MU2 Clinical Visit Summary 1357 Amber Drive Aloha OR 97006 UNK Isabella Jones 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 Robert Adams Holly Garner Henry Seven Nicholas Radon
Reason for Visit
Reason For Visit
Mild Fever 2 days, chills 2 days, cough productive of greenish sputum 2 days
Allergies and Adverse Reactions
Name Reaction Notes
aspirin
codeine sulfate
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(%)
8/6/2012 1:59:00 PM 135 mmHg 92 mmHg 194.007 lbs 69.685 in 28.089 kg/m² 2.0801 m²
Blood Pressure - Diastolic Blood Pressure - Systolic Body Mass Index Height Weight
Medications Administered
Name Start Date Estimated Completion Date SIG Comments
Proventil HFA Inhalation HFA Aerosol Inhaler 90 mcg/actuation 8/6/2012 inhale 2 puffs once
Proventil HFA Proventil HFA
Medications
Active
Name Start Date Estimated Completion Date SIG Comments
clarithromycin Oral Tablet 500 mg take 1 tablet (500 mg) by oral route every 12 hours for 14 days
metoprolol tartrate Oral Tablet 25 mg take 2 tablets (50 mg) by oral route once daily for 30 days
Proventil HFA Inhalation HFA Aerosol Inhaler 90 mcg/actuation 8/6/2012 inhale 2 puffs once
take 1 tablet (500 mg) by oral route every 12 hours for 14 days clarithromycin take 2 tablets (50 mg) by oral route once daily for 30 days metoprolol tartrate inhale 2 puffs once Proventil HFA
History Of Immunizations
Name Date Admin Mfg Name Mfg Code Trade Name Lot# Route Inj Vis Given Vis Pub CVX
pneumococcal 8/6/2012 Not Entered NE Not Entered Not Entered Not Entered 8/6/2012 1/1/0001 33
1044 Healthcare Drive Portland OR 97005 United States History K Family 1044 Healthcare Drive Portland OR 97005 United States
History of Procedures
Date Ordered Description Order Status Result Status
8/6/2012 12:00 AM Chest X-Ray, PA and Lateral Views Ordered
8/13/2012 12:00 AM X ray of sternoclavicular joints, 3 views Ordered
8/13/2012 12:00 AM Hemoglobin Ordered
9/22/2012 12:00 AM Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) Ordered
8/6/2012 12:00 AM Sputum, obtaining specimen, aerosol induced technique (separate procedure) Pending
Chest X-Ray, PA and Lateral Views X ray of sternoclavicular joints, 3 views Hemoglobin Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) Sputum, obtaining specimen, aerosol induced technique (separate procedure)
Results Summary
Data and Description Results
8/6/2012 2:01 PM Hct Fr Bld Auto 45.0 %
8/6/2012 2:01 PM Hgb Bld-mCnc 14.20 g/dL Platelet # Bld Auto 220.0 x10E3/uL WBC # Bld Auto 7.60 x10E3/uL
Reason for Referral
Reason for Referral Plan Date Provider
pulmonology consult 8/13/2012 Penny Puffer, 1047 Healthcare Drive, , Portland, OR, 97005, 555-555-1049
Plan of Treatment
Planned Activity Comments Planned Date Planned Time Plan/Goal
pulmonology consult 8/13/2012 4:00 PM
Smoking Cessation Plan 8/6/2012 2:02 PM Resources and instructions provided during visit
Smoking Cessation: Goal 8/6/2012 2:02 PM Quit smoking
(BCA) - Biopsy any source 8/27/2012 1:00 PM
(BCA) - Biopsy any source Dr Henry Seven 1002 Healthcare Dr Portland Oregan 555-555-1122 2 pm 8/11/2012 12:00 PM
Chest X-Ray, PA and Lateral Views 8/6/2012 12:00 AM
X ray of sternoclavicular joints, 3 views 8/13/2012 12:00 AM
Hemoglobin 8/13/2012 12:00 AM
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) 9/22/2012 12:00 AM
Sputum, obtaining specimen, aerosol induced technique (separate procedure) 8/6/2012 12:00 AM
pulmonology consult Smoking Cessation Plan Smoking Cessation: Goal (BCA) - Biopsy any source (BCA) - Biopsy any source Chest X-Ray, PA and Lateral Views X ray of sternoclavicular joints, 3 views Hemoglobin Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) Sputum, obtaining specimen, aerosol induced technique (separate procedure)
Clinical Instructions/Patient Decision Aids
Instruction
Patient may continue to experience low grade fever and chills
Return to clinic or call 911 if you experience chest pain, shortness of breath, high fevers, or intractable vomiting/diarrhea
Recommended Patient Decision Aids: Vendor supplied
Patient may continue to experience low grade fever and chills Return to clinic or call 911 if you experience chest pain, shortness of breath, high fevers, or intractable vomiting/diarrhea Recommended Patient Decision Aids: Vendor supplied
Social History
Name Status Comments
Tobacco Current
Tobacco
Problem List
Description Status Onset
Asthma Active
Hypoxemia Active
Community Acquired Pneumonia Active
Asthma Active Hypoxemia Active Community Acquired Pneumonia Active
History of Present Illness Not available.