Microsoft word - 080319 dixon, ruby l 88977 his note.doc
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History Note Patient: Ruby L Dixon, a 87 year old, White Female, Divorced, Methodist, residing at Autumn Breeze Health Care room DOS: 3/19/2008 Chart #: 88977 DOB: 6/9/1920 Primary Insurance: Medicare A Primary Policy Number: XXXXXXX Secondary Insurance: ADVANCED DIRECTIVES: Full Code PROGNOSIS: Good CHIEF COMPLAINT: CAD [414.00] Sub endothelial MI, Patient Request: test patient request Family Request: test family request Nursing Request: test nursing request Diagnostic Result Request: test diagnostic Regulatory Visit: test reg Telephone Order: test telephone Consultant/pharmacist Request: test consultant HISTORY OF PRESENT ILLNESS: (Comprehensive – Location, Duration, Timing, Quality, Severity, Context, Associated signs and Symptoms, modifying factors): Past HPI: 87 yo WF recent 3am chest pain, SOB, weakness, episode. ER eval non ST MI with elevated enzymes and chf. Patient also had Bacteremia treated with Zosyn. Hx of C-diff, Divertculosis, was found to have UTI as source of Bacteremia. Now stable Patient is transferred to MHCR for rehabilitation / Physical Therapy and disposition probably home. IMPRESSION/DIAGNOSIS/ASSESSMENT/PLAN/CURRENT MEDS: CAD [414.00] (Improved) Active, 3-New Problem, w/ no addtl work planned; Assessment: S/P Subendothelial MI c no present sgns or symptoms; Plan: Continue present therapy;
Congestive Heart Failure [428.0] (Improved) Under Control, 3-New Problem, w/ no addtl work planned;
Assessment: No signs or symptoms of CHF; Plan: Monitor for changes, worsening;
DVT [453.8] (Improved) Under Control, 3-New Problem, w/ no addtl work planned;
Assessment: Monitor and maintain adequate control of BP's; Plan: Review med records/ daily nursing assessment;
Diabetes Type I [250.01] (Improved) Under Control, 3-New Problem, w/ no addtl work planned;
GERD [530.81] (Improved) Under Control,
Hyperlipidemia Other Unspecific Mixed [272.4] (Improved) Active,
Hypertension Heart Inv [402.90] (Improved) Active, 3-New Problem, w/ no addtl work planned;
Assessment: No s/s of infection; Plan: Continue Antibiotics to completion;
Backache Unspecific [724.5] (Improved) Active,
Diverticulosis Colon [562.10] (Improved) Under Control,
Registered Copyright 2007 www.XLEMR.com , Dr. Joseph T. Hannan Page 1 of 2
Page 2 of 2 History Note
Trigeminal Neuralgia [350.1] (Improved) Active,
Overall Risk Level: 4-One or more chronic illness(es) with severe exacerbation or progression Diet: No special diet requirement. Ambulation Independent: Geri/chair ADLS: Eating: Independent Toileting: Independent Dressing: Independent Hygiene: Independent FAMILY AND SOCIAL HISTORY: Social History: No glasses, smoking, alcohol use, substance abuse, not a DFAC client. Former Occupation: Family History: CAD [414.00] Chronic Air Obstruction [496] Fatigue [780.79] Insomnia Nos [780.52] Nephrotic Syn In Oth Dis [581.81] PAST MEDICAL HISTORY Allergies: NONE Past Medical/Past Surgical History: REVIEW OF SYSTEMS: (Through Patient/Staff/Doctor) – Total Systems Reviewed(6), Total Bullets (16) (3) Constitutional/Systemic: well-groomed, fever, insomnia, no other clinically pertinent findings. (4) Skin: good turgor, good color, normal hair distribution, clear skin, no other clinically pertinent findings. (4) Pulmonary/Chest: no productive spittle, no orthopnea, no palpitations, no SOB, no other clinically pertinent findings. (3) Neurologic: Oriented x4, alert, lethargic, anxiety, no other clinically pertinent findings. PHYSICAL EXAMINATION: Total Systems Reviewed: (5) Total Bullets: (15) VITALS - Temp: 101 P: RR: BP: Wght: Pain: 0 - Denied (1) Systemic: pleasantly confused, no other clinically pertinent findings. (2) Skin: good turgor, good skin color, no other clinically pertinent findings. (2) ENT: dry mouth, neck: pain, no other clinically pertinent findings. (2) GU: female genitalia intact,lesion, no other clinically pertinent findings. (3) Extremities: full range movement - lower, Left foot intact, From x2, no other clinically pertinent findings. (5) Vascular: Pulse status: carotid (4-Normal), radial present (4-Normal), femoral (4-Normal), dorsalis pedis (4-Normal), posterior tibial (4-Normal), no other clinically pertinent findings. MEDICAL DECISION MAKING: Problem Points (Max 3): Diagnostic Procedures Data Points (Max 4): Risk Management (Max 4): Signature: Dr. Joseph T. Hannan Nurse: Nursing Facility: Autumn Breeze Health Care Nursing Facility Code: 99308 Physician License Number: 025759 Guarantor Information: Lloyd Dixon 1590 Longwood Dr, Marietta, GA.
Registered Copyright 2007 www.XLEMR.com, Dr. Joseph T. Hannan Page 2 of 2
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