Primary Care Corporate Event
Resume:
WH Urology At Midtown
Wilmington, NC 28412-2377
Phone: 910-***-****
Fax: 910-***-****
PATIENT PLAN
Name: Donna Plowman
Date of Birth: 08/02/1954
Date of Visit: 11/13/2023 10:00 AM
Visit Type: Office Visit (99213)
Location: WH Urology At Midtown
Thank you for choosing us for your healthcare needs. The following is a summary of the outcome of today's visit and
other instructions and information we hope you find helpful.
**New government legislation, the 21st Century CURES Act, requires medical practices to release testing results to patients immediately upon completion. This may mean that a patient will be notified and can view results in the Patient Portal before the ordering provider has seen them. Patients should review the results with the understanding that they will received the provider’s interpretation after this initial, automated notification. This can allow the patient to compare to previous results and to write down questions to ask of the provider or staff at the time of the notification from our office.
Future Appointment Date:
Date: 02/12/2024 10:30AM
Primary Care Provider: Healthcare Holly Ridge
Additional Care Team Members
Last Name
First Name
Phone#
Specialty
Provider Role
Holly Ridge
Healthcare
Multispecialty Clin/Grp Practi
primary care provider
Today's Visit 11/13/2023 10:00 AM
Reason for Visit
incontinence.
Assessment/Plan
#
Detail Type
Description
1.
Assessment
Urge incontinence (N39.41).
Impression
69-year-old female with bothersome OAB, urge incontinence. Status post Botox. Reports improvement, happy with results. No pushing or straining to void. PVR low. Would like to continue oxybutynin. Refill sent. RTC 3 months virtual visit or sooner if needed. Botox once symptoms recur.
2.
Assessment
Body mass index (BMI) 34.0-34.9, adult (Z68.34).
Provider Plan
Diagnosis code placed for administrative purposes.
Counseling/Educational Factors
Counseling / educational factors reviewed.
The patient was checked out at 10:46 AM by Amber Rodenberg.
Current Medications
Started
Medication
Directions
Adherence
Last Refilled
08/02/2019
tramadol 50 mg tablet
take 1 tablet by oral route every 6 hours as needed
taking as directed
08/20/2019
Physical Therapy
2-3 TIMES A WEEK FOR 4-6 WEEKS
taking as directed
08/05/2019
Percocet 5 mg-325 mg tablet
take 1 - 2 tablet by oral route every 4 - 6 hours as needed as needed
taking as directed
06/12/2023
oxybutynin chloride ER 15 mg tablet,extended release 24 hr
take 1 tablet by oral route every day
taking as directed
06/12/2023
08/16/2019
Norco 5 mg-325 mg tablet
take 1 tablet by oral route every 6 hours as needed for pain
taking as directed
08/09/2018
lisinopril 10 mg tablet
take 1 tablet by oral route every day
taking as directed
08/02/2019
Lexapro 5 mg tablet
take 1 tablet by oral route every day
taking as directed
08/07/2019
cyclobenzaprine 5 mg tablet
take 1 tablet by oral route 3 times every day
taking as directed
Medications reconciled today.
Vital Signs
Time
BP mm/Hg
Pulse /min
Resp /min
Temp F
Ht ft
Ht in
Ht cm
Wt lb
Wt kg
Weight %
BMI kg/m2
BMI %
BSA m2
O2 Sat%
10:38 AM
5.0
6.00
167.64
215.00
97.522
34.70
0
2.13
Measured by:
Time
Measured by
10:38 AM
Jimia Underwood, EMT
Allergies
Ingredient
Reaction (Severity)
Medication Name
Comment
MORPHINE
Skin lesion
Smoking Status
Type
Smoking Status
Usage Per Day
Years Used
Pack Years
Total Pack Years
Never smoker
Smoking status: Never smoker.
Alcohol Status
There is a history of alcohol use.
Drug Use/Abuse
The patient denies illicit drug use.
Demographics
Sex: Female
Race: White
Preferred Language: English
Sincerely,
Electronically signed by:
Mary Feinour PA-C 11/13/2023 12:28 PM
Phone Number: 910-***-****
Contact this candidate