ED Telemed

[textarea name="55" default=""]

Patient is being seen via HIPAA compliant audio/video platform.
[select name="variable_1" value="Initial|follow up"]

This is a [text name="1" default=" -year-old"] male being seen today for evaluation of erectile dysfunction. Patient with difficulty maintaining and achieving an erection. International Index of Erectile Function Questionnaire performed. Pt with a score of [select name="2" value="5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25"].

[select name="3" value="Does not have a|Does have a"] history of hypertension. [select name="4" value="Does not have a|Does have a"] history of diabetes.

[textarea name="5" default=""]

[select name="6" value="He has not|He has"] had testosterone screening in the past.

[textarea name="7" default=""]

Does state he has some anxiety regarding sexual activity now that he has had some erectile difficulty.

[select name="8" value="Has not used ED medication in the past.|Has used Viagra in the past without side effects and reports this worked well for him.|Has used Cialis in the past without side effects and reports this worked well for him.|Has used Levitra in the past without side effects and reports this worked well for him."]

Drug Allergies:
[checkbox name="9" value="-NKDA"]
[text name="10" default=""]
Current Medications:
[checkbox name="11" value="-No current medications"]
[textarea name="12" default=""]
PMHx:
[checkbox name="13" value="-No PMHx reported"]
[textarea name="14" default=""]
PSHx:
[checkbox name="15" value="-No PSHx reported"]
[textarea name="16" default=""]
FMHx:
[checkbox name="17" value="-No FMHx reported"]
[textarea name="18" default=""]
Social Hx:
[checkbox name="19" value="-Tobacco-denies/never"]
[textarea name="20" default=""]
[checkbox name="21" value="-EtOH-denies/never"]
[textarea name="22" default=""]
[checkbox name="23" value="-Illicit drugs-denies/never"]
[textarea name="24" default=""]
Review of systems:
Patient denies any fevers, chills, malaise, chest pain, SOA, cough, wheezing, abd pain, N/V, diarrhea, dysuria, headache, blurred vision, or syncope.

Please see HPI for additional ROS.

Physical exam performed using audio/visual technology

GENERAL: Well appearing. In no apparent distress.
SKIN: Skin color appears normal for ethnicity.
HEAD: Normocephalic.
CHEST/LUNGS: Resps are even and unlabored. No accessory muscle use. Speaking in full sentences. No signs or symptoms of respiratory distress.
MUSCULOSKELETAL: Full range of motion to bilateral upper extremities.
NEUROLOGIC: Alert and oriented x 3. Speech is clear. No focal findings.
PSYCHIATRIC: Mood and affect are appropriate.

Erectile dysfunction – N52.9

Rx Medications:
[checkbox name="25" value="Viagra|Cialis|Levitra"]
 30 to 60 minutes prior to sexual activity as directed. 
MG:
[text name="variable_1" default=""]
Month Supply: 
[text name="variable_1" default=""]

I have discussed the importance of laboratory evaluation including testosterone levels. [checkbox name="26" value="He reports that he would be willing to do this.|He refuses this at this time."]

[textarea name="27" default="Education regarding importance of honesty to healthcare providers about taking ED medication and the importance of monitoring side effects provided.
 
"]

Prescriptions sent electronically to pharmacy of pts choice.

Strict return precautions discussed.


Patient verbalizes understanding of all instructions.

Explained to the patient the importance of maintaining a primary care provider and that this was not a complete substitute for in-person consultation. In the event that symptoms worsen, or in the event that the patient develops concerns or side effects from treatment, it is explained in detail that the patient must immediately contact their PCP or go to the nearest urgent care or emergency room for evaluation.

Discussed other treatments for ED 
    therapy can be a helpful option for treating ED that’s related to a psychological factor such as stress or sexual performance anxiety.

Patient to follow up in: [textarea name="28" default=""]

[checkbox name="29" value="Established Patient - Straightforward: 99212|New Patient - Straightforward: 99201"]

Electronically signed by:
Mitchell Kohl, MD
NPI: 1306368691
[date name="30" default=""]
@[textarea name="31" default=""]