MND12MPHurryJack7/2/95 11:00 pm48126180-3583608092 437/2/1995Male7/2/1995Your NameMedicareGrant 32 ResearchMeningitis105Floor2FFTTTF48126180-358041476FFTT48126192390122129FTTTRiderBilly Joe7/2/95 11:08 pm4812618815769812637 257/1/1995Male7 412Your Name HereMedicareDiabetes Research GroupFever710 2Floor2FFTTFF48126188158017459FFTT48128788-283852FFTTBentlyJudy7/3/95 8:44 pm48127484506972364193 I 41 AtFemale/12/63Your Name Here 7MedicareDiabetes Research GroupHeart Palpitations11ioClinic2FFTTFF48127484507392539FFTT48127490-243234709FFTTMillerJenny4/18/94 9:40 a.m.474917806/1/94 10:13 am1155298/19/65Female5/28/1994Dr SocratesBlue CrossDiabetes Research GroupAbnormal Uterine Bleeding1Clinic1TTTTFF474917801001FTTTGordonBen5/30/94 3:45 pm475526256/4/94 8:00 am22332/12/94Male5/30/1994Dr SocratesBlue CrossDiabetes Research GroupChest Pain032Clinic2FFTTFF475526252001FTTT50182813-224108343FFTTBensonJoe5/27/95 10:49 pm48074329350016209345/27/1995MaleYour Name HereSIEZURE7ICU1FFTTFF48074329350352349FFTTJonesBilly5/27/95 10:52 pm48074332513699582MaleDr John DoeDiarrhea10Surgery1FFTTFF48074332514035722FFTTMannerFred5/27/95 10:54 pm48074334-413838148MaleDr John DoeAmennorrhea13Floor2FFTTFF48074334-413485201FFTT48074336-291499995FFTTMND13MEET-358360809481261807/2/95 11:00 pm48126180-3580414761F7/2/95 11:00 pm00:450TTFFSTtest# 1 degree of fever rigor cough lethargy X 53 kilograms night sweats appetite changes fever hypophagia bowel habit change fatigue tonsillitis tongue problems chronic hoarseness NECK easy bruising easy bleeding unusual hair loss skin masses finger/toe nail change hives uremic frost plethora neurofibromatosis lesion HEENT head masses vertigo loss of vision photophobia exudates eye pain eye surgery nose bleeds chronic sinusitis polyps edentulous (without teeth) partial plate full plate q 23 teaspoons BOM duration of fever neck stiffness malaise 12290OT0 degree of fever chills headache cough lethargy night sweats anorexia confusion vomiting skin rashes dysuria exposure to TB exposure to hepititis CHRONIC DISEASE bronchitis sinusitis HIV or AIDS immumosupression 12290AT ***** HISTORY OF PRESENT ILLNESS degree of fever chills headache sputum malaise night sweats irritablity nausea skin rashes exposure to TB foreign travel CHRONIC DISEASE bronchitis endocarditis HIV or AIDS diabetes tuberculosis tuberculin tests recent differential smoking caffeine 12290PT duration of fever headache cough malaise confusion skin rashes exposure to hepititis recent upper respiratory dz. pneumonia endocarditis HIV or AIDS alcholism 12290LTGIRTET157698126481261887/2/95 11:08 pm481261881580174591F7/2/95 11:08 pm02:000TTFFST duration of fever rhonchi HEART abdominal masses hepatomegaly Murphy's sign,(rt upper quad tenderness,& arrest of abscess pyelonephritis IV phlebitis otis media upper respiratory infection pelvic infection infected decubitus ulcer menorrhagia problems in pregnancy breast masses changes in axillary nodes breast feeding children sputum production pneumonia TB edema pacemaker appetite changes difficulty sleeping polyphagia changes in thirst sleeping habit change chronic ear infection hearing aid use recent change in vision photophobia glaucoma full plate oral lesions strep throat voice changes chronic halitosis Diabetes 12290OTATPTLTGIRTET-358360809481261807/2/95 11:12 pm481261923901221291F7/2/95 11:12 pm00:050TTFTST onset of fever chills neck stiffness sputum malaise night sweats confusion vomiting skin rashes dysuria exposure to hepititis recent upper respiratory dz. pneumonia sinusitis cellulitis immumosupression sickle cell dz. PREVIOUS TESTS recent WBC count smoking caffeine high fisk AIDS activities 12290OTATPTLTGIRTMonistat 7, suppositories #7 teaspoon(s)by eye dropsq 3 hours8 days capsule(s)4 RefillsNo SubstitutionNaprosyn teaspoon(s)by eye dropsq 3 hours9 days oz.No RefillsOK to SubstitutePenicillin, Injection,4cc capsule(s)by Inhailerq 4 hours10 days capsule(s)4 RefillsOK to Substitute0F60B00A011F49679495D34A4FCF3F9A3D82EAE96BB69711D9CE3D7D52D5000140016733ET506972364481274847/3/95 8:44 pm481274845073925391F7/3/95 8:44 pm00:060TTFFST ***** HISTORY OF PRESENT ILLNESS rapid, irregular heat beat duration of palpitations chest pain light headedness weakness nausea ***** HISTORY SYSTEMIC DISORDERS alcohol illicit drugs - cocaine GENERAL weight changes appetite changes fever chills sleeping habit change SKIN texture changes easy bruising unusual hair loss finger/toe nail change HEENT head trauma hearing loss chronic ear infection ear pain loss of vision dry eyes eye pain 12290OTATPTLTGIRTET506972364481274847/3/95 8:50 pm48127490-2432347091F7/3/95 8:50 pm01:150TTFFST Asthma 12290OTATPT12289LTGIRTET157698126481261887/4/95 3:28 pm48128608-1582722791F7/4/95 3:28 pm0FFFFSTOTATPTLTGIRTET1474917807/4/95 4:07 pm48128647833927381F7/4/95 4:07 pm0FFFFSTOTATPTLTGIRTET2475526257/4/95 6:17 pm481287774153630791F7/4/95 6:17 pm00:070TTFFST ***** HISTORY OF PRESENT ILLNESS associated pain12290OTATPTLTGIRTET157698126481261887/4/95 6:28 pm48128788-2838521F7/4/95 6:28 pm00:190TTFFST 12290OTATPTLTGIRTET504381101481304647/5/95 10:24 pm481304645047676621F7/5/95 10:24 pm0FFFFSTOTATPTLTGIRTET228822395481304657/5/95 10:25 pm481304652292089561F7/5/95 10:25 pm0FFFFSTOTATPTLTGIRTET265814602481304667/5/95 10:26 pm481304662662011631F7/5/95 10:26 pm0FFFFSTOTATPTLTGIRTET2475526256/8/95 4:25 am48090505-3530289591F6/8/95 4:25 am0TTFTST Acute illness Back pain Chest pain Chills Cough Dyspnea emotional stress Fatigue myocardial infarcation stroke prior ketoacidosis foot ulcers decreased extremity sensation Postural BP Pulse GENERAL Stuporous Kussmaul Resp. decreased Turgor Delayed capillary refill Hyperpigmented atrophic macules on legs Intertriginous candidiasis Hyperpigmented atrophic macules on legs Wheezes Hypoactive bowel sounds gastric dilitation tenderness suprapublic tenderness EXTREMITIES Foot ulcers 12289OT Abdominal pain Back pain Beta agonists Chest pain emotional stress Fatigue Fever Acetohexamide CAPOTEN DDAVP DIABINESE Glucagon Hydrochloride Glyburide Lypressin Crackles ABDOMEN gastric dilitation costovertebral angle tenderness Distal Pulses Foot ulcers NEURO Postural BP Temp Conscious Unconscious decreased Turgor Delayed capillary refill Hyperpigmented atrophic macules on legs Intertriginous candidiasis 12289AT Anorexia Chest pain Cough Dyspnea emotional stress Fatigue Hyperthyroidism Nausea New onset Diabetes Phenytoin Polyphagia Polyuria Pregnancy***** HISTORY Pregnancy***** HISTORY kidney disease myocardial infarcation gastroparesis prior ketoacidosis foot ulcers CAPOTEN Captopril DDAVP DIABINESE DIAPID Glipizide GLUCOTROL Glyburide Metoclopramide Hydrochloride ORINASE PITRESSIN Pneumococcal Vaccine REGLAN Tolazamide TOLINASE Vasopressin***** LAB Postural BP GENERAL Unconscious SKIN Delayed capillary refill Hyperpigmented atrophic macules on legs 12289PT location relieving factors radiation ***** HISTORY strep throat rheumatic fever tonsillitis tuberculosis COPD cirrhosis pancreatitis gout anemia neoplasms eye surgery appendectomy mastectomy hysterectomy MMR Hepatitis B (number of 3) pneumonia 12289LT location relieving factors related factors strep throat scarlet fever pneumonia tactile fremitus auscultation crackles breath sounds egophony ***** HEART regular rate & rhythm PMI masses tenderness nipple discharge ***** ABDOMEN bowel sounds hepatomegaly guarding penis circumcised inguinal hernia testicle mass varicocele ***** PELVIC EXAM vulva vagina cul-de-sac cyctocele rectocele sphincter tone hemorrhoids rectal fissures guaiac (occult blood) 12289GIRTET2475526256/8/95 4:34 am480905141449960651F6/8/95 4:34 am00:090TTFTMND14MEST character of symptom aggravating factors radiation INFECTIOUS DISEASES rheumatic fever scarlet fever tuberculosis meningitis STD's diabetes MI asthma Or emphysema pancreatitis arthritis anemia coagulopathy SURGERY eye surgery tonsillectomy appendectomy hysterectomy MMR Hepatitis B (number of 3) pneumonia polio PREVIOUS TESTS HIV brochoscopy TRAUMA OR INJURIES chest trauma MVA's congenital acquired married children caffeine LSD ALLERGY foods seasonal heart dz. stroke stroke Or'o'o 012289OT character of symptom aggravating factors relieving factors radiation related factors INFECTIOUS DISEASES rheumatic fever rheumatic fever scarlet fever tonsillitis weight changes anorexia fever chills hypophagia changes in thirst sleeping habit change texture changes pruritis ecchymosis unusual hair loss changes in hair distribution skin masses striae uremic frost plethora neurofibromatosis lesion HEENT skull fractures head masses hearing loss vertigo recent change in vision visual acuity diplopia (double vision) glaucoma dry eyes cataracts itchy eyes excessive tearing corrective lenses nasal drainage changes in sense of smell full plate gingival bleeding oral lesions strep throat sore throat hoarseness 12289AT character of symptom location relieving factors related factors ***** HISTORY strep throat scarlet fever tuberculosis meningitis hepatitis STD's SYSTEMIC DISORDERS diabetes MI hypertension asthma emphysema cirrhosis pancreatitis kidney dz. gout coagulopathy SURGERY eye surgery tonsillectomy cholecystectomy IMMUNIZATIONS tetanus Hepatitis B (number of 3) pneumonia polio PREVIOUS TESTS TB (PPD) 12289PT location relieving factors INFECTIOUS DISEASES scarlet fever tonsillitis STD's CHRONIC DISEASE diabetes heart dz. thyroid dz. hypertension asthma anemia neoplasms SURGERY tonsillectomy appendectomy coronary bypass breast biopsy mastectomy brochoscopy GI scopings head trauma abdominal trauma broken bones 12289LT character of symptom aggravating factors radiation related factors strep throat rheumatic fever tonsillitis pneumonia meningitis hepatitis CHRONIC DISEASE SYSTEMIC DISORDERS heart dz. thyroid dz. hypertension emphysema anemia neoplasms SURGERY eye surgery appendectomy breast biopsy mastectomy cholecystectomy hysterectomy 12289GIRTMotrin 500mg, prn tablet(s)by eye dropsq 5 hours10 days capsule(s)2 RefillsOK to SubstitutePhenergan supp, prn capsule(s)by eye dropsq 3 hours8 days oz.3 RefillsOK to Substitute196838C2EB3B5319B47CACFC4517501FF151AB7C8ECA9B39A97DD7F2D227973C8A148046417236ET2475526256/8/95 4:44 am48090524-3297610861F6/8/95 4:44 am00:090TTFTST character of symptom radiation INFECTIOUS DISEASES rheumatic fever scarlet fever tuberculosis pneumonia hepatitis CHRONIC DISEASE diabetes MI hypertension emphysema ulcers anemia PREVIOUS HOSPITALIZATIONS tonsillectomy mastectomy cholecystectomy hysterectomy influenza PREVIOUS TESTS TB (PPD) brochoscopy GI x-rays TRAUMA OR INJURIES head trauma chest trauma 12289OT character of symptom aggravating factors radiation ***** HISTORY strep throat rheumatic fever scarlet fever tonsillitis tuberculosis HIV STD's SYSTEMIC DISORDERS diabetes MI hypertension asthma emphysema arthritis anemia neoplasms SURGERY PREVIOUS HOSPITALIZATIONS tonsillectomy appendectomy coronary bypass breast biopsy Hepatitis B (number of 3) polio PREVIOUS TESTS HIV allergy testing GI x-rays TRAUMA OR INJURIES 12289AT location relieving factors related factors INFECTIOUS DISEASES strep throat scarlet fever tonsillitis HIV hepatitis CHRONIC DISEASE diabetes heart dz. thyroid dz. hypertension emphysema influenza TB (PPD) CXR allergy testing GI scopings abdominal trauma MVA's congenital acquired SOCIAL HISTORY married children smoking occupation caffeine ALLERGY foods FAMILY HISTORY heart dz. stroke cancer cancer asthma ***** HISTORY INFECTIOUS DISEASES strep throat rheumatic fever 12289PT radiation related factors ***** HISTORY strep throat strep throat scarlet fever tonsillitis 12289LTGIRTInsulin 100 units SA, subqq 5 hours7 days3 RefillsOK to Substitute0D5420E11B3D85FED0B604B50E2020651361B5020D75F53F6024CCABBDE0CC366697361F4460EFAB7C9449B5DA43F66F881174142382B38F0A8BEAFD7D04F128FDD26431711019437ET1474917804/18/94 9:40 a.m.4749178010011T4/18/94 9:40 a.m.00:450TTTTSTHISTORY FDLMP: 1/23/95, Menarch 13, Regular, duration 5d, frequency q 29d, 5 pads per day, - passing tissue, + passing clots, + postcoital bleeding, + intermenstrual bleeding, - vasomotor flushes, - changes in hair/skin/texutre/distribution, + abdominal pain, - fever ,- chills, + lightheadedness, + nausea, pregnancy is possible, + emotional stress, + weight changes, + tricyclic antidepressives, - thyroid symptoms, grav 0, para 0, + diet pills, - IUD, - family history, 10240OTPHYSICAL EXAM hemodynamically stable, minimal bleeding, - orthostatic hypotension GYN + cervical lesions x 1 cm anterior, - clitoromegally, + cervical motion tenderness, Uterus size normal, GENERAL - skin/hair changes, - thyroid, - galactorrhea, + obesity, - hirsuitism, 10240ATPRIMARY Diet pills, R/O Tricyclic antidepressives SECONDARY Obesity10240PTD/C diet pills, increase exercise, 10240LTCBC - Lytes - Serum hCG - PAP pending GC pending Chlamydia - Guiac - x 3 LFTUs - Thyroid panel - LH/FSH - PT/PTT -10240GIRTET2475526255/30/94 3:45 pm4755262520011F5/30/94 3:45 pm00:300TTTTSTSensation of spinning x 4 days, + Faintness/lightheadedness, -blurred vision, worse with change in position, worse with coughing, - hyperventilation, -nausea, +postural unsteadiness, - weakness, - headache, has a car - vomiting, -tinnitis, - head trauma, - ototoxic drugs, - diplopia, - parasthesias, + Hypertension, - CVD. + antihypertensives x 3 weeks I10240OTPHYSICAL EXAM: + valsalva, +Orthostatic hypotension HEENT -sensory changes, visual acuity 20/20 OU, -tympanic membrane inflammation, - dizziness on head turning - Rinne, - Webber HEART Rhythm Regular, - murmurs NEURO A&O x4, -sensory loss or changes, - ataxia, - weakness, CN II-XII intact, U/L Reflexes 2/4. - BabinskiUs, good coordination RECTAL - occult blood10240ATPRIMARY Orthostatic Hypotension SECONDARY Antyhypertensive therapy10240PT10240LTCBC - Lytes - MRI -10240GIRTTylenol, 200mg2 capsulesbefore mealsDailyfor 18 days30 capsules2 refillsNo SubstitutionET350016209480743295/27/95 10:49 pm480743293503523491F5/27/95 10:49 pm01:000TTFFST nausea vomiting malaise anorexia fever diarrhea dark urine abdominal swelling Asthma use of contraception nipple discharge changes in axillary nodes breast feeding children 10242OT nausea anorexia diarrhea gynecomastia RUQ tenderness liver margins hepatomegaly splenomegaly appetite changes difficulty sleeping polyphagia changes in thirst sleeping habit change sputum production bronchitis TB exposure 10242ATPTPlans that go on forever10242LTMND15MEGIE91888D68D16954E8F4F1716EBC450B3D13A4C03FA39E5FA681D2BF2554AAE78FC6E914FE83309CDA4A3751D7744367FF95ABEBBCA400B5AD753BA7852FC0C7E6A2946ED391DEDC268D244F98C2FED53CA0E9F8D4B987CBD9E72FC5325B6A81D0E8441152131711D709881C9B3D131A8E67D2F9F3178080D294C504178D6CFA51D08F20B4803EC19157661980D1C4821E303FAFACE9A03E50038C43C118CE4AB6977D23D8898B09C4154EB9E139B08110A32509D1E954BFACFB599CBB53FB80D0173167165198052418390B11B18110442151548F890FD1E167AAE95AFC7C3012489363610A314F25502E8F39A1A18266ABEE796E2F3203D3EC55A61D0F04567A0772D69D0EE2A6F51F70229C0C34BCA12C53A3228937F3B8014-3159491108C0D14CD7263971A69B086A06969BF8F00F46439AE7742BF6E5330A93171-1216331D0CF087CBCE799C97D07582491056410D1619879AF447B0DA25EDE578824E2688823F8FF41D2F0890421214054E7E3D4072D4FD888ADB0CC408B745D8721315612395RTET513699582480743325/27/95 10:52 pm480743325140357221F5/27/95 10:52 pm00:020TTFFST number of stools per hour X 45 Billy Jonea10242OTAT GENERAL appetite changes difficulty sleeping chills hypophagia changes in thirst fatigue 10242PTLTGI292988D6650208288F16A5732EA33DC9D97B03CED49916DBDEE1A74A59FB74C559315ABF58771A5E9725E1848E16453F1180381920816807306833181564BBAB07E9D061697C60701211541470508884AEF3604864911869053C6062904D55030814952186690734886FE792A32792B5099E2D0308776411284053488DC568B8092D355F1FFC15ED5000614670182930518801BC4B0111103119111071450CB2C5012810313611043087015B4F3DE6600ED571629218105081885702C301B08129162159184RTET-413838148480743345/27/95 10:54 pm48074334-4134852011F5/27/95 10:54 pm00:020TTFFST never had a period metorrhagia length of bleeding time regular scant flow severe flow (menorrhagia) 10242OTATPTLTGI058C1805E406BD52531E97993A7F49659DDBC7D191C6F332255BAF509199E61997AA8C8A865883511913274270C4800FF1C19C6FF60FD5403E8767111098290C48716EF98CCE4AE52AEE2D0EC3FFFCE5990DCC243CD1442C60EA9C61087495112156051C707DB6A25403087797115106051C1030C4254EEB88D330A2014A131781481160768E0D123F06E00C08583A4C50962EBBB47E2B183D9339FE599BFCE727A52CE3018C93B5A4024152199180A381F2A005A1F75AAB7699C82C130C71F91C9F88A7DB44DC3361413AE57347701F6DDF135D5A21DA65EBE7C85732537480217B34ECB3D2D526278C3FED87281B6D904E67C3CEFD195AD20BF89877611C208C07D1026B-413207191156970807F77EC3AD392EBC953014CCA93C17532D13FFFE31840CB30FF6C22F159196DE034504E95AF1E127A1FFCE9F25145988C5FAE652C422DD7B4D76E36AF331FCE4B688052-2215143RTET-413838148480743345/27/95 10:56 pm48074336-2914999951F5/27/95 10:56 pm01:000TTFFSTA new visit regular cycle length between periods length of bleeding time regular scant flow uterine enlargement uterine tenderness cervical tenderness on movement adnexal tenderness ovarian cysts ovarian tumors Diabetes 10242OTATPTLTGI0578089760F801C0F400C8D76A109FF1F17070CF20AA2359371DD8FBEE0D214D2BBA6A0001722713672058820F16465498D749EDDA3A0F744192AEFA441B2A34B00504EBE79D1D125301CA311A385D2A034616A2031EF9939010148641281012540F0988B5E079E48F152B2B1188B07266707497EA347C07DE27C384FAC466721CEBCFC7B84E4CE89AB715850477BB3276A2E01AACABDACDB81136592371012550389F2349A6209E58092B0DABC350785CA7732458C21C0189CF2A849A1D9DA64EBE9F27E1F6FEAE2323E6BAE2EFA95BD1C7F7EC698DE4F298ABB3EA9EB2B8EEEB7ED6BB18E235971711543F1438420F5E20F917A98B898FB81EEB52CA321F16A091CC68336B0D05126125169190099C905EE4AD0DDC4AD8B6BFCCB9B618811331501682004D140029C43ED170C4B6B1C4C0CBCEDF7A6EDB48979981AECD0C20147130194170RTET2475526255/31/99 4:13 am50182813-2241083431F5/31/99 4:13 am01:150TTFFSTthis is a new eucounta 2 red Version area quotha12289OTobjective12289ATAssessment12289PTplans12289LThaf Na Cl K CO2 bun creat glucose RBC WBC HGB HCT 12289GIC51088D675F5884EA029CF17FF5F864C4B9D3C554E3F3EA3043473F0F4223F3D006543311701400934600011E16920FED6D96A696F3378AA8E81D36966E9EA0403534B06B066871441230534888F4D914027A3B94152D9000670531007009441850A7A31972E08C6E4974B131801134915468RTMND16LC