Charleston Mm
Resume:
Ambulatory Summary for Ryan Jefferson
Table of Contents
Allergies
Medications
Problems
Procedures
Results
Past Encounters
Social History
Vaccine List
Plan of Care
Vitals
Demographics
Care Team Members
Allergies
Code Code System Name Reaction Severity Status Onset 161 RxNorm Acetaminophen Active
Medications
Name Status Start Date Stop Date
amlodipine 10 mg tablet Completed 03/13/2022
amlodipine 5 mg tablet Completed 03/13/2022
amoxicillin 500 mg capsule Completed 03/13/2022
amoxicillin 875 mg-potassium clavulanate 125 mg tablet Take 1 tablet every 12 hours by oral route with meals for 7 days. Active Not available
atorvastatin 10 mg tablet Completed 03/13/2022
b-1 100 mg tabs
1 po qd
Completed 03/13/2022
bisacodyl 10 mg rectal suppository Completed 03/13/2022 cephalexin 500 mg capsule Completed 03/13/2022
chlordiazepoxide 25 mg capsule Active Not available ciprofloxacin 500 mg tablet Completed 02/24/2020
cyclobenzaprine 10 mg tablet Completed 03/13/2022
dicyclomine 20 mg tablet Active Not available
famotidine 20 mg tablet
1 po qd
Completed 03/13/2022
Flonase Allergy Relief 50 mcg/actuation nasal spray,suspension Spray 2 sprays twice a day by intranasal route as needed. Active Not available
folic acid 1 mg tablet Completed 03/13/2022
gabapentin 100 mg capsule Completed 01/29/2020
gabapentin 300 mg capsule Active Not available
gabapentin 400 mg capsule
1 po tid
Completed 02/24/2020
gabapentin 600 mg tablet Completed 03/13/2022
ibuprofen 800 mg tablet Completed 03/13/2022
lidocaine 5 % topical patch Completed 03/13/2022
meclizine 25 mg tablet Completed 03/13/2022
meloxicam 15 mg tablet Completed 02/24/2020
meloxicam 7.5 mg tablet Completed 03/13/2022
methocarbamol 500 mg tablet Completed 03/13/2022
methylprednisolone 4 mg tablets in a dose pack Completed 03/13/2022 metronidazole 500 mg tablet Completed 02/24/2020
Mucinex 600 mg tablet, extended release
Take 1 tablet every 12 hours by oral route for 5 days. Active Not available
naproxen 250 mg tablet Completed 04/21/2021
naproxen 500 mg tablet
1 po bid prn
Completed 03/13/2022
omeprazole 20 mg capsule,delayed release Active Not available omeprazole 40 mg capsule,delayed release Active Not available ondansetron 4 mg disintegrating tablet Completed 03/13/2022 ondansetron 8 mg disintegrating tablet Active Not available oxycodone 10 mg tablet Completed 03/13/2022
oxycodone 5 mg tablet Completed 03/13/2022
oxycodone-acetaminophen 5 mg-325 mg tablet
1 po tid prn
Completed 03/13/2022
pantoprazole 40 mg tablet,delayed release Completed 03/13/2022 prednisone 20 mg tablet Completed 02/24/2020
sodium chloride 0.9 % intravenous solution
1 liter administered via IV at: 1402
Completed 03/13/2022
Stool Softener 100 mg capsule Completed 03/13/2022 sucralfate 1 gram tablet Active Not available
sulfamethoxazole 800 mg-trimethoprim 160 mg tablet Completed 01/29/2020 tramadol 50 mg tablet Active Not available
Vitamin D3 50 mcg (2,000 unit) capsule
1 po qd
Active Not available
Zofran 2 mg/mL intravenous solution
4 mg IV administered on scene. Time administered:1410 Completed 03/13/2022
Problems
None recorded.
Procedures
Notes: no surgical hx
Results
Lab Results
None recorded.
Past Encounters
03/13/2022
Acute Sinusitis
Elizabeth Moura, NP: 3841 W Charleston Blvd, Ste 203, Las Vegas, NV 89102-1858, Ph. 702-***-**** 04/17/2021
Alcohol Dependence
Brian William Stark, PA: 3841 W Charleston Blvd, Ste 203, Las Vegas, NV 89102-1858, Ph. 702-***-**** 02/24/2020
Mild Dehydration; Hyponatremia; Nausea and Vomiting; Dizziness Camela Maupin, PA: 3841 W Charleston Blvd, Ste 203, Las Vegas, NV 89102-1858, Ph. 702-***-**** 01/29/2020
Lactic Acidosis
Annette Asbury, NP: 3841 W Charleston Blvd, Ste 203, Las Vegas, NV 89102-1858, Ph. 702-***-**** Social History
Tobacco Smoking Status Light Tobacco Smoker (1 pack per week) Vaccine List
None recorded.
Plan of Care
Patient Instructions
*If your symptoms change or worsen, seek re-evaluation immediately by calling 911, or by going to the ER or urgent care.
*Please schedule a follow up appointment with your PCP IN 48-72 hours if your symptoms are not improving, as you may need additional testing, treatment, and/or referrals.
*The patient is safe to stay at home and was left in stable condition.
*All questions/concerns were answered to the patient's satisfaction.
*Notes from this visit will be sent to your PCP.
Reminders Provider
Appointments None recorded.
Lab None recorded.
Referral None recorded.
Procedures None recorded.
Surgeries None recorded.
Imaging None recorded.
Vitals
03/13/2022 08:51AM D06 Established Patient
Blood Pressure
110/80 mm[Hg]
04/17/2021 03:10PM D07 New or Est Patient
Blood Pressure
118/84 mm[Hg]
02/24/2020 01:09PM D19 New or Est Patient
Blood Pressure
(1) 130/100 mm[Hg]
(2) 120/78 mm[Hg]
01/29/2020 01:38PM D19 New or Est Patient
Blood Pressure
100/70 mm[Hg]
Demographics
Sex: Male Ethnicity: Information not available
DOB: 03/01/1984 Race: Information not available
Preferred language: Information not available Marital status: Information not available Contact: 228 Steelhead Ln, 202, Las Vegas, NV 89110-4892, Ph. tel:+1-702-***-**** Care Team Members
Primary Care Provider
GERARDO LORENZANA MD 61 N NELLIS BLVD, LAS VEGAS, NV 89110, Ph. tel:+1-702-***-****
Contact this candidate