Summary of Care

Reason For ReferralPulmonary function tests
schedule in the next week

Functional StatusFunctional Status Health IssuesName Dates Details
No Known Impairments
Onset:30-May-2013 Status: Active5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMDProblemsName Dates Details
Acute pharyngitis (462, J02.9) 
Onset:28-Oct-2011 Status: Active
Essential hypertension (401.9, I10) 
Onset:25-Sep-2012 Status: Active
Pneumonia (486, J18.9) 
Onset:30-May-2013 Status: Active5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMDMedicationsName Dates Details
AZITHROMYCIN, 500MG (Oral Tablet)
 1 (one) Tablet daily for 5 days
 Quantity: 5  Refills: 0
 Ordered :30-May-2013
 Manning, Terry MD  Started 30-May-2013Active Comments: 500 on day one, then 250 for 4 days
METOPROLOL TARTRATE, 50MG (Oral Tablet)
 1 (one) Tablet daily for 30 days
 Quantity: 30  Refills: 0
 Ordered :30-May-2013
 Manning, Terry MD  Started 30-May-2013Active
PROVENTIL HFA, 108 (90 Base)MCG/ACT (Inhalation Aerosol Solution)
 2 (two) Puff four times daily, as needed for 30 days
 Quantity: 1  Refills: 0
 Ordered :30-May-2013
 Manning, Terry MD  Started 30-May-2013Active Comments: Medication taken as needed. 
Azithromycin5555 Waverly WayCaryNC27511USManningTerryAMDAzithromycin5555 Waverly WayCaryNC27511USManningTerryAMDMetoprolol Tartrate5555 Waverly WayCaryNC27511USManningTerryAMDMetoprolol Tartrate5555 Waverly WayCaryNC27511USManningTerryAMDAlbuterol Sulfate5555 Waverly WayCaryNC27511USManningTerryAMDAlbuterol Sulfate5555 Waverly WayCaryNC27511USManningTerryAMDMedications AdministeredName Dates Details
No Known Medications Administered
Allergies and Adverse ReactionsName Dates Details
Aspirin *ANALGESICS - NonNarcotic* Reaction: Hives
Status: Active
Codeine Sulfate *ANALGESICS - OPIOID* Reaction: Anaphylaxis
Status: Active
Penicillin G Benzathine & Proc *PENICILLINS* Reaction: Hives, Swelling, Shortness of breath
Status: Active5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMDAspirin *ANALGESICS - NonNarcotic*5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMDCodeine Sulfate *ANALGESICS - OPIOID*5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMDPenicillin G Benzathine & Proc *PENICILLINS*Past Medical HistoryName Dates Details
Asthma (493.90, J45.909) 
Onset:1-Mar-2013 Status: Active5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMDProceduresProcedure Dates Details
CHEST X-RAY, PA AND LATERAL (71020) Completed:30-May-20135555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMDImmunizationName Dates Details
Influenza (3 years and up)
Administered on:25-Sep-2012 5555 Waverly WayCaryNC27511USManningTerryAMDSocial HistoryName Dates Details
No Known Social History
Status: 
Smoking StatusSmoker. current stants unknownNever smokerVital SignsDate Test Result Details
30-May-2013 17:22
BP Systolic 120 mm[Hg]  Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
BP Diastolic 80 mm[Hg]  Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
Weight 162 lb 
Height 64 in 
Body Mass Index Calculated 27.83 kg/m2 
Body Surface Area Calculated 1.82 
28-May-2013 08:36
BP Systolic 155 mm[Hg]  Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
BP Diastolic 94 mm[Hg]  Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
Weight 155 lb 
Height 64 in 
Body Mass Index Calculated 26.63 kg/m2 
Body Surface Area Calculated 1.78 
1-May-2013 15:07
BP Systolic 114 mm[Hg]  Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
BP Diastolic 76 mm[Hg]  Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
Weight 150 lb 
Height 64 in 
Body Mass Index Calculated 25.77 kg/m2 
Body Surface Area Calculated 1.75 5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMDResultsDate Description Value Details
Resulted on:
30-May-2013 17:48 CHEST X-RAY, PA AND LATERAL (71020) Abdominal Circumference: 45 Abnormal

17:25 Copy of BLOOD COUNT, PLATELET, AUTOMATED (85049) 
Copy of BLOOD COUNT, PLATELET, AUTOMATED 170 Normal

17:25 WBC (85048) 
WBC 5  10X9cells/L Range: 4.5 - 11.0 = Normal

17:25 HGB (HEMOGLOBIN) (85018) 
HGB (HEMOGLOBIN) 15  g/dL Range: 14.4 - 16.6 = Normal

17:25 HCT (HEMATOCRIT) (85014) 
HCT (HEMATOCRIT) 44  % Range: 42.9 - 49.1 = Normal
5555 Waverly WayCaryNC27511USManningTerryAMDAbdominal Circumference: 455555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD4.5 - 11.05555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD14.4 - 16.65555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD42.9 - 49.1Plan of CareInstructionsNo Known InstructionsPlanned ObservationsName Dates Details
Goal: Smoking Cessation; Status: Started; Patient Engagement: -; 
Plan: Instructions: recources and instructions provided during visit; Progress: StartedReason: Essential hypertension On 28-May-2013
10:02 Goal
Goal: Weight Loss; Status: Started; Patient Engagement: -; 
Plan: Instructions: Diet and exercise counseling provided during visit; Progress: StartedReason: Essential hypertension On 28-May-2013
10:04 Goal
Goal: Preventative Health; Status: Started; Patient Engagement: -; 
Plan: Annual pap smear, biennial screening mammogram, and annual clinical breat exam; Progress: StartedReason: Essential hypertension On 28-May-2013
10:05 Goal5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMD5555 Waverly WayCaryNC27511USManningTerryAMDInterventions ProvidedPneumonia  (486 | J18.9)CHEST X-RAY, PA AND LATERAL (71020)Copy of BLOOD COUNT, PLATELET, AUTOMATED (85049)HCT (HEMATOCRIT) (85014)HGB (HEMOGLOBIN) (85018)Started Azithromycin 500MG, 1 (one) Tablet daily, #5, 5 days starting 05/30/2013, No Refill. (500 on day one, then 250 for 4 days)Started Metoprolol Tartrate 50MG, 1 (one) Tablet daily, #30, 30 days starting 05/30/2013, No Refill.Started Proventil HFA 108 (90 Base)MCG/ACT, 2 (two) Puff four times daily, as needed, 1 Cartridge, 30 days starting 05/30/2013, No Refill.WBC (85048)InstructionsNo Known InstructionsEncountersOffice Visit
On 29-May-2013
20:46
Office Visit
Encounter Diagnosis: Essential hypertension On 28-May-2013
08:34
Office Visit
Encounter Diagnosis: Acute pharyngitis On 1-May-2013
15:05

Name	Dates	Details
Acute pharyngitis (462, J02.9)	Onset:28-Oct-2011	Status: Active
Essential hypertension (401.9, I10)	Onset:25-Sep-2012	Status: Active
Pneumonia (486, J18.9)	Onset:30-May-2013	Status: Active

Name	Dates	Details
Aspirin ANALGESICS - NonNarcotic		Reaction: Hives Status: Active
Codeine Sulfate ANALGESICS - OPIOID		Reaction: Anaphylaxis Status: Active
Penicillin G Benzathine & Proc PENICILLINS		Reaction: Hives, Swelling, Shortness of breath Status: Active

Date	Test	Result	Details

30-May-2013 17:22	BP Systolic	120 mm[Hg]	Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
	BP Diastolic	80 mm[Hg]	Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
	Weight	162 lb
	Height	64 in
	Body Mass Index Calculated	27.83 kg/m2
	Body Surface Area Calculated	1.82

28-May-2013 08:36	BP Systolic	155 mm[Hg]	Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
	BP Diastolic	94 mm[Hg]	Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
	Weight	155 lb
	Height	64 in
	Body Mass Index Calculated	26.63 kg/m2
	Body Surface Area Calculated	1.78

1-May-2013 15:07	BP Systolic	114 mm[Hg]	Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
	BP Diastolic	76 mm[Hg]	Comments: Patient Position: Sitting; Cuff Location: Left Arm; Cuff Size: Standard
	Weight	150 lb
	Height	64 in
	Body Mass Index Calculated	25.77 kg/m2
	Body Surface Area Calculated	1.75

Date	Description	Value	Details
Resulted on: 30-May-2013 17:48	CHEST X-RAY, PA AND LATERAL (71020)	Abdominal Circumference: 45	Abnormal

17:25	Copy of BLOOD COUNT, PLATELET, AUTOMATED (85049)
	Copy of BLOOD COUNT, PLATELET, AUTOMATED	170	Normal
17:25	WBC (85048)
	WBC	5 10X9cells/L	Range: 4.5 - 11.0 = Normal
17:25	HGB (HEMOGLOBIN) (85018)
	HGB (HEMOGLOBIN)	15 g/dL	Range: 14.4 - 16.6 = Normal
17:25	HCT (HEMATOCRIT) (85014)
	HCT (HEMATOCRIT)	44 %	Range: 42.9 - 49.1 = Normal

Name	Dates	Details
Goal: Smoking Cessation; Status: Started; Patient Engagement: -; Plan: Instructions: recources and instructions provided during visit; Progress: StartedReason: Essential hypertension	On 28-May-2013 10:02	Goal
Goal: Weight Loss; Status: Started; Patient Engagement: -; Plan: Instructions: Diet and exercise counseling provided during visit; Progress: StartedReason: Essential hypertension	On 28-May-2013 10:04	Goal
Goal: Preventative Health; Status: Started; Patient Engagement: -; Plan: Annual pap smear, biennial screening mammogram, and annual clinical breat exam; Progress: StartedReason: Essential hypertension	On 28-May-2013 10:05	Goal

Office Visit	On 29-May-2013 20:46
Office Visit Encounter Diagnosis: Essential hypertension	On 28-May-2013 08:34
Office Visit Encounter Diagnosis: Acute pharyngitis	On 1-May-2013 15:05