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Precision Software Appli…tions Silver Collection 1
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Precision Software Applications Silver Collection Volume One (PSM) (1993).iso
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REPORTS
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1993-02-08
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NORTH MEDICAL GROUP
Internal Medicine
123 Main Street
KENSINGTON, PA 94708
(510) 555-1223
Dec 23 1992 12:17PM
Re: James Wilson (#219)
Visit: 15831 (#1/1 visits)
Chief Complaint: James Wilson is a 46 year old man who presents with
a chief complaint of SOB.
Subjective:
Over the last four months, patient complains of progressive shortness
of breath with exertion, cough, productive of yellowish green sputum,
and wheezing, particularly at night. He has smoked 2 packs per day
for the last 26 years and inhales moderately. There is no prior
history of asthma, tuberculosis, rib fractures or other lung disease.
Allergies: Penicillin
Hospitalizations: Positive for: acute appendicitis, and T&A.
Past Medical Illnesses: There is no history of diabetes mellitus,
tuberculosis, rheumatic fever, or hypertension.
Surgeries: Positive for: appendectomy.
Transfusions: None
Childhood Illnesses: Positive for: chicken pox, earaches, recurrent
sore throats, and measles.
Immunizations:
Type Date Rcvd Next Due Comments
____________________________________________________________
Influenza 10/12/92 At work
Social History: The patient's social history is unremarkable with no
history of drug abuse or severe alcohol abuse.
Family History: Unremarkable
Work History: Currently, the patient is working full-time as an ICU
nurse.
General Health: Patient is generally in excellent health.
NORTH MEDICAL GROUP
Re :James Wilson (#219)
Visit# 15831 12/23/92
Lymphatics: There is no history of adenopathy or diseases of the
lymphatics.
Skin System: There is no history of skin rash or disease of the skin.
HEENT System: There is no history of disease of the head, eyes, ears,
nose, or throat. A history of chronic or recurrent headaches,
blurring of vision or changes in visual acuity are absent. A history
of chronic sinus infections and chronic epistaxis are denied. The
patient denies mouth sores, a loss or change of taste or dry mouth.
Cardiovascular: The cardiac history is unremarkable. There is no
history of angina pectoris, myocardial infarctions or valvular
disease. The patinet denies a history of rheumatic fever.
Pulmonary: See present illness
Gastrointestinal: No abdominal pain, no constipation, no vomiting and
no nausea is reported. The patient reports no history of jaundice.
Genitourinary: Review of symptoms referable to the genitourinary
system discloses no history of hematuria, dysuria, nocturia, urgency,
frequency, nephrolithiasis, recurrent urinary tract infections,
sexually transmitted diseases or problems of a sexual nature. There
has been no history of flank pain.
Musculoskeletal: Symptoms referable to the musculoskeletal system
were reviewed including: muscle strength and pain, sciatica, varicose
veins, morning stiffness, Raynaud's phenomenon, arthralgias and back
pain. All symptoms were negative.
Endocrine: There is no history of heat or cold intolerence,
polydipsia, polyphagia or polyuria.
Central Nervous System: The patient describes no change in ability to
remember things or in concentration. There has been no loss of
coordination, no paresthesias and no weakness or loss of motor
strength. The patient denies a history of sleep disturbance and
denies having unusual emotional changes or mood swings.
Physical Examination
General Health: In general, the patient appears well nourished and
well developed, in no acute distress. Temp: 98.6 BP: 125/80 supine
and 120/85 upright Pulse: 80 and 85 RR: 16 Wt: 175 Ht: 5' 10"
Page# :2
NORTH MEDICAL GROUP
Re :James Wilson (#219)
Visit# 15831 12/23/92
Lymphatics: There is no lymphadenopathy present. Skin: Skin color and
turgor are normal. No bruises or rashes and no jaundice noted.
HEENT: Normocephalic; PERRLA; sclera anicteric; conjunctivae normal;
Ear, nose and throat exam within normal limits. Soft tissue intra and
extraoral exam within normal limits and the teeth are in good repair.
Neck: The neck is supple, no adenopathy or thyroid enlargement
noted; trachea in midline. Chest: Chest exam disclosed ronchi and
wheezes bilaterally. Heart: The cardiac exam was within normal
limits; PMI in 5th ICS; no gallops, murmurs or rubs. Abdomen: The
exam of the abdomen was within normal limits, bowel sounds normal;
soft and not tender; no hepatosplenomegaly noted. The genitourinary
exam was within normal limits. Genital: The examination of the
genitalia is normal. Rectal: A rectal exam was not performed.
Extremities: Joint and musculoskeletal exam was normal as was the
extremities exam with no cyanosis, clubbing or edema. Joints: The
examination of the joints was normal without joint pain or swelling.
Neuro: The neurologic exam was grossly normal.
Impressions:
Diagnosis Dx Date Stop Date Comments
________________________________________________________________
CHRONIC BRONCHITIS (491.0) 12-23-92 C
Pneumonia, LLL 12-23-92 C
Tobacco abuse 12-23-92 C
Respiratory insufficiency 12-23-92 C
Respiratory insufficiency: Secondary to 1-3
Laboratory Tests in Visit Record:
Ord Date Test Name ST Result
_____________________________________
12-23-92 CBC M Increased WBC count
12-23-92 CXR M LLL pneumonia
12-23-92 PFT with ABG O
STatus: F-File O-Open M-Maintain R-Order
Medications:
Drug Dose No Freq Start Stop Comments
______________________________________________________________
+ Proventil PUFFS 2 QID 12-23-92 C
+ Aerobid PUFFS 5 BID 12-23-92 C
+ Erythromycin 500MG 1 QID 12-23-92 C
Page# :3
NORTH MEDICAL GROUP
Re :James Wilson (#219)
Visit# 15831 12/23/92
Other Treatment Measures:
Other Therapy Start Stop Comments/Special Directions
_______________________________________________________________________
Chest percussion/postural 12-23-92 C
Discussion:
The patient is to start on the program noted below. He is instructed
to call with any problems. The following changes were made to the
patient's medications: The following medications were added:
Proventil PUFFS 2 QID, Aerobid PUFFS 5 BID, Erythromycin 500MG 1 QID.
Pulmonary function tests were ordered.
Patient Discussion:The findings of today's visit were discussed with
the patient.
Followup: The patient is to return for another visit in approximately
2 weeks.
Anna Smith, MD
cc.
Dr. Thaddeus Cwalina
Page# :4
[PRESCRIPTION]
NORTH MEDICAL GROUP James Wilson
Internal Medicine
123 Main Street
KENSINGTON, PA 94708
(510) 555-1223 JAN 29 1993
_____________________________________________________________________________
Medication Dose Qty Sig Freq Refills Please Label Medicine
_____________________________________________________________________________
Erythromycin 500MG 60 1 QID 0
Aerobid PUFFS 1 5 BID 0
Proventil PUFFS 1 2 QID 0
Anna Smith,MD
DEA# AS6859685
SUBSTITUTION PERMISSABLE ______________________________M.D.
IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED,
THE PRESCRIBER MUST HANDWRITE 'BRAND NECESSARY' OR
'BRAND MEDICALLY NECESSARY' IN THE SPACE BELOW.
______________________________________________________________________________
[MEDICATION SCHEDULE]
NORTH MEDICAL GROUP
Internal Medicine
123 Main Street
KENSINGTON, PA 94708
(510) 555-1223
December 23 1992
Detailed Medication Program and Schedule For:
James Wilson (ID# 219)
Time Medication Qty Dose
07:00AM ******
1 Erythromycin 1 500MG
2 Aerobid 5 PUFFS
3 Proventil 2 PUFFS
11:00AM ******
1 Erythromycin 1 500MG
2 Proventil 2 PUFFS
04:00PM ******
1 Erythromycin 1 500MG
2 Proventil 2 PUFFS
07:00PM ******
1 Aerobid 5 PUFFS
09:00PM ******
1 Erythromycin 1 500MG
2 Proventil 2 PUFFS
Other Therapies
_______________
1 Chest percussion/postural drainage
Please call me if you have any questions regarding these medicines
or any other aspect of this treatment program.
A Smith, MD
[CHARGE TICKET]
NORTH MEDICAL GROUP
Internal Medicine
123 Main Street
KENSINGTON, PA 94708
(510) 555-1223
Dec 23 1992 12:17PM
James Wilson (#219)
Visit: 15831 (#1/1 visits)
Charge Ticket
Charge Codes
1) 90020 OFFICE VISIT COMPREHEN.
Charge Diagnosis
1) CHRONIC BRONCHITIS (491.0)
2) Pneumonia, LLL
Lab Ordered
PFT with ABG
Next visit: 2 weeks
Examining Physician: A Smith, MD