Summarization of Episode Note
Alice Newman
Patient Identifiers
OID: 82ad77c3-5fb6-0142-7501-f47fe12864d1
About
Date of Birth
05/1/1970
Sex
Female
Race
White
Ethnicity
Not Hispanic or Latino
Contact
Primary Home
1357 Amber Dr
Beaverton, OR
97006, USA
Tel : +1-(555)777-1234
Service Event
Dr Albert Davis of Neighborhood Physicians Practice
06/20/2015 - 06/25/2015
Service Event
Tracy Davis
06/20/2015 - 06/25/2015
Author
Dr Albert Davis - Neighborhood Physicians Practice
Contact
2472, Rocky place
Beaverton, OR
97006
Medications
| Medication | Timing | Route | Freq | Dose |
|---|---|---|---|---|
| Ceftriaxone 100 MG/ML | ~ | Injection | Injectable, two times daily, 1 unit | 1 |
| Tylenol 500mg | ~ | Oral | PRN | 1 |
| Aranesp 0.5 MG/ML | ~ | Injection | Injectable, once a week, 1 unit | 1 |
| Medication | Date | Route | Dose |
|---|---|---|---|
| No records | |||
Problems
| Problem | Noted Date | Diagnosed Date |
|---|---|---|
| Essential hypertension | ~ | ~ |
| Severe hypothyroidism | ~ | ~ |
| Chronic rejection of renal transplant | ~ | ~ |
| Fever (finding) | ~ | ~ |
| Problem | Noted Date | Diagnosed Date | Resolved Date |
|---|---|---|---|
| Overweight (finding) | 12/31/2006 12:00AM UTC | ~ | ~ |
Goals
a. Get rid of intermittent fever that is occurring every few weeks.
b. Need to gain more energy to do regular activities
Results
-
Urinanalysis macro (dipstick) panel, No performer ID, No Lab, No Lab Address:
Code Value Date Color of urine YELLOW 06/22/2015 12:00AM UTC Appearance of urine CLEAR 06/22/2015 12:00AM UTC Specific gravity of urine by test strip 1.015 1 06/22/2015 12:00AM UTC pH of urine by test strip 5.0 [pH] 06/22/2015 12:00AM UTC Glucose [Mass/volume] in urine by test strip 50 mg/dL 06/22/2015 12:00AM UTC Ketones [Mass/Volume] in urine by test strip Negative 06/22/2015 12:00AM UTC Protein [Mass/Volume] in urine by test strip 100 mg/dL 06/22/2015 12:00AM UTC
Social History
| Element | Date | Value |
|---|---|---|
| Tobacco smoking status NHIS | 06/22/2015 12:00AM UTC | Current every day smoker |
| Sex Assigned At Birth | ~ | Female |
Vital Signs
| Vital sign | Date | Value and units |
|---|---|---|
| Blood Pressure Systolic | 06/22/2015 3:08PM UTC | 145 mm[Hg] |
| Blood Pressure Diastolic | 06/22/2015 3:08PM UTC | 88 mm[Hg] |
| Heart Rate | 06/22/2015 3:10PM UTC | 80 /min |
| Body Temperature | 06/22/2015 3:15PM UTC | 38 Cel |
| Respiratory Rate | 06/22/2015 3:15PM UTC | 18 /min |
| O2 % BldC Oximetry | 06/22/2015 3:12PM UTC | 95 % |
| Inhaled Oxygen Concentration | 06/22/2015 3:12PM UTC | 36 % |
| Weight | 06/22/2015 3:05PM UTC | 88 kg |
| Height | 06/22/2015 3:05PM UTC | 177 cm |
| BMI | ~ | ~ |
| Head Occipital Circumference | ~ | ~ |
Allergies and Intolerances
| Type | Substance | Onset | Reactions | Status |
|---|---|---|---|---|
| allergy | Ampicillin | 10/05/1980 12:00AM UTC |
10/05/1980 12:00AM UTC - Hives - moderate |
active |
| N/A | Penicillin G | 10/05/1980 12:00AM UTC |
10/05/1980 12:00AM UTC - Hives - moderate |
active |
Encounters
| Date | Type | Department | CareTeam | Description |
|---|---|---|---|---|
| No records | ||||
Functional Status
No data for section Functional Status
Immunizations
| Vaccine | Date | Status | Lot | Notes |
|---|---|---|---|---|
| Tetanus and diphtheria toxoids | 01/04/2012 12:00AM UTC | completed | N/A | N/A |
| Influenza, intradermal, quadrivalent, preservative-free | 06/22/2015 12:00AM UTC | not-done | No Lot number provided | Immunization was not given - Patient rejected immunization |
Medical Equipment
| ID | Assigning Auth | Code | Date |
|---|---|---|---|
| (01)00643169007222(17)160128(21)BLC200461H | FDA | Cardiac resynchronization therapy implantable pacemaker | 10/05/2011 12:00AM UTC |
Mental Status
No data for section Mental Status
Payers
No data for section Payers
Procedures
| Procedures | Date | Status |
|---|---|---|
| Nebulizer Therapy | 06/22/2015 12:00AM UTC | completed |
| Introduction of cardiac pacemaker system via vein | 10/05/2011 12:00AM UTC | completed |
Hospital Course
Ms. Alice Newman is a 45 year old female with a history of Hypertension, Hypothyroidism,
Iron
deficiency and is a recipient of Renal Allograft visits Neighborhood Physicians Practice
on 6/22/2015 at
10am EST. The patient disclosed history of nausea, loose stools and weakness. After
initial examination
the patient was found to have fever, she was administered necessary medications and
after examining
the history of the patient and the lab results, the doctor suspected anemia. So the
patient was referred
to Community Health Hospitals an Inpatient facility to get appropriate treatment and
was asked to
watch for appropriate changes in body temperature, blood pressure and take nebulizer
treatment as
needed.
Assesments
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.
Procedures Notes
Albert Davis - 06/22/2015 12:00AM UTC: Dr Albert Davis examined Ms Alice Newman and found that the pacemaker is operating properly and the breathlessness is due to high fever and anxiety.
History And Physical Notes
No data for section History And Physical Notes
Consultation Notes
No data for section Consultation Notes
Progress Notes
Albert Davis - 06/22/2015 12:00AM UTC: Ms Alice Newman seems to be developing high fever and hence we recommend her to get admitted to a nearby hospital using the provided referral.
Plan of treatment
i. Get an EKG done on 6/23/2015.
ii. Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract
Structure.
iii. Take Clindamycin 300mg three times a day as needed if pain does not subside
iv. Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015
v. Urinanalysis macro (dipstick) panel (24356-8) on 6/29/2015
Health Concerns
a. Chronic Sickness exhibited by patient
b. HealthCare Concerns refer to underlying clinical facts
i. Documented HyperTension problem
ii. Documented HypoThyroidism problem
iii. Watch Weight of patient
Laboratory Notes
Albert Davis - 06/22/2015 12:00AM UTC: Ms Alice Newman was tested for the Urinanalysis macro panel and the results have been found to be normal.
Discharge Instructions
No data for section Discharge Instructions
Discharge Summary
No data for section Discharge Summary
Document maintained by
Neighborhood Physicians Practice
Contact
2472, Rocky place
Beaverton, OR
97006
Tel : +1-(555)-555-1002
Document Information
| Document Identifier | Document Created |
|---|---|
| OID: ee05e1da-df1b-7f7e-166c-e182e1d39f86 | 02/2/2023 |