Tra Test

Approach

• Patient last name: Test
• Patient first name: Tra
• Code status: Full Code
• Out-of-hospital DNR: No
• Seen for: physical exam
• Problem: Backache
• Stopped medication: Esgic with Codeine 50 mg-325 mg-40 mg-30 mg capsule
• Stopped medication: metoprolol succ 25 mg-hydrochlorothiazide 12.5 mg tablet,ext.rel 24 hr

Arrival

• Parking

  Parking: recorded in no system today (not in athena, not in CareDash).

• Gate code

  Gate code: recorded in no system today (not in athena, not in CareDash).

• Pets: Yes
• Guns in the home: Yes
• Precautions

  Precautions (airborne or contact): held in CareDash (the care plan and precautions field), not in athena.

• Walks alone: Yes: walks without restrictions
• Caregiver: Yes

Orders

Encounter 02/06/2024

• Diagnosis: chest pain

Consult

• Order: interventional cardiology referral
• Order status: REVIEW

Prescription

• Order: Esgic with Codeine 50 mg-325 mg-40 mg-30 mg capsule
• Order status: REVIEW

• Order: Esgic with Codeine 50 mg-325 mg-40 mg-30 mg capsule
• Order status: REVIEW
• Diagnosis: dyspnea

Consult

• Order: interventional cardiology referral
• Order status: REVIEW

Encounter 07/13/2023

• Diagnosis: pain of knee region

Prescription

• Order: aspirin 325 mg tablet
• Order status: REVIEW

Imaging

• Order: XR, knee
• Order status: REVIEW

Lab

• Order: T3, free, serum or plasma
• Order status: REVIEW

• Order: T4, free, serum
• Order status: REVIEW

• Order: TSH, serum or plasma
• Order status: REVIEW

Allergies

• Allergy: raspberry
• Reaction: vomiting

Problems

• Problem: Backache
• Status: CHRONIC

Medications

ANALGESIC/ANTIPYRETICS, SALICYLATES

• Medication: aspirin 325 mg tablet
• Sig: Take 1 tablet every day by oral route.
• Route: oral
• Status: REVIEW

ANTIHYPERTENSIVES, ACE INHIBITORS

• Medication: lisinopril 20 mg tablet
• Sig: Take 1 tablet every day by oral route.
• Route: oral
• Status: REVIEW

BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING

• Medication: albuterol sulfate HFA 90 mcg/actuation aerosol inhaler
• Sig: Inhale 2 puffs every 4 hours by inhalation route.
• Route: inhalation
• Status: SUBMIT

BETA-ADRENERGIC BLOCKING AGENTS

• Medication: atenolol 50 mg tablet
• Sig: Take 1 tablet every day by oral route.
• Route: oral
• Status: REVIEW

• Medication: metoprolol tartrate 25 mg tablet
• Sig: Take 1 tablet twice a day by oral route.
• Route: oral
• Status: SUBMIT

PRENATAL VITAMIN PREPARATIONS

• Medication: Prenatal Vitamin 27 mg iron-0.8 mg tablet
• Status: REVIEW

NSAIDS, CYCLOOXYGENASE INHIBITOR TYPE ANALGESICS

• Medication: ibuprofen

THYROID HORMONES

• Medication: levothyroxine 100 mcg capsule
• Sig: Take 1 capsule every day by oral route before meals for 90 days.
• Route: oral

Social history

• Are you able to care for yourself independently?: Yes
• Are you able to walk independently without assistance or assistive devices?: Yes: walks without restrictions
• Do you have difficulty walking or climbing stairs?: No
• Do you have difficulty dressing, bathing, grooming, or toileting?: No
• Do you have difficulty doing errands alone?: No
• Do you have difficulty concentrating, remembering or making decisions?: No
• Are you blind or do you have difficulty seeing?: No
• Where do you live?: Single-level house
• Have there been any changes to your family or social situation?: No
• Are you a caregiver?: Yes
• Do you have transportation difficulties?: No
• What is your code status?: Full Code
• Do you have an out of hospital DNR?: No
• Do you have an advance directive?: No
• Do you have a directive to physicians?: No
• Do you have a medical power of attorney?: No
• Do you have a patient advocate?: No
• Do you or have you ever smoked tobacco?: Never smoker
• How many years have you consumed alcohol?: 12
• Do you or have you ever used any illicit or recreational drugs?: No
• Are there any guns present in your home?: Yes
• Do you have any pets?: Yes

Vitals

BP

• BP 11/22/2022, Diastolic blood pressure: 80 unit not given by athena (L arm, sitting, adult)
• BP 11/22/2022, Systolic blood pressure: 120 unit not given by athena (L arm, sitting, adult)

BMI

• BMI 11/22/2022, Body mass index (BMI) [Ratio]: 22.2 unit not given by athena

Ht

• Ht 11/22/2022, Body height: 175.26 unit not given by athena (Standing)

Wt

• Wt 11/22/2022, Body weight: 68038.8555 g (With clothes)

BSA

• BSA 11/22/2022, Body surface area Derived from formula: 1.82 unit not given by athena

Refusals

• Refused or not performed: Not Performed (6 readings)

Symptoms

• Review of systems 02/06/2024: None recorded.
• Review of systems 07/13/2023: None recorded.
• Review of systems 07/05/2023: None recorded.
• Review of systems 11/22/2022: None recorded.
• Review of systems 09/01/2022: None recorded.
• Review of systems 08/15/2022: None recorded.
• Screener: PHQ-2/PHQ-9
• Screener: HOOS-PS
• HOOS-PS score: 56.88
• Screener: AUDIT-C

Last visit

• Visit: physical exam
• Date: 02/06/2024
• Provider first name: Carter
• Provider last name: Rome

Reason for enrollment

This needs a FHIR scope that the app does not hold.

Hospital course

This needs a FHIR scope that the app does not hold.

Outstanding actions

This needs a FHIR scope that the app does not hold.

Labs

No lab result in Preview for this patient.

Departure checklist

The checkboxes stay on this screen only: nothing is saved or sent.

• Order done? interventional cardiology referral
• Order done? Esgic with Codeine 50 mg-325 mg-40 mg-30 mg capsule
• Order done? Esgic with Codeine 50 mg-325 mg-40 mg-30 mg capsule
• Order done? interventional cardiology referral
• Order done? aspirin 325 mg tablet
• Order done? XR, knee
• Order done? T3, free, serum or plasma
• Order done? T4, free, serum
• Order done? TSH, serum or plasma
• Vitals taken? Last recorded: 11/22/2022
• Change reconciled? Esgic with Codeine 50 mg-325 mg-40 mg-30 mg capsule
• Change reconciled? metoprolol succ 25 mg-hydrochlorothiazide 12.5 mg tablet,ext.rel 24 hr