MND12MPHurryJack7/2/95 11:00 pm48126180-3583608092 437/2/1995Male7/2/1995Your NameMedicareGrant 32 ResearchMeningitis105Floor2FFTTTF48126180-358041476FFTT48126192390122129FTTTRiderBilly Joe7/2/95 11:08 pm4812618815769812637 257/1/1995Male7 412Your Name HereMedicareDiabetes Research GroupFever710 2Floor2FFTTFF48126188158017459FFTT48128788-283852FFTTBentlyJudy7/3/95 8:44 pm48127484506972364193 I 41 AtFemale/12/63Your Name Here 7MedicareDiabetes Research GroupHeart Palpitations11ioClinic2FFTTFF48127484507392539FFTT48127490-243234709FFTTMillerJenny4/18/94 9:40 a.m.474917806/1/94 10:13 am1155298/19/65Female5/28/1994Dr SocratesBlue CrossDiabetes Research GroupAbnormal Uterine Bleeding1Clinic1TTTTFF474917801001FTTTGordonBen5/30/94 3:45 pm475526256/4/94 8:00 am22332/12/94Male5/30/1994Dr SocratesBlue CrossDiabetes Research GroupChest Pain032Clinic2FFTTFF475526252001FTTT50182813-224108343FFTTBensonJoe5/27/95 10:49 pm48074329350016209345/27/1995MaleYour Name HereSIEZURE7ICU1FFTTFF48074329350352349FFTTJonesBilly5/27/95 10:52 pm48074332513699582MaleDr John DoeDiarrhea10Surgery1FFTTFF48074332514035722FFTTMannerFred5/27/95 10:54 pm48074334-413838148MaleDr John DoeAmennorrhea13Floor2FFTTFF48074334-413485201FFTT48074336-291499995FFTTMND13MEET-358360809481261807/2/95 11:00 pm48126180-3580414761F7/2/95 11:00 pm00:450TTFFSTtest# 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
12290OT0
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
12290AT
***** 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
12290PT
duration of fever
headache
cough
malaise
confusion
skin rashes
exposure to hepititis
recent upper respiratory dz.
pneumonia
endocarditis
HIV or AIDS
alcholism
12290LTGIRTET157698126481261887/2/95 11:08 pm481261881580174591F7/2/95 11:08 pm02:000TTFFST
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
12290OTATPTLTGIRTET-358360809481261807/2/95 11:12 pm481261923901221291F7/2/95 11:12 pm00:050TTFTST
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
12290OTATPTLTGIRTMonistat 7, suppositories #7        teaspoon(s)by eye dropsq 3 hours8 days     capsule(s)4 RefillsNo SubstitutionNaprosyn        teaspoon(s)by eye dropsq 3 hours9 days     oz.No RefillsOK to SubstitutePenicillin, Injection,4cc        capsule(s)by Inhailerq 4 hours10 days     capsule(s)4 RefillsOK to Substitute0F60B00A011F49679495D34A4FCF3F9A3D82EAE96BB69711D9CE3D7D52D5000140016733ET506972364481274847/3/95 8:44 pm481274845073925391F7/3/95 8:44 pm00:060TTFFST
***** 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
12290OTATPTLTGIRTET506972364481274847/3/95 8:50 pm48127490-2432347091F7/3/95 8:50 pm01:150TTFFST
Asthma
12290OTATPT12289LTGIRTET157698126481261887/4/95 3:28 pm48128608-1582722791F7/4/95 3:28 pm0FFFFSTOTATPTLTGIRTET1474917807/4/95 4:07 pm48128647833927381F7/4/95 4:07 pm0FFFFSTOTATPTLTGIRTET2475526257/4/95 6:17 pm481287774153630791F7/4/95 6:17 pm00:070TTFFST
***** HISTORY OF PRESENT ILLNESS
associated pain12290OTATPTLTGIRTET157698126481261887/4/95 6:28 pm48128788-2838521F7/4/95 6:28 pm00:190TTFFST

12290OTATPTLTGIRTET504381101481304647/5/95 10:24 pm481304645047676621F7/5/95 10:24 pm0FFFFSTOTATPTLTGIRTET228822395481304657/5/95 10:25 pm481304652292089561F7/5/95 10:25 pm0FFFFSTOTATPTLTGIRTET265814602481304667/5/95 10:26 pm481304662662011631F7/5/95 10:26 pm0FFFFSTOTATPTLTGIRTET2475526256/8/95 4:25 am48090505-3530289591F6/8/95 4:25 am0TTFTST
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
12289OT
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
12289AT
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
12289PT
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
12289LT
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)
12289GIRTET2475526256/8/95 4:34 am480905141449960651F6/8/95 4:34 am00:090TTFTMND14MEST
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
012289OT
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
12289AT
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)
12289PT
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
12289LT
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
12289GIRTMotrin 500mg, prn        tablet(s)by eye dropsq 5 hours10 days     capsule(s)2 RefillsOK to SubstitutePhenergan supp, prn        capsule(s)by eye dropsq 3 hours8 days     oz.3 RefillsOK to Substitute196838C2EB3B5319B47CACFC4517501FF151AB7C8ECA9B39A97DD7F2D227973C8A148046417236ET2475526256/8/95 4:44 am48090524-3297610861F6/8/95 4:44 am00:090TTFTST
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
12289OT
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
12289AT
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
12289PT
radiation
related factors
***** HISTORY
strep throat
strep throat
scarlet fever
tonsillitis
12289LTGIRTInsulin 100 units SA, subqq 5 hours7 days3 RefillsOK to Substitute0D5420E11B3D85FED0B604B50E2020651361B5020D75F53F6024CCABBDE0CC366697361F4460EFAB7C9449B5DA43F66F881174142382B38F0A8BEAFD7D04F128FDD26431711019437ET1474917804/18/94 9:40 a.m.4749178010011T4/18/94 9:40 a.m.00:450TTTTSTHISTORY
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, 10240OTPHYSICAL 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, 
10240ATPRIMARY
Diet pills, R/O Tricyclic antidepressives
SECONDARY
Obesity10240PTD/C diet pills, increase exercise, 10240LTCBC -
Lytes -
Serum hCG -
PAP pending
GC pending
Chlamydia -
Guiac - x 3
LFTUs  -
Thyroid panel -
LH/FSH -
PT/PTT -10240GIRTET2475526255/30/94 3:45 pm4755262520011F5/30/94 3:45 pm00:300TTTTSTSensation 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
I10240OTPHYSICAL 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 blood10240ATPRIMARY
Orthostatic Hypotension
SECONDARY
Antyhypertensive therapy10240PT10240LTCBC -
Lytes -
MRI -10240GIRTTylenol, 200mg2 capsulesbefore mealsDailyfor 18 days30 capsules2 refillsNo SubstitutionET350016209480743295/27/95 10:49 pm480743293503523491F5/27/95 10:49 pm01:000TTFFST
nausea
vomiting
malaise
anorexia
fever
diarrhea
dark urine
abdominal swelling
Asthma
use of contraception
nipple discharge
changes in axillary nodes
breast feeding children
10242OT
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
10242ATPTPlans that go on forever10242LTMND15MEGIE91888D68D16954E8F4F1716EBC450B3D13A4C03FA39E5FA681D2BF2554AAE78FC6E914FE83309CDA4A3751D7744367FF95ABEBBCA400B5AD753BA7852FC0C7E6A2946ED391DEDC268D244F98C2FED53CA0E9F8D4B987CBD9E72FC5325B6A81D0E8441152131711D709881C9B3D131A8E67D2F9F3178080D294C504178D6CFA51D08F20B4803EC19157661980D1C4821E303FAFACE9A03E50038C43C118CE4AB6977D23D8898B09C4154EB9E139B08110A32509D1E954BFACFB599CBB53FB80D0173167165198052418390B11B18110442151548F890FD1E167AAE95AFC7C3012489363610A314F25502E8F39A1A18266ABEE796E2F3203D3EC55A61D0F04567A0772D69D0EE2A6F51F70229C0C34BCA12C53A3228937F3B8014-3159491108C0D14CD7263971A69B086A06969BF8F00F46439AE7742BF6E5330A93171-1216331D0CF087CBCE799C97D07582491056410D1619879AF447B0DA25EDE578824E2688823F8FF41D2F0890421214054E7E3D4072D4FD888ADB0CC408B745D8721315612395RTET513699582480743325/27/95 10:52 pm480743325140357221F5/27/95 10:52 pm00:020TTFFST
number of stools 
   per hour X 45
Billy Jonea10242OTAT
GENERAL
appetite changes
difficulty sleeping
chills
hypophagia
changes in thirst
fatigue
10242PTLTGI292988D6650208288F16A5732EA33DC9D97B03CED49916DBDEE1A74A59FB74C559315ABF58771A5E9725E1848E16453F1180381920816807306833181564BBAB07E9D061697C60701211541470508884AEF3604864911869053C6062904D55030814952186690734886FE792A32792B5099E2D0308776411284053488DC568B8092D355F1FFC15ED5000614670182930518801BC4B0111103119111071450CB2C5012810313611043087015B4F3DE6600ED571629218105081885702C301B08129162159184RTET-413838148480743345/27/95 10:54 pm48074334-4134852011F5/27/95 10:54 pm00:020TTFFST
never had a period
metorrhagia
length of bleeding time regular
scant flow
severe flow (menorrhagia)
10242OTATPTLTGI058C1805E406BD52531E97993A7F49659DDBC7D191C6F332255BAF509199E61997AA8C8A865883511913274270C4800FF1C19C6FF60FD5403E8767111098290C48716EF98CCE4AE52AEE2D0EC3FFFCE5990DCC243CD1442C60EA9C61087495112156051C707DB6A25403087797115106051C1030C4254EEB88D330A2014A131781481160768E0D123F06E00C08583A4C50962EBBB47E2B183D9339FE599BFCE727A52CE3018C93B5A4024152199180A381F2A005A1F75AAB7699C82C130C71F91C9F88A7DB44DC3361413AE57347701F6DDF135D5A21DA65EBE7C85732537480217B34ECB3D2D526278C3FED87281B6D904E67C3CEFD195AD20BF89877611C208C07D1026B-413207191156970807F77EC3AD392EBC953014CCA93C17532D13FFFE31840CB30FF6C22F159196DE034504E95AF1E127A1FFCE9F25145988C5FAE652C422DD7B4D76E36AF331FCE4B688052-2215143RTET-413838148480743345/27/95 10:56 pm48074336-2914999951F5/27/95 10:56 pm01:000TTFFSTA 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
10242OTATPTLTGI0578089760F801C0F400C8D76A109FF1F17070CF20AA2359371DD8FBEE0D214D2BBA6A0001722713672058820F16465498D749EDDA3A0F744192AEFA441B2A34B00504EBE79D1D125301CA311A385D2A034616A2031EF9939010148641281012540F0988B5E079E48F152B2B1188B07266707497EA347C07DE27C384FAC466721CEBCFC7B84E4CE89AB715850477BB3276A2E01AACABDACDB81136592371012550389F2349A6209E58092B0DABC350785CA7732458C21C0189CF2A849A1D9DA64EBE9F27E1F6FEAE2323E6BAE2EFA95BD1C7F7EC698DE4F298ABB3EA9EB2B8EEEB7ED6BB18E235971711543F1438420F5E20F917A98B898FB81EEB52CA321F16A091CC68336B0D05126125169190099C905EE4AD0DDC4AD8B6BFCCB9B618811331501682004D140029C43ED170C4B6B1C4C0CBCEDF7A6EDB48979981AECD0C20147130194170RTET2475526255/31/99 4:13 am50182813-2241083431F5/31/99 4:13 am01:150TTFFSTthis is a new eucounta 2 red Version area quotha12289OTobjective12289ATAssessment12289PTplans12289LThaf
Na
Cl
K
CO2
bun
creat
glucose
RBC
WBC
HGB
HCT


12289GIC51088D675F5884EA029CF17FF5F864C4B9D3C554E3F3EA3043473F0F4223F3D006543311701400934600011E16920FED6D96A696F3378AA8E81D36966E9EA0403534B06B066871441230534888F4D914027A3B94152D9000670531007009441850A7A31972E08C6E4974B131801134915468RTMND16LC