+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ + Instructions: +
++ Planned Observations: +
+Name | +Dates | +Details | +
---|---|---|
+ + + HGB (85018) + + + + Reason: + + Community acquired pneumonia + + + | +
+
+ On
+ 13-Aug-2012
+
+
+ + + + 4:21 PM + + |
+ + + Request + + | +
+ + + CULTURE, SPUTUM (87070) + + + + Reason: + + Community acquired pneumonia + + + | +
+
+ On
+ 6-Aug-2012
+
+
+ + + + 3:46 PM + + |
+ + + Request + + | +
+ Planned Encounters: +
+
+
+
+
+
+ + + + Clinic One + + + + + + + + + Seven + , Henry + + |
+
+
+ On
+ 8-Aug-2013
+
+
+ + + + 9:00 AM + + |
+
+
+
+
+
+ + + + Clinic One + + + + + + + + + Seven + , Henry + + |
+
+
+ On
+ 7-Aug-2013
+
+
+ + + + 9:00 AM + + |
+
+
+
+
+
+ + + + Clinic One + + + + + + + + + Seven + , Henry + + |
+
+
+ On
+ 6-Aug-2013
+
+
+ + + + 9:00 AM + + |
+
+ Planned Procedures: +
+Name | +Dates | +Details | +
---|---|---|
+ + + DIAGNOSTIC COLONOSCOPY (45378) + + + + By: + + Seven + , Henry + + + | ++ On + 22-Sep-2012 + | ++ + Intent + + | +
+ + + CHEST XRAY, PA & LATERAL (71020) + + + + By: + + Seven + , Henry + + + | ++ On + 13-Aug-2012 + | ++ + Intent + + | +
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Date | +Test | +Result | +Details | +
---|---|---|---|
+ | + | + | + |
+ 6-Aug-2012 3:15 PM
+
+ + + |
+ + BP Systolic + | ++ 135 + mm[Hg] + | +
+
+ Comments:
+ Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
+
+
+ + + |
+
+ BP Diastolic + | ++ 92 + mm[Hg] + | +
+
+ Comments:
+ Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
+
+
+ + + |
+ |
+ Weight + | ++ 88 + kg + | ++ | |
+ Height + | ++ 177 + cm + | ++ | |
+ Body Mass Index Calculated + | ++ 28.09 + kg/m2 + | ++ | |
+ Body Surface Area Calculated + | ++ 2.05 + | ++ |
+
+
+
+
+
+
+ Name | +Dates | +Details | +|||
---|---|---|---|---|---|
+
+ CLARITHROMYCIN, 500MG (Oral Tablet)
+
+
+ + + + + 1 (one) Tablet two times daily for 7 days + + + + + +
+ + + + + |
+
+
+
+ Ordered
+ :
+
+ 6-Aug-2012
+
+
+ + + + Seven + , Henry + + |
+
+
|
+ |||
+
+ METOPROLOL TARTRATE, 25MG (Oral Tablet)
+
+
+ + + + + 1 (one) Tablet daily for 30 days + + + + + +
+ + + + + |
+
+
+
+ Ordered
+ :
+
+ 6-Aug-2012
+
+
+ + + + Seven + , Henry + + |
+
+
|
+ |||
+
+ PROVENTIL HFA, 108 (90 Base)MCG/ACT (Inhalation Aerosol Solution)
+
+
+ + + + + 2 (two) Puff every six hours, as needed for wheezing for 30 days + + + + + +
+ + + + + |
+
+
+
+ Ordered
+ :
+
+ 6-Aug-2012
+
+
+ + + + Seven + , Henry + + |
+
+
+ + |
+
+
+
+
+
+
+
+ Name | +Dates | +Details | +||
---|---|---|---|---|
+
+ PROVENTIL HFA, 108 (90 Base)MCG/ACT (Inhalation Aerosol Solution)
+
+
+ + + + + 2 (two) Puff + + + + + + + + + |
+
+
+
+ Ordered
+ :
+
+ 6-Aug-2012
+
+
+ + + + Seven + , Henry + + |
+
+
+ + |
+
+
+
+
+
+
+
+ Name | +Dates | +Details | +
---|---|---|
+
+ Asthma, moderate persistent
+
+
+
+
+
+ + + |
+ + | + + + Status: + Active + + + | +
+
+ Community acquired pneumonia
+
+
+
+
+
+ + + |
+ + |
+
+ Comments:
+ Patient may continue to experience low grade fever and chills
+
+
+ + + + + Status: + Active + + + |
+
+
+ Hypoxemia
+
+
+
+
+
+ + + |
+ + | + + + Status: + Active + + + | +
+
+
+
+
+
+
+ Name | +Dates | +Details | +
---|---|---|
+ + Aspirin *ANALGESICS - NonNarcotic* + + | ++ + + + Onset + : + + 2011 + + + | ++ + Status: + Active + + | +
+ + Codeine Sulfate *ANALGESICS - OPIOID* + + | ++ + + + Onset + : + + 2010 + + + | ++ + Status: + Active + + | +
+ + Penicillin G Benzathine *PENICILLINS* + + | ++ + + + Onset + : + + 1-June-2012 + + + | ++ + Status: + Active + + | +
+
+
+
+
+
+
+ Date | +Description | +Value | +Details | +|
---|---|---|---|---|
+
+ Resulted on:
+
+
+ + + 6-Aug-2012 4:06 PM + |
+ + PNEUMOCOCCAL VACCINE (90732) + | ++ + | +
+ Normal
+
+ + + |
+ |
+ | + | + | + | |
+
+ + + 3:30 PM + |
+ + CHEST XRAY, PA & LATERAL (71020) + | ++ Comments: consistent with pneumonia + | +
+ Normal
+
+ + + |
+ |
+ | + | + | + | |
+
+ + + 18-July-2013 3:21 PM + |
+ + HCT (85014) + | ++ | + | |
+ | + HCT + | ++ 45 % + | +
+ Range: 42.9 - 49.1 = Normal
+
+ + + |
+ |
+
+ + + 3:21 PM + |
+ + HGB (85018) + | ++ | + | |
+ | + HGB + | ++ 14.2 g/dL + | +
+ Range: 14.4 - 16.6 = Abnormal
+
+ + + |
+ |
+
+ + + 3:21 PM + |
+ + PLT (85049) + | ++ | + | |
+ | + PLT + | ++ 220 10^3/ul + | +
+ Normal
+
+ + + |
+ |
+
+ + + 3:21 PM + |
+ + WBC (85048) + | ++ | + | |
+ | + WBC + | ++ 7.6 10^3/ul + | +
+ Range: 4.5 - 11.0 = Normal
+
+ + + |
+
+
+
+
+
+
+
+ Procedure | +Dates | +Details | +
---|---|---|
+ PNEUMOCOCCAL VACCINE (90732) + | ++ | + + + Completed + : + + 6-Aug-2012 + + | +
+ CHEST XRAY, PA & LATERAL (71020) + | ++ | + + + Completed + : + + 6-Aug-2012 + + | +
+ ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG (J7609) + | ++ | + + + Completed + : + + 6-Aug-2012 + + | +
+
+
+
+
+
+
+ Name | +Dates | +Details | +
---|---|---|
+
+ Influenza (3 years and up)
+
+
+ + + |
+ + + + Administered on + : + + 1-Nov-2010 + + | ++ |
+
+ Influenza (3 years and up)
+
+
+ + + |
+ + + + Administered on + : + + 10-Sep-2011 + + | ++ |
+
+ Pneumococcal (2 years and up)
+
+
+ + + Lot #: + MK456987 + |
+ + + + Administered on + : + + 6-Aug-2012 + + | +
+
+ Comments:
+ Site: Deltoid (Left)
+
+
+ + + |
+
+
+ Td (7 years and up)
+
+
+ + + |
+ + + + Administered on + : + + 4-Jan-2007 + + | ++ |
+
+
+
+
+
+
+ Name | +Dates | +Details | +
---|---|---|
+
+ Tobacco use
+
+ Current every day smoker.
+
+
+
+
+ + + |
+ + |
+
+ Comments:
+ Current every day smoker. Start: 1992
+
+
+ + + |
+
+ Smoking Status: +
+
+
+
+
+
+
+
+
+
+ Office Visit
+
+
+ + + + Encounter Reason: + Fever and chills - The fever and chills have been occurring for 2 days. There has been associated cough (green sputum). + + + Encounter Diagnosis: + Community acquired pneumonia + , + Asthma, moderate persistent + , + Hypoxemia + + + + Clinic One + + + + + |
+
+
+ On
+ 6-Aug-2012
+
+
+ + + + 3:03 PM + + |
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ + Instructions: +
++ Planned Observations: +
+Name | +Dates | +Details | +
---|---|---|
+ + + HGB (85018) + + + + Reason: + + Community acquired pneumonia + + + | +
+
+ On
+ 13-Aug-2012
+
+
+ + + + 4:21 PM + + |
+ + + Request + + | +
+ + + CULTURE, SPUTUM (87070) + + + + Reason: + + Community acquired pneumonia + + + | +
+
+ On
+ 6-Aug-2012
+
+
+ + + + 3:46 PM + + |
+ + + Request + + | +
+ Planned Encounters: +
+
+
+
+
+
+ + + + Clinic One + + + + + + + + + Seven + , Henry + + |
+
+
+ On
+ 8-Aug-2013
+
+
+ + + + 9:00 AM + + |
+
+
+
+
+
+ + + + Clinic One + + + + + + + + + Seven + , Henry + + |
+
+
+ On
+ 7-Aug-2013
+
+
+ + + + 9:00 AM + + |
+
+
+
+
+
+ + + + Clinic One + + + + + + + + + Seven + , Henry + + |
+
+
+ On
+ 6-Aug-2013
+
+
+ + + + 9:00 AM + + |
+
+ Planned Procedures: +
+Name | +Dates | +Details | +
---|---|---|
+ + + DIAGNOSTIC COLONOSCOPY (45378) + + + + By: + + Seven + , Henry + + + | ++ On + 22-Sep-2012 + | ++ + Intent + + | +
+ + + CHEST XRAY, PA & LATERAL (71020) + + + + By: + + Seven + , Henry + + + | ++ On + 13-Aug-2012 + | ++ + Intent + + | +
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Date | +Test | +Result | +Details | +
---|---|---|---|
+ | + | + | + |
+ 6-Aug-2012 3:15 PM
+
+ + + |
+ + BP Systolic + | ++ 135 + mm[Hg] + | +
+
+ Comments:
+ Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
+
+
+ + + |
+
+ BP Diastolic + | ++ 92 + mm[Hg] + | +
+
+ Comments:
+ Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
+
+
+ + + |
+ |
+ Weight + | ++ 88 + kg + | ++ | |
+ Height + | ++ 177 + cm + | ++ | |
+ Body Mass Index Calculated + | ++ 28.09 + kg/m2 + | ++ | |
+ Body Surface Area Calculated + | ++ 2.05 + | ++ |
+
+
+
+
+
+
+ Name | +Dates | +Details | +|||
---|---|---|---|---|---|
+
+ CLARITHROMYCIN, 500MG (Oral Tablet)
+
+
+ + + + + 1 (one) Tablet two times daily for 7 days + + + + + +
+ + + + + |
+
+
+
+ Ordered
+ :
+
+ 6-Aug-2012
+
+
+ + + + Seven + , Henry + + |
+
+
|
+ |||
+
+ METOPROLOL TARTRATE, 25MG (Oral Tablet)
+
+
+ + + + + 1 (one) Tablet daily for 30 days + + + + + +
+ + + + + |
+
+
+
+ Ordered
+ :
+
+ 6-Aug-2012
+
+
+ + + + Seven + , Henry + + |
+
+
|
+ |||
+
+ PROVENTIL HFA, 108 (90 Base)MCG/ACT (Inhalation Aerosol Solution)
+
+
+ + + + + 2 (two) Puff every six hours, as needed for wheezing for 30 days + + + + + +
+ + + + + |
+
+
+
+ Ordered
+ :
+
+ 6-Aug-2012
+
+
+ + + + Seven + , Henry + + |
+
+
+ + |
+
+
+
+
+
+
+
+ Name | +Dates | +Details | +||
---|---|---|---|---|
+
+ PROVENTIL HFA, 108 (90 Base)MCG/ACT (Inhalation Aerosol Solution)
+
+
+ + + + + 2 (two) Puff + + + + + + + + + |
+
+
+
+ Ordered
+ :
+
+ 6-Aug-2012
+
+
+ + + + Seven + , Henry + + |
+
+
+ + |
+
+
+
+
+
+
+
+ Name | +Dates | +Details | +
---|---|---|
+
+ Asthma, moderate persistent
+
+
+
+
+
+ + + |
+ + | + + + Status: + Active + + + | +
+
+ Community acquired pneumonia
+
+
+
+
+
+ + + |
+ + |
+
+ Comments:
+ Patient may continue to experience low grade fever and chills
+
+
+ + + + + Status: + Active + + + |
+
+
+ Hypoxemia
+
+
+
+
+
+ + + |
+ + | + + + Status: + Active + + + | +
+
+
+
+
+
+
+ Name | +Dates | +Details | +
---|---|---|
+ + Aspirin *ANALGESICS - NonNarcotic* + + | ++ + + + Onset + : + + 2011 + + + | ++ + Status: + Active + + | +
+ + Codeine Sulfate *ANALGESICS - OPIOID* + + | ++ + + + Onset + : + + 2010 + + + | ++ + Status: + Active + + | +
+ + Penicillin G Benzathine *PENICILLINS* + + | ++ + + + Onset + : + + 1-June-2012 + + + | ++ + Status: + Active + + | +
+
+
+
+
+
+
+ Date | +Description | +Value | +Details | +|
---|---|---|---|---|
+
+ Resulted on:
+
+
+ + + 6-Aug-2012 4:06 PM + |
+ + PNEUMOCOCCAL VACCINE (90732) + | ++ + | +
+ Normal
+
+ + + |
+ |
+ | + | + | + | |
+
+ + + 3:30 PM + |
+ + CHEST XRAY, PA & LATERAL (71020) + | ++ Comments: consistent with pneumonia + | +
+ Normal
+
+ + + |
+ |
+ | + | + | + | |
+
+ + + 18-July-2013 3:21 PM + |
+ + HCT (85014) + | ++ | + | |
+ | + HCT + | ++ 45 % + | +
+ Range: 42.9 - 49.1 = Normal
+
+ + + |
+ |
+
+ + + 3:21 PM + |
+ + HGB (85018) + | ++ | + | |
+ | + HGB + | ++ 14.2 g/dL + | +
+ Range: 14.4 - 16.6 = Abnormal
+
+ + + |
+ |
+
+ + + 3:21 PM + |
+ + PLT (85049) + | ++ | + | |
+ | + PLT + | ++ 220 10^3/ul + | +
+ Normal
+
+ + + |
+ |
+
+ + + 3:21 PM + |
+ + WBC (85048) + | ++ | + | |
+ | + WBC + | ++ 7.6 10^3/ul + | +
+ Range: 4.5 - 11.0 = Normal
+
+ + + |
+
+
+
+
+
+
+
+ Procedure | +Dates | +Details | +
---|---|---|
+ PNEUMOCOCCAL VACCINE (90732) + | ++ | + + + Completed + : + + 6-Aug-2012 + + | +
+ CHEST XRAY, PA & LATERAL (71020) + | ++ | + + + Completed + : + + 6-Aug-2012 + + | +
+ ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG (J7609) + | ++ | + + + Completed + : + + 6-Aug-2012 + + | +
+
+
+
+
+
+
+ Name | +Dates | +Details | +
---|---|---|
+
+ Influenza (3 years and up)
+
+
+ + + |
+ + + + Administered on + : + + 1-Nov-2010 + + | ++ |
+
+ Influenza (3 years and up)
+
+
+ + + |
+ + + + Administered on + : + + 10-Sep-2011 + + | ++ |
+
+ Pneumococcal (2 years and up)
+
+
+ + + Lot #: + MK456987 + |
+ + + + Administered on + : + + 6-Aug-2012 + + | +
+
+ Comments:
+ Site: Deltoid (Left)
+
+
+ + + |
+
+
+ Td (7 years and up)
+
+
+ + + |
+ + + + Administered on + : + + 4-Jan-2007 + + | ++ |
+
+
+
+
+
+
+ Name | +Dates | +Details | +
---|---|---|
+
+ Tobacco use
+
+ Current every day smoker.
+
+
+
+
+ + + |
+ + |
+
+ Comments:
+ Current every day smoker. Start: 1992
+
+
+ + + |
+
+ Smoking Status: +
+
+
+
+
+
+
+
+
+
+ Office Visit
+
+
+ + + + Encounter Reason: + Fever and chills - The fever and chills have been occurring for 2 days. There has been associated cough (green sputum). + + + Encounter Diagnosis: + Community acquired pneumonia + , + Asthma, moderate persistent + , + Hypoxemia + + + + Clinic One + + + + + |
+
+
+ On
+ 6-Aug-2012
+
+
+ + + + 3:03 PM + + |
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+