- One day post-op report cataract extraction and IOL completed left eye on 03/26/2020
- The patient tolerated the surgery well
Patient | Legal: Clare M TESCA Date of Birth: February 14, 1952 (68yr) Gender: Female Patient-ID: 123456789 (SSN), 404.1 (1.3.6.1.4.1.115) |
Encounter | ID: 20200327103000 (2.16.840.1.113883.3.2820.10.1.3.10) , Date/Time: March 27, 2020 10:30AM -0400 - 11:30AM -0400 |
Documentation Of | Care provision, First postoperative examination and eye dressing (procedure), Date/Time: March 27, 2020 10:30AM -0400 - 11:30AM -0400, Performer: Stan STEDYHAN |
Author | Dr Stan STEDYHAN, Authored On: March 27, 2020, 11:30AM -0400 |
Time | Substance | Reaction | Severity | Status |
---|---|---|---|---|
01/20/1998 | egg | Hives | Moderate | Active |
Name | Code | Instructions | Start Date | Stop Date | Status |
---|---|---|---|---|---|
ketorolac tromethamine 5 MG/ML | 860107 (RxNorm) | qid for 2 weeks - right eye | 2020-03-05 | 2020-03-19 | Inactive |
moxifloxacin 5 MG/ML | 403818 (RxNorm) | qid for 2 weeks - right eye | 2020-03-05 | 2020-03-19 | Inactive |
prednisolone acetate 10 MG/ML | 1376335 (RxNorm) | qid for 2 weeks then taper - right eye tid for 1 week - right eye bid for 1 week - right eye qd for 1 week - right eye |
2020-03-05 2020-03-20 2020-03-28 2020-04-05 |
2020-03-19 2020-03-27 2020-04-04 2020-04-12 |
Active |
Name | Code | Instructions | Start Date | Stop Date | Status |
---|---|---|---|---|---|
ketorolac tromethamine 5 MG/ML | 860107 (RxNorm) | qid for 2 weeks - left eye | 2020-03-26 | 2020-04-09 | Active |
moxifloxacin 5 MG/ML | 403818 (RxNorm) | qid for 2 weeks - left eye | 2020-03-26 | 2020-04-09 | Active |
prednisolone acetate 10 MG/ML | 1376335 (RxNorm) | qid for 2 weeks then taper - left eye tid for 1 week - left eye bid for 1 week - left eye qd for 1 week - left eye |
2020-03-26 2020-04-10 2020-04-18 2020-04-26 |
2020-04-09 2020-04-17 2020-04-25 2020-05-03 |
Active |
Name | Code | Instructions | Start Date | Stop Date | Status |
---|---|---|---|---|---|
Crestor 5 mg | 859426 (RxNorm) | 1 tablet by mouth once a day for 90 | 2019-07-28 | Active | |
metformin 1,000 mg | 861004 (RxNorm) | 1 tablet by mouth twice a day for 180 | 2014-04-20 | Active | |
Invokana 100mg | 50458-140-01 (NDC) | 1 tablet by mouth once a day for 90 | 2019-07-28 | Active | |
lisinopril 10 mg | 314076 (RxNorm) | 1 tablet by mouth once a day for 90 | 2019-07-28 | Active |
System | Finding |
---|---|
Visual Acuities | VA uncorrected OS 20/20 |
IOP | IOP OS 16mmHg |
Slip-Lamp | Slip-lamp exam
surgical wound intact |
Member | Role on Team | Status | Date |
---|---|---|---|
Dr. Joseph Gooddoc, MD (NPI: 2734441159 ) | Primary Care Physician | (Active) | 2005 - current |
Maka Felgood | Diabetic Educator | (Active) | 2014 - current |
Dr. Arthur Feetler, DPM (NPI: 8402871106) | Podiatrist | (Active) | 2018 - current |
Dr. Donald Singletooth, DDS (NPI: 8477778822) | Dentist | (Active) | 1990 - current |
Dr. Yul Seemore, OD (NPI: 1973535929) | Optometrist | (Active) | 2020 - current |
Dr. Stan Stedyhan, MD (NPI: 2173512387) | Ophthalmologist | (Active) | 2020 - current |