Good Health Clinic Care Record Summary 17 Daws Rd. Blue Bell MA 02368 USA Mrs. Ellen Ross Good Health Clinic 21 North Ave Burlington MA 01803 USA Dr. Bernard Wiseman Jr. Mrs. Abigail Ruth Mr. Joseph T. Jones Jane Queen Good Health Clinic 21 North Ave Burlington MA 01803 USA 21 North Ave Burlington MA 01803 USA Dr. Phil Green Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 USA Mrs. Abigail Ruth 17 Daws Rd. Blue Bell MA 02368 USA Mr. Kenneth Ross Good Health Insurance Company 3191 Broadbridge Avenue Stratford CT 06614-2559 USA 17 Daws Rd. Blue Bell MA 02368 USA Mr. Kenneth Ross 21 North Ave Burlington MA 01803 USA Dr. Bernard Wiseman Sr.
Reason for Visit/Chief Complaint Ankle Sprain
Reason for Referral Follow-up care for Ankle Sprain
Advance Directives Living Will, 1994, obtain from her husband. Power of Attorney, 1994, obtain from her husband. Healthcare Proxy, 1994, obtain from her husband. Organ Donor, 1/27/2004, Massachusetts Registry of Motor Vehicles.
History of Present Illness Patient slipped and fell on ice, twisting her ankle as she fell.
Family History Father, alchoholic, died of liver cancer.
Social History Smokes 1/2 pack per day till 1996 Has 1-2 drinks per week
Conditions Cholecystitis, 9/28/2002 - 6/2003, Surgery postponed until after delivery Pregnancy, 7/2001 - 4/22/2002, Prior history of miscarraige Ankle Sprain, 3/28/2005, Slipped on ice and fell
Allergies and Adverse Reactions Patient is allergic to Penicillin, main reaction is hives. Amoxicillin is OK.
Medications Indomethacin, 50mg bid with food, 12/10/2003 - present Acetaminophen with codeine, #3 1-2 tablets for pain as needed, 03/28/2005
Immunizations DTP - 1962 Polio Virus - 1961 MMR - 1961
Procedures Laparoscopic Cholecystectomy, 9/28/2002 Cesarian Section, 3/22/2002
Prior Encounters 3/28/2005, Community Hospital, ED Visit for Ankle Sprain 9/28/2002, City Hospital, Gall Bladder Surgery 3/21/2002, Community Hospital, Labor and Delivery 10/28/2001, Community Hospital, ED Visit for Acute Cholecystitis
Review of Systems Normal except for left foot and ankle.
Physical Examination Left foot and ankle are swollen profusely.
Vital Signs
DateHeightWeightTemperature BPPulseRespirationO2
3/28/20055'9"215 lbs.98.7 °F 120/80681699%
Related Reports X-Ray Study - Left Ankle, No Fracture, 3/28/2005
Plan of Care Acetaminophen with codiene prn for pain. Stay off the foot. Keep foot elevated, and use supplied air splint and crutches. Follow-up with orthopedist in next 5 days.