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Microsoft word - 080319 dixon, ruby l 88977 his note.doc
Phone: (404) 408-4014 Fax: (678) 669-2024
Ruby L Dixon, a 87 year old, White Female, Divorced, Methodist, residing at Autumn Breeze Health Care room DOS:
3/19/2008 Chart #:
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;
S/P Subendothelial MI c no present sgns or symptoms;
Continue present therapy;
Congestive Heart Failure [428.0] (Improved) Under Control, 3-New Problem, w/ no addtl work planned;
No signs or symptoms of CHF;
Monitor for changes, worsening;
DVT [453.8] (Improved) Under Control, 3-New Problem, w/ no addtl work planned;
Monitor and maintain adequate control of BP's;
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;
No s/s of infection;
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 FAMILY AND SOCIAL HISTORY:
No glasses, smoking, alcohol use, substance abuse, not a DFAC client. Former Occupation:
Chronic Air Obstruction 
Insomnia Nos [780.52]
Nephrotic Syn In Oth Dis [581.81]
PAST MEDICAL HISTORY
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):
Dr. Joseph T. Hannan Nurse:
Autumn Breeze Health Care Nursing Facility Code:
99308 Physician License Number: 025759
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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