217 Portion Road

Ronkonkoma. NY 11779-2341
Tel: (631) 758-7003 | Fax: (833) 443-0531

Patient Name: JEAN, STACEY Date: 1/11/2024

Patient Number: 6506231 Date Of Birth: 10/29/1986

FAMILY MEDICINE FOLLOW UP VISIT

Allergies
ibuprofen

Patient Born as:

female.

Gender Identity
Patient identifies as female.

Chief Complaint:
Thursday, January 11, 2024 2:10:53 PM
Annual Physical

History of Present Illness

Thursday, October 27, 20222:31:40 PM

35 year old female presents to establish primary care

Pt. presents to establish care.

Pt. with PMHx of IDA, Migraines- stopped meds 7 years ago due to pregnancy Has not needed to resume, symptoms resolved.
Pt. with PSHx of C-section x 3, abdominoplasty 2018 & gastric sleeve 2020.
LMP: 10/26/22
Patient reports eating regular diet.
Drinks 2 cups of caffeine per day.
Reports not exercising.
Denies skin rashes/lesions.
Denies sleep apnea symptoms.
Denies changes to bladder or bowel habits.
Up to date with dentist
Pt. is up to date on COVID & influenza vaccines.
Pt. is up to date on routine screenings.
Last pap: 2-3 years ago.
Pt. follows with gyn.
Advanced Directives discussed in detail with pt.

Monday, November 21, 2022

Presents for routine f/u. TC 208 HDL 79 LDL 124 HDL risk 2.6. HgA1c 6.0% Iron 32 iron sat 9%. She has appt, with hematology
pending. She offers no new physical complaints at this time. She would like to try weight loss medication. Denies family or self hx
of Medullary thyroid cancer or MEN 2.

Friday, January 6, 2023

Pt. presents for routine f/u. Ozempic pending PA. Reports pain and tingling to bilateral upper extremities. Reports sensation of
weakness to right hand with activities of daily living. States she sleeps on her stomach. Pt. reports no recent illnesses, injuries or
changes in condition since last visit.

Friday, December 1, 2023, 2:42:16 PM

Pt is a 37 year old female with a PMH of Prediabetes, Obesety, Anemia
Pt presents for follow up and MMR vacc. Pt states she did have MMR twice in the past, never developed immunity. Patient denies
being on any immunosuppressive medication or steroids. Patient denies pregnancy. She reports her fallopian tubes have been
removed. She is not planning pregnancy for the next 3 months.

Thursday, January 11, 2024 2:11:04 PM

Pt is a 37 year old female with a PMH of Prediabetes, Obesety, Anemia
Pt presents for follow up and MMR titers. Patient received MMR vaccine on December 1,2023. Pt states she did have MMR twice
in the past, never developed immunity. Patient denies being on any immunosuppressive medication or steroids. Patient denies
pregnancy. She reports her fallopian tubes have been removed. She is not planning pregnancy for the next 3 months.
Patient reports that her job either requires immunity or 2 vaccinations a month apart. Patient denies any acute complaints at this
time.

MEDICAL HISTORY
IDA
Obesity

migraines
hx gastric ulcers
IDA
Obesity

Past Surgical History

3 c sections - 2015, 2018, 2019
bariatric surgery 12/2020
3 d&c 2012, 2014
abdominoplasty
fallopian tube removal

Date Type Details Outcome Comment

1/24/2019 Hospitalization Hospital: discharged, ICD de

Code: 280.9/D50.9

12/1/2020 Other Therapies Mammogram - screening 12/01/20 pt denies 11/21/22

JC

12/1/2020 Other Therapies Screening colonoscopy 12/01/20 more than 10years

ago Dr DiSanti 11/21/22 JC

Social History
Patient is married. Active sexual history.
Fallopian tube removal
Non smoker Not applicable Patient reports alcohol use as follows:socially
Denies any illicit drug use.
nurse case manager Patient has had no occupational exposure.

Personal History
Patient reports having annual Pap smears. Last PAP smear:2020 Patient reports having routine colonoscopy. Last
done:unsure when due to bowel issues that have resolved. Had polyp removed. Followed by Gl after. No further
colonoscopy reccommended.
Patient states they have received blood products in the past. Patient denies any reaction to blood products received.

GYN History
LMP was 11/12/23. Menarche: Age of Menarche was: 12
Estrogen Use: Patient denies any prior use of estrogen.
Patient has had 6 Pregnancies. Patient has had 3 live births.

Family History
maternal aunt breast cancer Other Relative: maternal aunt - breast 58 Other Relative: maternal aunt - breast 58
Patient reports family history of coronary artery disease. Father: CAD & CVA
Other Relative: maternal side Patient reports family history of diabetes. Mother: 58.
No family history of Hyperthyroidism.
Other Relative: paternal side

Medications

Inside Drug Script Date Qty Rfls Instructions

Y Ozempic 0.25 mg or 0.5 mg (2 mg/1.5 mL) 11/21/2022 1 0 inject 0.25 mg
subcutaneous pen injector subcutaneously
weekly

Review Of Systems
13 point review of systems with positives reported by patient since last visit.
Nothing reported.
Fever: No Fever. Chills No Rigors. No Chills.

VS

' Vitals for 1/11/2024 2:10:00 PM

Name Value Units Range Comment

Height 64 in 48-90

Weight 239 lb 80-275

Temp 97.6 f 97-100

Pulse 98 0-0

Resp 16 12-20

SystolicBP 111 90-150

DiastolicBP 79 66-96

02 Sat 98 % 0-100

BMI:41 BSA:2.11

Patient reported pain

Pain : No pain.

Physical Exam
Thursday, January 11, 2024
Exam.
General: in NAD. AAOX3. Well appearing
HEENT: EOMI, PERRLA, no pallor. No thyromegaly noted
CVS: S1S2nl, no M/R/G, RRR
Lungs: clear, no adventitious lung sounds
Gl: Soft, NT, BS +, No rebound/guarding
GU: Not examined
Rectal: Not examined
Ext: Motor 5/5 in all extremities. No c/c/e
Neuro: CN ll-XII grossly intact, Moves all 4 extremities. Gait observed -normal
Psych: Appropriate mood/affect.
Skin: Grossly intact

Labs
Lab results on 12/1/2023: Urine Beta HCG=NEG

Other Results
Lab results on 12/1/2020: WBC=4.8 x10*3/UL, RBC=4.74 x10*6/UL, Hgb=11«0 g/dl, HCT=34.7 %, MCV=73,2fL, MCH=23.2 pg,
MCHC=31.7 g/dL, RDW=16.4 %, Plat=358 x10*3/UL, MPV=11.3 fL, ANC=3.0 x10*3/UL, Lymph#=1.1 x10*3/UL, MONO#=0.6
x10*3/UL, BASO#=0.0 x10*3/UL, EOS#=0.1 x10*3/UL, Gran%=63.5 %, Lymph%=22.1 %, MONO%=11.5 %, BASO%=0.2 %,
EOS%=2.7 %, ProTime=10.6 sec, INR=1.0 ratio, Sodium=138 mmol/L, Potassium=4.5 mmol/L, Chloride=101 mmol/L, CO2=23
mmol/L, Glucose=82 mg/dL, BUN=11 mg/dL, Creat=0.67 mg/dL, Total Protein=7.7 g/dL, Albumin=4.4 g/dL, A/G=1.3 , Globulin=3.3
g/dL, Total Bili=0.4 mg/dL, Aik Phos=46 IU/L, ALT=11 IU/L, AST=18 IU/L, Calcium=9.1 mg/dL, IRON=38 ug/dL, UIBC=367 ug/dL,
TIBC=405 ug/dL, %Sat=9 %, Ferritin=25 ng/mL, B12=536 pg/mL

Radiology

Pathology

Diagnosis

Date Type ICD-9 ICD-10 Problem Comment Status

Active Problems Assessed

• D50.9 - Iron deficiency anemia, unspecified

Assessment/lmpression
Friday, December 1, 2023, 2:42:16 PM
Pt is a 37 year old female with a PMH of Prediabetes, Obesity, Anemia
Pt presents for follow up and MMR vacc

Encounter for Immunization

Patient will receive MMR vaccine in office today
Advised to avoid pregnancy for the next 3 months.
Consider checking titers in 4 weeks. If does not mount an immune response would consider possible 1 more injection. If no
immunity after that I would not do any further vaccinations and consider this patient to be a nonresponder.

Iron Deficiency s/p gastric sleeve

c/w Bariatric MVI daily

Obesity, Prediabetes
Advised to attempt weight loss through improved eating habits by avoiding fast foods/processed foods/junk foods.
Increase vegetables, salads, protein, and low fat dairy.
Consider Starting a 1,200-1500 calorie diet. Consider joining weight watchers.
Low carbs, low cholesterol, low fat and low sodium.
Exercise at least 30-40 minutes most days of the week.
Stress management.

Follow up: 3 months

Discussed lifestyle modifications/maintenance regarding: recommended amount of sleep, hydration (water), exercise routinely and
self monitoring. Follow ups with MDs should include my name/number and fax so that we can obtain reports. Routine age
appropriate screening and the importance of maintenance reviewed. Immunizations that are age appropriate also discussed. A list of
updated medications should be maintained and kept with patient at all times in order to have an updated list of medications. If
possible, all medications should be brought to office visits to do a complete medication reconciliation.

Thursday, January 11, 2024 2:11:04 PM

Pt is a 37 year old female with a PMH of Prediabetes, Obesety, Anemia
Pt presents for follow up and MMR titers. Patient received MMR vaccine on December 1,2023. Pt states she did have MMR twice
in the past, never developed immunity. Patient denies being on any immunosuppressive medication or steroids. Patient denies
pregnancy. She reports her fallopian tubes have been removed. She is not planning pregnancy for the next 3 months.
Patient reports that her job either requires immunity or 2 vaccinations a month apart. Patient denies any acute complaints at this
time.

Encounter for Immunization

Status post MMR vaccine on 12/01/2023
Will get MMR titers today with labs
If does not mount an immune response would consider possible 1 more injection. If no immunity after that I would not do any further
vaccinations and consider this patient to be a nonresponder.

Iron Deficiency s/p gastric sleeve

c/w Bariatric MVI daily

Obesity, Prediabetes
Advised to attempt weight loss through improved eating habits by avoiding fast foods/processed foods/junk foods.
Increase vegetables, salads, protein, and low fat dairy.
Consider Starting a 1,200-1500 calorie diet. Consider joining weight watchers.
Low carbs, low cholesterol, low fat and low sodium.
Exercise at least 30-40 minutes most days of the week.
Stress management

Follow up: 3 months

Recommendation/Plan:
Order Tests: *FE/lron, *Ferritin, *Total Iron Binding (TIBC)/UIBC, *B-12, *Folic Acid / Folate, X Ray - Cervical Spine Complete
Required/KP. More than half of time was spent for providing counseling and coordination of care. The diagnosis and care plan were
discussed with patient in detail. Should the patient develop any acute or unexpected medical problems, advised to promptly contact
our clinic or on-call service if outside of regular office hours. Understanding expressed by patient. Patients laboratory results were
reviewed and explained in full. All questions answered.
No action needed
- Schedule follow-up in 3 months.

U.S. Preventative/Screening Guidelines

The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD)
risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention.

Signed
 217 Portion Road
Ronkonkoma, NY 11779-2341
Tel: (631) 758-7003 | Fax: (833) 443-05.31

Letter
Patient Name: JEAN, STACEY Date: 1/16/2024
Patient Number: 6506231 Date Of Birth: 10/29/1986
Tuesday, January 16, 2024

To Whom It May Concern,

Patient Stacey Jean is currently being treated under my care. Patient is fully vaccinated for MMR but is nonresponsive to vaccine.

If you have any further questions or concerns, please contact my office.

Thank you,

Dr Syed Hussain

Signed By: Jocelyn Vazquez LPN on 1/16/2024 at 3:19 PM

Signed
 217 Portion Road
Ronkonkoma, NY 11779-2341
Tel: (631) 758-7003 | Fax: (833) 443-0531

Specimen Collection Date/Time: 1/11/2024 2:44 PM Report Status: Final

Patient Name: JEAN, STACEY DOB: 10/29/1986 Page: 1
Patient Number: 6506231 Sex: Female 1/11/2024
Report Date: 1/12/2024 11:26 AM
Laboratory Use Only: AN: SC, RN: 8758131, SN: 6506231240111

Comments:

Result Value (Previous) Units Range Lab

MMRV IgG -Final Ordered by: Syed Hussain

Comments: 1. The numeric value of the final result is not indicative of the amount of
IgG antibodies present for Measles, Mumps, Rubella, or Varicella-zoster.
2. Test results should be interpreted in conjunction with the clinical history,
epidemiological data and other information available to the attending physician in
evaluating the patient.

i Measles (Rubeola) IgG : 0.7 LOW ; Antibody Index = t NYCSLAB-AV

! (A|) [
Value interpretation

Negative: <= 0.8 Al

No IgG antibodies specific to Measles detected. Patient is presumed not to have had a
previous exposure to Measles through infection or vaccination.
Not consistent with immunity.

Equivocal (E) : = 0.9,1.0 Al

Equivocal results: Suggest repeat testing in two weeks

Positive: >= 1.1 Al

IgG antibody to Measles detected. This may indicate that the patient was exposed to
Measles through infection or vaccination. Consistent with immunity.

; Mumps IgG i 2.5 i Antibody Index i NYCSLAB-AV

I <AI) !
Value interpretation

Negative: <= 0.8 Al

No IgG antibodies specific to Mumps detected. Patient is presumed not to have had a
previous exposure to Mumps through infection or vaccination.
Not Consistent with immunity.

Equivocal (E):= 0.9,1.0 Al

Equivocal results: Suggest repeat testing in two weeks.

Positive: >= 1.1 Al

IgG antibody to Mumps detected. This may indicate that the patient was exposed to Mumps
through infection or vaccination. Consistent with immunity.
 Rubella IgG (Antibody Index) i 4.9 i Antibody Index I i NYCSLAB—AV I
I <AI) I J
Value interpretation

Negative: <= 0.7 Al

No Rubella specific IgG antibodies detected. Patient is presumed not to have had a
previous exposure to Rubella through infection or vaccination.
Not consistent with immunity.

Equivocal (E) : = 0.8,0.9 Al

Equivocal results: Suggest repeat testing in two weeks.

Positive: >= 1.0 Al

IgG antibody to Rubella detected. IgG antibody levels are at a level considered to
indicate positive immunity.
Consistent with immunity.

; Varicella-Zoster Virus IgG ! 2.3 i Antibody Index i j NYCSLAB-AV

j (Antibody Index) I (Ai) !
Value interpretation

Negative: <= 0.8 Al

No IgG antibodies specific to Varicella detected. Patient is presumed not to have had a
previous exposure to Varicella through infection or vaccination.
Not consistent with immunity.

Equivocal (E): = 0.9,1.0 Al

Equivocal results: Suggest repeat testing in two weeks.

Positive: >= 1.1 Al

IgG antibody to Varicella detected. This may indicate that the patient was exposed to
Varicella through infection or vaccination. Consistent with immunity.

— End of Report -

Signed By: Syed Hussain, MD on 1/15/2024 at 8:21 AM

12/10/24, 9:08 AM Summary - OncoEMR®

Immunization History New external immunization Edit registry preferences

Date Office Location Description
Edit 1/11/2024 External influenza, seasonal, injoetoblo

Edit 10/27/2022 External

Edit 10/15/2021 External Pfizer-BioNTech COVID-19 Vaccine (PF) 30 mcg/0,3 mL IM susp (purple)

Edit 10/1/2021 External Pfizer-BioNTech COVID-19 Vaccine (PF) 30 mcg/0.3 mL IM susp (purple)

Edit 12/1/2020 External Infioenza,-seasonal, injeetabie

Edit 12/1/2020 External pnettfneeeeea^-poiysaeehartde-PPV23

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