Clinical Summary Document

Patient Aana Test
Date of birth February 5, 1983 Sex Female
Race Asian Ethnicity
Contact info Primary Home:

, US
Tel: 9510206644
Patient IDs 0000000015 7e6ebf9c-775e-4f17-b497-0b6dbd2f6774
Document Id 616b1718-7915-4d56-a89f-2302e8f26379
Document Created April 28, 2017, 05:50
Performer (primary care physician) David Smith of Glendale
Author StreamlineMD EHR
Contact info Work Place:
6320 W. Union Hills Drive
Building A Suite 140
Glendale, AZ 85308, US
Tel: 6234358346
Encounter Id 12389790 2.16.840.1.113883.19
Encounter Date  From April 28, 2017 to April 28, 2017
Encounter Location Glendale
Responsible party David Smith of Glendale
Contact info Work Place:
6320 W. Union Hills Drive
Building A Suite 140
Glendale, AZ 85308, US

Document maintained by Glendale
Contact info Work Place:
6320 W. Union Hills Drive
Building A Suite 140
Glendale, AZ 85308, US
Tel: 6234358346

Table of Contents


Reason for Visit

Plan of Care

Information is not available

Instructions

Allergies

Date Onset Allergy Code Reaction Status Type
04/28/2017 Imatinib Analogues anemia active 416098002 - Drug Allergy
04/28/2017 Pan-2400 active 416098002 - Drug Allergy

Problems

Date Onset Problem Desc Code Condition Status
09/06/2013 Cramp in limb (finding) 424647005 Active
04/28/2017 Type II diabetes mellitus without complication (disorder) 313436004 Active
04/28/2017 Benign hypertension (disorder) 10725009 Active
10/13/2015 Low back pain (finding) 279039007 Active
10/13/2015 Ischemic heart disease (disorder) 414545008 Active
10/13/2015 Type II diabetes mellitus without complication (disorder) 313436004 Active
10/13/2015 Benign hypertension (disorder) 10725009 Active
02/01/2017 Non-neoplastic nevus (disorder) 195381005 Active
04/28/2017 Phlebitis and thrombophlebitis of lower extremities, unsp I80.3 Active
04/28/2017 Vulval varices (disorder) 48868008 Active
04/28/2017 Postphlebitic syndrome (disorder) 20427003 Active
04/28/2017 Peripheral venous insufficiency (disorder) 20696009 Active
04/28/2017 Lymphedema (disorder) 234097001 Active
04/28/2017 Other specified soft tissue disorders M79.89 Active
09/06/2013 Cramp in limb (finding) 424647005 Active
04/28/2017 Bleeding (finding) 131148009 Active
10/13/2015 Peripheral vascular disease (disorder) 400047006 Active
04/28/2017 Thrombosis of the popliteal vein (disorder) 427776007 Active
04/28/2017 Thrombosis of the popliteal vein (disorder) 427776007 Active
04/28/2017 Thrombosis of superficial vein of lower limb (disorder) 429434005 Active
04/28/2017 Varicose veins of lower extremity with ulcer AND inflammation (disorder) 69352009 Active
04/28/2017 Varicose veins of lower extremity with ulcer AND inflammation (disorder) 69352009 Active
04/28/2017 Varicose veins of right lower extremities with pain I83.811 Active
04/28/2017 Varicose veins of left lower extremities with pain I83.812 Active
08/30/2016 Asymptomatic varicose veins of right lower extremity I83.91 Active
08/30/2016 Asymptomatic varicose veins of left lower extremity I83.92 Active
04/28/2017 Venous hypertension (disorder) 234072000 Active
04/28/2017 Venous hypertension (disorder) 234072000 Active
04/28/2017 Peripheral venous insufficiency (disorder) 20696009 Active
04/28/2017 Peripheral venous insufficiency (disorder) 20696009 Active
04/28/2017 Peripheral venous insufficiency (disorder) 20696009 Active
04/28/2017 Peripheral venous insufficiency (disorder) 20696009 Active
04/28/2017 Venous hypertension (disorder) 234072000 Active
04/28/2017 Venous hypertension (disorder) 234072000 Active
04/28/2017 Low back pain (disorder) 279039007 Active
04/28/2017 Pain in right leg (finding) 287048003 Active
04/28/2017 Pain in left leg (finding) 287047008 Active
04/28/2017 Edema (finding) 267038008 Active

Medications

Medication Administered During Visit

Start Date Medication Code Sig Status
04/28/2017 Compression Stockings, Knee-High 30-40 mmHg To be worn as directed Active

Current Medication

Start Date Medication Code Sig Status
Para-Hist 12-15-15 mg tablet extended release 1423964 Take 1 Tablets oral Active

Vital

Date/Time Vital Name Loinc Code Value Unit
2017/04/28 02:12:00 Temperature 8310-5 99 Farenheit
2017/04/28 02:12:00 BP Sitting Systolic 8480-6 120/77 mmHg
2017/04/28 02:12:00 Breath Rate 9279-1 20 Breaths/Min
2017/04/28 02:12:00 Pulse Rate 8867-4 20 Beats/Min
2017/04/28 02:12:00 O2 Saturation 2710-2 10 %

Results

Information is not available

Immunizations

Information is not available

Procedures

Date Procedure Code
04/28/2017 ANES VEINS OF UPPER LEG INCLUDING EXPLORATIO 01260
04/28/2017 ANESTHESIA VEINS KNEE & POPLITEAL AREA 01430

Social Hx

Date Code Smoking Status