Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
Hospital No. 999 INPATIENT FACE SHEET Patient Name and Address Gender PIRE, SALLY
1122 CHERRY STREET
ALMOND, NY 14804 Race F Admission Date Time Discharge Date Time 06-30-YYYY 12:45 07-07-YYYY 10:00 Marital Status W S Patient No. IPCase006 Date of Birth Age Maiden
Name Occupation 06/23/YYYY 60 NA Nurses’
Aide Length of Stay Telephone Number 05 DAYS (607)000-4397 Guarantor Name and Address Next Of Kin Name and Address PIRE, SALLY
1122 CHERRY STREET
ALMOND, NY 14804 PIRE, JACOB
556 MILL STREET
ALMOND, NY 14804 Guarantor Telephone No. Relationship to Patient Next of Kin Telephone Number Relationship to Patient (607) 000-4397 Self (607)555-7676 BROTHER Admitting Physician Service Admit Type Room Number/Bed John Black, MD ME NA 0371 Attending Physician Admitting Diagnosis John Black, MD Bacterial pneumonia Primary Insurer Policy and Group Number Secondary Insurer Policy and Group Number New Age Insurance PW 6790456 NEBC 229162171
ICD Code Diagnoses and Procedures
Principal Diagnosis Bacterial Pneumonia
Secondary Diagnoses Arteriosclerotic cardiovascular disease
Principal Procedure Secondary Procedures Discharge Instructions
Activity: Bed rest Light Diet: Regular Low Cholesterol Follow-Up: Call for appointment Usual Unlimited Low Salt ADA Other: As tolerated. _____ Calorie Office appointment on 07-14 Other: Special Instructions:
Attending Physician Authentication: Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 01:00:00 PM EST) 1|Page
Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 I, CONSENT TO ADMISSION Sally Pire hereby consent to admission to the Global Care Medical Center (ASMC) , and I further consent to
such
routine hospital care, diagnostic procedures, and medical treatment that the medical and professional staff of ASMC may
deem necessary or advisable. I authorize the use of medical information obtained about me as specified above and the
disclosure of such information to my referring physician(s). This form has been fully explained to me, and I understand its
contents. I further understand that no guarantees have been made to me as to the results of treatments or examinations
done at the ASMC. Reviewed and Approved: Sally Pire
ATP-B-S:02:1001261385: Sally Pire
(Signed: 06/30/YYYY 01:45:05 PM EST)
Signature of Patient
Signature of Parent/Legal Guardian for Minor
Relationship to Minor
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 06/30/YYYY 01:45:05 PM EST)
WITNESS: Global Care Medical Center Staff Member CONSENT TO RELEASE INFORMATION FOR REIMBURSEMENT PURPOSES
In order to permit reimbursement, upon request, the Global Care Medical Center (ASMC) may disclose such treatment
information pertaining to my hospitalization to any corporation, organization, or agent thereof, which is, or may be liable
under contract to the ASMC or to me, or to any of my family members or other person, for payment of all or part of the
ASMC’s charges for services rendered to me (e.g. the patient’s health insurance carrier). I understand that the purpose of
any release of information is to facilitate reimbursement for services rendered. In addition, in the event that my health
insurance program includes utilization review of services provided during this admission, I authorize ASMC to release
information as is necessary to permit the review. This authorization will expire once the reimbursement for services
rendered is complete. Reviewed and Approved: Sally Pire
ATP-B-S:02:1001261385: Sally Pire
(Signed: 06/30/YYYY 01:47:05 PM EST)
Signature of Patient
Signature of Parent/Legal Guardian for Minor
Relationship to Minor
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 06/30/YYYY 01:48:05 PM EST)
WITNESS: Global Care Medical Center Staff Member
2|Page
Permission to reuse granted by Alfred State College and Michelle A. Green. GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 ADVANCE DIRECTIVE Your answers to the following questions will assist your Physician and the Hospital to respect your wishes regarding your
medical care. This information will become a part of your medical record.
YES NO PATIENT’S INITIALS X 1. Have you been provided with a copy of the information called
“Patient Rights Regarding Health Care Decision?”
2. Have you prepared a “Living Will?” If yes, please provide the
Hospital with a copy for your medical record. X 3. Have you prepared a Durable Power of Attorney for Health
Care? If yes, please provide the Hospital with a copy for your
medical record. X 4. Have you provided this facility with an Advance Directive on
a prior admission and is it still in effect? If yes, Admitting
Office to contact Medical Records to obtain a copy for the
medical record. X 5. Do you desire to execute a Living Will/Durable Power of
Attorney? If yes, refer to in order:
a. Physician
b. Social Service
c. Volunteer Service X HOSPITAL STAFF DIRECTIONS: Check when each step is completed.
1. Verify the above questions where answered and actions taken where required. 2. If the “Patient Rights” information was provided to someone other than the patient, state reason: Name of Individual Receiving Information Relationship to Patient 3. If information was provided in a language other than English, specify language and method. 4. Verify patient was advised on how to obtain additional information on Advance Directives. 5. Verify the Patient/Family Member/Legal Representative was asked to provide the Hospital with a copy of
the Advanced Directive which will be retained in the medical record.
File this form in the medical record, and give a copy to the patient. Name of Patient Name of Individual giving information if different from Patient Reviewed and Approved: Sally Pire
ATP-B-S:02:1001261385: Sally Pire
(Signed: 06/30/YYYY 01:48:05 PM EST)
Signature of Patient Date Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 06/30/YYYY 01:49:05 PM EST)
3|Page
Permission to reuse granted by Alfred State College and Michelle A. Green. Signature of Hospital Representative Date GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 PATIENT HISTORY PROBLEMS: 1. Arteriosclerotic cardiovascular disease; 2. Past history of alcoholism; 3.
Past history of hypokalemia; 4. Past history of gastritis.
MEDICATIONS: Lanoxin 0.125 milligrams a day
Lasix 20 milligrams a day
Klotrix tablets 1 tablet three times daily
PAST MEDICAL HISTORY: Patient has had some problems with alcohol in the past and a
history of gastritis due to excessive alcohol intake. She had a fractured wrist last year
potentially a secondary injury due to excessive inebriation. She also has recently been
put on Lanoxin and Lasix, apparently for arteriosclerotic cardiovascular problems, as she
experienced mild angina. Subsequent to her second admission in YYYY, she was referred to
General Hospital for further evaluation and treatment of her abnormal liver function
studies. It was determined at that time that she did not have an active process.
ALLERGY TO ASPIRIN
FAMILY HISTORY: History of alcoholism on mother’s side and cardiovascular disease on
father’s side. Brother has had heart attack related to coronary artery disease.
SOCIAL HISTORY: She works as a nurse’s aide. She’s a moderate smoker. Denies heavy
drinking, but we are not quite sure about that. DD: 06/30/YYYY Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 06:05:44 PM EST) DT: 07/01/YYYY Physician Name 4|Page
Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 ADMISSION DATE: 06/30/YYYY DISCHARGE SUMMARY DISCHARGE DATE: 07/07/YYYY ADMISSION DIAGNOSIS: 1. Viral pneumonia; 2. Arteriosclerotic cardiovascular
disease; 3. Past history of alcoholism; 4. Past history of hypokalemia; 5. Past
history of gastritis.
DISCHARGE DIAGNOSES: Pneumonia. Arteriosclerotic cardiovascular disease.
SUMMARY: This is a 61-year-old white female who has been doing fairly well
recently until the onset of an upper respiratory infection with a cough,
recurrent chills, sweats, fever. She tried to work, was unable to. Her
temperature went to 102. Abdominal x-ray showed a pneumonia, and I felt that she
should be admitted for further evaluation and treatment.
Work-up has included a chest x-ray which revealed a small area of infiltrate in
the lingular of the right side compatible with an acute pneumonia; a follow-up
study is suggested. Repeat chest x-ray showed bilateral pneumonia, clearing;
however, there was a remaining area of consolidation in the lateral portion of
the middle lobe. Her urine showed a specific gravity of 1.015, albumin and sugar
were negative, white blood cells rare, red blood cells 0-6. White count 15,000.
Hemoglobin 11.8, hematocrit 34.8, segmented cells 52, lymphocytes 18, monocytes
12, eosinophils 3, and 5 band cells. Complete blood count was normal. Sodium 137,
potassium 3.4, carbon dioxide 27, chloride 97, alkaline phosphatase 10.4, blood
sugar 81, cholesterol 138, Serum glutamic oxalacetic transaminase 42, Lactate
dehydrogenase 260, creatinine 0.4, calcium 8.3, phosphorus 2.2, bilirubin 1.2,
total protein 6.1, albumin 3.2, uric acid 0.5. Sputum culture grew out a 1+
enterobacter. Cardiogram was reported as showing sinus tachycardia; this later
slowed down clinically.
She was started originally on Ampicillin 500 milligrams, four times a day,
Intermittent positive pressure breathing. She was continued on her Lanoxin 0.125
a day, Lasix 20 milligrams a day, Klotrix tablets 1 tablet three times a day. Her
temperature stayed up, her Ampicillin was stopped, and she was switched to
Enalapril 500 milligrams, four times a day. Now her temperature has been normal
for 48 hours. She feels better, and her cough has lessened. She is up ambulatory,
and she is anxious to go home. She is being discharged at this time on E-Mycin
333 milligrams, three times a day and Afrin nasal spray. She will continue on her
Lanoxin 0.125 milligrams a day, Lasix 20 milligrams a day, and should be seen in
follow-up in the office early next week. Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 05:44:18 PM EST) DD: 06/30YYYY
DT: 07/01/YYYY Physician Name GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 5|Page
Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 CURRENT VISIT & PHYSICAL
EXAM ADMISSION DIAGNOSIS: 1. Bacterial pneumonia; 2. Arteriosclerotic cardiovascular disease;
3. Past history of alcoholism; 4. Past history of hypokalemia; 5. Past history of
gastritis.
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 60-year-old female who has been in the hospital on
two occasions within the past year or two. Her last admission was related to some
problems with alcohol. Prior to that she had been in with some abnormal liver function
studies that were later evaluated at Strong. Recently she’s been doing fairly well until
a few days ago when she had the onset of upper respiratory symptoms. She continued to
work. She now is coughing, having chills, fever, and sweats. She was seen and evaluated
in the office this morning. She had fever of 102. We referred her over for a chest x-ray
which showed pneumonia of the left lung field, and she subsequently was admitted for
further investigation, evaluation, and treatment.
FAMILY HISTORY: History of alcoholism on mother’s side and cardiovascular disease on
father’s side. Brother has had heart attack related to coronary artery disease.
SOCIAL HISTORY: She works as a nurse’s aide. She’s a moderate smoker. Denies heavy
drinking, but we are not quite sure about that.
REVIEW OF SYSTEMS: She has hacking cough, slight dyspnea on exertion, 2 pillow orthopnea,
no hemoptysis. Appetite has been fair. She denies any specific bowel or bladder
symptomatology.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 102. Pulse 90, Respirations 24.
SKIN: Warm, dry.
EYES: pupils round, reactive and equal. Extraocular muscles intact. Sclera clear; no
evidence of any jaundice. Nose and throat are unremarkable.
NECK: Supple. No nodes or thyroid abnormalities.
CHEST: Scattered rales and rhonchi at both mid-lung fields. HEART: Sounds are somewhat
distant. No significant murmurs are heard. BREASTS: Soft and free of masses.
ABDOMEN: No palpable organomegaly or masses. No tenderness or bruits. Bowel sounds
normally active.
PELVIC: Not done. RECTAL: Not done.
EXTREMITIES: Warm, pulses good.
NEUROLOGIC: Okay.
DD: 06/30/YYYY Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 06:05:44 PM EST) DT: 07/01/YYYY Physician Name
GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 6|Page
Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 Date
06/30/YYYY Time
1300 PROGRESS NOTES Physician’s signature required for each order. (Please skip one line between dates.) CHIEF COMPLAINT: Shortness of breath.
DIAGNOSIS: 1) Pneumonia. 2) Arteriosclerotic
cardiovascular disease.
Confirmed _______ Provisional __X___ PLAN OF TREATMENT: Admit for evaluation and
treatment.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 01:47:02 PM EST)
06/30/YYYY 1800 Intermittent positive pressure breathing ordered four
times a day and saline for 48 hours. Started at 1730.
Patient tolerated well. Slight production with cough,
sputum clear in color.
Reviewed and Approved: Rose Markam, CPT
ATP-B-S:02:1001261385: Rose Markam, CPT
(Signed: 06/30/YYYY 06:07:22 PM EST) 07/01/YYYY 0800 Intermittent positive pressure breathing treatment
given at 0700. Non-productive cough noted.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/01/YYYY 08:17:30 AM EST) 07/01/YYYY 1000 Intermittent positive pressure breathing treatment
given at 1000. Tolerated well.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/01/YYYY 10:06:00 AM EST) 07/01/YYYY 1300 Intermittent positive pressure breathing treatment given
at 1300. Good treatment.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/01/YYYY 01:17:30 PM EST) 7|Page
Permission to reuse granted by Alfred State College and Michelle A. Green. GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 8|Page
Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 Date
07/01/YYYY Time
1600 PROGRESS NOTES Physician’s signature required for each order. (Please skip one line between dates.) Intermittent positive pressure breathing treatment given
at 1600. Tolerated well.
Reviewed and Approved: Rose Markam, CPT
ATP-B-S:02:1001261385: Rose Markam, CPT
(Signed: 07/01/YYYY 04:10:30 PM EST) 07/01/YYYY 1900 Still feels “lousy.” Temperature up.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/01/YYYY 07:07:42 PM EST) 07/02/YYYY 1000 Intermittent positive pressure breathing treatment not
given at 0700. Therapist busy in Intensive Care Unit. 1000
tolerated.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/02/YYYY 10:06:00 AM EST) 07/02/YYYY 1300 Intermittent positive pressure breathing treatment given.
Some production.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/02/YYYY 01:17:30 PM EST) 07/02/YYYY 1600 Intermittent positive pressure breathing treatment given
at 1600. Tolerated.
Reviewed and Approved: Rose Markam, CPT
ATP-B-S:02:1001261385: Rose Markam, CPT
(Signed: 07/02/YYYY 04:06:00 PM EST) 07/02/YYYY 1900 Hydration good. Not much appetite.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/02/YYYY 07:07:42 PM EST) 07/03/YYYY 0800 Temperature still up. Will switch to Erythromycin. Still
ambulatory as tolerated.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/03/YYYY 08:07:42 AM EST) 9|Page
Permission to reuse granted by Alfred State College and Michelle A. Green. GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234
PIRE, SALLY
IPCase006
Dr. BLACK Date
07/03/YYYY Admission: 06/30/YYYY
DOB: 06/23/YYYY
ROOM: 0371 Time
1030 PROGRESS NOTES Physician’s signature required for each order. (Please skip one line between dates.) Intermittent positive pressure breathing treatment with
normal saline four times a day for 48 hours started at
1030. Tolerated well. No cough noted.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/03/YYYY 10:36:00 AM EST) 07/03/YYYY 1300 Intermittent positive pressure breathing treatment at
1300. Tolerated well.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/03/YYYY 01:06:45 PM EST) 07/03/YYYY 1700 Intermittent positive pressure breathing treatment at
1700. Tolerated well.
Reviewed and Approved: Rose Markam, CPT
ATP-B-S:02:1001261385: Rose Markam, CPT
(Signed: 07/03/YYYY 05:03:00 PM EST) 07/04/YYYY 0700 Feels better. Temperature coming down.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/04/YYYY 07:02:30 AM EST) 07/04/YYYY 0700 Intermittent positive pressure breathing treatment at
0700. Tolerated well. No cough.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/04/YYYY 07:06:45 AM EST) 07/04/YYYY 1000 Intermittent positive pressure breathing treatment at
1000. Tolerated.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/04/YYYY 10:02:17 AM EST) 07/04/YYYY 1300 Intermittent positive pressure breathing treatment at 1300.
Tolerated well. No cough.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT 10 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green. (Signed: 07/04/YYYY 01:06:45 PM EST)
GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 11 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 Date
07/04/YYYY Time
1800 PROGRESS NOTES Physician’s signature required for each order. (Please skip one line between dates.) Intermittent positive pressure breathing treatment at
1800. Tolerated well. No cough.
Reviewed and Approved: Rose Markam, CPT
ATP-B-S:02:1001261385: Rose Markam, CPT
(Signed: 07/04/YYYY 06:01:25 PM EST) 07/05/YYYY 0700 Intermittent positive pressure breathing treatment at
0700. Tolerated well. Dry cough released completion of 48
hours.
Reviewed and Approved: Shelly White CPT
ATP-B-S:02:1001261385: Shelly White CPT
(Signed: 07/05/YYYY 07:07:45 AM EST) 07/05/YYYY 0800 Dry cough. Fever down. Improving with intermittent
positive pressure breathing treatments. Serous otitis left
ear.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/05/YYYY 08:02:30 AM EST) 07/06/YYYY 0800 Afebrile. Regaining strength. Home tomorrow if chest x-ray
warrants.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/06/YYYY 08:06:45 AM EST) GLOBAL MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 12 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green. 13 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 DOCTORS’ ORDERS Date Time Physician’s signature required for each order. (Please skip one line between dates.) 06-30-YYYY 1530 Complete blood count
Urinalysis
Chest X-ray done as outpatient. Get report.
Electrocardiogram
SCG II
Electrolytes
Sputum for culture and sensitivity
Regular diet
Aspirin, 650 milligrams every four hours for elevated
temperature
Bed rest with bathroom privileges
Intermittent positive pressure breathing with saline four
times a day for 48 hours
Ampicillin 500 milligrams four times a day for 7 days
History and physical exam dictated.
Lanoxin, 0.125 milligram daily
Lasix, 20 milligrams daily
Klotrix one tablet three times a day
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 06/30/YYYY 03:33:12 PM EST) 07/01/YYYY 1115 Tylenol one or two tablets every four to six hours as needed
for fever.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/01/YYYY 11:18:44 AM EST) 07/01/YYYY 1515 Dalmane 15 milligrams every bedtime as needed for sleep.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/01/YYYY 03:20:00 PM EST) 07/03/YYYY 0930 Discontinue Ampicillin. Erythromycin 500 milligrams every six
hours for 5 days.
Intermittent positive pressure breathing with saline four
times a day for 48 hours
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/03/YYYY 09:32:12 AM EST) GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 14 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 Date
07/04/YYYY DOCTORS’ ORDERS Time Physician’s signature required for each order. (Please skip one line between dates.) 0800 Chest X-ray and Complete blood count scheduled for 07/05.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/04/YYYY 08:05:23 AM EST) 07/05/YYYY 1330 Dimetapp extentabs one tablet now then twice daily.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/05/YYYY 03:40:44 PM EST) 07/06/YYYY 1515 Afrin nasal spray – 2 squeezes in each nostril every 12 hours.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/06/YYYY 03:20:00 PM EST) 07/07/YYYY 0900 Discharge.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 07/07/YYYY 09:02:12 AM EST) GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 15 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 RADIOLOGY REPORT Date of X-ray: 07/05/YYYY
REASON: Pneumonia
TECHNICAL DATA: Posteroanterior and lateral.
CHEST: Posteroanterior and lateral views reveal partial clearing of the
lingular pneumonia since 06/30/YYYY. There is now an area of consolidation
In the lateral portion of the middle lobe. The lungs otherwise appear
clear.
CONCLUSION: Bilateral bacterial pneumonia. DD: 07/05/YYYY
DT: 07/06/YYYY Reviewed and Approved: Randall Cunningham MD
ATP-B-S:02:1001261385: Randall Cunningham MD
(Signed:07/05/YYYY 02:24:44 PM EST) GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 16 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 RADIOLOGY REPORT Date of X-ray: 06/30/YYYY
REASON: Rule out pneumonia.
TECHNICAL DATA: Please call.
06/30/YYYY
CHEST: Posteroanterior and lateral views reveal a small area of infiltrate
in the lingual. This would be compatible with an acute pneumonia and a
follow-up study is suggested. The heart is of normal size and the lungs
otherwise appear clear. There is an old fracture in the lower thoracic
spine and several old healing left rib fractures. DD: 06/30/YYYY
DT: 07/01/YYYY Reviewed and Approved: Randall Cunningham MD
ATP-B-S:02:1001261385: Randall Cunningham MD
(Signed:06/30/YYYY 02:32:08 PM EST) GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 17 | P a g e
Permission to reuse granted by Alfred State College and Michelle A. Green. PIRE, SALLY Admission: 06/30/YYYY IPCase006 DOB: 06/23/YYYY Dr. BLACK ROOM: 0371 SPECIMEN COLLECTED:
IN: 06/30YYYY
1614 LABORATORY DATA
SPECIMEN RECEIVED
OUT: 06/30/YYYY
1749 BLOOD CHEMISTRY 1
TEST REFERENCE ACID PHOSPHATASE 0.0-0.8 U/I RESULT ALKALINE PHOSPHATASE 50-136 U/I AMYLASE 23-85 U/I LIPASE 4-24 U/I GLUCOSE FASTING 70-110 mg/dl GLUCOSE Time collected BUN 7-22 mg/dl SODIUM 136-147 mEq/1 137 POTASSIUM 3.7-5.1 mEq/l **3.4** CARBON DIOXIDE 24-32 mEq/l 27 CHLORIDE 98-108 mEq/l 97 CHOLESTEROL 120-280 mg/dl SERUM GLUTAMATE
PYRU...

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