John Davis, MD

Family and General Medicine

1600 Creekside Dr., Suite 3300

Folsom, CA 95630

voice (916) 983-7200

fax (916) 983-8591

 

Dr.

fax number:

This is a sample of a release

of medical records. It only requires

filling in the doctors name to whom it is

being sent. It takes perhaps 10 seconds.

It can be faxed directly from the computer

and saves signficant expense and

yet is a good summary.

 

re: Adams, John dob 10/01/1923 79 & 4/12 y/o 2-26-03

000-0000 ---

 

subject: Medical Record

 

Dear Sir or Madam,

 

John Adams's medical record summary follows. If further specific information is desired, please let us know so that we can selectively copy it and send it to you.

 

Sincerely,

 

 

 

John Davis, MD


 

_______________next page________________________________________

Adams, John dob 10/01/1923 79 & 4/12 y/o 2-26-03

000-0000 ---

 

Patient Medical Record Summary

prepared for Dr.

 

Note: this table usually adds some information at each visit http: //coremedicalconcepts.com

PMH: long tobacco habit, hypoxemia, PVD w/ bypass, HBP, asthma, RLL pneumonia 1995, chol/HDL 215-61 7/96; O2 sat on RA at rest 82 and 76 w/ accurate pulse pick up, w/o gross dyspnea; left carotid? Surgery 70s w/ subsequent chronic left frontalis muscle non-function and left angle of mouth weakness; visual field loss x 2/98; COPD; aspiration pneumonia 398, prior chronic severe hypoxemia: sat 76-82% on RA 1/98 w/o gross dyspnea; but 96% O2 sat on RA since off tobacco x 1/98 10/14/98

FH: f cancer ? type, m HBP

Problem Progress List

02/16/01

02/13/01

02/07/01

12/14/00

04/18/00

7/6/98

 

Cholesterol - HDL

 

 

 

191-55

207-79

150--

 

LDL -- trigly

 

 

 

124-88

119-45

 

 

weight and/or height

 

135

 

 

 

124

 

BUN-creatinine

K+

47-2.4

wnl

59-2.7

6.5

76-3.4

6.3

 

 

1.9-54

 

RBS or FBS

560

266

283

 

 

 

 

 

Ongoing Meds

Past meds used & notes about them below:

Lisinopril stopped

x ~ 02/09/01; previously, 10 mg 4 qd x before 1298

glucotrol 5 mg 1/2 qd

x 02/20/01; previously, qd started x 2/14/01

Atrovent neb qid prn

resumed 6/5/98

Atrovent 500 m vial nebulized qid prn

 

Lasix stopped

x 02/14/01; previously, 40 mg qd x 7/6/98; before that, bid x 6/29/98

K+ stopped

x ~ 02/09/01; previously, 8 meq qd w/ H2O, 10 meq x 01/12/99 ok qs 6 mos; previously, 10 meq qd w/ h20 x 6/98, D to base formulary

Albuterol nebulizer 0.5 cc 3 cc NS qid prn

1998 abx prophylaxis cefzil 500 mg qd x 6/22/9810/26/00

Guaituss AC 1-2 t q 4-6 hr prn 8 oz mr2

X 10/26/00

azmacort 2 p qid prn

 

humabid 600 bid

 

Quinine sulfate 325 mg q hs prn

qs 6 months 9/28/00 X 10/26/00; before that x 9/2/98 before that, lower dose x 8/11/98 R quadriceps cramps

Biaxin 250 mg bid pc

X 11/00

Pravachol 20 mg q hs

# 90 x 11/29/00

selected test results: Dr. Pecha; CXR increase in infiltrate and slight increase in CM 5/29/98; EKG LAE, Incomplete RBBB, RVH, AS MI 7/8/98; PSA 0.5 and urine C&S wnl 10/16/98; CXR severe chronic interstitial lung dz scarring bullae and pul HBP 05/99; urine C&S neg 11/99; 02sat RA w/ walking 85%; resting w/ O2 96% 2/3/2000; XR ileus & possible gall stones 3 way abd with US gall stones w/o appendicitis, pnacreas obscured wnl CT abd but for severe lung bullae inferiorly 11/00; renal failure w/ wbc & hgb both 10.7, RBS 59 2/7/01

ADR: ativan 7/6/98; benadryl muscle twitches; cough syrup insomnia 399; Immunizations: pnvax 94; flu 11/12/99 , flu ~11/7//00

Office visit record: ... ctd ... ctd

02/13/01 renal failure

02/14/01 new DM, dehyration, renal failure, chronic pneumonia, COPD, K+

02/16/01 new onset DM w/ dehydration & renal failure, lisinopril & lasix stopped, pneumonia, hyperkalemia, COPD

02/20/01 hypoglycemia, chronic pneumonia & chronic DOE

 

John Smith, MD 2-26-03


Remote office visit record:

3/6/98 CVA, left lateral visual field loss & paresis of left lateral gaze paresis, [no MRI nor CT] dysphagia, LL pneumonia, probable aspiration etiology x 2/98; peg tube x ~2/25/98

3/31/98 seasonal allergic rhinitis; vision loss post stroke

5/6/98 HBP; CVA sequelae; aspiration pneumonia.

4/15/98 aspiration pneumonia; COPD hx

5/29/98 chronic bronchitis; COPD O2 sat 86% on 2-3 L

6/8/98 recurrent pneumonia; COPD +/- aspiration; dry mouth; 81% sat on 3 L 6/15/98 pneumonia; hx aspiration and stroke; [microhematuria] hospital pneumonia pyelonephritis 6/24/98

6/29/98 marked edema both legs

7/6/98 edema; COPD

7/15/98 new onset CHF resolved, COPD; oximetry 99% on RA; ABG pCO2 39.4, p02 64, O2 calc 93%

8/11/98 COPD, leg cramps, K+ frustrations w/ pharmacy

9/14/98 COPD, stroke vision loss, PVD

10/14/98 prostatic enlargement [PSA wnl]; prostatitis element; COPD; [urine C&S wnl]

11/13/98 COPD

12/28/98 COPD, bronchitis

02/03/99 bradycardia

02/17/99 uri post cataract repair yesterday

03/01/99 bronchitis, bradycardia (atenolol dcd)

03/23/99 bronchitis

04/05/99 GERD

05/17/99 bronchitis

05/24/99 chest wall pain, myalgia vs cracked rib

09/21/99 BPH, cataracts

09/23/99 authorization to treat to MFH ER

10/04/99 COPD, BPH

10/26/99 bronchitis, COPD, pneumonia sequelae

11/05/99 suspect pyelonephritis, responded to cipro

11/12/99 COPD, flu shot

12/21/99 ophth referral, cataracts

12/28/99 multi-medicine multi-month rx

01/7/00 hospitalized MFH, COPD, viral syndrome, pneumonia

01/18/00 resolved pneumonia

02/08/00 pneumonia f/u, COPD

04/12/00 pneumonia, hypoxemia, ST-T wave Ds

04/14/00 pneumonia

05/03/00 bronchitis

10/26/00 leg cramps, bronchitis

11/13/00 recurrent bronchitis

11/16/00 MFH admit: RUL & RLL pneumonia w/ new L frontal stroke

11/29/00 strokeincreased visual loss, nocturnal leg cramps, pneumonia better

02/05/01 suspect pneumonia

John Smith, MD 2/14/01

 

Problem Progress List

04/18/00

7/6/98

4/15/98

3/31/98

3/6/98

7/96

12/95

Cholesterol - HDL

207-79

150--

 

 

 

215-61

210-47

LDL -- trigly

119-45

 

 

 

 

 

 

Dysphagia p CVA 298

 

 

 

B80%

 

 

 

Creatinine-BUN

 

1.9-54

 

 

 

 

1.1-23

HBP

 

 

 

 

 

 

 

weight 127# 7/15/98

 

124

144

131#

 

139