Substance | Reaction | Severity | Status |
---|---|---|---|
Product containing benzodiazepine | Allergic Headache | Mild | Active |
Patient | Legal: Jeremy V WONG jr Date of Birth: June 1, 1980 (35yr) Gender: Male Patient-ID: 116263337 (SSN) |
Encounter | ID: 9937012 (Examples) , Date/Time: July 22, 2015 6PM -0500 - 11PM -5000 |
Documentation Of | Care provision, Burn by Fire, Date/Time: July 22, 2015 6PM -0500 - 11PM -5000, Performer: Dr Henry SEVEN, Performer: Mary MCDONALD |
Author | Dr Henry SEVEN, Authored On: July 22, 2015 |
Substance | Reaction | Severity | Status |
---|---|---|---|
Product containing benzodiazepine | Allergic Headache | Mild | Active |
Medication | Directions | Start Date |
---|---|---|
Ceftriaxone 100MG/ML | Two Times Daily | June 22, 2015 |
Vantin | Two Times Daily | June 22, 2015 |
Tylenol 500mg | As needed | June 22, 2015 |
Clindamycin 300mg | Three Times Daily | June 23, 2015 |
Torsemide 20mg | Daily | June 23, 2015 |
Levothyroxine Sodium | Daily | June 23, 2015 |
Prednisolone 10mg | Daily | June 23, 2015 |
FenoFibric Acid 35mg | At the hour o sleep | June 24, 2015 |
Mycophenolic Acid 360mg | Two Times Daily | June 24, 2015 |
Everolimus 0.5mg | Two Times Daily | June 24, 2015 |
Ciprofloxacin 2mg/ml | Three Times Daily | June 25, 2015 |
Procedure | Date |
---|---|
Application of Dressing for burn | July 22, 2015 |
Patient has no history of implantable devices
Date / Time: | June 22, 2015 |
---|---|
Height | 177 cm |
Weight | 88 kg |
Blood Pressure | 145/88 mm[Hg] |
Date / Time: | July 22, 2015 |
---|---|
Body Temperature | 99 degrees Fahrenheit |
Social History Observation | Description | Dates Observed |
---|---|---|
Current Smoking Status | Current every day | July 22, 2015 |
Birth Sex | Male | July 22, 2015 |
Gender Identity | Asked but Unknown | Unknown |
Sexual Orientation | Unknown | Unknown |
Basic Occupation | Odd Jobs Day Worker | June 22, 2022 |
Tribal Affiliation | Coquille Indian Tribe | June 22, 2022 |
Pregnancy Status | Not Pregnant | June 22, 2022 |
Planned Care | Start Date |
---|---|
Schedule an appointment with Dr Seven after 1 week for Follow up with Outpatient facility. | July 29, 2015 |
Medication: Tylenol 500mg | As needed |
Goal | Value | Date |
---|---|---|
Achieve Food Security with appropriate help | N/A | July 22, 2015 |
Functional Category | Effective Dates |
---|---|
Dependence on Cane | May 01, 2005 |
Do you have serious difficulty walking or climbing stairs - Yes | June 22, 2022 |
Performer Name | Performer Role |
---|---|
Dr Henry seven | Physician |
Summary | Written by: | Date |
---|---|---|
Dr Henry Seven diagnosed Mr Jeremy Wong to be suffering from first degree burns, but provided the necessary care and discharged Mr Wong letting him know that it would heal in time and he can go home. | Dr Henry Seven | 07/22/2020 |