Epigastric pain, GERD, sleep disorder fatigue visit 11/8/2022 Dr. McMullen. To be more specific these are the listed symptoms / reasons for this 11/8/2022 clinic visit with Dr. Susan McMullen. This office visit took place at the UT Health East Texas – Cedar Creek Lake location.
11/8/2022 Symptoms
- Continuous epigastric pain
- Chronic GERD
- Recurrent boils
- Chronic fatigue
- Sleep-disordered breathing
In this office visit notes McMullen notes that I told her that I stopped taking the doxycycline because it wasn’t effective. She also noted that I was consuming extra caffeine during my work day to fight off excessive drowsiness she used the medical term – “somnolence” to describe my excessive daytime sleepiness.
She also notes that I told her I was trying to watch my food intake for weight loss. I wasnt currently taking nsaids regularly for pain management. Also noted is that I am a stressed out cigarette smoker.
I do kind of remember this office visit – I remember that I had spoken with Dr. McMullen about my snoring. I told her that my husband often complained that I was snoring loud. I believe this detail was considered with Dr. McMullen’s treatment plan for this office visit – even though it wasn’t specifically mentioned in the visit notes.
My Office Nurse Check
- Blood Pressure: 132/64
- Temperature: 97.5
- BMI: 49.43
- Pulse: 111
- Weight: 292 lbs 8oz
- Respiration: 18
- Height: 5′ 4.5″”
- Oxygen Saturation: 98%
When entering these office nurse check information, I noted that my resting heart rate was noted as being 111 for this clinic visit. Google says that 60-100 heart rate is normal for a resting adult. So 111 that was noted for me on that day was considered higher than normal for a resting adult. Tachycardia was noted in this visit.
Patient Active Problem List includes:
- Chronic gastroesophageal reflux disease / Diagnosed 2/8/2022
- There is no mention of the “Fatty Liver” or “Gallstone” listed in active problem list. The radiologist Daniel Christopher Bennett, MD seen these issues and released the sonogram report on 4/20/2022.
New Diagnosis For 11/08/2022
- Class 3 severe obesity in adult (HCC) / Diagnosed 11/8/2022
- The Class 3 severe obesity is a new diagnosis for this clinic visit. I don’t think there is a specific test for Class 3 obesity – But at the same time its important to say that Dr. McMullen did not perform any special test to come up with the new diagnosis. I think its fair to say that any average health care provider would agree with her diagnosis on this day. Actually I believe that any average health care provider would have made the class 3 obesity diagnosis on 2/8/2022.
Continued Medication Is As Listed – The Medication List Was Corrected
- sulfamethoxazole-trimethoprim 800-160 mg per tabletCommonly known as: Bactrim, Take 1 tablet by mouth 1 (one) time each day. To prevent boils. Stop doxycycline
- clotrimazole (LOTRIMIN) 1 % cream; Apply topically 2 (two) times per day.
Changed Prescriptions Were
- pantoprazole (PROTONIX) 40 mg EC tablet, Take 1 tablet (40 mg total) by mouth 1 (one) time each day.
- was changed to = pantoprazole (PROTONIX) 40 mg EC tablet, Take 1 tablet (40 mg total) by mouth twice day
Removed Medications Were:
- doxycycline (VIBRAMYCIN) 100 mg capsule; Take 1 capsule (100 mg total) by mouth 1 (one) time each day. SUN protection
Extra Attention With These Medical Records
Neurological: On 2/8/2022 McMullen noted that I showed no signs of neurological issues. Negative for dizziness, tremors, seizures, weakness, light-headedness, numbness and headaches. On 3/8/2022 The notes for neurological only say “she is alert”. There is no mention of the other neurological stuff previously mentioned. 3/23/2022 McMullen noted negative for dizziness, weakness, light-headedness and numbness. 4/22/2022 visit just notes “she is alert” for neurological. 11/8/2022 everything for neurological was noted as normal.
Psychiatric /Behavioral: 11/8/2022 notes were made that My mood was normal ect. But that I was positive for “sleep disturbance”
Constitutional: On 2/8/2022 McMullen noted “she is obese. She is not ill-appearing, toxic-appearing or diaphoretic.” I believe the term “Obese” that McMullen was incorrect. I believe the correct term for me would be “Class III obesity” because my BMI at the time was over 40. On 3/8/2022 McMullen noted “she is obese”. Again, I do not agree we the label of “Obese” I believe the correct term to label me should be Class lll obesity since my BMI is over 40. 3/23/2022 McMullen labeled me as “Obese” again. 4/22/2022 again just noted as “obese” this is 2 days after the radiologist noted “fatty liver” on my sonogram. 11/8/2022 Dr. McMullen diagnosed me with Class 3 severe obesity.
Gastrointestinal / Abdominal: On 3/8/2022 Dr. McMullen did not comment on gastrointestinal issues or left CVA” tenderness as previously mention on the 2/8/2022 records. 3/23/2022 McMullen noted abdominal pain, left CVA tenderness in the area for gastrointestinal symptoms. 4/22/2022 nothing noted about gastrointestinal symptoms. 11/8/2022 Abdominal pain, abdominal tenderness, and epigastric tenderness were noted
Cardiovascular: 11/8/2022 was the first instance of noted Tachycardia.
The same useless “leaflet” distributed by Ardent Health was also attached to this visit summary on 11/8/2022.
This Clinic Visits Action Plan:
For the “epigastric pain” / GERD my pantoprazole prescription changed. Instead of taking 1 40mg dose per day, the prescription was changed to 1 40mg dose twice a day. I was also referred again to a Gastroenterology specialist.
For the “chronic fatigue“ I was referred to Sleep studies / sleep medicine with suspected sleep apnea. 3 blood labs were also ordered on the visit. – THESE BLOOD TEST LABS WERE NOTED AS ORDERED BUT NOT ACTUALLY ORDERED.
There were no orders that specifically addressed the “abdominal pain and abdominal tenderness that was noted on this visit.
Blood Lab Test Results for 11/8/2022
- When I went in to MyChart for these blood lab results for test ordered by Dr. Susan McMullen _ there were no results found. I’m not sure if my insurance was billed for these blood test _ but no samples were tested because no such test were actually ordered.
- Unfortunately my insurance does not show insurance claims all the way back to 2022, since we are currently 11/30/2025.
- If these blood lab test were ordered as noted in this medical records they would have been taken as soon as the clinic visit ended in the same building.
- Just In Case : Dr. McMullen’s office attempts to suggest that I somehow refused to be tested or left without being tested. Maybe they say that I probably forgot to stop by to be tested _ Dr. McMullen electronically signed the medical record 11/10/2022 8:18 PM. There are no notes or mention of me refusing or missing any test she ordered on this visit.
- The most recent test results at the time were done 5/9/2022 from my well woman’s visit from my pap results. Then I have no further test results until 1/31/2023. – Just covering all information since these blood lab results seem to have disappeared as soon as the orders were made by Dr. McMullen.
Specialist Referrals for 11/8/2022
Dr. McMullen referred me to Gastroenterology specialist and sleep studies / sleep medicine for this office visit. These are the results from those referrals. I just want to bring attention to the fact that both of these referrals are to specialist within the UT Health East Texas hospital system.
- 12/14/2022 / Dr Mapakshi From UT Health East Texas Physicians- Gastroenterology (Athens).
- The listed reasons for this referral to Dr. Mapakshi is as noted here: Abdominal pain, pit of stomach, acid reflux
- This is actually the exact same doctor office with Dr Takata but with a different doctor. I have no idea what ever happened to Dr. Takata.
- 12/22/2022 / Dr Gass From UT Health East Texas Physicians – Pulmonology
- The listed reasons for referral to Dr. Gass is as noted here: sleep apnea, snoring, daytime hypersomnolence
Attorney Documents For This Clinic Visit
- #11-22-1 = Image of MyChart appointment Calendar
- #11-22-2 = After Visit Summary For Clinic Visit on 11/8/2022 with Dr. McMullen
- #11-22-3 = Notes from Care Team For Clinic Visit on 11/8/2022 with Dr. McMullen
- #22-8 = Medical Bill from this office visit on 11/8/2022 with Dr. McMullen
- 12-22-1 = Image of referrals from 12/22/22 – 2/2/2023
- 12-22-1 = Referral from Dr. Gass to UTMG Tyler Sleep Center on 1/26/2023
Billing For This Clinic Visit
- $238.00 = Office / Outpatient Established Mod Mdm 30 min / Dr. McMullen
- McMullen did put that she ordered 3 blood test in this medical record, but she didn’t actually order the blood test. I believe that these 3 blood test were added to this medical record, so my health insurance with pre-authorize the sleep clinic referral. I was not billed for the 3 lab test and they were never actually ordered, they are just ordered in the medical record.
- I’m not sure if the 3 lab test that were in this medical record were charged to my health insurance. IF Dr. McMullen put that the test were done for the purpose of getting the sleep clinic pre-authorized – I’m not sure how that would work unless my insurance was charged for the test.
The medical bill says that my Ambetter health insurance policy paid 100% of the medical bill for this clinic visit.
On This Day I Had Been Taking Pantoprazole For This Long:
- 9 months 0 days = 7 Months longer than the recommended 2 Months
- or 39 weeks 0 days = 31 WEEKS LONGER THAN THE FDA RECOMMENDED 8 WEEKS
- or 273 days = 217 days longer than the recommended 56 days
FDA recommends a 8 week treatment period for Pantoprazole. At the end of those 8 weeks the doctor is supposed to reevaluate as to rather or not the patient needs to continue to take the Proton Pump Inhibitor PPI.
UT Health East Texas and Ardent Health were made aware of this specific medical record on November 30, 2025.
Maybe the health insurance requires blood testing before specialist referrals. Just a thought