MU2 Clinical Visit Summary 123 test Carrollton GA 30117 US Data 5 Export5 Get Well Clinic 1004 Healthcare Dr. practice Portland OR 97005 United States 1004 Healthcare Dr. practice Portland OR 97005 United States Henry Seven Get Well Clinic 1004 Healthcare Dr. practice Portland OR 97005 United States Get Well Clinic 1004 Healthcare Dr. practice Portland OR 97005 United States Henry Seven, M.D.
Reason for Visit Not available.
Allergies and Adverse Reactions
Name Reaction Notes
penicillin G benzathine rash
aspirin hives
codeine sulfate nasea
rash hives nasea
Vital Signs
Date Time BP-Sys(mm[Hg] BP-Dia(mm[Hg]) HR(bpm) RR(rpm) Temp WT HT BMI BSA BMI Percentile O2 Sat(%)
1/21/2013 9:28:00 AM 130 mmHg 84 mmHg 162 lbs 70 in 23.2443 kg/m² 1.905 m²
Blood Pressure - Diastolic Blood Pressure - Systolic Body Mass Index Height Weight
Medications Administered Not available.
Medications
Expired
Name Start Date Expiration Date SIG Comments
azithromycin Oral Tablet 250 mg 1/21/2013 1/26/2013 take 2 tablets (500 mg) by oral route once daily for 1 day then 1 tablet (250 mg) by oral route once daily for 4 days
albuterol sulfate Inhalation HFA Aerosol Inhaler 90 mcg/actuation 1/21/2013 2/20/2013 inhale 1 puff by inhalation route every 6 hours for 30 days for wheezing
take 2 tablets (500 mg) by oral route once daily for 1 day then 1 tablet (250 mg) by oral route once daily for 4 days azithromycin Expired - inhale 1 puff by inhalation route every 6 hours for 30 days for wheezing albuterol sulfate Expired -
History Of Immunizations Not available.
History of Procedures
Date Ordered Description Order Status Result Status
3/30/2012 12:00 AM Influenza virus vaccine, split virus, preservative free, for intramuscular use Reviewed
1/21/2013 12:00 AM Chest X-Ray, PA and Lateral Views Reviewed
Influenza virus vaccine, split virus, preservative free, for intramuscular use Chest X-Ray, PA and Lateral Views
Results Summary
Data and Description Results
1/21/2013 1:35 PM Hgb Bld-mCnc 13.40 g/dL Hct Fr Bld Auto 51.20 % WBC # Bld Auto 8.90 x10E3/uL Platelet # Bld Auto 246.0 x10E3/uL
Reason for Referral
Reason for Referral Plan Date Provider
Pulmonary Function Test 1/28/2013 Penny Puffer, 1047 Healthcare Drive, , Portland, OR, 97005, 555-555-1049
Plan of Treatment
Planned Activity Comments Planned Date Planned Time Plan/Goal
Pulmonary Function Test 1/28/2013 4:00 PM
Pulmonary Function Test
Clinical Instructions/Patient Decision Aids Not available.
Social History
Name Status Comments
Tobacco Current
Tobacco
Problem List
Description Status Onset
Asthma Active 092511
Essential hypertension Active 03/30/2012
Acute Pharyngitis Resolved 10/28/2011
Pneumonia Active 01/21/2013
Asthma Active Essential hypertension Active Acute Pharyngitis Resolved Pneumonia Active
History of Present Illness
Diagnosis Date
Pneumonia 01/21/2013