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170.315_b1_toc_amb_ccd_r21_sample1 test data
Section Author: Dr. Davis Albert, Neighborhood Physicians Practice
Section Author: Dr. Davis Albert, Neighborhood Physicians Practice
PROHIBITION ON REDISCLOSURE OF CONFIDENTIAL INFORMATION:
This notice
accompanies a disclosure of information concerning a client in alcohol/drug
treatment, made to you with the consent of such client. This information has
been disclosed to you from records protected by federal confidentiality
rules (42 C.F.R. Part 2). The federal rules prohibit you from making any
further disclosure of this information unless further disclosure is
expressly permitted by the written consent of the person to whom it pertains
or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for
the release of medical or other information is NOT sufficient for this
purpose. The federal rules restrict any use of the information to criminally
investigate or prosecute any alcohol or drug abuse patient.
Substance |
Reaction |
Severity |
Status |
Penicillin G benzathine
|
Hives
|
Moderate
|
Active |
Ampicillin Sodium
|
Hives
|
Moderate
|
Active |
Medication |
Directions |
Start Date |
Ceftriaxone 100MG/ML |
BID |
June 22, 2015 |
Tylenol 500mg |
For 10 days As needed |
June 22, 2015 |
Darbepoetin Alfa 0.5 MG/ML |
Once a week |
June 22, 2015 |
Active Concerns
- Problem #1
- Essential hypertension (Disorder)
- Problem #2
- Severe Hypothyroidism (Disorder)
- Problem #3
- Chronic rejection of renal transplant (disorder)
- Problem #4
Resolved Concerns
Encounter Diagnosis |
Location |
Date |
Fever |
Neighborhood Physicians Practice |
June 22, 2015 at 10am EST |
Vaccine |
Date |
Status |
Influenza Virus Vaccine |
May 10, 2014 |
Completed |
Tetanus and diphtheria toxoids |
January 4, 2012 |
Completed |
influenza, intradermal, quadrivalent, preservative free |
June 22, 2015 |
Refused by Patient |
Date / Time: |
June 22, 2015 |
Height |
177 cm |
Weight |
88 kg |
Blood Pressure |
145/88 |
Heart Rate |
80 beats per minute |
O2 Percentage BldC Oximetry |
95 percent |
Body Temperature |
38 degree celsius |
Respiratory Rate |
18 breaths per minute |
Social History Observation |
Description |
Dates Observed |
Smoking Status |
Heavy tobacco smoker |
May 1, 2005 - February 27, 2011 |
Current Smoking Status |
Current every day |
June 22, 2015 |
Procedure |
Date |
Nebulizer Therapy |
June 22, 2015 |
Introduction of cardiac pacemaker system via vein |
October 5, 2011 |
Result Type |
Result Value |
Relevant Reference Range |
Interpretation |
Date |
Color of Urine |
YELLOW |
YELLOW |
Normal |
06/22/2015 |
Appearance of Urine |
CLEAR |
CLEAR |
Normal |
06/22/2015 |
Specific gravity of Urine by Test strip |
1.015 |
1.005 - 1.030 |
Normal |
06/22/2015 |
pH of Urine by Test strip |
5.0 pH |
5.0 - 8.0 |
Normal |
06/22/2015 |
Glucose [Mass/volume] in urine by test strip |
50mg/dl |
Neg |
|
06/22/2015 |
Ketones [Mass/Volume] in urine by test strip |
Negative |
Negative |
|
06/22/2015 |
Protein[Mass/Volume] in urine by test strip |
100mg/dl |
negative |
|
06/22/2015 |
Functional Category |
Effective Dates |
Dependence on Cane |
May 01, 2005 |
The patient was found to have fever and Dr Davis is suspecting Anemia based on the patient history. So Dr Davis asked the patient to closely monitor the temperature and blood pressure and get admitted to Community Health Hospitals if the fever does not subside within a day.
Hand-off Communication:
Planned Care |
Start Date |
Urinanalysis macro (dipstick) panel |
June 22, 2015 |
Get an EKG done on 6/23/2015. |
June 23, 2015 |
Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract Structure. |
June 23, 2015 |
Take Clindamycin 300mg three times a day as needed if pain does not subside. |
June 23, 2015 three times a day as needed |
Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015. |
July 7, 2015 |
Goal |
Value |
Date |
Get rid of intermittent fever that is occurring every few weeks (Visual Inspection) |
N/A |
June 23, 2015 |
Need to gain more energy to do regular activities (Visual Inspection) |
N/A |
June 23, 2015 |
Observation |
Status |
Date |
Chronic Sickness exhibited by patient |
Active |
June 22, 2015 |
Concern |
Status |
Date |
Documented HyperTension problem |
Active |
June 22, 2015 |
Documented HypoThyroidism problem |
Active |
June 22, 2015 |
Watch Weight of patient |
Active |
June 22, 2015 |
Ms Alice Newman is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia.
Status |
Date |
Amnesia |
May 05, 2005 |