Name: Jane Doe
DOB: 01/01/1990
MR#: 9999999
Updated: 12/13/2012
Medical Summary
(sample)
PROBLEM LIST WITH ICD – 9 CODES
344.09; Glucose intolerance 250.00; Chronic constipation 564.01; Degenerative arthritis in knees and shoulders 715.09; Obesity 278.01; Attention deficit, hyperactivity disorder 314.01; Mild intellectual disability 318
ALLERGIES
None
CARDIAC
Normal blood pressure; Baseline ECHO
Normal (9/93)
DERMATOLOGY
History of pressure sores
4/16/11 Second degree pressure ulcer resolved.
6/23/12 second degree pressure sore on buttocks. Pressure reducing mattress and
evaluation of wheelchair seating. No increase in time spent in wheelchair, but father with
back pain and caregiver stress. Called regional center for additional support.6/30/12 pressure
sore healed.
DEVELOPMENT
Patient is fraternal twin born to 38 year old mother at 25 weeks gestation after an
uncomplicated pregnancy conceived through IVF. Patient’s ability to ambulate long distances
declined around age 18; attended regular education classrooms with a 1:1 aide. Patient
graduated from high school and has started community college.
Most recent Genetics Evaluation: Normal screening for Fragile X in 1999
EAR NOSE THROAT
Hearing
normal; Dental
no caries, uses electric toothbrush with wide handle and chlorhexidate wash. 2mg Ativan pre sedation two hours prior to procedures.
FLUID ELECTROLYTES NUTRITION
Height: 50 inches
Ideal Weight goal 85 95 lbs; current weight 118 lbs, BMI: 33.2
Nutrition – good
Exercise – none
Diet texture – pureed, thickened liquids
Swallow study: moderate dysphagia on video fluorscopy; feeding recommendations include
nosey cup, built up handle and curved plate, double swallow and sip of water between bites.
Turn head to left when swallowing. Remain upright after feeds.