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James, Patricia |
02011926 |
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02/01/1926 |
76
& 6/12 y/o |
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fam.
members: Tanya? |
Occupation:: |
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941-0000 |
000-0000 |
858-0000 |
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Hospital
MR #00000 |
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:Hill / HealthNetSeniorPlus |
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Clinic
MR # |
:00080H |
: James, Patricia E |
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:n/a |
:408-62-0000 |
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patient address street
number: |
2000
Hilldale Dr |
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Patient address city state
zip: |
Sacramento,
CA 95760 |
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insurance name: |
Some
Name |
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insurance billing street
address: |
0000
Some Street, Apt 00 |
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insurance billing city,
state, zip: |
Some
City, Some State 00000-0000 |
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Patient’s Email address: |
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Patient picture: |
--- |
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Patient’s Pharmacy email
address: |
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main page: http://www.CoreMedicalConcepts.com
There are samples multiple medicine rx, lab orders, PT
& XR orders at bottom of this file.
This file represents a complex patient.
James, Patricia dob 02/01/1926
Please place this sheet in its proper location.
Remote office
visit record:
9/12/97
chest pain
12/16/97 modest insomnia
4/1997
Crohn’s
12/16/97
modest insomnia; modest depression; urinary incontinence [no fistula, just loss
of angle per urology]
1/19/98 modest insomnia;
Crohn’s
2/20/98
generics request, Crohn’s, HRT, seborrheic keratoses
6/10/98 dependent edema
9/4/98
BSE instructed; breast exam & mammogram wnl
11/4/98
patellar contusion and bursitis
02/01/99
interscapular myalgia, bronchitis
02/26/99
dependent edema
03/19/99
flare of Crohn’s +/- PUD or diverticulitis [wnl CBC sgpt alk phos]
03/23/99
Ibid., cleared
05/04/99
Crohn’s RLQ vs diverticular dz; suspect foreign body from remote abdominal
surgery
09/28/99
bronchitis
10/05/99
PA, hip neuralgia
11/06/99
flu shot & B12 injections
12/06/99
B12 injection, PA
12/21/99
hip DJD vs myalgia
01/05/00
hospitalized small bowel obstruction +/- inflammatory bowel dz, adhesions,
bowel resection Dr O'Malley
02/22/00
seizure disorder
03/09/00
acute sinusitis
03/16/00
viral syndrome? chills
05/09/00
jury duty excuse
08/01/00
dependent edema, MVA whiplash
08/04/00
silent UTI, hypokalemia, hyperglycemia
03/14/01
Crohn's, Pernicious Anemia
see progress notes for details after the above dates. .
Ten Second Medical
RecordTM http://CoreMedicalConcepts.com
John Smith, MD .
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automatic
old labs overflow: |
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Problem Progress List |
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Visits prior to 12/10/2001
deleted for purposed of this sample.
James, Patricia dob 02/01/1926 75 & 11/12 y/o 12/10/01
941-0000 ---
Symptoms: 2 days of Right neck pain, then for one day, spinning room sensation w/ dysequilibrium triggered by neck ROM & decays if holds still for a minute or two w/o frank nasal congestion sore throat nor cough
Exam: NAD nontoxic no sinus percussion tenderness TM's wnl; tender R posterolateral neck muscles w/ decreased ROM same
Assessment: labyrinthitis, neck myalgia
Rx: meclizine 25
mg qid prn #100; discussed syndrome; call if not better; soma 350 mg qid prn
#40; names given for asking about remicade or enterocort from GI consultant;
vit B12 & flu shots given
James, Patricia dob 02/01/1926 76 & 0/12 y/o 1/2/02
941-0000 --- Hospital MR #00000 ooo@hospital1.com
problem #1:
S: needs extension of refills on Pentasa; has qs one month for now at regular dosing of 4 cap qid; didn’t get along well with GI so would like to go elsewhere; list of contracted doctors given her; Pentasa not covered through her insurance? We’ll seek authorization
O: gi: nontender w/o HSKM; CVA nontender
A : Crohn’s
P: consider the newer Crohn’s meds but will refill the Pentasa indefinitely.
John Smith, MD 1/2/02 .
James, Patricia dob 02/01/1926 76 & 3/12 y/o 4/9/02
941-0000 ---
Patient to sign here for receipt of this private
information.____________________________ 4/9/02
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Note:
this table usually adds some information at each visit http: //coremedicalconcepts.com PMH: gyn hx infra, appy ~ 15
y/o; Crohn's; urinary incontinence
but no fistula, just loss of angle per urology; seizure disorder, DJD neck,
HH, COPD, recurrent UTI, monilial angular stomatitis, partial small bowel obstruction resection 1970, 1988; B12
injection need; no tobacco x ‘85; TIA ~’75, stroke? per Dr Goldstein hx |
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FH: no breast ca |
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Problem Progress List |
03/14/01 |
3/00 |
4/1997 |
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Cholesterol -
HDL |
195-106 |
195-106 |
226-118 |
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LDL -- trigly |
69-100 |
69-100 |
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‘ “ weight ® |
106 |
90# |
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Ongoing Meds |
Past meds used & notes
about them below: |
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Dilantin
100 mg tid |
x
‘85 for seizure |
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Estropipate
0.625 qd |
(=ogen=orthoest);
previously on premarin 2/98; TAH BSO
‘70, bladder suspension, wnl mammogram 9’98 |
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Hcthz
25 mg q AM |
x
02/00; previously, hcthz 25 mg q AM or dyazide x ‘95 |
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K+
8 meq qd |
X
8/4/00 |
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Stopped |
x 02/00;
previously, lorazepam 0.5 mg 1-2 tid prn x ‘96; # 60 mr2 03/08/99 |
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Prednisone
5 mg qd |
x
1970 |
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Pentasa
250 mg 4 qid |
x
1/00; previously, azulfidine 500 mg 1-2 qid x 2/98; stopped 2/98; hx asacol 400
mg 2 tid ‘96; occl prednisone x 10 yrs; vit B12 injections 09/08/99 |
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Quinine
SO4 325 mg hs prn |
x
before ‘94; B12 q several months |
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Monthly
B12 injection |
stopped
lomotil 1-2 qid if needed x years; #240 mr6
03/29/99 |
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Darvocet
N 100 1 q 4-6 hr prn pain max #30/mo |
zantac
150 mg hs x ‘93; bentyl prn; occl lomotil; B12 1000 mg IM 06/18/99 |
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vicodin
5 mg q 4-6 hr prn pain max #30/mo |
for
neck pain, see MFH ER visit 05'01 |
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Selected test results: cardiac w/u ETT + 8’95,
echo heart Normal 7’95; gi Dr. Schneiderman 4/1/98; colon wnl except
diverticulosis 5/12/98; wnl EKG and CXR ‘97; CBC sgot alk phos lipase wnl but
UA and C&S + 03/99; urine C&S neg 03/29/99; CXR probable old histoplasmosis
06/99; R hip post-op pelvic changes noted, w/ diffuse osteopenia w/o advanced arthropathy 12/99; CBC ESR K+ giardia Ag
stool O&P C- difficile wnl 2'00;
neck XR trace anterolisthesis C4 on 5, minimal DDD neck 8/00; CBC CMP UA lipids ESR SPE & TSH wnl
except ¯ K+ 3.3, FBS 159 [Hgb A1C 5.6], & UTI sensitive to sulfa 8/00; wnl CXR neck
XR & EKG MFH ER 05'01; XR L5-S1 DDD 10'01 |
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ADR: penicillin rash, macrobid & motrin
gastritis Immunizations: pneumovax & Td 5’95; flu 11/6/99 &
10/29/01 |
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Office visit record: ... ct’d 10/1/01
chronic LBP x '97 fall, psoas myalgia?, seborrheic keratosis L preauricular
region, pointed L malar red papule 10/29/01
seborrheic keratosis, facial papule, flu & B12 shot |
12/10/01
labyrinthitis, neck myalgia 1/2/02 Crohn’s |
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John Smith, MD 4/9/02
multiple medicine rx written 4/9/02
John Smith, MD
Family and General Medicine
1600 Creekside Dr., Suite 3300
Folsom, CA 95630
voice (916) 984-0000
fax (916)
983-0000
This is a prescription for
James, Patricia dob 02/01/1926 76 & 3/12 y/o 4/9/02
941-0000 ---
Ongoing Meds
Dilantin 100 mg tid
Estropipate 0.625 qd
Hcthz 25 mg q AM
K+ 8 meq qd
Prednisone 5 mg qd
Pentasa 250 mg 4 qid
Quinine SO4 325 mg hs prn
Darvocet N 100 1 q 4-6 hr prn pain max #30/mo
vicodin 5 mg q 4-6 hr prn pain max #30/mo
QS 6 months, please. All of them may not be wanted at the present time.
John Smith, MD
C34000 AC 9030000
John Smith, MD
Family and General Medicine
1600 Creekside Dr., Suite 3300
Folsom, CA 95630
voice (916) 984-0000
fax (916) 983-0000
Radiological Associates
1561 Creekside
Dr.,(immediate left after entering bldg)
Folsom, CA 95630
(916) 984-0739
This is a request for x-ray service for
James, Patricia dob 02/01/1926 76 & 3/12 y/o 4/9/02
000-0000 000-000
screening mammogram
Thank you,
Electronic signature John Smith, MD
John Smith, MD
John Smith, MD
Family and General Medicine
1600 Creekside Dr., Suite 3300
Folsom, CA 95630
voice (916) 984-0000
fax (916) 983-0000
Unilab
1600 Creekside Dr., 1st floor
Folsom, CA 95630
(916) 984-8032
Mon-Fri 7 AM-5:30 PMSat 8 AM-1 PM
This is a lab request for
James, Patricia dob 02/01/1926 76 & 3/12 y/o 4/9/02
941-0000 ---
fasting: 10 hrs, water and meds only for 10 hrs prior to lab test, appointment not needed
CBC ESR comp metabolic panel ("CMP"), TSH, UA, lipids
ICD # 784.0
Thank you,
Electronic signature John Smith, MD
John Smith, MD
John Smith, MD
Family and General Medicine
1600 Creekside Dr., Suite 3300
Folsom, CA 95630
voice (916) 984-0000
fax (916) 983-0000
HealthSouth Physical Therapy
1611 Creekside
Dr., Suite 100
(across the
stree from Mercy Folsom Hospital)
Folsom, CA 95630
(916) 984-7909, fax (916) 984-7919
This is a request for Physical Therapy
James, Patricia dob 02/01/1926 76 & 3/12 y/o 4/9/02
941-0000 ---
PT please for R shoulder myalgia x 6 weeks
Thank you,
Electronic signature John Smith, MD
John Smith, MD