Patient's Clinical Encounter Report

Branch : NEUROLOGY [SCECO DAMMAM]

Patient Profile : Medical Profile :

MRN No. : DMM50000041206 BloodGroup : N/A
: MONA ABDULRAHMAN HAMAD Chronic Diseases : No Chronic Disease
Name
ALDOSSARI Physical Fitness : Normal
Gender : FEMALE Intravascular systolic : 110.00 [95-140]N/A
Age : 61[dob:342/12/1961 ]
Weight : 70.20 [55-80]N/A
Marital Status :
BMI : N/A [18.5-24.9]N/A
Childrens : N/A
Weight : N/A [55-80]N/A
Occupation : N/A
: Provider : MEDGULF Intravascular systolic : 148.00 [95-140]N/A
Insurance
Coverage Policy No. : 1449858 MAP : 98.33 [60-110]N/A
Expired On : 01/01/2024
Intravascular diastolic : 84.00 [60-90]N/A
CoPayment : N/A
Status : 01 - APPROVED Pulse : 83.00 [50-80]N/A

Weight : 82.80 [55-80]N/A

Weight : 82.90 [55-80]N/A

Intravascular systolic : 147.00 [95-140]N/A

MAP : 107.00 [60-110]N/A

MAP : 86.67 [60-110]N/A

Intravascular systolic : 130.00 [95-140]N/A

Intravascular systolic : 144.00 [95-140]N/A

Intravascular diastolic : 88.00 [60-90]N/A

RR : 22.00 [12-20]N/A

Intravascular diastolic : 75.00 [60-90]N/A

MAP : 86.33 [60-110]N/A

Temperature : 36.10 [36.5-37.4]N/A

Intravascular systolic : 145.00 [95-140]N/A

MAP : 99.33 [60-110]N/A

Intravascular systolic : 117.00 [95-140]N/A

Temperature : 36.50 [36.5-37.4]N/A

Intravascular systolic : 120.00 [95-140]N/A

Pulse : N/A [50-80]N/A

Intravascular diastolic : 76.00 [60-90]N/A

Intravascular systolic : 155.00 [95-140]N/A

MAP : 110.33 [60-110]N/A

Weight : 82.50 [55-80]N/A

Intravascular diastolic : 71.00 [60-90]N/A

Pulse : 62.00 [50-80]N/A

16/03/2023
Consultant Signature: Date
 Patient's Clinical Encounter Report
Branch : NEUROLOGY [SCECO DAMMAM]

RR : N/A [12-20]N/A

MAP : 102.00 [60-110]N/A

Oxygen Saturation : N/A [94-100]N/A

Intravascular diastolic : 85.00 [60-90]N/A

MAP : 96.67 [60-110]N/A

Pulse : 80.00 [50-80]N/A

Intravascular diastolic : 82.00 [60-90]N/A

MAP : 103.67 [60-110]N/A

Intravascular systolic : 125.00 [95-140]N/A

Intravascular diastolic : 70.00 [60-90]N/A

Intravascular systolic : 137.00 [95-140]N/A

Temperature : 36.30 [36.5-37.4]N/A

Intravascular systolic : 109.00 [95-140]N/A

MAP : 94.00 [60-110]N/A

Intravascular diastolic : 87.00 [60-90]N/A

Intravascular systolic : 140.00 [95-140]N/A

Temperature : 36.20 [36.5-37.4]N/A

Oxygen Saturation : 100.00 [94-100]N/A

Intravascular diastolic : 79.00 [60-90]N/A

Weight : 83.00 [55-80]N/A

Pulse : 65.00 [50-80]N/A

Pulse : 61.00 [50-80]N/A

MAP : 93.33 [60-110]N/A

MAP : 101.33 [60-110]N/A

Intravascular diastolic : 98.00 [60-90]N/A

Height : N/A [100-270]N/A

MAP : 116.67 [60-110]N/A

Intravascular systolic : 122.00 [95-140]N/A

Pulse : 71.00 [50-80]N/A

Intravascular diastolic : 83.00 [60-90]N/A

MAP : 96.33 [60-110]N/A

History of tobacco use : N/A [1500-1502]N/A

Temperature : 36.40 [36.5-37.4]N/A

MAP : 87.33 [60-110]N/A

Weight : 77.00 [55-80]N/A

16/03/2023
Consultant Signature: Date
 Patient's Clinical Encounter Report
Branch : NEUROLOGY [SCECO DAMMAM]

MAP : 104.00 [60-110]N/A

Intravascular systolic : 150.00 [95-140]N/A

Intravascular diastolic : 100.00 [60-90]N/A

Intravascular diastolic : 80.00 [60-90]N/A

Temperature : 36.70 [36.5-37.4]N/A

SoapNote :Dr Ahmed Saad SCDM , NEUROLOGY [SCECO DAMMAM] | Started On: 16/03/2023 17:13:56 | Ended On: NA | CSLTG Per.: NA,
Visit:OP-030

Diagnosis:
Unspecified deforming dorsopathy, cervical region:M43.92
Narrattive Diagnosis:N/A
Chief Complaint

that f patient with no past history of medical importance except for HTN DLP
neck pain headahe occipital
xray cervical SPINE ----spondylosis
reported ::Straightening of cervical spine denoting muscle spasm .
Spondylodegenerative changes in the form of anterior osteophytic lipping .
Left cervical rib & prominant right transverse process of C7 .
MRI DONE:::: C3-4 DISC LESION C4-5 C5-6 DISC LESION
labs crp esr ca total and ionzed NAD
vertebrobasilar doppler --- normal study ---accidently discovered thyroid nodule as informed by radiologist to put
the order for her for report confirmation and to be written
for relaxants dr mustafa added avalon and physiotherapy sessions +i addded RELAXON
BP 147/87 >>>>125/85

History Of Present Illness

Symptoms

that f patient with no past history of medical importance except for HTN DLP neck pain headahe occipital xray
cervical SPINE ----spondylosis reported ::Straightening of cervical spine denoting muscle spasm .
Spondylodegenerative changes in the form of anterior osteophytic lipping . Left cervical rib & prominant right
Severity transverse process of C7 . MRI DONE:::: C3-4 DISC LESION C4-5 C5-6 DISC LESION labs crp esr ca total and
ionzed NAD vertebrobasilar doppler --- normal study ---accidently discovered thyroid nodule as informed by
radiologist to put the order for her for report confirmation and to be written for relaxants dr mustafa added avalon
and physiotherapy sessions +i addded RELAXON BP 147/87 >>>>125/85
Duration

Location

Others

16/03/2023
Consultant Signature: Date
 Patient's Clinical Encounter Report
Branch : NEUROLOGY [SCECO DAMMAM]

Service Orders
CPT Code Desc.
01 Follow Up
Pharmacy Orders
Code ITEM NAME Frequency Dose Units Intake Qty Days Total Quantity
22001366 AVALON ACTIVE THE ORIGINAL CREAM 100ML [EACH] Thrice a Day 1 Apply 1 30 1 [EACH]
22000471 RELAXON CAPSULES 250MG 30 PK [EACH] Once a Day 2 Capsule 1 15 1 [EACH]

16/03/2023
Consultant Signature: Date