skin; psychiatric; neurological; hematological and lymphatic. Other than as noted above and as
will follow, all systems are negative.

PHYSICAL EXAMINATION
Vital Signs: BP (!) 154/92 | Ht 6' 1" (185.4 cm) | Wt 103.3 kg (227 lb 11.8 oz) | BMI 30.05 kg/m²

Constitutional: 38yo male in no apparent distress.

Mental status: The patient is awake and alert, oriented to person, place and time.

Cognitive Function: Recent and remote memory appear appropriate for age; concentration and attention span appropriate for
age; fund of knowledge normal for patient's age and stated education.

Speech: No word-finding difficulty. Language is fluent.

Cranial Nerves:
2:Visual fields intact to gross confrontation, PERRL.
3,4,6:EOMI.
8: Hearing intact
11: Shoulder shrug equal and symmetric.

Sensation:
In the upper and lower extremities bilaterally, Light touch intact in all dermatomes tested

Reflexes: 2+ and symmetric in bilateral UE's and LE's, no long tract signs

Musculoskeletal:
Muscle Strength:
Bicep (C5, C6): Right 5/5 and Left 5/5
Triceps (C7): Right 5/5 and Left 5/5
Hand Intrinsic (C8): Right 5/5 and Left 5/5

Hip adduction (L2, L3): Right 5/5 and Left 5/5

Quadriceps (L4): Right 5/5 and Left 5/5
Dorsiflexion and EHL (L5): Right 5/5 and Left 5/5
Plantar flexion (S1): Right 5/5 and Left 5/5

Tone/Bulk: Normal in arm and legs bilaterally.

Station and Gait: Gait stable and normal, stable stance.

Cardiovascular: Equal and symmetric distal pulses in all extremities.

Respiratory: normal effort, no use of accessory muscles, speaks in full sentences without pause. No signs of respiratory distress

RADIOGRAPHIC IMAGING:I did review the L spine XR from 1/18/21 which were unremarkable.

ASSESSMENT
Ryan was seen today for new patient.

Diagnoses and all orders for this visit:

Chronic neck pain

Chronic bilateral low back pain without sciatica

PLAN
Mr. Gomez is a 38yo male on no AC/AP medication who was referred to us by Dr. Bryant for chronic neck and back pain that
began 9 yrs ago after trying to move a heavy object up some stairs. The pain has been worse the past 2 yrs. The pain will come
and go but he has had a severe episode every few weeks to one month. The pain improves with muscle relaxers and pain
medications. The pain is localized to the posterior neck and R side of the low back. He denies any significant radicular pain. He
has only had one session of PT in the past. He does notice some improvement with naprosyn and robaxin.

No deficits on exam.

I did review the XR from one year ago of the L spine. Those looked unremarkable. We did discuss the nature of musculoskeletal
pain as well as early degenerative changes to the spine. I recommended PT for core strengthening and improved flexibility. We
will avoid additional anti-inflammatories since his BP is not currently well controlled. He will f/u after 4-6wks. If the pain has not
improved we can consider MRIs.

Electronically signed by:

Sara Seifert, PA-C
1/4/2022
11:06 AM
Electronically signed by Sara Seifert at 01/04/2022 11:27 AM EST

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
Chronic neck pain - Primary
Chronic bilateral low back pain without sciatica
Care Teams - documented as of this encounter
Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Jan. 04, 2022
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Sara Seifert (Attending) Jan. 04, 2022
NPI: 1790776102
502-394-6390 (Work)
502-394-6388 (Fax)
4915 Norton Healthcare Blvd #301
Louisville, KY 40241
Physician Assistant-Surgery

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
Annual Exam

Encounter Details
Date Type Department Care Team Description
11/22/2021 Office Visit Norton Community Medical Jing Bryant
10:40 AM Associates - Brownsboro 9880 Angie's Way
EST 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 10/21/2021 04/01/2022 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 1 10/21/2021 12/28/2021 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 11/19/2021 11/22/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 20 MG tablet Daily Amount: 40 mg
sertraline (ZOLOFT) 25 MG daily. 0 01/04/2022 Discontinued
tablet
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 11/22/2021 12/24/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 30 MG tablet Daily Amount: 60 mg

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Chronic bilateral low back pain 11/22/2021
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020
Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)
Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Former Cigarettes 0.3 Quit: 01/2019
Cigars
Smokeless Tobacco: Never

Tobacco Cessation: Counseling Given: Yes

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 11/22/2021 10:47 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 118/76 11/22/2021 10:55 AM EST
Pulse 76 11/22/2021 10:55 AM EST
Temperature 36.6 °C (97.8 °F) 11/22/2021 10:55 AM EST
Respiratory Rate - -
Oxygen Saturation 97% 11/22/2021 10:55 AM EST
Inhaled Oxygen Concentration - -
Weight 102.8 kg (226 lb 10.1 oz) 11/22/2021 10:55 AM EST
Height 185.4 cm (6' 1") 11/22/2021 10:55 AM EST
Body Mass Index 29.9 11/22/2021 10:55 AM EST

Patient Instructions - documented in this encounter

Patient Instructions
Jing Bryant - 11/22/2021 11:19 AM EST
Formatting of this note is different from the original.
Images from the original note were not included.

It was nice seeing you today! I hope that your visit today was a positive one. I'd appreciate any feedback you may have through
our online feedback form/survey, so that I can do my best to continue to provide the best care.
------------------------------------------------------------------------

Please take your ADHD medication as directed.

Please call our office 7 days ahead for your refills.

Follow up in 2 months for ADHD medication refill.

I will inform you of your lab results through Mychart once they are all back.

Continue to follow up with your specialist(s) as scheduled/needed.

For general health educational information, may check out familydoctor.org.

Return to our office in a year to review your health. We need to see you annually to prescribe any medications. If you have other
medical problems you may need to be seen sooner.

Maintain healthy life style, including: keep a healthy diet; exercise regularly (2 hours/week minimum); normalize your weight (BMI
less than 30), adequate sleep (7-8 hours per day). Remember: Eat healthy food, mostly vegetables, drink water, and exercise
more.

- Alcohol: consider holding Alcohol intake to less than 10 drinks a week. A drink is one 12 oz beer, a 4 oz glass of wine, or 1.5 oz
of liquor. Some patients should consider avoiding Alcohol entirely.

- Nutrition: "Eat healthy food, less of it, mostly vegetables". Avoid sweetened drinks and concentrated sugars. Limit "white" foods
like rice, bread and pasta.

Pain medications sold over-the-counter like ibuprofen (Motrin/Advil) and naproxen (Aleve) should be limited, they can cause
bleeding and kidney damage.

Pain & Cold medications sold over-the-counter that contain acetaminophen (Tylenol) can cause serious harm if not taken as
directed, particulalry to your liver.

Vaccinations: Make sure you get your Flu shot every year, if not contraindicated. Flu shots annually protect you AND our
community.

Vaccinations: Pneumonia shots usually happen at age 65. Smokers, diabetics, and people with heart, lung or immune disease
may need them earlier.

Vaccinations: Shingles immunization usually happens at age 60. You may want to check your insurance coverage.

Vaccinations: Tetanus shots are needed every 10 years, and once as an adult you should get a Tetanus shot that boosts Pertussis
("whooping cough").

Please consider/ continue life style modifications including daily calcium (recommended 1200 mg dietary calcium daily) and
vitamin D (recommended 800 IU daily), with weight bearing exercise for your bone health.

Target Heart Rate: Google "Target Heart Rate" and click on the American Heart Association Link (likely first or second option).
That is where chart below was obtained from.

Age Target HR Zone 50-85% Average Maximum Heart Rate, 100%

20 years 100-170 beats per minute 200 beats per minute
30 years 95-162 beats per minute 190 beats per minute
35 years 93-157 beats per minute 185 beats per minute
40 years 90-153 beats per minute 180 beats per minute
45 years 88-149 beats per minute 175 beats per minute
50 years 85-145 beats per minute 170 beats per minute
55 years 83-140 beats per minute 165 beats per minute
60 years 80-136 beats per minute 160 beats per minute
65 years 78-132 beats per minute 155 beats per minute
70 years 75-128 beats per minute 150 beats per minute

Avoid all tobacco products and exposure to them both at home and at work.

Wear seatbelts whenever riding in a car or truck. Safety Belts used regularly save lives.

Apply sunscreen 30 minutes before exposure to the sun. Choose a sunscreen that screens out both UVA and UVB rays, with a sun
protection factor (SPF) of 15 or greater. Avoid tanning salons.

Twice yearly routine dental care is recommended. Brush and floss your teeth at least twice daily.

See the eye doctor every two years after you turn 40.

Follow up as needed for acute issues.

From 12 pm - 1 pm, no patients will be placed in exam rooms for appointments. This will ensure that providers and nurses/
medical assistants are able to eat lunch and catch up on any work from that morning. If you have an appointment at 11:40 am,
we ask that you arrive on or before your appointment time if possible. We understand that unforeseen circumstances occur. If at
all possible if you could call the office and inform the front desk, in which case we will try our best to accommodate you as much
as possible. (Please note that all phone lines will be open during this time)

Wellness Visit for Adults

WHAT YOU NEED TO KNOW:
What is a wellness visit? A wellness visit is when you see your healthcare provider to get screened for health problems. Your
healthcare provider will also give you advice on how to stay healthy. Write down your questions so you remember to ask them.
Ask your healthcare provider how often you should have a wellness visit.
What happens at a wellness visit? Your healthcare provider will ask about your health, and your family history of health
problems. This includes high blood pressure, heart disease, and cancer. He or she will ask if you have symptoms that concern
you, if you smoke, and about your mood. You may also be asked about your intake of medicines, supplements, food, and
alcohol. Any of the following may be done:
· Your weight will be checked. Your height may also be checked so your body mass index (BMI) can be calculated. Your BMI
shows if you are at a healthy weight.

· Your blood pressure and heart rate will be checked. Your temperature may also be checked.

· Blood and urine tests may be done. Blood tests may be done to check your cholesterol levels. Abnormal cholesterol levels
increase your risk for heart disease and stroke. You may also need a blood or urine test to check for diabetes if you are at
increased risk. Urine tests may be done to look for signs of an infection or kidney disease.

· A physical exam includes checking your heartbeat and lungs with a stethoscope. Your healthcare provider may also check your
skin to look for sun damage.

· Screening tests may be recommended. A screening test is done to check for diseases that may not cause symptoms. The
screening tests you may need depend on your age, gender, family history, and lifestyle habits. For example, colorectal screening
may be recommended if you are 50 years old or older.

What screening tests do I need if I am a woman?

· A Pap smear is used to screen for cervical cancer. Pap smears are usually done every 3 to 5 years depending on your age. You
may need them more often if you have had abnormal Pap smear test results in the past. Ask your healthcare provider how often
you should have a Pap smear.

· A mammogram is an x-ray of your breasts to screen for breast cancer. Experts recommend mammograms every 2 years starting
at age 50 years. You may need a mammogram at age 49 years or younger if you have an increased risk for breast cancer. Talk to
your healthcare provider about when you should start having mammograms and how often you need them.

What vaccines might I need?

· Get an influenza vaccine every year. The influenza vaccine protects you from the flu. Several types of viruses cause the flu. The
viruses change over time, so new vaccines are made each year.

· Get a tetanus-diphtheria (Td) booster vaccine every 10 years. This vaccine protects you against tetanus and diphtheria. Tetanus
is a severe infection that may cause painful muscle spasms and lockjaw. Diphtheria is a severe bacterial infection that causes a
thick covering in the back of your mouth and throat.

· Get a human papillomavirus (HPV) vaccine if you are female and aged 19 to 26 or male 19 to 21 and never received it. This
vaccine protects you from HPV infection. HPV is the most common infection spread by sexual contact. HPV may also cause
vaginal, penile, and anal cancers.

· Get a pneumococcal vaccine if you are aged 65 years or older. The pneumococcal vaccine is an injection given to protect you
from pneumococcal disease. Pneumococcal disease is an infection caused by pneumococcal bacteria. The infection may cause
pneumonia, meningitis, or an ear infection.

· Get a shingles vaccine if you are aged 60 or older, even if you have had shingles before. The shingles vaccine is an injection to
protect you from the varicella-zoster virus. This is the same virus that causes chickenpox. Shingles is a painful rash that develops
in people who had chickenpox or have been exposed to the virus.

How can I eat healthy? My Plate is a model for planning healthy meals. It shows the types and amounts of foods that should go
on your plate. Fruits and vegetables make up about half of your plate, and grains and protein make up the other half. A serving
of dairy is included on the side of your plate. The amount of calories and serving sizes you need depends on your age, gender,
weight, and height. Examples of healthy foods are listed below:
· Eat a variety of vegetables such as dark green, red, and orange vegetables. You can also include canned vegetables low in
sodium (salt) and frozen vegetables without added butter or sauces.

· Eat a variety of fresh fruits , canned fruit in 100% juice, frozen fruit, and dried fruit.

· Include whole grains. At least half of the grains you eat should be whole grains. Examples include whole-wheat bread, wheat
pasta, brown rice, and whole-grain cereals such as oatmeal.

· Eat a variety of protein foods such as seafood (fish and shellfish), lean meat, and poultry without skin (turkey and chicken).
Examples of lean meats include pork leg, shoulder, or tenderloin, and beef round, sirloin, tenderloin, and extra lean ground beef.
Other protein foods include eggs and egg substitutes, beans, peas, soy products, nuts, and seeds.

· Choose low-fat dairy products such as skim or 1% milk or low-fat yogurt, cheese, and cottage cheese.
· Limit unhealthy fats such as butter, hard margarine, and shortening.

How much exercise do I need? Exercise at least 30 minutes per day on most days of the week. Some examples of exercise
include walking, biking, dancing, and swimming. You can also fit in more physical activity by taking the stairs instead of the
elevator or parking farther away from stores. Include muscle strengthening activities 2 days each week. Regular exercise provides
many health benefits. It helps you manage your weight, and decreases your risk for type 2 diabetes, heart disease, stroke, and
high blood pressure. Exercise can also help improve your mood. Ask your healthcare provider about the best exercise plan for
you.
What are some general health and safety guidelines I should follow?
· Do not smoke. Nicotine and other chemicals in cigarettes and cigars can cause lung damage. Ask your healthcare provider for
information if you currently smoke and need help to quit. E-cigarettes or smokeless tobacco still contain nicotine. Talk to your
healthcare provider before you use these products.

· Limit alcohol. A drink of alcohol is 12 ounces of beer, 5 ounces of wine, or 1½ ounces of liquor.

· Lose weight, if needed. Being overweight increases your risk of certain health conditions. These include heart disease, high
blood pressure, type 2 diabetes, and certain types of cancer.

· Protect your skin. Do not sunbathe or use tanning beds. Use sunscreen with a SPF 15 or higher. Apply sunscreen at least 15
minutes before you go outside. Reapply sunscreen every 2 hours. Wear protective clothing, hats, and sunglasses when you are
outside.

· Drive safely. Always wear your seatbelt. Make sure everyone in your car wears a seatbelt. A seatbelt can save your life if you are
in an accident. Do not use your cell phone when you are driving. This could distract you and cause an accident. Pull over if you
need to make a call or send a text message.

· Practice safe sex. Use latex condoms if are sexually active and have more than one partner. Your healthcare provider may
recommend screening tests for sexually transmitted infections (STIs).

· Wear helmets, lifejackets, and protective gear. Always wear a helmet when you ride a bike or motorcycle, go skiing, or play
sports that could cause a head injury. Wear protective equipment when you play sports. Wear a lifejacket when you are on a
boat or doing water sports.

CARE AGREEMENT:
You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment
options with your healthcare providers to decide what care you want to receive. You always have the right to refuse treatment.
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments.
Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.
© Copyright IBM Corporation 2018 Information is for End User's use only and may not be sold, redistributed or otherwise used
for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or
IBM Watson Health

Electronically signed by Jing Bryant at 11/22/2021 2:41 PM EST

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
amphetamine- Take 1 tablet by mouth 2 (two) 60 tablet 0 11/22/2021 12/24/2021
dextroamphetamine times daily. Max Daily Amount:
(ADDERALL) 30 MG tablet 60 mg

Progress Notes - documented in this encounter

Jing Bryant - 11/22/2021 1:16 PM EST
Formatting of this note is different from the original.
Subjective:

Ryan S Gomez is a 38 yr/o male and is here for a comprehensive physical exam. The patient reports problems - back and neck
pain; ADD.

He was evaluated by Robert Watson, Psy. D, in 12/2020. Dr. Watson thinks that his untreated ADD might have caused his anxiety
and depression to certain degree. Dr. Watson recommended that patient should be treated for his ADD.

He was started on 36 mg Concerta with moderate response. He stated that the effects weans off after 8-9 hours. He was started
on 54 mg Concerta in 2/2021, then 72 mg; however, it didn't last long enough. We changed his Concerta to 20 mg Adderall bid
in 5/2021. Patient is doing well on current medication till lately. Due to holiday, his work schedule switched from 12 hours a day
to 14 hours a day. He takes 20 mg Adderall around 5 am upon waking up (he starts working around 6:30 am), then 20 mg with
lunch. However, he does skip lunch at times; thus, he forgets to take his PM dose when he skips lunch. He wonders whether he
may try a higher dose Adderall. Denies tremor, palpitations, chest pain, sleeping trouble, headache. Appetite normal. No weight
loss. Patient is adherent with follow up visits with being on a controlled medication. He does take occational drug holidays.

He was found to have elevated BP of 148/100 in 11/2020. He has no microalbuminuria. His

Thyroid Stimulating Hormone (TSH)3rd Gen (u(iU)/mL)

Date Value
11/25/2020 1.030

Free T4 (ng/dL)
Date Value
11/25/2020 1.22

He checks his BP first thing in the morning. His BP's have been in 120s/70s. Denies CP/SOA/palpitations.

I saw him in 1/2021: "He reports having a very bad lower back pain 5-6 yrs ago, treated with TENS unit and chiropractic
manipulation. He began to have lower back pain, worse on right, 2 days ago. Pain worsens with certain movement, better with
heat. No saddle anesthesia. No weakness. No incontinence. No UTI symptoms. No abdominal pain. No chest pain. No recent
trauma. He went to ER yesterday due to worsening back pain. His x-ray lumbar showed "Negative examination". He was
prescribed medrol dose pack, Robaxin, and Lidocaine patch from his ER visit."

He has been on Naproxen and Robaxin PRN. He continues to have lower back pain b/l. He also developed neck (occipital area)
pain in the past 1 month. He sees a chiropractor now.

He has HLD, on life style modifications. His

Triglycerides (mg/dL)
Date Value
11/25/2020 158 (H)

Cholesterol (mg/dL)
Date Value
11/25/2020 180

HDL Cholesterol (mg/dL)

Date Value
11/25/2020 37 (L)

No results found for: LDLCHOLM

LDL Cholesterol-Calculated (mg/dL)
Date Value
11/25/2020 111 (H)

He is a manager for Amazon, walking constantly at work, 14 hours a day now. He lives with his wife (who is in the exam room
with him today) and daughter who has ADHD.

Do you take any herbs or supplements that were not prescribed by a doctor? no
Are you taking calcium supplements? no
Are you taking aspirin daily? no

The following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past
family history, past medical history, past social history, past surgical history and problem list.

Review of Systems
Do you have pain that bothers you in your daily life? yes

Review of Systems
Musculoskeletal: Positive for arthralgias, back pain, myalgias and neck pain. Negative for joint swelling.
Psychiatric/Behavioral: Positive for decreased concentration. Negative for dysphoric mood and sleep disturbance. The patient is
not nervous/anxious.
Constitutional: negative for chills, fevers, fatigue
Ears, nose, mouth, throat, and face: negative for nasal congestion, sore throat and voice change
Respiratory: negative for cough and wheezing
Cardiovascular: negative for chest pain and irregular heart beat
Gastrointestinal: negative for abdominal pain, constipation and diarrhea
Genitourinary:negative for dysuria, frequency and hematuria
Neurological: negative for dizziness and headaches
Skin: negative for rash, color changes
The following portions of the patient's history were reviewed and updated as appropriate:
He has a past medical history of ADD (attention deficit disorder) and Elevated LFTs (11/28/2020).
He does not have any pertinent problems on file.
He has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).
His family history includes ADD / ADHD in his daughter; Heart disease in his father, maternal grandfather, maternal grandmother,
and maternal uncle; Hypertension in his father, maternal grandfather, maternal grandmother, and maternal uncle; Thyroid disease
in his sister.
He reports that he quit smoking about 2 years ago. His smoking use included cigars. He smoked 0.25 packs per day. He has
never used smokeless tobacco. He reports current alcohol use of about 1.0 standard drink of alcohol per week. He reports that
he does not use drugs.
He has No Known Allergies..

Health Maintenance Summary |

Postponed - Influenza Vaccine (1) Postponed until 6/30/2022
11/25/2020 Declined

Tdap/Td Vaccine >11 yo (2 - Td or Tdap) Next due on 9/1/2028

09/01/2018 Done at another facility - due to having left arm Fx.

Haemophilus Influenzae Type B (Hib) Vaccine (Series Information) Aged Out

No completion history exists for this topic.

Hepatitis B (HepB) Vaccine (Series Information) Aged Out

No completion history exists for this topic.

Polio (IPV) (Series Information) Aged Out

No completion history exists for this topic.

Pneumococcal Conjugate (PCV) 0-5 yo (Series Information) Aged Out

No completion history exists for this topic.

Hepatitis A (HepA) Vaccine (Series Information) Aged Out

No completion history exists for this topic.

Meningococcal ACWY (Series Information) Aged Out

No completion history exists for this topic.

Rotavirus (RV) Vaccine (Series Information) Aged Out

No completion history exists for this topic.

Health Maintenance Plans

Haemophilus Influenzae Type B (Hib) Vaccine
Hepatitis A (HepA) Vaccine
Hepatitis B (HepB) Vaccine
Inactivated Poliovirus (IPV) Vaccine
Influenza Vaccine Sequential
Meningococcal ACWY
Pneumococcal Conjugate (PCV) Vaccine 0-5 yo
Rotavirus (RV) Vaccine
Tdap/Td Vaccine >11yo

Outpatient Medications Marked as Taking for the 11/22/21 encounter (Office Visit) with Bryant, Jing, MD
Medication Sig Dispense Refill
• amphetamine-dextroamphetamine (ADDERALL) 20 MG tablet Take 1 tablet by mouth 2 (two) times daily. Max Daily Amount: 40
mg 60 tablet 0
• methocarbamol (ROBAXIN) 750 MG tablet Take 1 tablet by mouth 3 (three) times daily as needed (back pain). 30 tablet 1
• Multiple Vitamin (MULTIVITAMIN PO) Take by mouth.
• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth 2 (two) times daily as needed (mild headache). 30 tablet 1
• sertraline (ZOLOFT) 25 MG tablet daily.

Immunization History
See Immunization Record

Patient Care Team:

Bryant, Jing, MD as PCP - General (Family Medicine)
Hopper, Jason A, MD (Cardiology)
Meiers, Henry N, MD (Urology)

Objective:

Vitals:
11/22/21 1055
BP: 118/76
Pulse: 76
Temp: 97.8 °F (36.6 °C)
TempSrc: Temporal
SpO2: 97%
Weight: 102.8 kg (226 lb 10.1 oz)
Height: 6' 1" (185.4 cm)

Physical Exam

Constitutional: Oriented to person, place, and time. Appears well-developed and well-nourished. No distress.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: Tympanic membrane normal.
Left Ear: Tympanic membrane normal.
Eyes: Conjunctivae and EOM are normal.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. No low extremity edema.
Pulmonary/Chest: Effort normal and breath sounds normal. No accessory muscle usage.
Abdominal: Soft. Bowel sounds are normal. There is no tenderness. There is no rebound and no guarding.
Musculoskeletal: Exhibits no edema. Normal gait.
Lymphadenopathy:
No cervical adenopathy.
Right: No supraclavicular adenopathy present.
Left: No supraclavicular adenopathy present.
Neurological: Alert and oriented to person, place, and time. Normal strength. No cranial nerve deficit.
Skin: Skin is warm. No lesion and no rash noted. No erythema. No induration.
Psychiatric: Normal mood and affect. Behavior is normal. Judgment and thought content normal.

Assessment:

1. Annual physical exam

2. Elevated blood pressure reading without diagnosis of hypertension Microalbumin, random urine
Microalbumin, random urine
3. Microalbuminuria absent
4. Attention deficit disorder, unspecified hyperactivity presence amphetamine-dextroamphetamine (ADDERALL) 30 MG tablet
5. Dyslipidemia
6. Neck pain Ambulatory referral to Back and Neck Pain Clinic
7. Chronic bilateral low back pain, unspecified whether sciatica present Ambulatory referral to Back and Neck Pain Clinic
8. Screening for diabetes mellitus Hemoglobin A1C
Comprehensive Metabolic Panel (CMP)
Comprehensive Metabolic Panel (CMP)
Hemoglobin A1C
9. Screening for cholesterol level Lipid panel
Lipid panel

Plan:

Maintain healthy life style, including diet, exercise and weight control.

Patient Counseling (available also in after visit summary):

--Nutrition: Stressed importance of moderation in sodium/caffeine intake, saturated fat and cholesterol, caloric balance,
sufficient intake of fresh fruits, vegetables, etc.
--Exercise: Stressed the importance of regular exercise.
--Substance Abuse: Discussed cessation/primary prevention of tobacco, alcohol, or other drug use.
--Dental health: Discussed importance of regular dental visits.
--Immunizations reviewed.
--Discussed benefits of screening colonoscopy.
--After hours service

Discussed the patient's BMI with him. The BMI is above average range. Patient is advised to adapt life style modificaitons
including diet, exercise to lose weight.

Follow up as needed for acute issues.

Routine labs today; Caucasian.

Follow up in 1 year for annual physical.

Elevated BP without microalbuminuria: doing well on life style modifications now.

Will check labs.

ADD: will try 30 mg Adderall bid.

Discussed diagnosis, treatment options, risks and benefits, alternate therapies. Patient agreeable to treatment and understands
risks and benefits of treatment plan. Informed consent was obtained and in file. Patient's signed contract is in file; his UDS was
consistent with history today; KASPER (from Appriss) showed no irregularity. Patient is advised not to drive or operate machinery
under the influence of sedating medications, and to avoid alcohol and illicit drug use.

HLD: on life style modifications now.

Will check labs.

Neck and lower back pain: refer to Norton Neck and Back pain clinic.

Declined flu shot today.

Screening & Prevention:

Age-appropriate Screening & Interventions recommended by USPSTF were reviewed with the patient, and Health Maintenance
was updated in Epic.

Medical Problems & Treatment Plans:

For details, see Problem List, Medications, and Orders sections in Epic, and AVS related to this day-of-service.
Electronically signed by Jing Bryant at 11/22/2021 2:41 PM EST

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk
Results - documented in this encounter
(ABNORMAL) HEMOGLOBIN A1C - Final result (11/22/2021 11:37 AM EST)
Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Hemoglobin A1C 6.0 (H) 4.3 - 5.6 11/24/2021 Norton
% 7:20 AM Medical
EST Group
Central Lab
Estimated Average 126 mg/dL 11/24/2021 Norton
Glucose 7:20 AM Medical
EST Group
Central Lab

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Whole Blood (Blood) 11/22/2021 11:37 AM 11/24/2021 7:19 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217

(ABNORMAL) COMPREHENSIVE METABOLIC PANEL (CMP) - Final result (11/22/2021 11:37 AM EST)
Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Sodium 137 137 - 11/24/2021 Norton
145 7:19 AM Medical
mmol/L EST Group
Central Lab
Potassium 4.2 3.5 - 5.1 11/24/2021 Norton
mmol/L 7:19 AM Medical
EST Group
Central Lab
Chloride 99 98 - 107 11/24/2021 Norton
mmol/L 7:19 AM Medical
EST Group
Central Lab
Carbon Dioxide 21 (L) 22 - 30 11/24/2021 Norton
mmol/L 7:19 AM Medical
EST Group
Central Lab
Glucose 97 74 - 99 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
Blood Urea Nitrogen 14 7 - 20 11/24/2021 Norton
(BUN) mg/dL 7:19 AM Medical
EST Group
Central Lab
Creatinine-Blood 0.6 (L) 0.7 - 1.5 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
BUN/Creatinine Ratio 23.0 (H) 10.0 - 11/24/2021 Norton
20.0 7:19 AM Medical
RATIO EST Group
Central Lab
Estimated GFR >60 >60 / 11/24/2021 Norton
1.73 m2 7:19 AM Medical
EST Group
Central Lab
Total Protein 7.9 6.3 - 8.2 11/24/2021 Norton
g/dL 7:19 AM Medical
EST Group
Central Lab
Albumin 4.5 3.5 - 5.0 11/24/2021 Norton
g/dL 7:19 AM Medical
EST Group
Central Lab
Globulin 3.5 1.5 - 4.5 11/24/2021 Norton
g/dL 7:19 AM Medical
EST Group
Central Lab
Albumin/Globulin Ratio 1.3 1.1 - 2.5 11/24/2021 Norton
RATIO 7:19 AM Medical
EST Group
Central Lab
Calcium 9.8 8.4 - 11/24/2021 Norton
10.2 mg/ 7:19 AM Medical
dL EST Group
Central Lab
Total Bilirubin 0.3 0.2 - 1.3 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
AST/SGOT 28 15 - 46 11/24/2021 Norton
U/L 7:19 AM Medical
EST Group
Central Lab
ALT/SGPT 57 13 - 69 11/24/2021 Norton
U/L 7:19 AM Medical
EST Group
Central Lab
Alkaline Phosphatase 101 38 - 126 11/24/2021 Norton
U/L 7:19 AM Medical
EST Group
Central Lab
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/22/2021 11:37 AM 11/24/2021 7:19 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217
(ABNORMAL) LIPID PANEL - Final result (11/22/2021 11:37 AM EST)
Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Triglycerides 183 (H) 0 - 149 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
Cholesterol 193 0 - 199 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
HDL Cholesterol 42 >39 mg/ 11/24/2021 Norton
dL 7:19 AM Medical
EST Group
Central Lab
LDL Cholesterol- 106 (H) 0 - 100 11/24/2021 Norton
Calculated mg/dL 7:19 AM Medical
EST Group
Central Lab
VLDL 38 5 - 40 11/24/2021 Norton
mg/dL 7:19 AM Medical
EST Group
Central Lab
CHOL/HDL Ratio 4.6 RATIO 11/24/2021 Norton
7:19 AM Medical
EST Group
Central Lab
Is patient fasting? Yes (arb'U) 11/22/2021 NPS NCMA
11:14 AM OBC 410
EST

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 11/22/2021 11:37 AM 11/24/2021 7:19 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NPS NCMA OBC 410 9880 Angie's Way Suite LOUISVILLE, KY 40241, 502-636-8095
410 USA
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217
NPS NCMA OBC 410 9800 ANGIES WAY LOUISVILLE, KY 40241
STE 410

MICROALBUMIN, RANDOM URINE - Final result (11/22/2021 11:37 AM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Microalbumin-Urine 1.4 0.0 - 11/24/2021 Norton
Conc 19.9 mg/ 7:20 AM Medical
dL EST Group
Central Lab
 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Creatinine-Urine 153.1 15 - 500 11/24/2021 Norton
Concentration mg/dL 7:20 AM Medical
EST Group
Central Lab
Microalb/Creat Ratio 9 <20 mg/ 11/24/2021 Norton
g 7:20 AM Medical
EST Group
Central Lab
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Urine (Urine) 11/22/2021 11:37 AM 11/24/2021 7:18 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant URINE ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr.,
Central Lab Suite LL2
Louisville, KY 40217

Visit Diagnoses - documented in this encounter

Diagnosis
Encounter for annual physical exam - Primary
Elevated blood pressure reading without diagnosis of hypertension
Microalbuminuria absent
Dyslipidemia
Neck pain
Chronic bilateral low back pain, unspecified whether sciatica present
Screening for diabetes mellitus
Screening for cholesterol level

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)
Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Nov. 22, 2021
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Nov. 22, 2021
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
Medication Refill
Office Visit

Encounter Details
Date Type Department Care Team Description
08/17/2021 Office Visit Norton Community Medical Jing Bryant
1:40 PM Associates - Brownsboro 9880 Angie's Way
EDT 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 04/21/2021 10/20/2021 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 1 05/21/2021 10/20/2021 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 08/12/2021 09/13/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 20 MG tablet Daily Amount: 40 mg

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021
Immunizations - documented as of this encounter
Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Tobacco Cessation: Ready to Quit: No; Counseling Given: Yes

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 8/17/2021 1:42 PM EDT
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 124/78 08/17/2021 1:49 PM EDT
Pulse 84 08/17/2021 1:49 PM EDT
Temperature 36.8 °C (98.2 °F) 08/17/2021 1:49 PM EDT
Respiratory Rate - -
Oxygen Saturation 99% 08/17/2021 1:49 PM EDT
Inhaled Oxygen Concentration - -
Weight 96.8 kg (213 lb 6.5 oz) 08/17/2021 1:49 PM EDT
Height 185.4 cm (6' 1") 08/17/2021 1:49 PM EDT
Body Mass Index 28.16 08/17/2021 1:49 PM EDT

Patient Instructions - documented in this encounter

Patient Instructions
Jing Bryant - 08/17/2021 1:55 PM EDT
Formatting of this note is different from the original.

It was nice seeing you today! I hope that your visit today was a positive one. I'd appreciate any feedback you may have through
our online feedback form/survey, so that I can do my best to continue to provide the best care.
------------------------------------------------------------------------

Please take your ADHD medication as directed.

Please call our office 7 days ahead for your refills.

Follow up in 3 months for ADHD medication refill.

For help in becoming and staying tobacco free, call 502-629-1234 or go to NortonScreenings.com to enroll in a no-
cost Freedom from Smoking course offered by Norton Healthcare. This 7-week course begins about every two weeks. Assistance
with nicotine replacement is available if using a Norton Pharmacy. Para obtener clases para dejar de fumar en español, llame al
502-899-6842. In-person and virtual classes are available. If this is not an option for you, the toll free Quitline (1-800-QUIT-
NOW) is available for counseling, referrals and assistance with medications to help you stay tobacco-free.

NOTE: Pregnant patients should consult their Obstetrical provider before starting nicotine replacement.

Electronically signed by Jing Bryant at 08/17/2021 3:53 PM EDT

Progress Notes - documented in this encounter
Jing Bryant - 08/17/2021 1:56 PM EDT
Formatting of this note is different from the original.
Subjective:

Patient ID: Ryan S Gomez is a 37 yr/o male.

Chief Complaint
Patient presents with
• Medication Refill
• Office Visit

HPI

I saw him in 5/2021:

"He was evaluated by Robert Watson, Psy. D, in 12/2020. Dr. Watson thinks that his untreated ADD might have caused his anxiety
and depression to certain degree. Dr. Watson recommended that patient should be treated for his ADD. He states not getting
good review at work which was unusual for him. He states that even his supervisor notices that he was not focused at work
when around people. He was started on 36 mg Concerta with moderate response. He states that the effects weans off after 8-9
hours. He was started on 54 mg Concerta in 2/2021. He works 16-hour shifts, 3 days a week. He reports 54 mg Concerta doesn't
last that long. He took an extra 18 mg Concerta on the long working hour day with good response. He wonders whether he may
try something to last longer than 9 hours.

He was found to have elevated BP of 148/100 in 11/2020. He has no microalbuminuria. His

Thyroid Stimulating Hormone (TSH)3rd Gen (u(iU)/mL)

Date Value
11/25/2020 1.030

Free T4 (ng/dL)
Date Value
11/25/2020 1.22

He reports having stress lately (a new house, new car, MVA, flat tires, etc). He returned from a trip this past weekend and had just
2 hours sleep last night. Denies CP/SOA/palpitations."

We changed his Concerta to 20 mg Adderall bid. Patient is doing well on current medication, taking as directed. Controlling
symptoms, staying focused, organized skills, well. No side effects noted. Denies tremor, palpitations, chest pain, sleeping trouble,
headache. Appetite normal. No weight loss. Patient is adherent with follow up visits with being on a controlled medication. He
does take occational drug holidays.

The following portions of the patient's history were reviewed and updated as appropriate:
He has a past medical history of ADD (attention deficit disorder) and Elevated LFTs (11/28/2020).
He does not have any pertinent problems on file.
He has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).
His family history includes ADD / ADHD in his daughter; Heart disease in his father, maternal grandfather, maternal grandmother,
and maternal uncle; Hypertension in his father, maternal grandfather, maternal grandmother, and maternal uncle; Thyroid disease
in his sister.
He reports that he has been smoking cigars. He has been smoking about 0.25 packs per day. He has never used smokeless
tobacco. He reports current alcohol use of about 1.0 standard drinks of alcohol per week. He reports that he does not use drugs.
He has No Known Allergies..

Review of Systems
Constitutional: Negative for chills, fatigue, fever and unexpected weight change.
Cardiovascular: Negative for chest pain and palpitations.
Neurological: Negative for dizziness and headaches.
Psychiatric/Behavioral: Positive for decreased concentration. Negative for sleep disturbance. The patient is not nervous/anxious.

Outpatient Medications Marked as Taking for the 8/17/21 encounter (Office Visit) with Bryant, Jing, MD
Medication Sig Dispense Refill
• amphetamine-dextroamphetamine (ADDERALL) 20 MG tablet Take 1 tablet by mouth 2 (two) times daily. Max Daily Amount: 40
mg 60 tablet 0
• methocarbamol (ROBAXIN) 750 MG tablet Take 1 tablet by mouth 3 (three) times daily as needed (back pain). 30 tablet 1
• Multiple Vitamin (MULTIVITAMIN PO) Take by mouth.
• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth 2 (two) times daily as needed (mild headache). 30 tablet 1

Patient Care Team:

Bryant, Jing, MD as PCP - General (Family Medicine)
Hopper, Jason A, MD (Cardiology)
Meiers, Henry N, MD (Urology)

Objective:

Vitals:
08/17/21 1349
BP: 124/78
Pulse: 84
Temp: 98.2 °F (36.8 °C)
TempSrc: Temporal
SpO2: 99%
Weight: 96.8 kg (213 lb 6.5 oz)
Height: 6' 1" (185.4 cm)

Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
Pulmonary/Chest: Effort normal and breath sounds normal. He has no wheezes.
Neurological: He is alert and oriented to person, place, and time.
Psychiatric: He has a normal mood and affect. His behavior is normal. Judgment and thought content normal.
Nursing note and vitals reviewed.

Assessment and Plan:

Ryan was seen today for medication refill and office visit.

Diagnoses and all orders for this visit:

Attention deficit disorder, unspecified hyperactivity presence

Elevated blood pressure reading without diagnosis of hypertension

Microalbuminuria absent

ADD: doing well on 20 mg Adderall bid; continue.

Discussed diagnosis, treatment options, risks and benefits, alternate therapies. Patient agreeable to treatment and understands
risks and benefits of treatment plan. Informed consent was obtained and in file. Patient's signed contract is in file; his UDS was
consistent with history today; KASPER (from Appriss) showed no irregularity. Patient is advised not to drive or operate
machinery under the influence of sedating medications, and to avoid alcohol and illicit drug use.
May call for 3 more refills.

Elevated BP without microalbuminuria: BP is in goal today.

Continue life style modifications including diet (low-fat, low sodium), exercise and weight control.

Return in 14 weeks (on 11/23/2021) for 7:40am annual physical, ADHD med refill, come in fasting.
Electronically signed by Jing Bryant at 08/17/2021 3:53 PM EDT

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
Elevated blood pressure reading without diagnosis of hypertension
Microalbuminuria absent
Care Teams - documented as of this encounter
Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Aug. 17, 2021
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Aug. 17, 2021
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason Onset Date
Medication Refill 06/30/2021

Encounter Details
Date Type Department Care Team Description
06/30/2021 Refill Norton Community Medical Jing Bryant
Associates - Brownsboro 9880 Angie's Way
9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 04/21/2021 10/20/2021 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
diazePAM (VALIUM) 10 MG Take 1 tablet by mouth 1 0 04/07/2021 08/10/2021 Discontinued
tablet hour prior to procedure (Therapy
completed)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 1 05/21/2021 10/20/2021 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 06/01/2021 06/30/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 20 MG tablet Daily Amount: 40 mg
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 06/30/2021 08/12/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 20 MG tablet Daily Amount: 40 mg
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 08/12/2021 09/13/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 20 MG tablet Daily Amount: 40 mg
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

Last Filed Vital Signs - documented in this encounter

Not on file

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
amphetamine- Take 1 tablet by mouth 2 (two) 60 tablet 0 08/12/2021 09/13/2021
dextroamphetamine times daily. Max Daily Amount:
(ADDERALL) 20 MG tablet 40 mg
amphetamine- Take 1 tablet by mouth 2 (two) 60 tablet 0 06/30/2021 08/12/2021
dextroamphetamine times daily. Max Daily Amount:
(ADDERALL) 20 MG tablet 40 mg

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file
Care Teams - documented as of this encounter
Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper Jun. 30, 2021 - Aug. 14, 2021
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Jun. 30, 2021
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
Office Visit

Encounter Details
Date Type Department Care Team Description
05/03/2021 Office Visit Norton Community Medical Jing Bryant
8:20 AM Associates - Brownsboro 9880 Angie's Way
EDT 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
lidocaine (LIDODERM) 5 % Place 1 patch onto the 6 patch 0 01/18/2021 05/03/2021 Discontinued
skin daily Remove & (Patient
Discard patch within 12 Choice)
hours or as directed by
MD.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 1 02/04/2021 05/21/2021 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 03/25/2021 05/03/2021 Discontinued
ER) 54 MG ER tablet every morning. Max (Alternate
Daily Amount: 54 mg therapy)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 3 30 tablet 1 04/21/2021 10/20/2021 Discontinued
750 MG tablet (three) times daily as (Reorder)
needed (back pain).
diazePAM (VALIUM) 10 MG Take 1 tablet by mouth 1 0 04/07/2021 08/10/2021 Discontinued
tablet hour prior to procedure (Therapy
completed)
amphetamine- Take 1 tablet by mouth 2 60 tablet 0 05/03/2021 06/01/2021 Discontinued
dextroamphetamine (two) times daily. Max (Reorder)
(ADDERALL) 15 MG tablet Daily Amount: 30 mg
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Immunizations - documented as of this encounter

Name Administration Dates Next Due
COVID-19 MODERNA 04/19/2021, 03/18/2021
MONOVALENT AGES 12 AND
OLDER

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Tobacco Cessation: Ready to Quit: No; Counseling Given: Yes

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 5/3/2021 8:24 AM EDT
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 140/80 05/03/2021 8:28 AM EDT
Pulse 69 05/03/2021 8:28 AM EDT
Temperature 36.6 °C (97.8 °F) 05/03/2021 8:28 AM EDT
Respiratory Rate - -
Oxygen Saturation 97% 05/03/2021 8:28 AM EDT
Inhaled Oxygen Concentration - -
Weight 96.4 kg (212 lb 8.4 oz) 05/03/2021 8:28 AM EDT
Height 185.4 cm (6' 1") 05/03/2021 8:28 AM EDT
Body Mass Index 28.04 05/03/2021 8:28 AM EDT
Patient Instructions - documented in this encounter
Patient Instructions
Jing Bryant - 05/03/2021 8:35 AM EDT
Formatting of this note might be different from the original.

It was nice seeing you today! I hope that your visit today was a positive one. I'd appreciate any feedback you may have through
our online feedback form/survey, so that I can do my best to continue to provide the best care.
------------------------------------------------------------------------

Please take your ADHD medication as directed.

Please call our office 7 days ahead for your refills.

Follow up in 3 months for ADHD medication refill.

For help in becoming and staying tobacco free, call 502-629-1234 or go to NortonScreenings.com to enroll in a no-cost
Freedom from Smoking course offered by Norton Healthcare. This 7-week course begins about every two weeks. Assistance with
nicotine replacement is available if using a Norton Pharmacy. Para obtener clases para dejar de fumar en español, llame al
502-899-6842. In-person and virtual classes are available. If this is not an option for you, the toll free Quitline (1-800-QUIT-
NOW) is available for counseling, referrals and assistance with medications to help you stay tobacco-free.

NOTE: Pregnant patients should consult their Obstetrical provider before starting nicotine replacement.

Electronically signed by Jing Bryant at 05/03/2021 9:32 AM EDT

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
amphetamine- Take 1 tablet by mouth 2 (two) 60 tablet 0 05/03/2021 06/01/2021
dextroamphetamine times daily. Max Daily Amount:
(ADDERALL) 15 MG tablet 30 mg

Progress Notes - documented in this encounter

Jing Bryant - 05/03/2021 8:34 AM EDT
Formatting of this note is different from the original.
Subjective:

Patient ID: Ryan S Gomez is a 37 yr/o male.

Chief Complaint
Patient presents with
• Office Visit
10 week follow up for ADHD, med refill and HTN

HPI

He was evaluated by Robert Watson, Psy. D, in 12/2020. Dr. Watson thinks that his untreated ADD might have caused his anxiety
and depression to certain degree. Dr. Watson recommended that patient should be treated for his ADD. He states not getting
good review at work which was unusual for him. He states that even his supervisor notices that he was not focused at work
when around people. He was started on 36 mg Concerta with moderate response. He states that the effects weans off after 8-9
hours. He was started on 54 mg Concerta in 2/2021. He works 16-hour shifts, 3 days a week. He reports 54 mg Concerta doesn't
last that long. He took an extra 18 mg Concerta on the long working hour day with good response. He wonders whether he may
try something to last longer than 9 hours.

He was found to have elevated BP of 148/100 in 11/2020. He has no microalbuminuria. His

Thyroid Stimulating Hormone (TSH)3rd Gen (u(iU)/mL)

Date Value
11/25/2020 1.030

Free T4 (ng/dL)
Date Value
11/25/2020 1.22

He reports having stress lately (a new house, new car, MVA, flat tires, etc). He returned from a trip this past weekend and had just
2 hours sleep last night. Denies CP/SOA/palpitations.
The following portions of the patient's history were reviewed and updated as appropriate:
He has a past medical history of ADD (attention deficit disorder) and Elevated LFTs (11/28/2020).
He does not have any pertinent problems on file.
He has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).
His family history includes ADD / ADHD in his daughter; Heart disease in his father, maternal grandfather, maternal grandmother,
and maternal uncle; Hypertension in his father, maternal grandfather, maternal grandmother, and maternal uncle; Thyroid disease
in his sister.
He reports that he has been smoking cigars. He has been smoking about 0.25 packs per day. He has never used smokeless
tobacco. He reports current alcohol use of about 1.0 standard drinks of alcohol per week. He reports that he does not use drugs.
He has No Known Allergies..

Review of Systems
Constitutional: Negative for chills, fatigue, fever and unexpected weight change.
Cardiovascular: Negative for chest pain and palpitations.
Neurological: Negative for dizziness and headaches.
Psychiatric/Behavioral: Positive for decreased concentration. Negative for sleep disturbance. The patient is not nervous/anxious.

Outpatient Medications Marked as Taking for the 5/3/21 encounter (Office Visit) with Bryant, Jing, MD
Medication Sig Dispense Refill
• methocarbamol (ROBAXIN) 750 MG tablet Take 1 tablet by mouth 3 (three) times daily as needed (back pain). 30 tablet 1
• methylphenidate (CONCERTA ER) 54 MG ER tablet Take 1 tablet by mouth every morning. Max Daily Amount: 54 mg 30 tablet 0
• Multiple Vitamin (MULTIVITAMIN PO) Take by mouth.
• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth 2 (two) times daily as needed (mild headache). 30 tablet 1

Patient Care Team:

Bryant, Jing, MD as PCP - General (Family Medicine)
Hopper, Jason A, MD (Cardiology)
Meiers, Henry N, MD (Urology)

Objective:

Vitals:
05/03/21 0828
BP: (!) 140/80
Pulse: 69
Temp: 97.8 °F (36.6 °C)
TempSrc: Temporal
SpO2: 97%
Weight: 96.4 kg (212 lb 8.4 oz)
Height: 6' 1" (185.4 cm)

Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress.
Cardiovascular: Normal rate and regular rhythm.
Pulmonary/Chest: Effort normal. No respiratory distress.
Neurological: He is alert and oriented to person, place, and time.
Psychiatric: He has a normal mood and affect. His behavior is normal. Judgment and thought content normal.
Nursing note and vitals reviewed.

Assessment and Plan:

Existing problems with new management.

Ryan was seen today for office visit.

Diagnoses and all orders for this visit:

Attention deficit disorder, unspecified hyperactivity presence

- amphetamine-dextroamphetamine (ADDERALL) 15 MG tablet; Take 1 tablet by mouth 2 (two) times daily. Max Daily Amount:
30 mg

Elevated blood pressure reading without diagnosis of hypertension

ADD: on 54 mg Concerta but would like to be on something that lasts longer than 9 hours as he works 16-hour shifts.
Will try 15 mg Adderall IR bid and titrate up if needed.
If not tolerating Adderall IR, will consider 54 mg Concerta with 18 mg Concerta on the days that he works.
Discussed diagnosis, treatment options, risks and benefits, alternate therapies. Patient agreeable to treatment and understands
risks and benefits of treatment plan. Informed consent was obtained and in file. Patient's signed contract is in file; his UDS was
consistent with history today; KASPER (from Appriss) showed no irregularity. Patient is advised not to drive or operate machinery
under the influence of sedating medications, and to avoid alcohol and illicit drug use.
May call for 2 more refills.

Elevated BP: slept 2 hours last night, recent stress.

He is advised to reduce stress.
He is advised to have adequate sleep.

Patient is advised to stop smoking. Smoking cessation information is available in AVS for patient.

Return in about 10 weeks (around 7/12/2021) for ADHD med refill.

Electronically signed by Jing Bryant at 05/03/2021 9:32 AM EDT

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
Elevated blood pressure reading without diagnosis of hypertension

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Henry N Meiers Urology 4/7/21
NPI: 1245297217
3920 Dupont Square South
LOUISVILLE, KY 40207
502-897-7172 (Work)
502-897-1421 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Jason A Hopper May 03, 2021
Present) NPI: 1548605108
NPI: 1023317880 502-891-8300 (Work)
502-394-6000 (Work) 502-891-8338 (Fax)
502-394-3689 (Fax) 6420 Dutchmans Parkway
Family Medicine Suite 200
Norton Healthcare Louisville, KY 40205-3373
Louisville, KY 40202 Cardiology
Norton Healthcare
Louisville, KY 40202
Henry N Meiers
NPI: 1245297217
502-897-7172 (Work)
502-897-1421 (Fax)
3920 Dupont Square South
LOUISVILLE, KY 40207
Urology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) May 03, 2021
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
ADD

Encounter Details
Date Type Department Care Team Description
02/22/2021 Office Visit Norton Community Medical Jing Bryant
1:40 PM Associates - Brownsboro 9880 Angie's Way
EST 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies
Medications - documented as of this encounter (statuses as of 09/29/2023)
Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 4 20 tablet 0 01/18/2021 04/21/2021 Discontinued
750 MG tablet (four) times daily. (Reorder)
lidocaine (LIDODERM) 5 % Place 1 patch onto the 6 patch 0 01/18/2021 05/03/2021 Discontinued
skin daily Remove & (Patient
Discard patch within 12 Choice)
hours or as directed by
MD.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 1 02/04/2021 05/21/2021 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 02/09/2021 02/22/2021 Discontinued
ER) 36 MG ER tablet every morning. Max (Reorder)
Daily Amount: 54 mg
methylPREDNISolone TAKE 6 TABLETS ON DAY 0 01/19/2021 02/22/2021 Discontinued
(MEDROL DOSPACK) 4 MG 1 AS DIRECTED ON
tablet PACKAGE AND
DECREASE BY 1 TAB
EACH DAY FOR A TOTAL
OF 6 DAYS
VYVANSE 30 MG capsule 0 01/14/2021 02/22/2021 Discontinued
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 02/22/2021 03/25/2021 Discontinued
ER) 54 MG ER tablet every morning. Max (Reorder)
Daily Amount: 54 mg

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Tobacco Cessation: Ready to Quit: No; Counseling Given: Yes

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 2/22/2021 1:44 PM EST
was confirmed or suspected to have Coronavirus / COVID-19?
Last Filed Vital Signs - documented in this encounter
Vital Sign Reading Time Taken Comments
Blood Pressure 120/82 02/22/2021 2:09 PM EST
Pulse 70 02/22/2021 2:09 PM EST
Temperature 36.1 °C (97 °F) 02/22/2021 2:09 PM EST
Respiratory Rate - -
Oxygen Saturation 97% 02/22/2021 2:09 PM EST
Inhaled Oxygen Concentration - -
Weight 100.6 kg (221 lb 12.5 oz) 02/22/2021 2:09 PM EST
Height 185.4 cm (6' 1") 02/22/2021 2:09 PM EST
Body Mass Index 29.26 02/22/2021 2:09 PM EST

Patient Instructions - documented in this encounter

Patient Instructions
Jing Bryant - 02/22/2021 2:11 PM EST
Formatting of this note might be different from the original.
For help in becoming and staying tobacco free, call 502-629-1234 or go to NortonScreenings.com to enroll in a no-cost
Freedom from Smoking course offered by Norton Healthcare. This 7-week course begins about every two weeks. Assistance with
nicotine replacement is available if using a Norton Pharmacy. Para obtener clases para dejar de fumar en español, llame al
502-899-6842. In-person and virtual classes are available. If this is not an option for you, the toll free Quitline (1-800-QUIT-
NOW) is available for counseling, referrals and assistance with medications to help you stay tobacco-free.

It was nice seeing you today! I hope that your visit today was a positive one. I'd appreciate any feedback you may have through
our online feedback form/survey, so that I can do my best to continue to provide the best care.
------------------------------------------------------------------------

Please take your ADHD medication as directed.

Please call our office 7 days ahead for your refills.

Follow up in 3 months for ADHD medication refill.

Electronically signed by Jing Bryant at 02/22/2021 6:27 PM EST

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
methylphenidate (CONCERTA Take 1 tablet by mouth every 30 tablet 0 02/22/2021 03/25/2021
ER) 54 MG ER tablet morning. Max Daily Amount:
54 mg

Progress Notes - documented in this encounter

Jing Bryant - 02/22/2021 6:22 PM EST
Formatting of this note is different from the original.
Subjective:

Patient ID: Ryan S Gomez is a 37 yr/o male.

Chief Complaint
Patient presents with
• ADD

HPI

He was evaluated by Robert Watson, Psy. D, in 12/2020. Dr. Watson thinks that his untreated ADD might have caused his anxiety
and depression to certain degree. Dr. Watson recommended that patient should be treated for his ADD. He states not getting
good review at work which was unusual for him. He states that even his supervisor notices that he was not focused at work when
around people. He was started on 36 mg Concerta with moderate response. He states that the effects weans off after 8-9 hours.
He'd like to try a higher dose for a longer duration of the effect.

He was found to have elevated BP of 148/100 in 11/2020. He has no microalbuminuria. His

Thyroid Stimulating Hormone (TSH)3rd Gen (u(iU)/mL)

Date Value
11/25/2020 1.030
Free T4 (ng/dL)
Date Value
11/25/2020 1.22

Denies CP/SOA/palpitations.

The following portions of the patient's history were reviewed and updated as appropriate:
He has a past medical history of ADD (attention deficit disorder) and Elevated LFTs (11/28/2020).
He does not have any pertinent problems on file.
He has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).
His family history includes ADD / ADHD in his daughter; Heart disease in his father, maternal grandfather, maternal grandmother,
and maternal uncle; Hypertension in his father, maternal grandfather, maternal grandmother, and maternal uncle; Thyroid disease
in his sister.
He reports that he has been smoking cigars. He has been smoking about 0.25 packs per day. He has never used smokeless
tobacco. He reports current alcohol use of about 1.0 standard drinks of alcohol per week. He reports that he does not use drugs.
He has No Known Allergies..

Review of Systems
Constitutional: Negative for chills, fatigue, fever and unexpected weight change.
Cardiovascular: Negative for chest pain and palpitations.
Neurological: Negative for dizziness and headaches.
Psychiatric/Behavioral: Positive for decreased concentration. Negative for sleep disturbance. The patient is not nervous/anxious.

Outpatient Medications Marked as Taking for the 2/22/21 encounter (Office Visit) with Bryant, Jing, MD
Medication Sig Dispense Refill
• methocarbamol (ROBAXIN) 750 MG tablet Take 1 tablet by mouth 4 (four) times daily. 20 tablet 0
• methylphenidate (CONCERTA ER) 36 MG ER tablet Take 1 tablet by mouth every morning. Max Daily Amount: 54 mg 30 tablet 0

• Multiple Vitamin (MULTIVITAMIN PO) Take by mouth.

• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth 2 (two) times daily as needed (mild headache). 30 tablet 1
• Orlistat (ALLI PO) Take by mouth.

Patient Care Team:

Bryant, Jing, MD as PCP - General (Family Medicine)
Hopper, Jason A, MD (Cardiology)

Objective:

Vitals:
02/22/21 1409
BP: (!) 120/82
Pulse: 70
Temp: 97 °F (36.1 °C)
TempSrc: Temporal
SpO2: 97%
Weight: 100.6 kg (221 lb 12.5 oz)
Height: 6' 1" (185.4 cm)

Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress.
HENT:
Head: Normocephalic and atraumatic.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate and normal heart sounds.
Pulmonary/Chest: Effort normal and breath sounds normal.
Neurological: He is alert and oriented to person, place, and time.
Psychiatric: He has a normal mood and affect. His behavior is normal. Judgment and thought content normal.
Nursing note and vitals reviewed.

Assessment and Plan:

Ryan was seen today for add.

Diagnoses and all orders for this visit:

Attention deficit disorder, unspecified hyperactivity presence

- methylphenidate (CONCERTA ER) 54 MG ER tablet; Take 1 tablet by mouth every morning. Max Daily Amount: 54 mg

Elevated blood pressure reading without diagnosis of hypertension

ADD: on 36 mg Concerta with moderate response.
Will increase dose to 54 mg.
Discussed diagnosis, treatment options, risks and benefits, alternate therapies. Patient agreeable to treatment and understands
risks and benefits of treatment plan. Informed consent was obtained and in file. Patient's signed contract is in file; his UDS was
consistent with history today; KASPER (from Appriss) showed no irregularity. Patient is advised not to drive or operate machinery
under the influence of sedating medications, and to avoid alcohol and illicit drug use.
May call for 2 more refills.

Elevated BP: in goal.

Patient is advised to stop smoking. Smoking cessation information is available in AVS for patient.

Return in about 10 weeks (around 5/3/2021) for ADHD med refill, HTN.
Electronically signed by Jing Bryant at 02/22/2021 6:27 PM EST

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
Elevated blood pressure reading without diagnosis of hypertension

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Jason A Hopper Feb. 22, 2021
NPI: 1023317880 NPI: 1548605108
502-394-6000 (Work) 502-891-8300 (Work)
502-394-3689 (Fax) 502-891-8338 (Fax)
Family Medicine 6420 Dutchmans Parkway
Norton Healthcare Suite 200
Louisville, KY 40202 Louisville, KY 40205-3373
Cardiology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Feb. 22, 2021
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason Onset Date
change appointment 02/16/2021

Encounter Details
Date Type Department Care Team Description
02/16/2021 Telephone Norton Community Medical Bonnie P
Associates - Brownsboro
9880 Angies Way
Suite 420
LOUISVILLE, KY 40241-2848
502-394-6200

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
methocarbamol (ROBAXIN) Take 1 tablet by mouth 4 20 tablet 0 01/18/2021 04/21/2021 Discontinued
750 MG tablet (four) times daily. (Reorder)
lidocaine (LIDODERM) 5 % Place 1 patch onto the 6 patch 0 01/18/2021 05/03/2021 Discontinued
skin daily Remove & (Patient
Discard patch within 12 Choice)
hours or as directed by
MD.
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 1 02/04/2021 05/21/2021 Discontinued
MG tablet (two) times daily as (Reorder)
needed (mild headache).
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 02/09/2021 02/22/2021 Discontinued
ER) 36 MG ER tablet every morning. Max (Reorder)
Daily Amount: 54 mg

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020
Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)
Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who Unable to assess 2/16/2021 12:43 PM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Not on file

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Jason A Hopper Feb. 16, 2021 - Feb. 17, 2021
NPI: 1023317880 NPI: 1548605108
502-394-6000 (Work) 502-891-8300 (Work)
502-394-3689 (Fax) 502-891-8338 (Fax)
Family Medicine 6420 Dutchmans Parkway
Norton Healthcare Suite 200
Louisville, KY 40202 Louisville, KY 40205-3373
Cardiology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Bonnie P (Attending) Feb. 16, 2021

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason Onset Date
other 02/03/2021

Encounter Details
Date Type Department Care Team Description
02/03/2021 Telephone Norton Community Medical Jing Bryant
Associates - Brownsboro 9880 Angie's Way
9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 0 01/04/2021 02/04/2021 Discontinued
MG tablet (two) times daily as
needed (mild headache)
for up to 10 days Take
with food.
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 01/12/2021 02/09/2021 Discontinued
ER) 36 MG ER tablet every morning. Max (Reorder)
Daily Amount: 54 mg
methocarbamol (ROBAXIN) Take 1 tablet by mouth 4 20 tablet 0 01/18/2021 04/21/2021 Discontinued
750 MG tablet (four) times daily. (Reorder)
lidocaine (LIDODERM) 5 % Place 1 patch onto the 6 patch 0 01/18/2021 05/03/2021 Discontinued
skin daily Remove & (Patient
Discard patch within 12 Choice)
hours or as directed by
MD.
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who Unable to assess 1/21/2021 8:16 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Not on file

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Jason A Hopper Feb. 03, 2021
NPI: 1023317880 NPI: 1548605108
502-394-6000 (Work) 502-891-8300 (Work)
502-394-3689 (Fax) 502-891-8338 (Fax)
Family Medicine 6420 Dutchmans Parkway
Norton Healthcare Suite 200
Louisville, KY 40202 Louisville, KY 40205-3373
Cardiology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Feb. 03, 2021
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Encounter Details
Date Type Department Care Team Description
01/23/2021 Telephone Norton Community Medical Madelyn J Jacobs
Associates - Brownsboro 9880 Angie's Way
9880 Angies Way Suite 420
Suite 420 Louisville, KY 40241
LOUISVILLE, KY 40241-2848 502-394-6200 (Work)
502-394-6200 502-394-6210 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 0 01/04/2021 02/04/2021 Discontinued
MG tablet (two) times daily as
needed (mild headache)
for up to 10 days Take
with food.
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 01/12/2021 02/09/2021 Discontinued
ER) 36 MG ER tablet every morning. Max (Reorder)
Daily Amount: 54 mg
methocarbamol (ROBAXIN) Take 1 tablet by mouth 4 20 tablet 0 01/18/2021 04/21/2021 Discontinued
750 MG tablet (four) times daily. (Reorder)
lidocaine (LIDODERM) 5 % Place 1 patch onto the 6 patch 0 01/18/2021 05/03/2021 Discontinued
skin daily Remove & (Patient
Discard patch within 12 Choice)
hours or as directed by
MD.

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020
Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)
Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who Unable to assess 1/21/2021 8:16 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Not on file

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Jason A Hopper Jan. 23, 2021
NPI: 1023317880 NPI: 1548605108
502-394-6000 (Work) 502-891-8300 (Work)
502-394-3689 (Fax) 502-891-8338 (Fax)
Family Medicine 6420 Dutchmans Parkway
Norton Healthcare Suite 200
Louisville, KY 40202 Louisville, KY 40205-3373
Cardiology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Madelyn J Jacobs (Attending) Jan. 23, 2021
NPI: 1699730655
502-394-6200 (Work)
502-394-6210 (Fax)
9880 Angie's Way
Suite 420
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
Back Pain

Encounter Details
Date Type Department Care Team Description
01/19/2021 Telemedicine Norton Community Medical Jing Bryant
11:00 AM Associates - Brownsboro 9880 Angie's Way
EST 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 0 01/04/2021 02/04/2021 Discontinued
MG tablet (two) times daily as
needed (mild headache)
for up to 10 days Take
with food.
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 01/12/2021 02/09/2021 Discontinued
ER) 36 MG ER tablet every morning. Max (Reorder)
Daily Amount: 54 mg
methocarbamol (ROBAXIN) Take 1 tablet by mouth 4 20 tablet 0 01/18/2021 04/21/2021 Discontinued
750 MG tablet (four) times daily. (Reorder)
lidocaine (LIDODERM) 5 % Place 1 patch onto the 6 patch 0 01/18/2021 05/03/2021 Discontinued
skin daily Remove & (Patient
Discard patch within 12 Choice)
hours or as directed by
MD.
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 1/18/2021 8:35 PM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Not on file

Patient Instructions - documented in this encounter

Patient Instructions
Jing Bryant - 01/19/2021 1:00 PM EST
Formatting of this note is different from the original.
Images from the original note were not included.

Please complete medrol dose pack (oral steroid) with food as directed.

May apply ice/heat on lower back area 20 minutes every 2-3 hours as needed to reduce pain.

May take 400-600 mg ibuprofen with food 2-3 times a day as needed for increased pain.

May take methocarbamol (aka, Robaxin), a muscle relaxant, at bedtime as needed.

Muscle relaxants can make you drowsy; do not drive or operate machinery while under the influence of muscle relaxants.

Allow pain be your daily activity guide. Avoid bed rest.

Do lower back exercise as tolertated.

Follow up as needed.

Low Back Pain Exercises

Regular exercises to restore the strength of your back and a gradual return to everyday activities are important for your full
recovery. Your doctor and physical therapist may recommend that you exercise 10 to 30 minutes a day 1 to 3 times a day during
your early recovery. They may suggest some of the following exercises. This guide can help you better understand your exercise
and activity program.

Initial Exercise Program

Ankle Pumps
· Lie on your back.
· Move ankles up and down. Repeat 10 times.
· Repeat 10 times.
Heel Slides

· Lie on your back.

· Slowly bend and straighten knee.
· Repeat 10 times.
Abdominal Contraction

· Lie on your back with knees bent and hands resting below ribs.
· Tighten abdominal muscles to squeeze ribs down toward back.
· Be sure not to hold breath.
· Hold 5 seconds.
· Relax.
· Repeat 10 times.
Wall Squats

· Stand with back leaning against wall.

· Walk feet 12 inches in front of body.
· Keep abdominal muscles tight while slowly bending both knees 45 degrees.
· Hold 5 seconds.
· Slowly return to upright position.
· Repeat 10 times.
Heel Raises

· Stand with weight even on both feet.

· Slowly raise heels up and down.
· Repeat 10 times.
Straight Leg Raises

· Lie on your back with one leg straight and one knee bent.
· Tighten abdominal muscles to stabilize low back.
· Slowly lift leg straight up about 6 to 12 inches and hold 1 to 5 seconds.
· Lower leg slowly.
· Repeat 10 times.
Intermediate Exercise Program
Single Knee to Chest Stretch

· Lie on your back with both knees bent.

· Hold thigh behind knee and bring one knee up to chest.
· Hold 20 seconds.
· Relax.
· Repeat 5 times on each side.
Hamstring Stretch

· Lie on your back with legs bent.

· Hold one thigh behind knee.
· Slowly straighten knee until a stretch is felt in back of thigh.
· Hold 20 seconds.
· Relax.
· Repeat 5 times on each side.
Lumbar Stabilization Exercises With Swiss Ball
Abdominal muscles must remain contracted during each exercise (see Abdominal Contraction). Perform each exercise for 60
seconds. The farther the ball is from your body, the harder the exercise.
Lying on Floor

· Lie on your back with knees bent and calves resting on ball.
· Slowly raise arm over head and lower arm, alternating right and left sides.
· Slowly straighten one knee and relax, alternating right and left sides.
· Slowly straighten one knee and raise opposite arm over head. Alternate opposite arms and legs.
· Slowly "walk" ball forward and backward with legs.
Sitting on Ball

· Sit on ball with hips and knees bent 90°and feet resting on floor.
· Slowly raise arm over head and lower arm, alternating right and left sides.
· Slowly raise and lower heel, alternating right and left sides.
· Slowly raise one heel and raise opposite arm over head. Alternate opposite arm and heel.
· Marching: Slowly raise one foot 2 inches from floor, alternating right and left sides.
Standing
· Stand with ball between your low back and wall.
· Slowly bend knees 45 ° to 90 ° . Hold 5 seconds. Straighten knees.
· Slowly bend knees 45 ° to 90 ° while raising both arms over head.
Lying on Ball

· Lie on your stomach over ball

· Slowly raise alternate arms over head.
· Slowly raise alternate legs 2 to 4 inches from floor.
· Combine 1 and 2, alternating opposite arms and legs.
· Bend one knee. Slowly lift this leg up, alternating right and left legs.
NOTE: Be careful not to arch your low back!

Electronically signed by Jing Bryant at 01/19/2021 1:01 PM EST

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
Chronic right-sided low back pain without sciatica - Primary
Vasectomy evaluation

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Jason A Hopper Jan. 19, 2021
NPI: 1023317880 NPI: 1548605108
502-394-6000 (Work) 502-891-8300 (Work)
502-394-3689 (Fax) 502-891-8338 (Fax)
Family Medicine 6420 Dutchmans Parkway
Norton Healthcare Suite 200
Louisville, KY 40202 Louisville, KY 40205-3373
Cardiology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Jan. 19, 2021
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
COLD
Back Pain

Encounter Details
Date Type Department Care Team Description
01/18/2021 Emergency NBH Emergency Department Charlotte Crowley Discharge Disposition: Home
8:40 PM 4960 Norton Healthcare Blvd 1 Audubon Plaza Drive or Self Care
EST - Louisville, KY 40241-2831 Louisville, KY 40217-1318
01/18/2021 502-446-8125 502-636-7225 (Work)
11:23 PM 502-636-8032 (Fax)
EST

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 0 01/04/2021 02/04/2021 Discontinued
MG tablet (two) times daily as
needed (mild headache)
for up to 10 days Take
with food.
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 01/12/2021 02/09/2021 Discontinued
ER) 36 MG ER tablet every morning. Max (Reorder)
Daily Amount: 54 mg
methylPREDNISolone follow package 21 tablet 0 01/18/2021 01/18/2021 Expired
(MEDROL DOSPACK) 4 MG directions.
tablet
methocarbamol (ROBAXIN) Take 1 tablet by mouth 4 20 tablet 0 01/18/2021 04/21/2021 Discontinued
750 MG tablet (four) times daily. (Reorder)
lidocaine (LIDODERM) 5 % Place 1 patch onto the 6 patch 0 01/18/2021 05/03/2021 Discontinued
skin daily Remove & (Patient
Discard patch within 12 Choice)
hours or as directed by
MD.
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 1/18/2021 8:35 PM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 135/86 01/18/2021 11:13 PM EST
Pulse 84 01/18/2021 11:13 PM EST
Temperature 36.8 °C (98.3 °F) 01/18/2021 8:33 PM EST
Respiratory Rate 18 01/18/2021 11:13 PM EST
Oxygen Saturation 98% 01/18/2021 8:33 PM EST
Inhaled Oxygen Concentration - -
Weight 95.3 kg (210 lb) 01/18/2021 8:33 PM EST
Height 185.4 cm (6' 1") 01/18/2021 8:33 PM EST
Body Mass Index 27.71 01/18/2021 8:33 PM EST

Discharge Instructions - documented in this encounter

Discharge Instructions
Melanie M Pleiss - 01/18/2021 9:51 PM EST
Formatting of this note is different from the original.
Follow up with Neck and Back Pain clinic regarding back pain if it worsens. Complete the entire steroid pack. Use Robaxin as
needed for muscle ache and spasm. Apply lidocaine patch every 24 hours to help with discomfort. A heating pad may help with
discomfort.

Return immediately for any worsening symptoms, fever, chest pain, shortness of breath, abdominal pain, intractable vomiting,
new/worsening headache, one-sided numbness/weakness, syncope, or any other concerning symptoms.

Follow up with PCP in 2-3 days for further evaluation and management of the above ED diagnoses, as well as a blood pressure
check.
Consider the following in order to assist with blood pressure control: weight loss if overweight, sodium restricted diet, increased
physical activity, decreasing alcohol consumption.

Your Vitals today were:

Vitals:
01/18/21 2033
BP: (!) 155/104
Pulse: (!) 103
Temp: 98.3 °F (36.8 °C)
TempSrc: Oral
SpO2: 98%
Weight: 95.3 kg (210 lb)
Height: 6' 1" (1.854 m)

If you are a smoker, work on decreasing tobacco use. Tobacco use can lead to several health problems and impairs your ability to
heal. Follow up with your PCP to discuss medications that may assist in tobacco cessation if interested.

Do Not Drive For 6 Hours

You received medication during your emergency department visit today than can impair your consciousness and responsiveness.
As such, driving and/or operating machinery can put you or others around you at risk for serious injury. Please refrain from these
activities for 6 hours after receiving medication in the ED.

Acute Low Back Pain

WHAT YOU NEED TO KNOW:
Acute low back pain is sudden discomfort in your lower back area that lasts for up to 6 weeks. The discomfort makes it difficult
to tolerate activity.
DISCHARGE INSTRUCTIONS:
Return to the emergency department if:
· You have severe pain.

· You have sudden stiffness and heaviness on both buttocks down to both legs.

· You have numbness or weakness in one leg, or pain in both legs.

· You have numbness in your genital area or across your lower back.

· You cannot control your urine or bowel movements.

Contact your healthcare provider if:

· You have a fever.

· You have pain at night or when you rest.

· Your pain does not get better with treatment.

· You have pain that worsens when you cough or sneeze.

· You suddenly feel something pop or snap in your back.

· You have questions or concerns about your condition or care.

Medicines: You may need any of the following:

· NSAIDs help decrease swelling and pain. This medicine is available with or without a doctor's order. NSAIDs can cause stomach
bleeding or kidney problems in certain people. If you take blood thinner medicine, always ask your healthcare provider if NSAIDs
are safe for you. Always read the medicine label and follow directions.

· Acetaminophen decreases pain and fever. It is available without a doctor's order. Ask how much to take and how often to take
it. Follow directions. Read the labels of all other medicines you are using to see if they also contain acetaminophen, or ask your
doctor or pharmacist. Acetaminophen can cause liver damage if not taken correctly. Do not use more than 4 grams (4,000
milligrams) total of acetaminophen in one day.

· Muscle relaxers decrease pain by relaxing the muscles in your lower spine.

· Prescription pain medicine may be given. Ask your healthcare provider how to take this medicine safely. Some prescription pain
medicines contain acetaminophen. Do not take other medicines that contain acetaminophen without talking to your healthcare
provider. Too much acetaminophen may cause liver damage. Prescription pain medicine may cause constipation. Ask your
healthcare provider how to prevent or treat constipation.

Self-care:
· Stay active as much as you can without causing more pain. Bed rest could make your back pain worse. Start with some light
exercises, such as walking. Avoid heavy lifting until your pain is gone. Ask for more information about the activities or exercises
that are right for you.

· Apply ice on your back for 15 to 20 minutes every hour or as directed. Use an ice pack, or put crushed ice in a plastic bag.
Cover it with a towel before you apply it to your skin. Ice helps prevent tissue damage and decreases swelling and pain.

· Apply heat on your back for 20 to 30 minutes every 2 hours for as many days as directed. Heat helps decrease pain and muscle
spasms. Alternate heat and ice.

Prevent acute low back pain:

· Use proper body mechanics.

? Bend at the hips and knees when you pick up objects. Do not bend from the waist. Use your leg muscles as you lift the load.
Do not use your back. Keep the object close to your chest as you lift it. Try not to twist or lift anything above your waist.

? Change your position often when you stand for long periods of time. Rest one foot on a small box or footrest, and then switch
to the other foot often.

? Try not to sit for long periods of time. When you do, sit in a straight-backed chair with your feet flat on the floor. Never reach,
pull, or push while you are sitting.

· Do exercises that strengthen your back muscles. Warm up before you exercise. Ask your healthcare provider the best exercises
for you.

· Maintain a healthy weight. Ask your healthcare provider how much you should weigh. Ask him or her to help you create a
weight loss plan if you are overweight.

Follow up with your healthcare provider as directed: Return for a follow-up visit if you still have pain after 1 to 3 weeks of
treatment. You may need to visit an orthopedist if your back pain lasts longer than 12 weeks. Write down your questions so you
remember to ask them during your visits.
© Copyright IBM Corporation 2020 Information is for End User's use only and may not be sold, redistributed or otherwise used
for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or
IBM Watson Health
The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments.
Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

Electronically signed by Melanie M Pleiss at 01/18/2021 9:51 PM EST

Medications at Time of Discharge - documented as of this encounter

Medication Sig Dispensed Refills Start Date End Date
lidocaine (LIDODERM) 5 % Place 1 patch onto the skin 6 patch 0 01/18/2021 05/03/2021
daily Remove & Discard patch
within 12 hours or as directed
by MD.
methocarbamol (ROBAXIN) Take 1 tablet by mouth 4 (four) 20 tablet 0 01/18/2021 04/21/2021
750 MG tablet times daily.
methylphenidate (CONCERTA Take 1 tablet by mouth every 30 tablet 0 01/12/2021 02/09/2021
ER) 36 MG ER tablet morning. Max Daily Amount:
54 mg
methylPREDNISolone follow package directions. 21 tablet 0 01/18/2021 01/18/2021
(MEDROL DOSPACK) 4 MG
tablet
Multiple Vitamin Take by mouth. 0 10/17/2022
(MULTIVITAMIN PO)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 (two) 30 tablet 0 01/04/2021 02/04/2021
MG tablet times daily as needed (mild
headache) for up to 10 days
Take with food.
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021
VYVANSE 30 MG capsule 0 01/14/2021 02/22/2021

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
lidocaine (LIDODERM) 5 % Place 1 patch onto the skin 6 patch 0 01/18/2021 05/03/2021
daily Remove & Discard patch
within 12 hours or as directed
by MD.
methocarbamol (ROBAXIN) Take 1 tablet by mouth 4 (four) 20 tablet 0 01/18/2021 04/21/2021
750 MG tablet times daily.
methylPREDNISolone follow package directions. 21 tablet 0 01/18/2021 01/18/2021
(MEDROL DOSPACK) 4 MG
tablet
Plan of Treatment - documented as of this encounter
Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

XR L SPINE COMP W OBLIQUES - Final result (01/18/2021 9:44 PM EST)
Anatomical Region Laterality Modality
Spine, L-spine NHC Radiographic Imaging

Anatomical Location / Collection Method /

Specimen (Source) Laterality Volume Collection Time Received Time
01/18/2021 9:45 PM EST

Narrative
01/18/2021 9:48 PM EST
RADIOLOGY REPORT

FACILITY: NORTON BROWNSBORO HOSPITAL

UNIT/AGE/GENDER: J.ED ER AGE:37 Y SEX:M
PATIENT NAME/DOB: GOMEZ, RYAN, S 11/11/1983
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10101326692
ACCESSION NUMBER: EPJ21RAD43798

DATE: 01/18/2021

HISTORY: bilateral back pain.

COMPARISON: none

EXAMINATION: LUMBAR SPINE 5 VIEWS INCLUDING OBLIQUES

FINDINGS: Normal alignment maintained. No compression deformity, vertebral body subluxation, or

fracture is detected. No spondylolysis or spondylolisthesis is identified. The sacroiliac joints have a
normal appearance.

CONCLUSION: Negative examination.

Dictated by: Greg Walton, M.D.

Images and Report reviewed and interpreted by: Greg Walton, M.D.

<PS><Electronically signed by: Greg Walton, M.D.>

01/18/2021 2147

D: 01/18/2021 2145
T: 01/18/2021 2145

Procedure Note
Greg S Walton - 01/18/2021
 Procedure Note
Formatting of this note might be different from the original.
RADIOLOGY REPORT

FACILITY: NORTON BROWNSBORO HOSPITAL

UNIT/AGE/GENDER: J.ED ER AGE:37 Y SEX:M
PATIENT NAME/DOB: GOMEZ, RYAN, S 11/11/1983
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10101326692
ACCESSION NUMBER: EPJ21RAD43798

DATE: 01/18/2021

HISTORY: bilateral back pain.

COMPARISON: none

EXAMINATION: LUMBAR SPINE 5 VIEWS INCLUDING OBLIQUES

FINDINGS: Normal alignment maintained. No compression deformity, vertebral body subluxation, or fracture is detected. No
spondylolysis or spondylolisthesis is identified. The sacroiliac joints have a normal appearance.

CONCLUSION: Negative examination.

Dictated by: Greg Walton, M.D.

Images and Report reviewed and interpreted by: Greg Walton, M.D.

<PS><Electronically signed by: Greg Walton, M.D.>

01/18/2021 2147

D: 01/18/2021 2145
T: 01/18/2021 2145

Authorizing Provider Result Type

Melanie M Pleiss IMG DIAGNOSTIC IMAGING ORDERABLES

Visit Diagnoses - documented in this encounter

Diagnosis
Acute bilateral low back pain without sciatica - Primary

Administered Medications - documented in this encounter

Inactive Administered Medications - up to 3 most recent administrations
Medication Order MAR Action Action Date Dose Rate Site
HYDROcodone-acetaminophen (NORCO) 5-325 Given 01/18/2021 1 tablet
MG per tablet 1 tablet 9:43 PM EST
1 tablet, Oral, Once, On Mon 1/18/21 at 2115,
For 1 dose, Maximum Recommended Dose for
Adults of Acetaminophen = 4 gm Per Day., STAT

ibuprofen (MOTRIN) tablet 600 mg Given 01/18/2021 600 mg

600 mg, Oral, Once, On Mon 1/18/21 at 2115, 9:43 PM EST
For 1 dose, Give with food or milk if able., STAT

lidocaine (LIDODERM) 5 % 1 patch Patch/ 01/18/2021 1 patch Other

1 patch, Transdermal, Once, On Mon 1/18/21 at Ointment 9:44 PM EST
2115, For 1 dose, Patch(s) Should be Removed For Applied
12 Hours per 24 Hours., Administer over 12 Hours,
STAT

methocarbamol (ROBAXIN) tablet 750 mg Given 01/18/2021 750 mg

750 mg, Oral, Once, On Mon 1/18/21 at 2115, 9:43 PM EST
For 1 dose, STAT
Care Teams - documented as of this encounter
Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Jason A Hopper Jan. 18, 2021
NPI: 1023317880 NPI: 1548605108
502-394-6000 (Work) 502-891-8300 (Work)
502-394-3689 (Fax) 502-891-8338 (Fax)
Family Medicine 6420 Dutchmans Parkway
Norton Healthcare Suite 200
Louisville, KY 40202 Louisville, KY 40205-3373
Cardiology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Charlotte Crowley (Attending) Jan. 18, 2021
NPI: 1871836940
502-636-7225 (Work)
502-636-8032 (Fax)
1 Audubon Plaza Drive
Louisville, KY 40217-1318
Emergency Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason Onset Date
Medication Refill 01/11/2021

Encounter Details
Date Type Department Care Team Description
01/11/2021 Refill Norton Community Medical Jing Bryant
Associates - Brownsboro 9880 Angie's Way
9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 0 01/04/2021 02/04/2021 Discontinued
MG tablet (two) times daily as
needed (mild headache)
for up to 10 days Take
with food.
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth 30 capsule 0 01/11/2021 01/12/2021 Discontinued
30 MG capsule every morning. Max (Cost of
Daily Amount: 30 mg medication)
methylphenidate (CONCERTA Take 1 tablet by mouth 30 tablet 0 01/12/2021 02/09/2021 Discontinued
ER) 36 MG ER tablet every morning. Max (Reorder)
Daily Amount: 54 mg

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020
Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)
Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 1/7/2021 6:49 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Not on file

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
methylphenidate (CONCERTA Take 1 tablet by mouth every 30 tablet 0 01/12/2021 02/09/2021
ER) 36 MG ER tablet morning. Max Daily Amount:
54 mg
lisdexamfetamine (VYVANSE) Take 1 capsule by mouth every 30 capsule 0 01/11/2021 01/12/2021
30 MG capsule morning. Max Daily Amount:
30 mg

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)
Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Jason A Hopper Jan. 11, 2021
NPI: 1023317880 NPI: 1548605108
502-394-6000 (Work) 502-891-8300 (Work)
502-394-3689 (Fax) 502-891-8338 (Fax)
Family Medicine 6420 Dutchmans Parkway
Norton Healthcare Suite 200
Louisville, KY 40202 Louisville, KY 40205-3373
Cardiology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Jan. 11, 2021
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason Onset Date
Advice Only 01/08/2021

Encounter Details
Date Type Department Care Team Description
01/08/2021 Telephone Norton Community Medical Jing Bryant
Associates - Brownsboro 9880 Angie's Way
9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 0 01/04/2021 02/04/2021 Discontinued
MG tablet (two) times daily as
needed (mild headache)
for up to 10 days Take
with food.

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021
Social History - documented as of this encounter
Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 1/7/2021 6:49 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Not on file

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Jason A Hopper Jan. 08, 2021
NPI: 1023317880 NPI: 1548605108
502-394-6000 (Work) 502-891-8300 (Work)
502-394-3689 (Fax) 502-891-8338 (Fax)
Family Medicine 6420 Dutchmans Parkway
Norton Healthcare Suite 200
Louisville, KY 40202 Louisville, KY 40205-3373
Cardiology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Jan. 08, 2021
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Auth/Cert
Specialty Diagnoses / Procedures Referred By Contact Referred To Contact

Expiration Visits Visits

Referral ID Status Reason Start Date Date Requested Authorized
28506874 1 1

Encounter Details
Date Type Department Care Team Description
01/07/2021 Hospital SCC Cardiology Jason A Hopper Discharge Disposition: Home
6:50 AM Encounter 6420 Dutchmans Parkway 6420 Dutchmans Parkway or Self Care
EST - Suite 75 Lower Level Suite 200
01/07/2021 Louisville, KY 40205-3373 Louisville, KY 40205-3373
11:59 PM 502-891-8577 502-891-8300 (Work)
EST 502-891-8338 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 0 01/04/2021 02/04/2021 Discontinued
MG tablet (two) times daily as
needed (mild headache)
for up to 10 days Take
with food.

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020
Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)
Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 1/7/2021 6:49 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Not on file

Medications at Time of Discharge - documented as of this encounter

Medication Sig Dispensed Refills Start Date End Date
Multiple Vitamin Take by mouth. 0 10/17/2022
(MULTIVITAMIN PO)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 (two) 30 tablet 0 01/04/2021 02/04/2021
MG tablet times daily as needed (mild
headache) for up to 10 days
Take with food.
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

TRANSTHORACIC ECHO 2D MMODE SPECTRAL COLOR, COMPLETE (ECHO DOPPLER 2D MMODE SPECT COLOR
COMPLETE) - Final result (01/07/2021 7:19 AM EST)
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
01/07/2021 6:53 AM
EST

Narrative
NH MCKCPACS - 01/07/2021 12:06 PM EST
CARDIOLOGY REPORT
FACILITY: NORTON CARDIOVASCULAR DIAGNOSTIC CENTER - SPRINGS

PATIENT NAME/DOB: GOMEZ, RYAN S 11/11/1983

UNIT/AGE/GENDER: AGE: 37 YR GENDER: M
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10100505266
ACCESSION NUMBER: EPSC21ECHO9625

DATE OF EXAM: 01/07/2021 06:53

EXAMINATION(S): ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE
Narrative

FINAL REPORT

Procedure
Type of Study

TTE procedure:ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE.

Clinical Indications:Abnormal ECG.Screening for ischemic heart disease.

Height: 185 cmWeight: 100 kgBSA: 2.24 m^2 BMI: 29.22 kg/m^2

BP: 138/80 mmHg

Conclusions

Summary
Normal left ventricular structure and systolic function.
The LVEF is 55-60%.
No significant valvular abnormalities.
Normal right ventricular size and function.

Any valve disease noted in the report is non-rheumatic unless otherwise

specifically noted.

Findings

Left Ventricle
The left ventricular chamber size, wall thickness, and systolic function are
within normal limits. There are no regional wall motion abnormalities
observed.
The estimated ejection fraction is 55-60%.
Normal diastolic filling pattern.

Left Atrium
The left atrial chamber size appears normal.

Right Ventricle
The right ventricular chamber size and systolic function are within normal
limits.

Right Atrium
The right atrial chamber size appears normal.

Aortic Valve
The aortic valve is trileaflet. The leaflets are thin with normal excursion.
There is no aortic stenosis or regurgitation present.

Mitral Valve
Structurally normal mitral valve.
Trace mitral regurgitation is present
No mitral stenosis.

Tricuspid Valve
Tricuspid valve is structurally normal.
Trace tricuspid regurgitation
There is inadequate tricuspid insufficiency to calculate accurate right
ventricular systolic pressure.

Pulmonic Valve
Trace pulmonic insufficiency
The pulmonic valve was not well visualized.

Pericardium
There is no evidence of pericardial effusion.

Great Vessels
The aortic root appears normal. There is no dilatation of the ascending
aorta. IVC appears normal.

Pleural Effusion
No evidence of pleural effusion.

M-Mode/2D Measurements & Calculations

LV Diastolic Dimension: LV Systolic Dimension: LA Dimension: 3.9 cmAO

4.41 cm 2.64 cm Root Dimension: 3.5 cm
LV PW Diastolic: 1.04 cm LV Volume Diastolic: 122
Septum Diastolic: 1.15 ml
cm LV Volume Systolic: 52
ml RV Diastolic Dimension:
LV EDV/LV EDV Index: 122 3.7 cm
Narrative
ml/54 m^2LV ESV/LV ESV
LV Area Diastolic: 41.9 Index: 52 ml/23 m^2 LA/Aorta: 1.11
cm^2 EF Calculated: 57.4 % Ascending Aorta: 3.5 cm
LV Area Systolic: 24 LA volume: 52ml
cm^2 LV Length: 10.1 cm LA volume/Index: 23ml/m^2
RA Area: 18.2 cm^2
LVOT: 2.3 cm RA volume: 50 ml
RA volume index: 22.3
ml/m2

Doppler Measurements & Calculations

MV Peak E-Wave: 0.63 m/s

MV Peak A-Wave: 0.61 m/s
MV E/A Ratio: 1.04

TV TAPSE:26 mm

MV E' Septal Velocity: 0.08 m/s

MV E' Lateral Velocity: 0.14 m/s
MV E/E' septal: 7.72
MV E/E' lateral: 4.68

Signature

Electronically signed by Jason Hopper, M.D. (Interpreting Physician) on

01/07/2021 at 12:06 PM

Procedure Note
Jason A Hopper - 01/07/2021
Formatting of this note might be different from the original.
CARDIOLOGY REPORT
FACILITY: NORTON CARDIOVASCULAR DIAGNOSTIC CENTER - SPRINGS

PATIENT NAME/DOB: GOMEZ, RYAN S 11/11/1983

UNIT/AGE/GENDER: AGE: 37 YR GENDER: M
UNIT NUMBER: EP01611383
ACCOUNT NUMBER: 10100505266
ACCESSION NUMBER: EPSC21ECHO9625

DATE OF EXAM: 01/07/2021 06:53

EXAMINATION(S): ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE

FINAL REPORT

Procedure
Type of Study

TTE procedure:ECHO DOPPLER 2D MMODE SPECT COLOR COMPLETE.

Clinical Indications:Abnormal ECG.Screening for ischemic heart disease.

Height: 185 cmWeight: 100 kgBSA: 2.24 m^2 BMI: 29.22 kg/m^2

BP: 138/80 mmHg

Conclusions

Summary
Normal left ventricular structure and systolic function.
The LVEF is 55-60%.
No significant valvular abnormalities.
Normal right ventricular size and function.

Any valve disease noted in the report is non-rheumatic unless otherwise

specifically noted.

Findings

Left Ventricle
The left ventricular chamber size, wall thickness, and systolic function are
within normal limits. There are no regional wall motion abnormalities
Procedure Note
observed.
The estimated ejection fraction is 55-60%.
Normal diastolic filling pattern.

Left Atrium
The left atrial chamber size appears normal.

Right Ventricle
The right ventricular chamber size and systolic function are within normal
limits.

Right Atrium
The right atrial chamber size appears normal.

Aortic Valve
The aortic valve is trileaflet. The leaflets are thin with normal excursion.
There is no aortic stenosis or regurgitation present.

Mitral Valve
Structurally normal mitral valve.
Trace mitral regurgitation is present
No mitral stenosis.

Tricuspid Valve
Tricuspid valve is structurally normal.
Trace tricuspid regurgitation
There is inadequate tricuspid insufficiency to calculate accurate right
ventricular systolic pressure.

Pulmonic Valve
Trace pulmonic insufficiency
The pulmonic valve was not well visualized.

Pericardium
There is no evidence of pericardial effusion.

Great Vessels
The aortic root appears normal. There is no dilatation of the ascending
aorta. IVC appears normal.

Pleural Effusion
No evidence of pleural effusion.

M-Mode/2D Measurements & Calculations

LV Diastolic Dimension: LV Systolic Dimension: LA Dimension: 3.9 cmAO

4.41 cm 2.64 cm Root Dimension: 3.5 cm
LV PW Diastolic: 1.04 cm LV Volume Diastolic: 122
Septum Diastolic: 1.15 ml
cm LV Volume Systolic: 52
ml RV Diastolic Dimension:
LV EDV/LV EDV Index: 122 3.7 cm
ml/54 m^2LV ESV/LV ESV
LV Area Diastolic: 41.9 Index: 52 ml/23 m^2 LA/Aorta: 1.11
cm^2 EF Calculated: 57.4 % Ascending Aorta: 3.5 cm
LV Area Systolic: 24 LA volume: 52ml
cm^2 LV Length: 10.1 cm LA volume/Index: 23ml/m^2
RA Area: 18.2 cm^2
LVOT: 2.3 cm RA volume: 50 ml
RA volume index: 22.3
ml/m2

Doppler Measurements & Calculations

MV Peak E-Wave: 0.63 m/s

MV Peak A-Wave: 0.61 m/s
MV E/A Ratio: 1.04
 Procedure Note
TV TAPSE:26 mm

MV E' Septal Velocity: 0.08 m/s

MV E' Lateral Velocity: 0.14 m/s
MV E/E' septal: 7.72
MV E/E' lateral: 4.68

Signature

Electronically signed by Jason Hopper, M.D. (Interpreting Physician) on

01/07/2021 at 12:06 PM

Authorizing Provider Result Type

Jason A Hopper CV ECHO ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NH MCKCPACS

Visit Diagnoses - documented in this encounter

Diagnosis
Screening for ischemic heart disease
Abnormal EKG

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Jason A Hopper Jan. 07, 2021
NPI: 1023317880 NPI: 1548605108
502-394-6000 (Work) 502-891-8300 (Work)
502-394-3689 (Fax) 502-891-8338 (Fax)
Family Medicine 6420 Dutchmans Parkway
Norton Healthcare Suite 200
Louisville, KY 40202 Louisville, KY 40205-3373
Cardiology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jason A Hopper (Attending) Jan. 07, 2021
NPI: 1548605108
502-891-8300 (Work)
502-891-8338 (Fax)
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
Cardiology

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
HTN
Abnormal ECG

Consultation (Routine) - Closed

Specialty Diagnoses / Procedures Referred By Contact Referred To Contact
Cardiology Diagnoses Jing Bryant
Elevated blood pressure 9880 Angie's Way
reading without diagnosis of STE 410
hypertension Louisville, KY 40241
Abnormal EKG Phone: 502-394-6000
Fax: 502-394-3689

Expiration Visits Visits

Referral ID Status Reason Start Date Date Requested Authorized
28453046 Closed 1/4/2021 2/4/2022 1 1

Encounter Details
Date Type Department Care Team Description
01/05/2021 Office Visit Norton Heart Specialists Jason A Hopper
1:00 PM 6420 Dutchmans Pkwy 6420 Dutchmans Parkway
EST Suite 200 Suite 200
Louisville, KY 40205-3373 Louisville, KY 40205-3373
502-891-8300 502-891-8300 (Work)
502-891-8338 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 0 01/04/2021 02/04/2021 Discontinued
MG tablet (two) times daily as
needed (mild headache)
for up to 10 days Take
with food.
Active Problems - documented as of this encounter (statuses as of 09/29/2023)
Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020

Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)

Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 1/4/2021 10:35 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 126/84 01/05/2021 1:01 PM EST
Pulse 81 01/05/2021 1:01 PM EST
Temperature - -
Respiratory Rate - -
Oxygen Saturation - -
Inhaled Oxygen Concentration - -
Weight 99.6 kg (219 lb 9.3 oz) 01/05/2021 1:01 PM EST
Height 185.4 cm (6' 1") 01/05/2021 1:01 PM EST
Body Mass Index 28.97 01/05/2021 1:01 PM EST

Progress Notes - documented in this encounter

Jason A Hopper - 01/05/2021 1:00 PM EST
Formatting of this note is different from the original.
OFFICE VISIT NOTE

NORTON HEART SPECIALISTS

Name: Ryan S Gomez

Date: 1/5/2021
MRN: EP01611383
DOB: 11/11/1983

REFERRING PROVIDER: Bryant, Jing, MD

PCP: Bryant, Jing, MD

CARDIAC HISTORY
Ryan has no previously diagnosed cardiovascular disease. He has attention deficit disorder and is being evaluated for initiation of
stimulant use and given a abnormal ECG was referred to our practice for additional evaluation

His other comorbidities include ADD, HLD, HTN

TODAY'S VISIT
Ryan S Gomez is a 37 yr/o male who presents today as a new referral from Bryant, Jing, MD to discuss abnormal ECG.

Chief Complaint
Patient presents with
• HTN
• Abnormal ECG

• No previous cardiovascular history.

• ECG obtained at office visit for screening purposes. No symptoms prompted ECG but given possibility of inferior infarction
patient was referred to our practice.
• He has no episodes of chest discomfort, pain, pressure.
• No shortness of breath, orthopnea, PND. No palpitations.
• He has recently started exercising more and has a Peloton bike at home and is doing classes on that without limitation at this
time.
• Family history of cardiovascular disease in his father

He has a past medical history of ADD (attention deficit disorder) and Elevated LFTs (11/28/2020).

He has a past surgical history that includes Fracture surgery (Left, 2018) and Hernia repair (1992).

Social History

Socioeconomic History
• Marital status: Married
Spouse name: Not on file
• Number of children: Not on file
• Years of education: Not on file
• Highest education level: Not on file
Occupational History
• Not on file
Social Needs
• Financial resource strain: Not on file
• Food insecurity
Worry: Not on file
Inability: Not on file
• Transportation needs
Medical: Not on file
Non-medical: Not on file
Tobacco Use
• Smoking status: Current Some Day Smoker
Packs/day: 0.25
Types: Cigars
• Smokeless tobacco: Never Used
• Tobacco comment: cigars infrequently: more social
Substance and Sexual Activity
• Alcohol use: Yes
Alcohol/week: 1.0 standard drinks
Types: 1 Glasses of wine per week
Comment: daily
• Drug use: No
• Sexual activity: Yes
Partners: Female
Lifestyle
• Physical activity
Days per week: Not on file
Minutes per session: Not on file
• Stress: Not on file
Relationships
• Social connections
Talks on phone: Not on file
Gets together: Not on file
Attends religious service: Not on file
Active member of club or organization: Not on file
Attends meetings of clubs or organizations: Not on file
Relationship status: Not on file
• Intimate partner violence
Fear of current or ex partner: Not on file
Emotionally abused: Not on file
Physically abused: Not on file
Forced sexual activity: Not on file
Other Topics Concern
• Not on file
Social History Narrative
• Not on file

Family History
Problem Relation Age of Onset
• Heart disease Father
• Hypertension Father
• Heart disease Maternal Grandmother
• Hypertension Maternal Grandmother
• Heart disease Maternal Grandfather
• Hypertension Maternal Grandfather
• ADD / ADHD Daughter
• Heart disease Maternal Uncle
• Hypertension Maternal Uncle
• Thyroid disease Sister
hyperthyroid
• Cancer, Other or Unknown Type Neg Hx
• Diabetes Neg Hx

Review of Systems
Constitution: Negative for chills, decreased appetite, fever, malaise/fatigue, weight gain and weight loss.
HENT: Negative for hearing loss and nosebleeds.
Eyes: Negative for blurred vision, double vision, vision loss in left eye and vision loss in right eye.
Cardiovascular: Negative for chest pain, claudication, dyspnea on exertion, leg swelling, orthopnea, palpitations and syncope.
Respiratory: Negative for cough, shortness of breath, sleep disturbances due to breathing, snoring and wheezing.
Hematologic/Lymphatic: Negative for bleeding problem. Does not bruise/bleed easily.
Skin: Negative for itching and rash.
Musculoskeletal: Negative for falls, muscle weakness and myalgias.
Gastrointestinal: Negative for abdominal pain, constipation, diarrhea, heartburn, hematemesis, hematochezia, melena, nausea
and vomiting.
Genitourinary: Negative for dysuria, frequency, hematuria and nocturia.
Neurological: Negative for excessive daytime sleepiness, dizziness, headaches, light-headedness, loss of balance, numbness,
paresthesias, seizures and weakness.
Psychiatric/Behavioral: Negative for depression. The patient does not have insomnia and is not nervous/anxious.
All other systems reviewed and are negative.

Allergies as of 1/5/2021 Review status set to Review Complete by Gore, Dairee at 12:59 PM
No Known Allergies

Outpatient Medications Marked as Taking for the 1/5/21 encounter (Office Visit) with Hopper, Jason A, MD
Medication Sig Dispense Refill
• Multiple Vitamin (MULTIVITAMIN PO) Take by mouth.
• naproxen (NAPROSYN) 500 MG tablet Take 1 tablet by mouth 2 (two) times daily as needed (mild headache) for up to 10 days
Take with food. 30 tablet 0

Vitals:
01/05/21 1301
BP: (!) 126/84
Pulse: 81
Weight: 99.6 kg (219 lb 9.3 oz)
Height: 1.854 m (6' 1")

Body mass index is 28.97 kg/m².

Wt Readings from Last 3 Encounters:
01/05/21 99.6 kg (219 lb 9.3 oz)
01/04/21 99.8 kg (220 lb 0.3 oz)
11/25/20 98.5 kg (217 lb 2.5 oz)

Physical Exam
Vitals signs reviewed.
Constitutional:
General: He is awake. He is not in acute distress.
Appearance: Normal appearance. He is well-developed.
Neck:
Vascular: No JVD.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Chest Wall: PMI is not displaced.
Pulses: Normal pulses.
Radial pulses are 2+ on the right side and 2+ on the left side.
Heart sounds: Normal heart sounds, S1 normal and S2 normal. No murmur. No friction rub. No gallop.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds. No wheezing, rhonchi or rales.
Musculoskeletal:
Right lower leg: No edema.
Left lower leg: No edema.
Skin:
General: Skin is warm and dry.
Neurological:
Mental Status: He is alert.

RESULTS / DATA:
Below data personally reviewed
Lab Results
Component Value Date
WBC 7.27 11/25/2020
HGB 15.8 11/25/2020
PLATELETCT 336 11/25/2020

No results found for: HGBA1CGLY

Lab Results
Component Value Date
NA 139 11/25/2020
POTASSIUM 4.5 11/25/2020
BUN 16 11/25/2020
CREATININE 0.7 11/25/2020

Lab Results
Component Value Date
TRIGLYCDES 158 (H) 11/25/2020
CHOL 180 11/25/2020
LDLCALC 111 (H) 11/25/2020
VLDL 32 11/25/2020

No results found for: TROPONIN, BNP

Imaging and tracings personally reviewed for this appointment are noted below. I generally agree with the interpretation
provided with the following comments:
ECG 1/4/21: sinus rhythm, baseline artifact. Diffuse non-specific ST segment changes. Possible BER.

ECG in the office today: Normal sinus rhythm. Abnormal Q-wave in lead III with nondiagnostic Q waves in the inferior leads
otherwise normal sinus rhythm

ASSESSMENT and PLAN:

Abnormal ECG: undiagnosed new problem with uncertain prognosis
ECG in the office today as well as previous tracing raise possibility of prior inferior infarct. No clinical history to support this
diagnosis and would have to have been a silent event.
• Given ECG abnormality will proceed with transthoracic echo to assess for underlying structural cardiac abnormalities
• Given no symptoms at rest or with exertion we will not proceed with functional testing at this time.
• Given no clear diagnosis we will not proceed with initiation of pharmacotherapy.
• Further recommendations pending testing results.
• If transthoracic echo is structurally normal then he is of acceptable risk to proceed with initiation of stimulant therapy for his
attention deficit disorder

Jason A Hopper, MD
Norton Heart Specialists
01/05/21 15:55

Medical Decision Making

Diagnosis: undiagnosed new problem with uncertain prognosis
Data: (review of prior external note(s), review of prior testing, ordering of testing), Independent interpretation of a test
Risk: moderate
Electronically signed by Jason A Hopper at 01/05/2021 4:04 PM EST

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
Screening for ischemic heart disease - Primary
Abnormal EKG

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Jason A Hopper Cardiology 1/5/21
NPI: 1548605108
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
502-891-8300 (Work)
502-891-8338 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact
Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Jason A Hopper Jan. 05, 2021
NPI: 1023317880 NPI: 1548605108
502-394-6000 (Work) 502-891-8300 (Work)
502-394-3689 (Fax) 502-891-8338 (Fax)
Family Medicine 6420 Dutchmans Parkway
Norton Healthcare Suite 200
Louisville, KY 40202 Louisville, KY 40205-3373
Cardiology
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jason A Hopper (Attending) Jan. 05, 2021
NPI: 1548605108
502-891-8300 (Work)
502-891-8338 (Fax)
6420 Dutchmans Parkway
Suite 200
Louisville, KY 40205-3373
Cardiology

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
Office Visit

Encounter Details
Date Type Department Care Team Description
01/04/2021 Office Visit Norton Community Medical Jing Bryant
10:40 AM Associates - Brownsboro 9880 Angie's Way
EST 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
ibuprofen (ADVIL,MOTRIN) 600 Take 600 mg by mouth 0 01/04/2021 Discontinued
MG tablet every 6 (six) hours as (Formulary
needed for Pain change)
Aspirin-Acetaminophen- Take by mouth as 0 01/04/2021 Discontinued
Caffeine (EXCEDRIN PO) needed . (Formulary
change)
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 30 tablet 0 01/04/2021 02/04/2021 Discontinued
MG tablet (two) times daily as
needed (mild headache)
for up to 10 days Take
with food.

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Microalbuminuria absent 11/28/2020
Dyslipidemia 11/28/2020
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020
Resolved Problems - documented as of this encounter (statuses as of 09/29/2023)
Resolved
Problem Noted Date Diagnosed Date Date
Elevated LFTs 11/28/2020 01/05/2021

Social History - documented as of this encounter

Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 1/4/2021 10:35 AM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 144/96 01/04/2021 10:46 AM EST
Pulse 85 01/04/2021 10:46 AM EST
Temperature 36.6 °C (97.8 °F) 01/04/2021 10:46 AM EST
Respiratory Rate - -
Oxygen Saturation 98% 01/04/2021 10:46 AM EST
Inhaled Oxygen Concentration - -
Weight 99.8 kg (220 lb 0.3 oz) 01/04/2021 10:46 AM EST
Height 185.4 cm (6' 1") 01/04/2021 10:46 AM EST
Body Mass Index 29.03 01/04/2021 10:46 AM EST

Ordered Prescriptions - documented in this encounter

Prescription Sig Dispensed Refills Start Date End Date
naproxen (NAPROSYN) 500 Take 1 tablet by mouth 2 (two) 30 tablet 0 01/04/2021 02/04/2021
MG tablet times daily as needed (mild
headache) for up to 10 days
Take with food.

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk
Results - documented in this encounter
POCT URINE DRUG TEST - Final result (01/04/2021 11:55 AM EST)
Ref Analysis
Component Value Range Test Method Time Performed At Pathologist Signature
BZO Benzodiazepine Negative Negative NORTON
Screen-Urine COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
BAR Barbiturate-Urine Negative Negative NORTON
Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
COC Cocaine-Urine Negative Negative NORTON
Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
THC Cannabinoids- Negative Negative NORTON
Urine Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
MET Methamphetamine Negative Negative NORTON
Screen Urine COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
MOP Opiates-Urine Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
MTD Methadone Negative Negative NORTON
Screen-Urine COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
BUP Buprenorphine- Negative Negative NORTON
Urine Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
OXY Oxycodone-Urine Negative Negative NORTON
Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
MDMA-Urine Screen Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
 Ref Analysis
Component Value Range Test Method Time Performed At Pathologist Signature
PCP-Urine Screen Negative Negative NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
AMP Amphetamine Negative Negative NORTON
-Urine Screen COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Internal QC Yes NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Lot Number w51200528 NORTON
COMMUNITY
MEDICAL
ASSOCIATES-
BROWNSBORO
410
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Urine 01/04/2021 11:55 AM
EST

Narrative

Authorizing Provider Result Type

Jing Bryant POINT OF CARE TEST ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON COMMUNITY 9880 Angie's Way Suite LOUISVILLE, KY 40241, 502-636-8095
MEDICAL ASSOCIATES- 410 USA
BROWNSBORO 410

HEPATIC FUNCTION PANEL - Final result (01/04/2021 11:45 AM EST)

Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Total Protein 7.7 6.3 - 8.2 01/04/2021 Norton
g/dL 3:54 PM Medical
EST Group
Central Lab
Albumin 4.4 3.5 - 5.0 01/04/2021 Norton
g/dL 3:54 PM Medical
EST Group
Central Lab
Globulin 3.3 1.5 - 4.5 01/04/2021 Norton
g/dL 3:54 PM Medical
EST Group
Central Lab
Albumin/Globulin Ratio 1.3 1.1 - 2.5 01/04/2021 Norton
RATIO 3:54 PM Medical
EST Group
Central Lab
 Ref Analysis Performed
Component Value Range Test Method Time At Pathologist Signature
Total Bilirubin 0.2 0.2 - 1.3 01/04/2021 Norton
mg/dL 3:54 PM Medical
EST Group
Central Lab
Conjugated Bilirubin <0.2 0.0 - 0.3 01/04/2021 Norton
mg/dL 3:54 PM Medical
EST Group
Central Lab
Unconjugated Bilirubin UNABLE TO 0.1 - 0.8 01/04/2021 Norton
CALCULATE mg/dL 3:54 PM Medical
EST Group
Central Lab
AST/SGOT 27 15 - 46 01/04/2021 Norton
U/L 3:54 PM Medical
EST Group
Central Lab
ALT/SGPT 62 13 - 69 01/04/2021 Norton
U/L 3:54 PM Medical
EST Group
Central Lab
Alkaline Phosphatase 108 38 - 126 01/04/2021 Norton
U/L 3:54 PM Medical
EST Group
Central Lab
Anatomical Location / Collection Method /
Specimen (Source) Laterality Volume Collection Time Received Time
Plasma (Blood) 01/04/2021 11:45 AM 01/04/2021 11:55 AM
EST EST

Narrative

Authorizing Provider Result Type

Jing Bryant LAB BLOOD ORDERABLES

Performing
Organization Address City/State/ZIP Code Phone Number
NORTON MEDICAL 3 Audubon Plaza Drive LOUISVILLE, KY 40207 502-636-4952
GROUP Ste LL2
Norton Medical Group 3 Audubon Plaza Dr., Louisville, KY 40217
Central Lab Suite LL2

Visit Diagnoses - documented in this encounter

Diagnosis
High risk medications (not anticoagulants) long-term use
Elevated blood pressure reading without diagnosis of hypertension
Abnormal EKG
Elevated LFTs
Headache disorder

Care Teams - documented as of this encounter

Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Jan. 04, 2021
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Family Medicine
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Jan. 04, 2021
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

Legal Authenticator
Director H
Ryan S Gomez "Ryan"
Summary of Care, generated on Sep. 29, 2023

Patient Demographics - Male; born Nov. 11, 1983

Patient Address Communication Language Race / Ethnicity Marital Status
14435 HALDEN RIDGE 502-356-2248 (Home) English (Preferred) Unknown / Unknown Married
WAY (Home) 502-356-2248 (Work)
LOUISVILLE, KY 40245 502-356-2248 (Mobile)
[email protected]
Former (Nov. 09, 2020 -
Apr. 08, 2021):
13510 SQUIRE
SPRINGS CT (Home)
LOUISVILLE, KY 40245

Note from Norton Healthcare

This document contains information that was shared with Ryan S Gomez. It may not contain the entire record from Norton
Healthcare.

Reason for Visit

Reason
New Patient
Annual Exam

Encounter Details
Date Type Department Care Team Description
11/25/2020 Office Visit Norton Community Medical Jing Bryant
1:40 PM Associates - Brownsboro 9880 Angie's Way
EST 9880 Angie's Way STE 410
Suite 410 Louisville, KY 40241
LOUISVILLE, KY 40241-2850 502-394-6000 (Work)
502-394-6600 502-394-3689 (Fax)

Allergies - documented as of this encounter (statuses as of 09/29/2023)

No known active allergies

Medications - documented as of this encounter (statuses as of 09/29/2023)

Medication Sig Dispensed Refills Start Date End Date Status
acetaminophen (TYLENOL) 500 Take 500 mg by mouth 0 11/25/2020 Discontinued
MG tablet every 6 (six) hours as (Therapy
needed for Pain completed)
ibuprofen (ADVIL,MOTRIN) 600 Take 600 mg by mouth 0 01/04/2021 Discontinued
MG tablet every 6 (six) hours as (Formulary
needed for Pain change)
loperamide (IMODIUM A-D) 2 Take 1 tablet by mouth 30 tablet 0 01/24/2015 11/25/2020 Discontinued
MG tablet four times daily as (Therapy
needed for Diarrhea for completed)
up to 7 days
Aspirin-Acetaminophen- Take by mouth as 0 01/04/2021 Discontinued
Caffeine (EXCEDRIN PO) needed . (Formulary
change)
Multiple Vitamin Take by mouth. 0 10/17/2022 Discontinued
(MULTIVITAMIN PO)
Orlistat (ALLI PO) Take by mouth. 0 05/03/2021 Discontinued
(Patient
Choice)

Active Problems - documented as of this encounter (statuses as of 09/29/2023)

Problem Noted Date Diagnosed Date
Encounter for annual physical exam 11/25/2020
HTN, goal below 130/80 11/25/2020
Social History - documented as of this encounter
Tobacco Use Types Packs/Day Years Used Date
Smoking Tobacco: Some Days Cigarettes 0.3
Cigars
Smokeless Tobacco: Never

Alcohol Use Standard Drinks/Week

Yes 1 (1 standard drink = 0.6 oz pure alcohol)

Sex and Gender Information Value Date Recorded

Sex Assigned at Birth Not on file
Gender Identity Not on file
Sexual Orientation Not on file

COVID-19 Exposure Response Date Recorded

In the last month, have you been in contact with someone who No / Unsure 11/25/2020 1:12 PM EST
was confirmed or suspected to have Coronavirus / COVID-19?

Last Filed Vital Signs - documented in this encounter

Vital Sign Reading Time Taken Comments
Blood Pressure 148/100 11/25/2020 1:33 PM EST
Pulse 80 11/25/2020 1:33 PM EST
Temperature 36.8 °C (98.3 °F) 11/25/2020 1:33 PM EST
Respiratory Rate - -
Oxygen Saturation 96% 11/25/2020 1:33 PM EST
Inhaled Oxygen Concentration - -
Weight 98.5 kg (217 lb 2.5 oz) 11/25/2020 1:33 PM EST
Height 185.4 cm (6' 1") 11/25/2020 1:33 PM EST
Body Mass Index 28.65 11/25/2020 1:33 PM EST

Patient Instructions - documented in this encounter

Patient Instructions
Jing Bryant - 11/25/2020 2:02 PM EST
Formatting of this note is different from the original.

It was nice seeing you today! I hope that your visit today was a positive one. I'd appreciate any feedback you may have through
our online feedback form/survey, so that I can do my best to continue to provide the best care.
------------------------------------------------------------------------

I will inform you of your lab results through Mychart once they are all back.

Please take your blood pressure medication(s) as directed.

Please monitor your blood pressure and heart rate (pulse) 3-4 times a week, and record your readings. Your goal is to have your
blood pressure below 130/80, and your heart rate (pulse) in between 60 - 90.

You may download the free app called "Blood Pressure Journal" to your smart device for your blood pressure log.

For colds and congestion, be careful about using over the counter medications. It is safe to use medication from the
CoricidinHBP line.
See coricidinhbp.com.

Follow up in 1-2 months for blood pressure check.

Continue to follow up with your specialist(s) as scheduled/needed.

For general health educational information, may check out familydoctor.org.

Return to our office in a year to review your health. We need to see you annually to prescribe any medications. If you have other
medical problems you may need to be seen sooner.

Maintain healthy life style, including: keep a healthy diet; exercise regularly (2 hours/week minimum); normalize your weight (BMI
less than 30), adequate sleep (7-8 hours per day). Remember: Eat healthy food, mostly vegetables, drink water, and exercise
more.
- Alcohol: consider holding Alcohol intake to less than 10 drinks a week. A drink is one 12 oz beer, a 4 oz glass of wine, or 1.5 oz
of liquor. Some patients should consider avoiding Alcohol entirely.

- Nutrition: "Eat healthy food, less of it, mostly vegetables". Avoid sweetened drinks and concentrated sugars. Limit "white" foods
like rice, bread and pasta.

Pain medications sold over-the-counter like ibuprofen (Motrin/Advil) and naproxen (Aleve) should be limited, they can cause
bleeding and kidney damage.

Pain & Cold medications sold over-the-counter that contain acetaminophen (Tylenol) can cause serious harm if not taken as
directed, particulalry to your liver.

Vaccinations: Make sure you get your Flu shot every year, if not contraindicated. Flu shots annually protect you AND our
community.

Vaccinations: Pneumonia shots usually happen at age 65. Smokers, diabetics, and people with heart, lung or immune disease
may need them earlier.

Vaccinations: Shingles immunization usually happens at age 60. You may want to check your insurance coverage.

Vaccinations: Tetanus shots are needed every 10 years, and once as an adult you should get a Tetanus shot that boosts Pertussis
("whooping cough").

Please consider/ continue life style modifications including daily calcium (recommended 1200 mg dietary calcium daily) and
vitamin D (recommended 800 IU daily), with weight bearing exercise for your bone health.

Target Heart Rate: Google "Target Heart Rate" and click on the American Heart Association Link (likely first or second option).
That is where chart below was obtained from.

Age Target HR Zone 50-85% Average Maximum Heart Rate, 100%

20 years 100-170 beats per minute 200 beats per minute
30 years 95-162 beats per minute 190 beats per minute
35 years 93-157 beats per minute 185 beats per minute
40 years 90-153 beats per minute 180 beats per minute
45 years 88-149 beats per minute 175 beats per minute
50 years 85-145 beats per minute 170 beats per minute
55 years 83-140 beats per minute 165 beats per minute
60 years 80-136 beats per minute 160 beats per minute
65 years 78-132 beats per minute 155 beats per minute
70 years 75-128 beats per minute 150 beats per minute

Avoid all tobacco products and exposure to them both at home and at work.

Wear seatbelts whenever riding in a car or truck. Safety Belts used regularly save lives.

Apply sunscreen 30 minutes before exposure to the sun. Choose a sunscreen that screens out both UVA and UVB rays, with a sun
protection factor (SPF) of 15 or greater. Avoid tanning salons.

Twice yearly routine dental care is recommended. Brush and floss your teeth at least twice daily.

See the eye doctor every two years after you turn 40.

Follow up as needed for acute issues.

From 12 pm - 1 pm, no patients will be placed in exam rooms for appointments. This will ensure that providers and nurses/
medical assistants are able to eat lunch and catch up on any work from that morning. If you have an appointment at 11:40 am,
we ask that you arrive on or before your appointment time if possible. We understand that unforeseen circumstances occur. If at
all possible if you could call the office and inform the front desk, in which case we will try our best to accommodate you as much
as possible. (Please note that all phone lines will be open during this time)

Blood Pressure Tracking Chart

Date Systolic Diastolic Pulse (heart rate) Date Systolic Diastolic Pulse (heart rate)
Hypertension
GENERAL INFORMATION:
What is hypertension? Hypertension is high blood pressure (BP). Your BP is the force of your blood moving against the walls of
your arteries. Normal BP is less than 120/80. Prehypertension is between 120/80 and 139/89. Hypertension is 140/90 or higher.
Hypertension causes your BP to get so high that your heart has to work much harder than normal. This can cause damage to
your heart. Hypertension is a long-term condition that you will need to control with a healthy lifestyle or medicines. A controlled
blood pressure helps protect your organs, such as your heart, lungs, brain, and kidneys.
What causes hypertension? The cause of hypertension may not be known. This type of hypertension is called essential or
primary hypertension. Hypertension can sometimes be caused by other medical conditions, such as kidney disease. This type of
hypertension is called secondary hypertension.
What increases my risk for hypertension?
· For men, being older than 55 years, and for women, being older than 65 years

· Family history of hypertension or heart disease

· Obesity or lack of exercise

· Too many high-sodium foods

· Stress

· Use of tobacco, alcohol, or illegal drugs

· Medical conditions, such as diabetes, high cholesterol, kidney disease, thyroid disease, or adrenal gland disorder

· Certain medicines, such as steroids or birth control pills

What are the signs and symptoms of hypertension? You may have no signs or symptoms, or you may have any of the following:
· Headache

· Blurred vision

· Chest pain

· Dizziness or weakness

· Trouble breathing

· Nosebleeds
How is hypertension diagnosed? Your healthcare provider will ask about your symptoms and the medicines you take. He will also
ask if you have a family history of hypertension and about any health conditions you have. He will check your BP and weight and
examine your heart, lungs, and eyes. You may need any of the following tests:
· Blood tests may help healthcare providers find the cause of your hypertension. Blood tests can also help find other health
problems caused by hypertension.

· Urine tests will be done to check your kidneys.

· An EKG records the electrical activity of your heart. It is used to check your heart rhythm or other problems caused by
hypertension.
How is hypertension treated? Your healthcare provider will recommend lifestyle changes to lower your BP. You may also need the
following medicines:
· Blood pressure medicine helps lower your blood pressure. You may need more than one type of blood pressure medicine. Take
your blood pressure medicine exactly as directed.

· Diuretics help decrease extra fluid that collects in your body. This will help lower your BP. You may urinate more often while you
take this medicine.
How do I check my BP at home? Sit and rest for 5 minutes before you take your BP. Extend your arm and support it on a flat
surface. Your arm should be at the same level as your heart. Follow the directions that came with your BP monitor. If possible,
take at least 2 BP readings each time. Take your BP at least twice a day at the same times each day, such as morning and
evening. Keep a log of your BP readings and bring it to your follow-up visits. Ask your healthcare provider what your BP should
be.
How can I manage my hypertension? Talk with your healthcare provider about these and other lifestyle changes you can make to
manage your hypertension:
· Eat less sodium (salt). Do not add salt to your food. Limit foods that are high in sodium, such as canned foods, potato chips,
and cold cuts. Your healthcare provider may suggest that you follow the DASH Eating Plan. The plan is low in sodium, unhealthy
fats, and total fat. It is high in potassium, calcium, and fiber. You get these nutrients by eating more fruits, vegetables, and whole
grains. Ask your healthcare provider or dietitian which meal plan you should follow.
· Exercise to maintain a healthy weight. Exercise at least 30 minutes per day, on most days of the week. This will help decrease
your BP. Ask your healthcare provider about the best exercise plan for you.

· Limit alcohol. Women should limit alcohol to 1 drink a day. Men should limit alcohol to 2 drinks a day. A drink of alcohol is 12
ounces of beer, 5 ounces of wine, or 1½ ounces of liquor.

· Do not smoke. If you smoke, it is never too late to quit. Smoking can increase your BP. Smoking also worsens other health
conditions you may have that can increase your risk for hypertension. Ask your healthcare provider for information if you need
help quitting.

· Manage any other health conditions you have. Health conditions such as diabetes can increase your risk for hypertension.
Follow your healthcare provider's instructions and take all your medicines as directed.

· Decrease stress. This may help lower your BP. Learn ways to relax, such as deep breathing or listening to music.
What are the risks of hypertension? Without treatment, you may develop other health problems over time. You may lose vision
in one or both eyes. You may develop heart and blood vessel disease. This increases your risk of a heart attack, stroke, heart
failure, or kidney disease and can be life-threatening.
When should I contact my healthcare provider?
· You feel faint, dizzy, confused, or drowsy.

· You have been taking your BP medicine and your BP is still higher than your healthcare provider says it should be.

· You have questions or concerns about your condition or care.

When should I seek immediate care or call 911?
· You have a severe headache or vision loss.

· You have weakness in an arm or leg.

· You become confused or have difficulty speaking.

· You have discomfort in your chest that feels like squeezing, pressure, fullness, or pain.

· You suddenly feel lightheaded or have trouble breathing.

· You have pain or discomfort in your back, neck, jaw, stomach, or arm.
CARE AGREEMENT:
You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment
options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. The above
information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your
doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.
© 2014 Truven Health Analytics Inc. Information is for End User's use only and may not be sold, redistributed or otherwise used
for commercial purposes. All illustrations and images included in CareNotes® are the copyrighted property of A.D.A.M., Inc. or
Truven Health Analytics.

Electronically signed by Jing Bryant at 11/25/2020 2:03 PM EST

Plan of Treatment - documented as of this encounter

Health Maintenance Due Date Last Done Comments
Influenza vaccine (#1) 09/01/2023
HPV Vaccine Aged Out No longer eligible based on patient's age to complete this topic
Pneumococcal Vaccines 6-64 Aged Out No longer eligible based on patient's age to complete this topic
yo Risk

Results - documented in this encounter

Not on file

Visit Diagnoses - documented in this encounter

Diagnosis
Encounter for annual physical exam - Primary
Elevated blood pressure reading without diagnosis of hypertension
Screening for deficiency anemia
Screening for cholesterol level
Screening for diabetes mellitus
Care Teams - documented as of this encounter
Team Member Relationship Specialty Start Date End Date
Jing Bryant PCP - General Family Medicine 11/25/20
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)

Patient Contacts
Contact Name Contact Address Communication Relationship to Patient
Woody Smith Unknown 502-905-9467 (Home) Relative, Emergency Contact
Laura Gomez Unknown 502-295-8679 (Mobile) Spouse, Emergency Contact

Document Information
Primary Care Provider Other Service Providers Document Coverage Dates
Jing Bryant (Nov. 25, 2020 - Present) Nov. 25, 2020
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
Family Medicine
Norton Healthcare
Louisville, KY 40202

Custodian Organization
Norton Healthcare
Louisville, KY 40202

Encounter Providers Encounter Date

Jing Bryant (Attending) Nov. 25, 2020
NPI: 1023317880
502-394-6000 (Work)
502-394-3689 (Fax)
9880 Angie's Way
STE 410
Louisville, KY 40241
Family Medicine

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