DRMC Neurology Clinical Summary

JULIE BLOSE

Birth Date: April 19, 1961 Address: 413 S MAIN ST PUNXSUTAWNEY, PA, 15767
1815
Sex: Female
Patient Contact Info: tel:+18149384304 Home
Marital Status: Single mailto:[email protected]
Race: White

Ethnicity: Not Hispanic or Latino

Language: English

Patient ID: 1591284470050010

Encounter Date: May 19, 2017 to May 19, 2017

Encounter Location: id: 1621779812008050 2.16.540.1.113883.19.2
Care Team: Jason Ignatius DO tel:+18143752070 Work

TableofContents

I. Reason for Visit

II. Chief Complaint
III. Instructions
IV. Plan of Care
V. Medications
VI. Conditions or Problems
VII. Allergies, Adverse Reactions, Alerts
VIII. Social History
IX. Vital Signs
X. Results
XI. Procedures
XII. Medications Administered
XIII. Immunizations
XIV. Advance Directives
XV. Assessments
XVI. Review of Systems
XVII. Family History
XVIII. History of Past Illness
XIX. History of Present Illness

ReasonforVisit
Reason For Visit Description Start Date
ReasonforVisit
Reason For Visit Description Start Date

Follow Up 2017/05/19

ChiefComplaint
Chief Complaint Description Start Date

Follow Up 2017/05/19

Instructions
No information available.

PlanofCare
Type Date Detail

Appointment 2017/05/19 09:20 Jason L Ignatius DO, 145 Hospital Avenue, Suite 211, DuBois, PA, 158011464, +1814
AM 3752070

Appointment 2017/07/14 10:40 Jason L Ignatius DO, 145 Hospital Avenue, Suite 211, DuBois, PA, 158011464, +1814
AM 3752070

Appointment 2017/08/17 09:40 Jason L Ignatius DO, 145 Hospital Avenue, Suite 211, DuBois, PA, 158011464, +1814
AM 3752070

Appointment 2017/12/18 08:30 Nicole L Hoover CRNP, 551 W Mahoning Street, Punxsutawney, PA, 157671909
AM

Pending 2017/05/19 MRI Brain w/ + w/o Contrast Routine

order

Medications
Medication Instructions Start Date Stop Generic Name NDC Provider
Date
TEMAZEPAM 15 MG CAPS 2017/05/19 TEMAZEPAM 00378401077 Jason L
take 1 po qhs. Ignatius
DO
CEFTIN 250 MG TABS 1 pill twice a day 2017/05/07 CEFUROXIME AXETIL 66105074503 Darlene A
Brink
CRNP
NORTRIPTYLINE HCL 10 3 caps at night 2016/12/21 NORTRIPTYLINE HCL 33358027030 Jason L
MG CAPS Ignatius
DO
SYNTHROID 200 MCG 1 tablet by mouth Monday 2015/05/15 LEVOTHYROXINE 00074714890 Nicole L
TABS to Wednesday, 2 tablets SODIUM Hoover
Thursday to Sunday CRNP
ACYCLOVIR 800 MG TABS 1 tab PO BID 2016/12/21 ACYCLOVIR 33261022750 Lu Ann
Mabie
CRNP
NITROFURANTOIN PATIENT NOT TAKING 2016/06/21 NITROFURANTOIN 54569831600 Nicole L
Medications
ACYCLOVIR 800 MG TABS 1 tab PO BID 2016/12/21 ACYCLOVIR 33261022750 Lu Ann
Medication Instructions Start Date Stop Generic Name NDC Mabie
Provider
Date CRNP
NITROFURANTOIN PATIENT NOT TAKING 2016/06/21 NITROFURANTOIN 54569831600 Nicole L
MONOHYD MACRO 100 MONOHYD MACRO Hoover
MG CAPS CRNP
PROCHLORPERAZINE 1 tab at onset of headache , 2016/09/22 PROCHLORPERAZINE 66267031830 Lu Ann
MALEATE 10 MG TABS then q6hrs PRN, nausea. MALEATE Mabie
CRNP
GABAPENTIN 600 MG 1 by mouth 3 times a day 2016/09/22 GABAPENTIN 31722040505 Lu Ann
TABS Mabie
CRNP
XARELTO 15 MG TABS 1 tab po daily 2013/09/12 George O
RIVAROXABAN Angheloiu
MD

ConditionsorProblems
Problem Name Problem Code Onset Date Status Entry Date Provider Comment Standard Description Annotate

Weakness, right side 278286009 2017/05/19 Active 2017/05/19 Jason L Right hemiparesis
of body SNOMED CT Ignatius
DO

Sinusitis 36971009 2017/05/07 Active 2017/05/07 Darlene A Sinusitis

SNOMED CT Brink
CRNP

Bronchitis 32398004 2017/05/07 Active 2017/05/07 Darlene A Bronchitis

SNOMED CT Brink
CRNP

Contusion 125667009 2017/03/25 Active 2017/03/25 Darlene A Contusion

SNOMED CT Brink
CRNP

Hip joint pain, right 49218002 2017/03/25 Active 2017/03/25 Darlene A Hip pain
SNOMED CT Brink
CRNP

Foot joint pain, left 279066007 2017/01/18 Active 2017/01/18 Ashlee N Foot joint pain
SNOMED CT Spack PA
C

Myalgia 68962001 2017/01/17 Active 2017/01/17 Michele R Muscle pain

SNOMED CT Harris
CRNP

Cervical 54404000 2017/01/17 Active 2017/01/17 Michele R Cervical

radiculopathy SNOMED CT Harris radiculopathy
CRNP

Neck pain 81680005 2017/01/17 Active 2017/01/17 Michele R Neck pain

SNOMED CT Harris
CRNP

Paresthesia 91019004 2016/06/08 Active 2016/06/08 Darlene A Paresthesia

SNOMED CT Brink
CRNP
ConditionsorProblems CRNP

Paresthesia
Problem Name 91019004
Problem Code 2016/06/08
Onset Date Active
Status 2016/06/08
Entry Date Darlene
Provider A Paresthesia
Comment Standard Description Annotate
SNOMED CT Brink
CRNP

UTI 68566005 2016/06/08 Active 2016/06/08 Darlene A Urinary tract

SNOMED CT Brink infectious disease
CRNP

Dizziness 404640003 2016/06/08 Active 2016/06/08 Darlene A Dizziness

SNOMED CT Brink
CRNP

Syncope and collapse 309585006 2016/01/26 Active 2016/01/26 Jason L Syncope and
SNOMED CT Ignatius collapse
DO

Orthostatic dizziness 103017008 2016/01/26 Active 2016/01/26 Jason L Postural dizziness

SNOMED CT Ignatius
DO

Back pain, lumbar 279039007 2016/01/26 Active 2016/01/26 Jason L Low back pain
SNOMED CT Ignatius
DO

Thyroid goiter, simple E04.0 ICD10CM 2015/05/15 Active 2015/05/15 Sarvesh Nontoxic diffuse
Rajan MD goiter

Insomnia, unspecified 193462001 2014/11/21 Active 2014/11/21 Jason L Insomnia

SNOMED CT Ignatius
DO

Migraine NOS w/o 425007008 2014/09/29 Active 2014/09/29 Jason L Migraine without
intractable migraine SNOMED CT Ignatius aura, not
DO refractory

Occipital neuralgia 71760005 2014/09/29 Active 2014/09/29 Jason L Cervicooccipital

SNOMED CT Ignatius neuralgia
DO

Other peripheral H81.399 ICD10 2014/09/11 Active 2014/09/11 Jason L Other peripheral
vertigo CM Ignatius vertigo,
DO unspecified ear

Mild cognitive 386806002 2014/06/20 Active 2014/06/20 Jason L Impaired

impairment, so stated SNOMED CT Ignatius cognition
DO

Dysarthria as late 133981000119106 2014/06/20 Active 2014/06/20 Jason L Dysarthria as late

effect of SNOMED CT Ignatius effects of
cerebrovascular DO cerebrovascular
disease disease

Vertigo of central 38403006 2014/06/20 Active 2014/06/20 Jason L Vertigo of central

origin SNOMED CT Ignatius origin
DO

Unspecified 62914000 2014/06/20 Active 2014/06/20 Jason L Cerebrovascular

cerebrovascular SNOMED CT Ignatius disease
disease DO

Hypoxemia 389087006 2014/04/22 Active 2014/04/22 George O Hypoxemia

SNOMED CT Angheloiu
ConditionsorProblems
cerebrovascular SNOMED CT Ignatius disease
disease DO
Problem Name Problem Code Onset Date Status Entry Date Provider Comment Standard Description Annotate
Hypoxemia 389087006 2014/04/22 Active 2014/04/22 George O Hypoxemia
SNOMED CT Angheloiu
MD

SNORING 72863001 2014/01/23 Active 2014/01/23 Susan M Snoring

SNOMED CT Mitchell
CRNP

SOMNOLENCE 271782001 2014/01/23 Active 2014/01/23 Susan M Drowsy

SNOMED CT Mitchell
CRNP

OBSTRUCTIVE SLEEP 78275009 2013/12/12 Active 2013/12/12 George O Obstructive sleep

APNEA SNOMED CT Angheloiu apnea syndrome
MD

PALPITATIONS 80313002 2013/04/01 Active 2013/04/01 George O Palpitations

SNOMED CT Angheloiu
MD

VITAMIN D 34713006 2013/02/28 Active 2013/02/28 Christine Vitamin D

DEFICIENCY SNOMED CT S Ferut deficiency

GOITER 3716002 2013/02/28 Active 2013/02/28 Christine Goiter

SNOMED CT S Ferut

HYPOTHYROIDISM 40930008 2013/02/28 Active 2013/02/28 Christine Hypothyroidism

SNOMED CT S Ferut

FATIGUE 84229001 2012/09/13 Active 2012/09/13 Susan M Fatigue

SNOMED CT Mitchell
CRNP

GERD 235595009 2012/03/28 Active 2012/03/28 Holly M Gastroesophageal

SNOMED CT Limerick reflux disease
LPN

CVA 230690007 2012/03/28 Active 2012/03/28 Holly M Cerebrovascular

SNOMED CT Limerick accident
LPN

CAD 53741008 2012/03/28 Active 2012/03/28 Holly M Coronary

SNOMED CT Limerick arteriosclerosis
LPN

DYSPNEA 267036007 2012/03/28 Active 2012/03/28 Holly M Dyspnea

SNOMED CT Limerick
LPN

DEPRESSION 35489007 2012/03/28 Active 2012/03/28 Holly M Depressive

SNOMED CT Limerick disorder
LPN

HEADACHE 25064002 2012/03/28 Active 2012/03/28 Holly M Headache

SNOMED CT Limerick
LPN

CHEST PAIN 29857009 2012/03/28 Active 2012/03/28 Holly M Chest pain

SNOMED CT Limerick
LPN
ConditionsorProblems
CHEST PAIN 29857009 2012/03/28 Active 2012/03/28 Holly M Chest pain
Problem Name SNOMED
Problem CT
Code Onset Date Status Entry Date Limerick
Provider Comment Standard Description Annotate
LPN

DEEP VENOUS 40198004 2011/09/06 Active 2011/09/06 Dana Thrombophlebitis

THROMBOPHLEBITIS, SNOMED CT Zelenky of deep veins of
LEG MA lower extremity

HEARING LOSS, LEFT 15188001 2011/09/06 Active 2011/09/06 Dana Hearing loss
EAR SNOMED CT Zelenky
MA

DIPLOPIA 24982008 2011/09/06 Active 2011/09/06 Dana Diplopia

SNOMED CT Zelenky
MA

PROBLEMS WITH Z86.59 ICD10 2011/09/06 Active 2011/09/06 Dana Personal history
COMMUNICATION CM Zelenky of other mental
MA and behavioral
disorders

NEURALGIA, 31681005 2011/09/06 Active 2011/09/06 Dana Trigeminal

TRIGEMINAL SNOMED CT Zelenky neuralgia
MA

UNSPECIFIED 234532001 2011/09/06 Active 2011/09/06 Dana Immunodeficiency

IMMUNITY SNOMED CT Zelenky disorder
DEFICIENCY MA

Allergies,AdverseReactions,Alerts
Allergy Name Reaction Description Start Date Severity Status Provider

AMBIEN Hallucinations 2017/04/19 Moderate Active Sharon I Freno LPN

IV CORTISONE Studdering 2012/09/13 Mild Active Susan M Mitchell CRNP

SocialHistory
No information available.

VitalSigns
Date Name Value Unit Description

2017/05/19 BMI Body Mass Index 36.09 kg/m2 Body Mass Index [Ratio]

2017/05/19 BP Diastolic 74 mm[Hg] blood pressure, diastolic 84624

2017/05/19 BP Systolic 114 mm[Hg] blood pressure, systolic 84806

2017/05/19 Heart Rate 76 /min pulse rate E&M 88674

2017/05/19 Height 63 [in_us] height E&M 83022

2017/05/19 Height 160 cm height in centimeters E&M

2017/05/19 Respiratory Rate 16 /min respiratory rate E&M 92791

2017/05/19 Weight Measured 203 [lb_av] weight E&M 31419

2017/05/19 Weight Measured 92.3 kg weight in kilograms E&M

VitalSigns
2017/05/19 Respiratory Rate 16 /min respiratory rate E&M 92791

2017/05/19
Date Weight
Name Measured 203
Value [lb_av]
Unit weight E&M
Description 31419

2017/05/19 Weight Measured 92.3 kg weight in kilograms E&M

Results
Date Name Value Unit Range Flag Description

Office Visit: NEURO F/U

2017/05/19 MEDS REVIEW Done Documentation of current medications procedure

Procedures
Code Procedure Name Date Entry Date

CPTG8427 Documentation of Current Medications 2017/05/19 2017/05/19

3008F Body Mass Index BMI, documented PV 2017/05/19 2017/05/19

MedicationsAdministered
No information available.

Immunizations
No information available.

AdvanceDirectives
There may be information available, but it has not been provided by the sender.

Assessments
There may be information available, but it has not been provided by the sender.

ReviewofSystems
There may be information available, but it has not been provided by the sender.

FamilyHistory
There may be information available, but it has not been provided by the sender.

HistoryofPastIllness
There may be information available, but it has not been provided by the sender.

HistoryofPresentIllness
There may be information available, but it has not been provided by the sender.
There may be information available, but it has not been provided by the sender.