AppliedAI
Wilson, Margaret T. 67 F
DOB: 04/12/1958  ·  MRN: 4872-29164  ·  SSN: ***-**-7741
Attending Dr. J. Carter, MD
Encounter Date 03/15/2026
Visit Type Follow-Up Office
Insurance Medicare Part B
Location Rm 214 — Internal Med
⚠ ALLERGIES:  Penicillin (rash · moderate)  ·  Sulfonamides (GI upset · mild)   |   Code Status: Full Code  ·  Advance Directive on file
Chart Summary SOAP Note Orders Labs & Results Medications Imaging Visit History Billing / Coding
📋 Enc #2026-031578
Chief Complaint: Follow-up HTN / DM2
CPT: 99214
ICD-10: I10 · E11.9 · E78.5
Attending: Dr. James R. Carter, MD   NPI: 1234567890
Vitals Today 9:14 AM
BP
148/92
mmHg ↑ Elevated
HR
78
bpm Regular
SpO2
97%
Room air
Temp
98.4°
°F Oral
Weight
178
lbs  (+2 lbs)
BMI
30.6
Obese I · 5'4"
Active Problems + Add
Hypertension
I10 · Dx 2018 · Active
Type 2 Diabetes Mellitus
E11.9 · Dx 2020 · Active
Hyperlipidemia
E78.5 · Dx 2019 · Active
GERD
K21.0 · Dx 2021 · Active
Obesity, Class I
E66.09 · BMI 30.6 · Active
Active Medications View All
Metformin HCl
1000 mg PO BID with meals
Lisinopril ↑ Dose Today
10 mg → 20 mg PO QD
Atorvastatin
40 mg PO QHS
Omeprazole
20 mg PO QD before meals
Aspirin EC
81 mg PO QD with food
Allergies & Reactions
⚠ Penicillin
Rash — moderate severity
⚠ Sulfonamides
GI upset — mild
Last Labs 01/08/2026
HbA1c7.8% ↑
Fasting BG162 mg/dL ↑
LDL-C88 mg/dL ✓
HDL-C52 mg/dL ✓
eGFR64 ✓
Creatinine1.0 mg/dL ✓
Sodium139 mEq/L ✓
Progress Note — SOAP Format
Internal Medicine Follow-Up  ·  Dr. James R. Carter, MD  ·  03/15/2026 9:22 AM
⚫ Draft — Unsigned
⚠ Voice dictation requires Google Chrome or Microsoft Edge. You can still use the ✨ AI Fill button or type notes manually in each section below.
🎤 AI Voice Dictation
Recording…
Web Speech API · Chrome / Edge · No audio stored
S
Subjective — Patient-reported symptoms & history of present illness
O
Objective — Physical exam findings & measurable data
A
Assessment — Clinical diagnoses, impressions & differential
P
Plan — Treatment plan, orders, referrals & follow-up
Unsaved Dr. James R. Carter, MD  ·  NPI 1234567890
Chart Summary
Patient overview · Wilson, Margaret T. · MRN 4872-29164
Active Patient
Demographics & Insurance
Full NameWilson, Margaret T.
DOB / Age04/12/1958 · 67 F
MRN4872-29164
Primary InsuranceMedicare Part B
SecondaryAARP Supplement Plan G
PCPDr. J. Carter, MD
Emergency ContactDavid Wilson (son) 570-555-0182
Active Problem List
🟠 HypertensionI10 · 2018
🟠 Type 2 DME11.9 · 2020
🟠 HyperlipidemiaE78.5 · 2019
🔴 GERDK21.0 · 2021
🔴 Obesity IE66.09 · BMI 30.6
✅ Hypothyroid (resolved)E03.9 · 2022
Recent Activity
Last Visit12/10/2025 — Follow-up
Last Labs01/08/2026
Last HbA1c7.8% ↑ (Jan 2026)
Last BP (clinic)152/94 (Dec 2025)
Next Appointment04/26/2026
Portal Messages2 unread
Active ReferralsOphthalmology (pending)
Vitals Trend — Last 4 Visits
Metric03/15/202612/10/202509/05/202506/18/2025Trend
BP (mmHg)148/92152/94144/90138/86📈 Worsening
HR (bpm)78747672➡ Stable
Weight (lbs)178176175173📈 +5 lbs / yr
BMI30.630.330.129.7📈 Trending up
SpO2 (%)97989798✓ Normal
Preventive Care & Quality Gaps
🚨
Dilated Eye Exam — OVERDUE
Last: Feb 2025 · Due: annually for DM patients · Referral placed today
⚠️
HbA1c — Due for repeat
Last: Jan 08, 2026 (7.8%) · Lab ordered today
⚠️
Urine Microalbumin — Due
Last: 06/2025 · Annual required for DM · Ordered today
✅
Influenza Vaccine — Administered today
Lot 24A88 · Right deltoid · 03/15/2026
✅
Colonoscopy — Current
Last: April 2023 · Polyp-free · Next due 2033
✅
Mammogram — Current
Last: Sept 2025 · BI-RADS 1 — Negative · Annual
Orders
Encounter #2026-031578 · 03/15/2026 · Dr. J. Carter
5 Active 3 Completed
Lab Orders
OrderPriorityOrdered ByDate / TimeStatus
HbA1c (Glycosylated Hemoglobin)RoutineDr. J. Carter03/15/2026 9:38 AMPending
Comprehensive Metabolic Panel (CMP)RoutineDr. J. Carter03/15/2026 9:38 AMPending
Lipid Panel (fasting)RoutineDr. J. Carter03/15/2026 9:38 AMPending
Urine Microalbumin / Creatinine RatioRoutineDr. J. Carter03/15/2026 9:38 AMPending
CBC with DifferentialRoutineDr. J. Carter12/10/2025 10:05 AMResulted
TSH (Thyroid Stimulating Hormone)RoutineDr. J. Carter09/05/2025 11:20 AMResulted
Medication Orders — Today
MedicationChangeSigQty / RefillsStatus
LisinoprilDose ↑ 10 mg → 20 mg1 tab PO QD30 tabs · 3 refillsSent to Pharmacy
Amlodipine 5 mgNew Start1 tab PO QD30 tabs · 3 refillsSent to Pharmacy
Metformin HCl 1000 mgContinued1 tab PO BID with meals60 tabs · 3 refillsRefilled
Atorvastatin 40 mgContinued1 tab PO QHS30 tabs · 3 refillsRefilled
Referrals & Procedures
Referral ToReasonPriorityOrderedStatus
Ophthalmology — Dr. R. PatelAnnual dilated retinal exam — DMRoutine03/15/2026Pending Auth
Diabetes Education ProgramDietary counseling / CDE referralRoutine03/15/2026Pending
Influenza Vaccine — In-OfficeAnnual immunizationAdministered03/15/2026Complete
Labs & Results
Most recent values shown · Reference ranges for adult female
New labs pending — ordered 03/15/2026
Comprehensive Metabolic Panel (CMP) — 01/08/2026
TestResultReference RangeFlagPrevious (09/2025)
Sodium (Na)139 mEq/L136–145N138 mEq/L
Potassium (K)4.1 mEq/L3.5–5.1N4.0 mEq/L
Creatinine1.0 mg/dL0.5–1.1N0.9 mg/dL
eGFR64 mL/min>60N66 mL/min
BUN18 mg/dL7–20N16 mg/dL
Glucose (fasting)162 mg/dL70–99H174 mg/dL
AST22 U/L10–40N20 U/L
ALT25 U/L7–56N22 U/L
CBC with Differential — 12/10/2025
TestResultReference RangeFlagPrevious (09/2025)
WBC6.8 K/µL4.0–11.0N7.1 K/µL
Hemoglobin12.8 g/dL12.0–16.0N12.6 g/dL
Hematocrit38.4%36–48N37.8%
Platelets218 K/µL150–400N224 K/µL
MCV88 fL80–100N87 fL
Lipid Panel — 01/08/2026
TestResultFlag
Total Cholesterol172 mg/dLN
LDL-C88 mg/dL ✓N
HDL-C52 mg/dLN
Triglycerides168 mg/dLH
Non-HDL120 mg/dLN
Endocrine — 01/08/2026
TestResultFlag
HbA1c7.8% ↑H
TSH2.1 mIU/LN
Free T41.1 ng/dLN
Urine Albumin/Cr42 mg/g ↑H
Vitamin D (25-OH)22 ng/mLL
Medications
Reconciled 03/15/2026 · Dr. J. Carter · 5 active · 3 discontinued
Reconciled Today
Active Medications
MedicationDose / Route / FrequencyIndicationPrescriberLast RefillStatus
Metformin HCl 1000 mg PO BID with meals Type 2 DM Dr. Carter 03/15/2026 Active
Lisinopril ↑ Changed today 20 mg PO QD (was 10 mg) Hypertension Dr. Carter 03/15/2026 Active
Amlodipine New today 5 mg PO QD Hypertension (add-on) Dr. Carter 03/15/2026 Active
Atorvastatin 40 mg PO QHS Hyperlipidemia Dr. Carter 03/15/2026 Active
Omeprazole 20 mg PO QD before meals GERD Dr. Carter 02/10/2026 Active
Aspirin EC 81 mg PO QD with food CV prophylaxis Dr. Carter 01/20/2026 Active
Discontinued Medications
MedicationDoseReason DiscontinuedDiscontinued ByDate
Glipizide 5 mg PO QD Switched to Metformin — better glycemic profile Dr. Carter 08/2020
Levothyroxine 50 mcg PO QD Hypothyroidism resolved — TSH normalized Dr. Carter 03/2022
Hydrochlorothiazide 12.5 mg PO QD Replaced with Lisinopril — better renal protection for DM Dr. Carter 11/2022
Drug Interaction Check
✅ No significant interactions detected across current medication list. Amlodipine + Lisinopril combination reviewed — appropriate co-prescription for HTN management. Metformin eGFR check: eGFR 64 — safe to continue.
Imaging
Radiology orders & results · Wilson, Margaret T.
2 Prior Studies
StudyBody Part / ModalityIndicationOrdered ByDateResultStatus
🩻
 X-Ray Chest PA/Lateral Chest · XR HTN baseline · r/o cardiomegaly Dr. Carter 06/18/2025 No acute cardiopulmonary process. Heart size normal. Lungs clear bilaterally. Final
🫀
 Echocardiogram (TTE) Heart · Ultrasound Evaluate cardiac function — longstanding HTN Dr. Carter 09/05/2025 Mild LV diastolic dysfunction (Grade I). EF 58%. No wall motion abnormalities. Mild LVH noted. Final
👁️
 Dilated Retinal Exam Eyes · Ophthalmology Annual DM screening — overdue Dr. Carter 03/15/2026 Referral placed — awaiting scheduling Pending
Echocardiogram Summary — 09/05/2025
EF
58%
Normal ≥55%
LV Function
Preserved
Grade I Diastolic Dysfx
LVH
Mild
Concentric pattern
Valves
Normal
No stenosis/regurg
Visit History
Encounter log · Wilson, Margaret T. · Showing last 8 visits
14 Total Encounters
03/15/2026
Follow-Up Office
Follow-up: Hypertension / Type 2 Diabetes Mellitus
BP 148/92 — elevated. HbA1c pending. Lisinopril increased 10→20 mg. Amlodipine 5 mg started. Labs ordered. Flu vaccine administered. Ophthalmology referral placed.
Dr. James R. Carter, MD · CPT 99214 · Draft
12/10/2025
Follow-Up Office
Follow-up: Hypertension / Diabetes — BP control review
BP 152/94. Weight 176 lbs. HbA1c 7.8% (trending down from 8.1%). Medication compliance reviewed. Dietary counseling reinforced. CBC resulted — normal. Continue current regimen.
Dr. James R. Carter, MD · CPT 99214 · Signed
09/05/2025
Follow-Up Office
Quarterly follow-up: HTN / DM2 / Hyperlipidemia
BP 144/90. Echocardiogram ordered — mild LVH found. TSH normal. GERD stable. LDL 88 on statin. Patient reports improved dietary habits. Continue current medications.
Dr. James R. Carter, MD · CPT 99213 · Signed
06/18/2025
Follow-Up Office
Annual wellness + HTN / DM2 follow-up
BP 138/86 — best reading in 2 years. Weight 173 lbs. Mammogram ordered. Chest XR — normal. Colonoscopy referral deferred (had colonoscopy April 2023). Labs: HbA1c 8.1%, glucose 174.
Dr. James R. Carter, MD · CPT 99396 · Signed
03/22/2025
Urgent Care — Sick
Acute sinusitis — 5-day history nasal congestion, facial pressure, fever
Temp 100.8°F. Sinus tenderness on palpation. Amoxicillin 500 mg × 10 days prescribed. Note: PCN allergy on file — CONFIRMED — switched to Azithromycin Z-pack. Patient instructed re: allergy flagging.
Dr. Sarah Nguyen, MD · CPT 99213 · Signed
12/08/2024
Follow-Up Office
Quarterly follow-up: HTN / DM2
BP 150/96. HbA1c 8.4% — elevated. Discussed need for improved glucose control. Patient tearful about dietary struggles. Motivational interviewing. Flu vaccine administered. Referral to nutritionist declined by patient.
Dr. James R. Carter, MD · CPT 99214 · Signed
09/12/2024
Follow-Up Office
Follow-up: review of new DM diagnosis + initiation of Metformin
HbA1c 8.9% at diagnosis. Metformin 500 mg BID started, titrated to 1000 mg BID over 4 weeks. Diabetes education packet provided. Dietary counseling. Foot exam normal.
Dr. James R. Carter, MD · CPT 99214 · Signed
06/04/2024
Annual Physical
Annual preventive exam — new finding: Type 2 DM
Labs notable for glucose 186 mg/dL fasting, HbA1c 8.9%. New DM diagnosis disclosed to patient. BP 146/90. Weight 170 lbs. Atorvastatin 40 mg started for hyperlipidemia. Follow-up in 3 months.
Dr. James R. Carter, MD · CPT 99395 · Signed
Billing & Coding
Encounter #2026-031578 · 03/15/2026 · Medicare Part B
Pending Signature
E&M Level & Charge
Selected Level of Service
99214
Office / Outpatient E&M — Established Patient
Moderate medical decision making · 30–39 min typical
99212 — Simple 99213 — Low 99214 — Moderate ✓ 99215 — High
Estimated Charges
99214 — Office Visit$215.00
90686 — Flu Vaccine (admin)$28.00
90656 — Flu Vaccine (supply)$18.50
Lab: HbA1c$38.00
Lab: CMP$42.00
Lab: Lipid Panel$36.00
Total Billed $377.50
CPT Procedure Codes
CPT CodeDescriptionUnitsModifierAmount
99214Office E&M — Established, Moderate Complexity1—$215.00
90686Influenza Vaccine — Quadrivalent, IM (administration)1—$28.00
90656Influenza Vaccine — Supply1—$18.50
83036Hemoglobin A1c (HbA1c)1—$38.00
80053Comprehensive Metabolic Panel1—$42.00
80061Lipid Panel1—$36.00
ICD-10 Diagnosis Codes
ICD-10DescriptionTypeLinked CPT
I10Essential (primary) hypertensionPrincipal99214
E11.9Type 2 diabetes mellitus without complicationsPrincipal99214 · 83036
E78.5Hyperlipidemia, unspecifiedSecondary80061
E66.09Other obesity due to excess caloriesSecondary99214
Z23Encounter for immunization — InfluenzaSecondary90686 · 90656
Payer & Authorization Status
Primary PayerMedicare Part B
Claim StatusReady to Submit
Authorization RequiredNo — Medicare lab orders self-authorize
Ophthalmology Referral AuthPending — Auth #TBD
Patient Copay (Est.)$0 (Medicare / 100% after deductible)