2026 Consolidated CDA

ALLERGIES AND ADVERSE REACTIONSNo Known Drug AllergiesNo Known Drug Allergies

MEDICATIONSMedication Start Date Directions Status

mupirocin 2 % topical ointment, [RxNorm: 103570]
02/21/2020
APPLY A SMALL AMOUNT TO THE AFFECTED AREA BY TOPICAL ROUTE 3 TIMES PER DAY
Active
hydrocortisone 2.5 % topical cream, [RxNorm: 1540356]
02/21/2020
APPLY A THIN LAYER TO THE AFFECTED AREA(S) BY TOPICAL ROUTE 2 TIMES PER DAY
Active
omeprazole 20 mg capsule,delayed release, [RxNorm: 104099]
02/21/2020
TAKE 1 CAPSULE (20 MG) BY ORAL ROUTE ONCE DAILY 30 MINUTES TO 1 HOUR BEFORE MEAL
Active
cephalexin 500 mg capsule, [RxNorm: 152655]
02/21/2020
TAKE 1 CAPSULE (500 MG) BY ORAL ROUTE EVERY 12 HOURS
Active
fluconazole 150 mg tablet, [RxNorm: 207108]
02/21/2020
TAKE 1 TABLET (150 MG) BY ORAL ROUTE ONCE, MAY REPEAT DOSE AFTER 3 DAYS IF SYMPTOMS PERSIST.
Active
Tri-Sprintec (28) 0.18 mg(7)/0.215 mg(7)/0.25 mg(7)-0.035 mg tablet, [RxNorm: 762333]
02/21/2020
TAKE AS DIRECTED
ActivePROBLEMSNo known health problemsENCOUNTERSEncounter Performer Location Date

INTERMEDIATE EST PT
Melodye Harvey
Auburn Montgomery Warhawk Health Services
Feb 21, 20207461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health ServicesPROCEDURESProcedure Date

UA, [CPT-4: 81003]
02/21/2020
COMP METABOLIC PANEL (QUEST), [CPT-4: 10231]
02/21/2020
CBC W/ DIFF (QUEST), [CPT-4: 6399]
02/21/2020
TSH W/REFLEX T4, FREE (QUEST), [CPT-4: 36127]
02/21/2020
VITAMIN D 25 - HYDROXY, TOTAL (QUEST), [CPT-4: 17306]
02/21/2020
UHCG, [LOINC: 2106-3]
02/21/20207461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health Services7461 East Dr STE 102MontgomeryAL361178092US7461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health Services7461 East Dr STE 102MontgomeryAL361178092US7461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health Services7461 East Dr STE 102MontgomeryAL361178092US7461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health Services7461 East Dr STE 102MontgomeryAL361178092US7461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health Services7461 East Dr STE 102MontgomeryAL361178092US7461 East Dr STE 102MontgomeryAL361178092USAuburn Montgomery Warhawk Health Services7461 East Dr STE 102MontgomeryAL361178092US

            MEDICAL EQUIPMENTPatient has no history of implantable devicesIMMUNIZATIONSNo immunization historyVaccinationVITAL SIGNSDate Height Weight BMI Blood Pressure Temperature Pulse Pulse Oximetry Respiratory Rate Inhaled Oxygen Concentration Head Circumference Percentage BMI Percentage Weight to Length Percentage

02/21/2020 138/80 mm[Hg] 37 Cel 103 bpm 98 pct 14 bpmRESULTSResult Type Result Value Date

Leukocytes-Urine
Negative
02/21/2020
Urobilinogen-Urine
Negative
02/21/2020
Protein [Mass/Volume] in Urine by Test strip
Positive mg/dL
02/21/2020
pH of Urine by Test strip
7 [pH]
02/21/2020
Blood-Urine
Negative
02/21/2020
Ketones [Mass/Volume] in Urine by Test strip
Negative mg/dL
02/21/2020
Glucose [Mass/Volume] in Urine by Test strip
Negative mg/dL
02/21/2020
Specific Gravity of Urine by Test strip
1.020
02/21/2020
Bilirubin-Urine
Negative
02/21/2020
Nitrites-Urine
Negative
02/21/2020
Appearance of Urine
Clear
02/21/2020
Color of Urine
Dark Yellow
02/21/2020NegativeNegativePositiveNegativeNegativeNegativeNegativeNegativeClearDark YellowPLAN OF TREATMENTNo Treatment Plan Defined Goals SectionNo goal informationHealth Concerns SectionNo Known Health Concerns on INSTRUCTIONSNo Known Instructions/Patient EducationSOCIAL HISTORYNo Social History Selected to be DisplayedFUNCTIONAL STATUSNo informationMENTAL STATUSNo information

Medication	Start Date	Directions	Status
mupirocin 2 % topical ointment, [RxNorm: 103570]	02/21/2020	APPLY A SMALL AMOUNT TO THE AFFECTED AREA BY TOPICAL ROUTE 3 TIMES PER DAY	Active
hydrocortisone 2.5 % topical cream, [RxNorm: 1540356]	02/21/2020	APPLY A THIN LAYER TO THE AFFECTED AREA(S) BY TOPICAL ROUTE 2 TIMES PER DAY	Active
omeprazole 20 mg capsule,delayed release, [RxNorm: 104099]	02/21/2020	TAKE 1 CAPSULE (20 MG) BY ORAL ROUTE ONCE DAILY 30 MINUTES TO 1 HOUR BEFORE MEAL	Active
cephalexin 500 mg capsule, [RxNorm: 152655]	02/21/2020	TAKE 1 CAPSULE (500 MG) BY ORAL ROUTE EVERY 12 HOURS	Active
fluconazole 150 mg tablet, [RxNorm: 207108]	02/21/2020	TAKE 1 TABLET (150 MG) BY ORAL ROUTE ONCE, MAY REPEAT DOSE AFTER 3 DAYS IF SYMPTOMS PERSIST.	Active
Tri-Sprintec (28) 0.18 mg(7)/0.215 mg(7)/0.25 mg(7)-0.035 mg tablet, [RxNorm: 762333]	02/21/2020	TAKE AS DIRECTED	Active

Procedure	Date
UA, [CPT-4: 81003]	02/21/2020
COMP METABOLIC PANEL (QUEST), [CPT-4: 10231]	02/21/2020
CBC W/ DIFF (QUEST), [CPT-4: 6399]	02/21/2020
TSH W/REFLEX T4, FREE (QUEST), [CPT-4: 36127]	02/21/2020
VITAMIN D 25 - HYDROXY, TOTAL (QUEST), [CPT-4: 17306]	02/21/2020
UHCG, [LOINC: 2106-3]	02/21/2020

Result Type	Result Value	Date
Leukocytes-Urine	Negative	02/21/2020
Urobilinogen-Urine	Negative	02/21/2020
Protein [Mass/Volume] in Urine by Test strip	Positive mg/dL	02/21/2020
pH of Urine by Test strip	7 [pH]	02/21/2020
Blood-Urine	Negative	02/21/2020
Ketones [Mass/Volume] in Urine by Test strip	Negative mg/dL	02/21/2020
Glucose [Mass/Volume] in Urine by Test strip	Negative mg/dL	02/21/2020
Specific Gravity of Urine by Test strip	1.020	02/21/2020
Bilirubin-Urine	Negative	02/21/2020
Nitrites-Urine	Negative	02/21/2020
Appearance of Urine	Clear	02/21/2020
Color of Urine	Dark Yellow	02/21/2020