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Microsoft word - 080319 dixon, ruby l 88977 his note.doc

Phone: (404) 408-4014 Fax: (678) 669-2024 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

Source: http://www.xlemr.com/images/screenshots/mobile_note.pdf

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