Patient History & Physical

PatientJohn Doe, Sr
Date of birthJune 18, 1990 SexMale
RaceAsian IndianEthnicityNot Hispanic or Latino
Contact info Primary Home:
234 Minor Street
123 Main Street & Road
Philadelphia, PA 19136, USA
Tel: (323)555-1111
Patient IDs1001 2.16.840.1.113883.19.5.99999.2
123-45-6789 2.16.840.1.113883.4.1
Document Id201806201202.: 2.16.840.1.113883.19.5.99999.1
Document CreatedJune 20, 2018, 12:02:50 -0900
Performer Get Well Clinic
AuthorAbbey Duck, MD
Contact info234 Main Street
Los Angeles, CA 90024, USA
Tel: (323)238-4727
SignedPeter Peterson, JD
Contact info92 Water Street
Los Angeles, CA 90077, USA
Tel: (818)267-8243
Information recipientJohn Doe, Sr
Legal authenticatorAbbey Duck, MD signed at June 20, 2018, 12:02:50 -0900
Contact info234 Main Street
Los Angeles, CA 90024, USA
Tel: (323)238-4727
Document maintained by Saint Joseph
Contact info99 Water Street
Culver City, CA 90230, USA
Tel: (310)555-2222

Table of Contents


Allergies, Adverse Reactions, Alerts

Type Date Substance Reaction Code Status
Allergy 09/28/2016 PEANUT head & arms ache 36987155001 (NDC) Active
Allergy 11/29/2016 ASPIRIN 1191 (RXNORM) Active
Adverse Reaction Approximate Onset Date: 2013 Headaches Current
Adverse Reaction 05/14/2012 Stress headaches, gastritis 73595000 (SNOMED) Current
Alert 12/21/2012 Headaches pain 2411 (NDC) Current
Alert 03/29/2014 Stress headaches, nausea Historical

Functional Status

Type Date Description Code Status
Ambulatory Status Onset Date: 03/25/2014 New York Heart Association Classification - Class IV 422293003 (SNOMED) Resolved
Assessment for Heart Failure Onset Date: 12/30/2016, 07:51 AM Fy sup(a) Ag RBC Ql 1027-2 (LOINC) Active
Functional Status Result Onset Date: 02/10/2017 % area reduction 397441001 (SNOMED) Active
Functional Status Result Onset Date: 02/10/2017 Norpropoxyph SerPl-mCnc 10341-6 (LOINC) Active

Social History

Social History Description Effective Date Code
Alcohol Alcohol consumption 03/01/2012 to 01/01/2015 123456789 (SNOMED)
Smoking Current every day smoker 10/30/2016 449868002 (SNOMED)
Smoking Smokeless Tobacco 06/10/2018 95269005 (SNOMED)
Marital Status Never Married
Religion Christian
Ethnicity Not Hispanic or Latino 2186-5 (SNOMED)
Primary Language English
Employment Full-time
Nationality Declines to answer
Citizenship ARMENIA
Birthplace Los Angeles
Time of Birth 04:23 AM
Birth Order 3
Highest Degree Doctorate
Indian Health Services (IHS) Tribe California Tribe
Race White, Native Hawaiian / Other Pacific Islander, Asian Indian
Usual Industry Legal Services 7270 (Census Industry Code)
Usual Occupation Civil Engineer 172051 (Census Occupation Code)

Vital Signs

May 13,2016 Jul 18,2016 Jul 20,2016
Temp 98.6 F 98.6 F 98.6 F
Weight 134 lb 122 lb 135 lb
Height 63 in 63 in 63 in
Blood Pressure 110/70 mmHg (Right Arm) 130/90 mmHg (Right Arm) 115/80 mmHg (Right Arm)
Pulse 23 20
BMI 23.73 21.61 23.91
Nov 30,2016 Feb 06,2017 Feb 10,2017
Temp 98.6 F 98.6 F
Weight 250 lb
Height 63 in 63 in 63 in
Blood Pressure 189/100 mmHg (Left Arm) 110/70 mmHg (Right Arm) 110/90 mmHg (Left Arm)
Pulse 34
BMI 44.28

Problems

Type Date Description Code Status
Diagnosis Onset: 06/04/2018 Cyclical vomiting, not intractable G43.A0 (ICD-10) Active
Problem Onset: 09/25/2016
Resolved: 06/10/2018
Alzheimer's disease 331.0 (ICD-10) Inactive
Problem 06/05/2018 Low back pain Active

Medications

Date Medication Dosage SIG Code Status
01/24/2017 LASIX [20 mg] TABLET As needed 00039006710 (NDC) Inactive
01/24/2017 ACETAMINOPHEN [325 mg] TABLET Four times a day 00615059131 (NDC) Active
06/16/2018 ASPIRIN [325 ng] TABLET by mouth once daily 49483001100 (NDC) Ordered

Progress Note

Date Progress Note
09/23/2016 This CDoc presents: John Doe 123 Main Street & Road Philadelphia, PA 19136 (323) 555-1111 Patient is a 18 year old Male with a history of + 8/4/2016 M8500/3 Infiltrating duct carcinoma + 8/18/2016 G43.A0 Cyclical vomiting, not intractable + 9/19/2016 176 Kaposi's sarcoma + 9/20/2016 005.1 Botulism The patient is under the care of: Abbey S. Duck 20140 Scholar Drive, Suite 316 Martinsburg, WV 25401 (301) 555-1212

Chief Complaint

Date Chief Complaint
09/23/2016 This CDoc presents: John Doe 123 Main Street & Road Philadelphia, PA 19136 (323) 555-1111 Patient is a 18 year old Male with a history of + 8/4/2016 M8500/3 Infiltrating duct carcinoma + 8/18/2016 G43.A0 Cyclical vomiting, not intractable + 9/19/2016 176 Kaposi's sarcoma + 9/20/2016 005.1 Botulism The patient is under the care of: Abbey S. Duck 20140 Scholar Drive, Suite 316 Martinsburg, WV 25401 (301) 555-1212
06/28/2017 This CDoc presents: John Doe 123 Main Street & Road Philadelphia, PA 19136 (323) 555-1111 Patient is a 18 year old Male with a history of + 8/4/2016 M8500/3 Infiltrating duct carcinoma + 8/18/2016 G43.A0 Cyclical vomiting, not intractable + 9/19/2016 176 Kaposi's sarcoma + 9/20/2016 005.1 Botulism The patient is under the care of: Abbey S. Duck 20140 Scholar Drive, Suite 316 Martinsburg, WV 25401 (301) 555-1212

Past Medical History

Past Medical History
01/04/2015 12:33 am [ASD] Patient reported Medical History: Arteriosclerosis, Blood disorders, Hypertension, Kidney disease Illnesses and Conditions: Allergic disorders [2009] Personal Habits: None reported Exercise Patterns: Exercise - never Sleep Patterns: Sleep: more than 12 hours / day Allergic Reaction to Medications: None reported Allergic Reaction to Foods: Beets; Nuts Allergic Reaction to Environment: Fiber Allergic Reaction to Bites and Stings: Honey bees Other Allergic Reactions: tide detergent Patient Annotations: nothing here Patient reported Medical History: Alcoholism, Allergic disorders

Assessment and Plan

Date Assessment and Plan
08/02/2016 dg dfgdfgdg
06/28/2017 Plan of Treatment: After completing an initial examination and evaluation of Mr. Doe, I have selected a plan of treatment that should return this patient to a pre-injury status and minimize the possibility of future residuals. The patient will be seen 2 times per week for a period of 6 weeks. The patient's treatment program will include a Gonstead adjustive technique at C3 with a normal degree of movement. Therapy will include traction on the lumbar region to reduce pain.

General Status

Date General Status
08/02/2016 sdfsdf sdf sdf s
06/28/2017 Prognosis is good.

Results

Date Description Result Units Abnormal Normal Range Code
11/15/2016 Rh [Type] in Blood 23 mg X 1 to 2 10331-7 (LOINC)
09/22/2015 PSA 8 mg 1234567 (LOINC)
06/08/2018 PSA 32 mg 234234 (SNOMED)

Immunizations

Date Immunizations Route Site Code
11/05/1992 DTaP-Hib-IPV 120 (CVX)
05/28/2018 HPV, bivalent Intradermal Left Arm 118 (CVX)
11/26/1994 Pneumo (PPV23) 33 (CVX)
05/17/1992 Tdap Intramuscular Left Arm 115 (CVX)
11/26/2016 Varicella 21 (CVX)

Advance Directive

Type Date Description Status
Resuscitation Status 01/23/2015 Supported by Healthcase Will Do not resuscitate
Intubation Status 11/07/2011 Verified with Family Only notes for & intubation status
IV Fluid and Support Status 11/07/2011 Supported by Healthcase Will notes for iv fluid & support status
CPR Status 11/07/2011 Verified with Family Only notes for cpr & status
Antibiotic Status 11/07/2011 Current and Verified notes for & anitbiotic status
Life Support Status 11/07/2011 Verified with Family Only notes for life & support status
Tube Feeding Status 11/07/2011 Current and Verified notes for tube & feeding status
Other Status 11/07/2011 Current and Verified notes for & other status

Medical Equipment

Type Date Device Quantity Serial# Instructions Status
Implantable Device 11/26/2013 Breast Implant 1 243211414 asd asd asd Completed
Device 11/26/2013 BONEFAST 1 On Hold
Implantable Device 08/02/2016 Breast Implant 1 Active

Medical Procedures

Date Description Body Site Code Status
02/13/2012 Standard chest X-ray 168731009 (SNOMED) ordered
03/21/2014 Obesity Head and neck arterial embolus 414916001 (SNOMED) performed
12/30/2014 Congestive heart failure 42343007 (SNOMED)
01/24/2015 Colonic polypectomy Imaging of abdomen (Snomed CT 441987005) 274025005 (SNOMED)
09/23/2016 Collection of blood specimen for laboratory 82078001 (SNOMED)
11/27/2016 % activity 258745004 (SNOMED)

Hospital Admission

Type Date Code
ED Admission date
ED Discharge date
05/21/2018
05/27/2018
32485007 (SNOMED)
INP Admission date
INP Discharge date
06/03/2018
06/09/2018
394656005 (SNOMED)

Care Plans

Date Plan Instructions Type Code
04/29/2015 Chest X-Ray Scheduled Imaging 198942000 (SNOMED)
05/01/2015 Colonoscopy Scheduled Procedure 45378 (SNOMED)
05/01/2015 HGB asdasdasd Scheduled Lab 30313-1 (NDC)
09/22/2016 , , - Donec fringilla tempus lacus. Aenean at neque non est fringilla volutpat. V Donec fringilla tempus lacus. Aenean at neque non est fringilla volutpat. Vivamus libero velit, rutrum quis, aliquet et, porta nec, dui. Maecenas venenatis, ipsum a laoreet ultrices, purus tellus iaculis eros, a ultrices tortor ligula et wisi. Morbi tincidunt odio et erat. Phasellus quis mi accumsan augue vestibulum euismod. Donec lorem. Sed sagittis erat at est. In pede massa, suscipit eu, rutrum vel, fermentum ut, dolor. Curabitur vel est congue nunc convallis lobortis. Referral to other provider
Thu 07/21/2016 at 11:00 am Abbey Duck MD, 20140 Scholar Drive, Suite 316, Martinsburg WV Future appointment

Care Plan Providers

Type Name Address Phone
Attending Provider Abbey S. Duck MD 20140 Scholar Drive, Suite 316, Martinsburg, WV 25401 (304) 555-1212
Referring Provider Nicholas Radon , ,
Last Ordering Provider Ben Kildare MD 234 Seaway Street, Miami, FL 33111 (800) 555-1199
Last Supervising Provider Adams Anderson PhD 222 Manin Street, Orlando, FL 32821 (313) 334-3599
Last Rendering Provider Abbey S. Duck MD 20140 Scholar Drive, Suite 316, Martinsburg, WV 25401 (304) 555-1212
Primary Care Provider Mickey M. Mouse MD 34 Disney Lane, Liverpool, NY 13090 (315) 555-3434
Primary Hospital - Preferred Adams Academy Hospital 335 Main Street, Los Angeles, CA 90024 (310) 283-4729
Second Hospital City Hospital 99 City Street, Martinsburg, WV 25401 (304) 273-4826

Instructions

Date Instructions Type Code
04/30/2015 test test test Clinical Instructions 311401005 (SNOMED)

Hospital Discharge Instructions

Date Instructions
09/22/2016 Abbey S. Duck, MD 20140 Scholar Drive, Suite 316 Los Angeles, CA 90024 (310) 555-0038 FAX (310) 555-8490 www.legacypress.com NAME: John Doe DOB: 06/18/1998 DATE: September 22, 2016 DIAGNOSIS: * 8/4/2016 M8500/3 Infiltrating duct carcinoma * 8/18/2016 G43.A0 Cyclical vomiting, not intractable * 9/17/2016 * 9/17/2016 * 9/19/2016 176 Kaposi's sarcoma * 9/20/2016 005.1 Botulism ALLERGIES: * CODEINE * SULFUR * ASPIRIN MEDICATIONS: * ALLOPURINOL [300 mg] TABLET, As needed * CLARITHROMYCIN [250 mg] TABLET, 1 tablet per day by mouth * LISINOPRIL, once daily We appreciate your choosing us for your urgent care needs. These are the instructions your Physician/PA has given you. Please read them carefully. We are here to serve you. The examination and treatment you have received in this clinic has been done on an urgent care basis. In most cases it is important that you be rechecked again. If you had any x-rays or special test they will be reviewed within 24-48 hours. You will be notified if a change in your treatment program is indicated. Please follow the instructions provided below.