Visit Summary1234 DGI BlvdRaleighNC27615USJonesIsabellaClinic One90001 1ST AVE STE 100WashingtonDC20000USClinic One90001 1ST AVE STE 100WashingtonDC20000US90001 1ST AVE STE 100WashingtonDC20000USClinic One90001 1ST AVE STE 100WashingtonDC20000US1047 Healthcare DrivePortlandOR97005USPufferPenny1002 Healthcare Dr.PortlandOR97005USSevenHenry
Reason for VisitFever and chills - The fever and chills have been occurring for 2 days. There has been associated cough (green sputum).
Plan of CareInstructionsNo Known Planned InstructionsPlanned Observations
NameDatesDetails
HGB (85018)Reason: Community acquired pneumoniaOn 13-Aug-2012
4:21 PM		Request
CULTURE, SPUTUM (87070)Reason: Community acquired pneumoniaOn 6-Aug-2012
3:46 PM		Request
Planned Encounters

Clinic One

 Seven, Henry 		On 8-Aug-2013
9:00 AM

Clinic One

 Seven, Henry 		On 7-Aug-2013
9:00 AM

Clinic One

 Seven, Henry 		On 6-Aug-2013
9:00 AM
Planned Procedures
NameDatesDetails
DIAGNOSTIC COLONOSCOPY (45378)By: Seven, Henry On 22-Sep-2012Intent
CHEST XRAY, PA & LATERAL (71020)By: Seven, Henry On 13-Aug-2012Intent
1002 Healthcare Dr.PortlandOR97005USSevenHenryClinic One1002 Healthcare Dr.PortlandOR97005USSevenHenryClinic One1002 Healthcare Dr.PortlandOR97005USSevenHenryClinic One
1002 Healthcare Dr.PortlandOR97005USSevenHenry
1002 Healthcare Dr.PortlandOR97005USSevenHenry1002 Healthcare Dr.PortlandOR97005USSevenHenry1002 Healthcare Dr.PortlandOR97005USSevenHenry
InstructionsCommunity acquired ... : Breathing Exercises: breathing exercisesCommunity acquired ... : Pneumococcal Pneumonia Shot *: immunizationCommunity acquired ... : Pneumonia *: coughingCommunity acquired ... : DISCONTINUED - HGB (HEMOGLOBIN) (85018)Community acquired ... : Return to clinic if symptoms worsen
Vital Signs
DateTestResultDetails
6-Aug-2012 3:15 PM
BP Systolic135 mm[Hg] Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
BP Diastolic92 mm[Hg] Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
Weight88 kg
Height177 cm
Body Mass Index Calculated28.09 kg/m2
Body Surface Area Calculated2.05
1002 Healthcare Dr.PortlandOR97005USSevenHenry
Medications
NameDatesDetails
CLARITHROMYCIN, 500MG (Oral Tablet)
 1 (one) Tablet two times daily for 7 days
Quantity: 14 Refills: 0

 Ordered :6-Aug-2012
 Seven, Henry
Started 6-Aug-2012
Active
METOPROLOL TARTRATE, 25MG (Oral Tablet)
 1 (one) Tablet daily for 30 days
Quantity: 30 Refills: 0

 Ordered :6-Aug-2012
 Seven, Henry
Started 6-Aug-2012
Active
PROVENTIL HFA, 108 (90 Base)MCG/ACT (Inhalation Aerosol Solution)
 2 (two) Puff every six hours, as needed for wheezing for 30 days
Quantity: 1 Refills: 0

 Ordered :6-Aug-2012
 Seven, Henry
Started 6-Aug-2012
Active Comments: Medication taken as needed.
ClarithromycinClarithromycinMetoprolol TartrateMetoprolol TartrateAlbuterol SulfateAlbuterol Sulfate
Medications Administered
NameDatesDetails
PROVENTIL HFA, 108 (90 Base)MCG/ACT (Inhalation Aerosol Solution)
 2 (two) Puff
 Ordered :6-Aug-2012
 Seven, Henry
Started 6-Aug-2012 Ended 6-Aug-2012
Administered Comments: Site: Nose and Mouth
Albuterol SulfateAlbuterol Sulfate
Problems
NameDatesDetails
Asthma, moderate persistent
Status: Active
Community acquired pneumonia
 Comments: Patient may continue to experience low grade fever and chills
Status: Active
Hypoxemia
Status: Active
1002 Healthcare Dr.PortlandOR97005USSevenHenry1002 Healthcare Dr.PortlandOR97005USSevenHenry1002 Healthcare Dr.PortlandOR97005USSevenHenry
Allergies and Adverse Reactions
NameDatesDetails
Aspirin *ANALGESICS - NonNarcotic*Onset:2011Status: Active
Codeine Sulfate *ANALGESICS - OPIOID*Onset:2010Status: Active
Penicillin G Benzathine *PENICILLINS*Onset:1-June-2012Status: Active
1002 Healthcare Dr.PortlandOR97005USSevenHenryAspirin *ANALGESICS - NonNarcotic*1002 Healthcare Dr.PortlandOR97005USSevenHenryCodeine Sulfate *ANALGESICS - OPIOID*1002 Healthcare Dr.PortlandOR97005USSevenHenryPenicillin G Benzathine *PENICILLINS*
Results
DateDescriptionValueDetails
Resulted on:
6-Aug-2012 4:06 PM		PNEUMOCOCCAL VACCINE (90732)Normal

3:30 PM		CHEST XRAY, PA & LATERAL (71020)Comments: consistent with pneumonia Normal

18-July-2013 3:21 PM		HCT (85014)
HCT45 %Range: 42.9 - 49.1 = Normal

3:21 PM		HGB (85018)
HGB14.2 g/dLRange: 14.4 - 16.6 = Abnormal

3:21 PM		PLT (85049)
PLT220 10^3/ulNormal

3:21 PM		WBC (85048)
WBC7.6 10^3/ulRange: 4.5 - 11.0 = Normal
Comments: consistent with pneumonia42.9 - 49.114.4 - 16.64.5 - 11.0
Procedures
ProcedureDatesDetails
PNEUMOCOCCAL VACCINE (90732)Completed:6-Aug-2012
CHEST XRAY, PA & LATERAL (71020)Completed:6-Aug-2012
ALBUTEROL, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, UNIT DOSE, 1 MG (J7609)Completed:6-Aug-2012
1002 Healthcare Dr.PortlandOR97005USSevenHenry1002 Healthcare Dr.PortlandOR97005USSevenHenry1002 Healthcare Dr.PortlandOR97005USSevenHenry
Immunization
NameDatesDetails
Influenza (3 years and up)
Administered on:1-Nov-2010
Influenza (3 years and up)
Administered on:10-Sep-2011
Pneumococcal (2 years and up)
Lot #: MK456987		Administered on:6-Aug-2012 Comments: Site: Deltoid (Left)
Td (7 years and up)
Administered on:4-Jan-2007
MK456987Merck and Co., Inc.1002 Healthcare Dr.PortlandOR97005USSevenHenry
Social History
NameDatesDetails
Tobacco use Current every day smoker.
Comments: Current every day smoker. Start: 1992
Smoking StatusCurrent every day smokerCurrent every day smoker. 1002 Healthcare Dr.PortlandOR97005USSevenHenry
Encounters
Office Visit
Encounter Reason: Fever and chills - The fever and chills have been occurring for 2 days. There has been associated cough (green sputum).Encounter Diagnosis: Community acquired pneumonia, Asthma, moderate persistent, HypoxemiaClinic One
On 6-Aug-2012
3:03 PM
Clinic One