Patient Name: McAnulty, Jennifer Ames LGMD AMB - UCC Carencro

Fin. Number: 9993533153

Date of Birth: 5/10/1968 917 W. Gloria Switch Rd
Age: 53 years Lafayette, LA 70507-2309
Sex: Female
Discharged: 4/9/2021

Attending Dr: Anderson MD,Meighan G

Discharge Documentation
DOCUMENT TYPE: Discharge Summary
SERVICE DATE/TIME: 4/9/2021 13:01 CDT
RESULT STATUS: Auth (Verified)
PERFORMED INFORMATION: Elzy,Shabana R (4/9/2021 13:01 CDT)
SIGNED INFORMATION:

Visit Summary
McAnulty, Jennifer Ames
Sex: F
DOB: 05/10/1968
Visit Summary
Summarization of Episode Note | 04/9/2021 to 04/9/2021
Source: LGMD AMB - UCC Carencro
Created: 04/9/2021
Demographics
Contact Information:
508 SOUTH MARKET STREETOPELOUSAS, LA 70570, US
Tel: 4058248894
Mail: jennifer.ames@att.net
Marital Status: Widowed
Religion: None
Race: White, White
Previous Name(s): --
Ethnic Group: Not Hispanic or Latino
Language: English
ID: 3339152

Care Team

Represented
Type Name Address Phone
Organization
primary care Charlie DO, Work:155 Hospital DrSte Work Tel:
--
physician Emily R 205Lafayette, LA 70503- , US (337)484-1091

Relationships

No Data to Display

Document Details
 Discharge Documentation

Source Contact Info

917 W Gloria Switch RdLafayette, LA 70507-2309, US

Tel: (337)886-6455

Author Contact Info

--

Recipient Contact Info

--

Healthcare Professionals

No Data to Display

IDs & Code Type Data

Document Type ID: 2.16.840.1.113883.1.3 : POCD_HD000040

Document Template ID: 2.16.840.1.113883.10.20.22.1.1 : --, 2.16.840.1.113883.10.20.22.1.2 : --
Document ID: 2.16.840.1.113883.3.1897.38.999362 : 82203554
Document Type Code: 2.16.840.1.113883.6.1, 34133-9
Document Language Code: en-US
Document Set ID: --
Document Version Number: --

Primary Encounter

Encounter Information

Registration Date: 04/9/2021

Discharge Date: --
Visit ID: --

Location Information

LGMD AMB - UCC Carencro

Work:917 W. Gloria Switch RdLafayette, LA 70507-2309, US

Providers

Type Name Address Phone

Anderson MD, Meighan Work:2810 Bonin RdYoungsville, LA 70592-
Attending Work Tel: (337)857-5765
G , US

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 Discharge Documentation

EncounterEncounter

4/9/21

LGMD AMB - UCC Carencro 917 W. Gloria Switch Rd Lafayette, LA 70507-2309 United States (337) 886-6455
Encounter Diagnosis

Acute cystitis (Discharge Diagnosis) - 4/9/21

Attending Physician: Anderson MD, Meighan G

VisitVisit

Visit Date Reason for Visit Provider

4/9/21

Reason for VisitReason for Visit

No data available for this section

Vital SignsVital Signs

4/9/21

Temperature Oral 37 DegC (Normal is 36-38 DegC)

Temperature Oral (calculated) 98.60 DegF
Peripheral Pulse Rate 94 bpm (Normal is 60-100 bpm)
Respiratory Rate 19 br/min (Normal is 12-24 br/min)
SpO2 97 % (Normal is 94 %)
Oxygen Therapy Room air
(Normal is 90-140/60-90
Blood Pressure 153/97 mmHg
mmHg)
Blood Pressure Location Left arm
Manual Cuff BP No
dysuira, malodorous urine, lower back
Chief Complaint
pain x 2 months
Height/Length Measured 168 cm
Weight Measured and Calculated in
302.03 lb
Lbs
Weight Measured 137 kg
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 Discharge Documentation

Last Menstrual Period 2021/03/20

Problem ListProblem List

Acute cystitis (This Visit)

GAD (generalized anxiety disorder) | IDA (iron deficiency anemia) | Morbid obesity | Urinary incontinence |
Well-controlled hypertension

Allergies, Adverse Reactions, AlertsAllergies, Adverse Reactions, Alerts

Bactrim (rash) | Flagyl (rash, abdominal upset) | Latex (rash) | sulfa drugs (rash)

MedicationsMedications

albuterol (PROAIR HFA 90 MCG INHALER)

Status: Ordered
Start Date: 1/28/19
aripiprazole (ARIPiprazole 2 mg oral tablet)

Status: Ordered
Start Date: 4/9/21
1 Tablet(s) Oral Daily.
ciprofloxacin (ciprofloxacin 500 mg oral tablet)

Status: Ordered Walmart Neighborhood Market 5125

Start Date: 4/9/21
Stop Date: 4/16/21 2310 S Union St Opelousas, LA
1 Tablet(s) Oral every 12 hours for 7 Days. Refills: 0. 705705734

Ordering provider: Anderson MD, Meighan G

ferrous gluconate (Fergon 240 mg (27 mg elemental iron) oral tablet)

Status: Ordered
Start Date: 11/24/20
Stop Date: 12/24/20
1 Tablet(s) Oral Daily for 30 Days.
FLUoxetine (FLUoxetine 40 mg oral capsule)

Status: Ordered
Start Date: 1/15/21
1 Cap Oral Daily. Refills: 1.

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 Discharge Documentation

Ordering provider: Charlie DO, Emily R

levothyroxine (Euthyrox 125 mcg (0.125 mg) oral tablet)
Walmart Neighborhood Market 5125
Status: Ordered
Start Date: 1/13/21
2310 S Union St Opelousas, LA
1 Tablet(s) Oral Daily. Refills: 1.
705705734
Ordering provider: Charlie DO, Emily R
lisinopril (lisinopril 40 mg oral tablet)
Walmart Neighborhood Market 5125
Status: Ordered
Start Date: 1/13/21
2310 S Union St Opelousas, LA
1 Tablet(s) Oral Daily. Refills: 1.
705705734
Ordering provider: Charlie DO, Emily R
NIFEdipine (NIFEdipine 30 mg oral tablet, extended release)
Walmart Neighborhood Market 5125
Status: Ordered
Start Date: 1/13/21
2310 S Union St Opelousas, LA
1 Tablet(s) Oral Daily. Refills: 1.
705705734
Ordering provider: Charlie DO, Emily R
phendimetrazine (phendimetrazine 105 mg oral capsule, extended release)

Status: Ordered
Start Date: 4/9/21
1 Cap Oral once a day (in the morning).
phendimetrazine (phendimetrazine 35 mg oral tablet)

Status: Ordered
Start Date: 4/9/21
1 Tablet(s) Oral 3 times a day before meals.

Medications Administered During Your VisitMedications Administered During Your Visit

No data available for this section

ResultsResults

4/9/21
Urine Color Urine Dipstick Dark yellow
Urine Appearance Urine Dipstick Cloudy

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 Discharge Documentation

pH Urine Dipstick 5
Specific Gravity Urine Dipstick 1.025
Blood Urine Dipstick Small
Glucose Urine Dipstick Negative
Ketones Urine Dipstick Negative
Protein Urine Dipstick 1+ (30 mg/dl)
Bilirubin Urine Dipstick Small
Urobilinogen Urine Dipstick 0.2 mg/dl
Leukocytes Urine Dipstick Large
Nitrite Urine Dipstick Positive

ImmunizationsImmunizations

Given and Recorded

Vaccine Date Status Refusal Reason

influenza virus vaccine, inactivated 11/9/20 Given

ProceduresProcedures

Procedure Date Related Diagnosis Body Site Status

right knee replacement 6/1/15 Completed
left knee replacement 3/1/15 Completed

Social HistorySocial History

Social History Type Response

Never (less than 100 in lifetime); Patient Wants Consult For Cessation Counseling No
Smoking Status
entered on: 4/9/21

Assessment and PlanAssessment and Plan

Extracted from:
Title: Office Visit Note Author: Anderson MD, Meighan G Date: 4/9/21
dysuira, malodorous urine, lower back pain x 2 months
1. Acute cystitis N30.00
Start antibiotic today
Watch closely for worsening symptoms
Contact this clinic for any further problems
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 Discharge Documentation

Urine culture results will be monitored and reported, treatment changes will be made if necessary

Ordered:
Office/Outpatient Visit Level 3 Established 99213 PC, Acute cystitis, 04/09/21 12:56:00 CDT
Urine Culture 87088, Routine collect, 04/09/21 12:56:00 CDT, Order for future visit, Urine, Clean Catch, Nurse
collect, Stop date 04/09/21 12:56:00 CDT, Acute cystitis

Orders:
ciprofloxacin, 500 mg = 1 tab(s), Oral, q12hr, X 7 day(s), # 14 tab(s), 0 Refill(s), Pharmacy: Walmart
Neighborhood Market 5125, 168, cm, Height/Length Dosing, 04/09/21 12:38:00 CDT, 137, kg, Weight Dosing,
04/09/21 12:38:00 CDT

Future Appointments

Appointment Date: 04/12/2021 04:00:00 PM

Scheduled Provider:

Location: CCA Clinic

Appointment Type: CCA Lab

Appointment Date: 04/19/2021 03:00:00 PM

Scheduled Provider: Thomas MD, Molly B
Location: CCA Clinic
Appointment Type: CCA OV

Appointment Date: 07/14/2021 08:00:00 AM

Scheduled Provider: Charlie DO, Emily R
Location: Charlie IM Group
Appointment Type: Established

Future Scheduled Tests

Laboratory:

• SARS CoV2 IgG Ab 5/4/20

• SARS CoV2 IgG Ab 5/4/20
• CBC with diff CLINIC 3/9/21
• Ferritin 3/9/21
• Iron Binding Capacity Total - Iron Profile 3/9/21
• Urine Culture 87088 4/9/21
• Type and Rh 12/3/20
• Urinalysis with Reflex 11/24/20
• zTrnsfusion Order RBC 12/4/20

Radiology:

• MG Tomo Screening Bilateral 1/4/21

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InstructionsInstructions

No data available for this section

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