2026 Consolidated CDA

ALLERGIES AND ADVERSE REACTIONSNo Known Drug AllergiesNo Known Drug Allergies

MEDICATIONSMedication Start Date Directions Status

Maxalt-MLT 10 mg disintegrating tablet, [RxNorm: 828537]
03/16/2022
PLACE 1 TABLET (10 MG) ON TOP OF TONGUE, ALLOW TO DISSOLVE THEN SWALLOW BY TRANSLINGUAL ROUTE ONCE, MAY REPEAT EVERY 2 HRS; MAX 30 MG/24HRS
Active
ibuprofen 800 mg tablet, [RxNorm: 202098]
03/16/2022
TAKE 1 TABLET (800 MG) BY ORAL ROUTE 3 TIMES PER DAY WITH FOOD as needed for pain 
Active
amoxicillin 875 mg-potassium clavulanate 125 mg tablet, [RxNorm: 824194]
03/10/2023
TAKE 1 TABLET BY ORAL ROUTE EVERY 12 HOURS FOR 7 DAYS
Active
Bromfed DM 2 mg-30 mg-10 mg/5 mL oral syrup, [RxNorm: 1358993]
03/10/2023
TAKE 10 MILLILITERS BY ORAL ROUTE EVERY 4 HOURS AS NEEDED FOR COUGH/CONGESTION. DO NOT EXCEED 40 ML/DAY
Active
fluticasone propionate 50 mcg/actuation nasal spray,suspension, [RxNorm: 1797909]
03/10/2023
SPRAY 1 - 2 SPRAYS (50 - 100 MCG) IN EACH NOSTRIL BY INTRANASAL ROUTE DAILY
Active
ondansetron HCl 4 mg tablet, [RxNorm: 104895]
08/15/2023
take 1 tablet PO every 8 hrs as needed for nausea/vomiting
ActivePROBLEMSNo known health problemsENCOUNTERSEncounter Performer Location Date
PROCEDURESProcedure Date

STREP A, [LOINC: 18481-2]
03/10/2023
UA, [CPT-4: 81003]
08/15/2023
COMP METABOLIC PANEL (QUEST), [CPT-4: 10231]
08/15/2023
CBC W/ DIFF (QUEST), [CPT-4: 6399]
08/15/2023
INFLUENZA Rapid Test, [CPT-4: 87804]
03/10/2023
INFLUENZA Rapid Test, [CPT-4: 87804]
03/16/2022
THERAPEUTIC INJECTION ADMIN, [CPT-4: 96372]
03/16/2022
Toradol 60 MG , [CPT-4: J1885]
03/16/2022
Toradol 60 MG , [CPT-4: J1885]
03/10/2023
Ear Irrigation, [CPT-4: 69209]
03/10/2023
Ondansetron 4mg/ml, [CPT-4: J2405]
08/15/2023
Dexamethasone 4mg/ml, [CPT-4: J1100]
03/10/2023
Abbott Binax Now Rapid COVID , [CPT-4: 87426]
03/16/2022
COVID-19, mRNA, LNP-S, PF, [CPT-4: 91300]
02/15/2021
COVID-19, mRNA, LNP-S, PF, [CPT-4: 91300]
03/08/2021
IV START WITH MEDS, [LOINC: 96365]
08/15/2023
Normal saline 1L Bolus, [CPT-4: 90774]
08/15/2023
Abbott COVID Rapid Test, [CPT-4: ABBO]
03/10/20237461 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 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 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 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 devicesIMMUNIZATIONSName Date Status

COVID-19, mRNA, LNP-S, PF
02/15/2021
Completed
COVID-19, mRNA, LNP-S, PF
03/08/2021
CompletedCOVID-19, mRNA, LNP-S, PFEN6200Pfizer, Inc7461 East DrMontgomeryALUSLindseyBartonCRNPAuburn Montgomery Student Health Services7461 East DrMontgomeryAL36117USCOVID-19, mRNA, LNP-S, PFEN6205Pfizer, Inc7461 East DrMontgomeryALUSLindseyBartonCRNPAuburn Montgomery Student Health Services7461 East DrMontgomeryAL36117USVITAL SIGNSDate Height Weight BMI Blood Pressure Temperature Pulse Pulse Oximetry Respiratory Rate Inhaled Oxygen Concentration Head Circumference Percentage BMI Percentage Weight to Length Percentage

03/16/2022 160 cm 65 kg 25.5 132/80 mm[Hg] 37 Cel 124 bpm 96 pct 16 bpm
03/10/2023 160 cm 71 kg 27.91 124/82 mm[Hg] 36 Cel 103 bpm 97 pct 16 bpm
08/15/2023 160 cm 72 kg 28.04 102/73 mm[Hg] 36 Cel 114 bpm 98 pct 16 bpmRESULTSResult Type Result Value Date

Leukocytes-Urine
Positive
08/15/2023
Urobilinogen-Urine
Positive
08/15/2023
Protein [Mass/Volume] in Urine by Test strip
Positive mg/dL
08/15/2023
pH of Urine by Test strip
5 [pH]
08/15/2023
Blood-Urine
Positive
08/15/2023
Ketones [Mass/Volume] in Urine by Test strip
Positive mg/dL
08/15/2023
Glucose [Mass/Volume] in Urine by Test strip
Negative mg/dL
08/15/2023
Specific Gravity of Urine by Test strip
1.020
08/15/2023
Bilirubin-Urine
Positive
08/15/2023
Nitrites-Urine
Negative
08/15/2023
Appearance of Urine
dark/clear
08/15/2023
Color of Urine
tea colored
08/15/2023
STREP A
Negative
03/10/2023
INFLUENZA Rapid Test
Negative
03/16/2022
INFLUENZA Rapid Test
Negative
03/10/2023
GLUCOSE
93
08/16/2023
UREA NITROGEN (BUN)
16
08/16/2023
CREATININE
0.87
08/16/2023
EGFR
88
08/16/2023
BUN/CREATININE RATIO
SEE NOTE:
08/16/2023
SODIUM
137
08/16/2023
POTASSIUM
3.7
08/16/2023
CHLORIDE
99
08/16/2023
CARBON DIOXIDE
25
08/16/2023
CALCIUM
9.4
08/16/2023
PROTEIN, TOTAL
7.5
08/16/2023
ALBUMIN
4.7
08/16/2023
GLOBULIN
2.8
08/16/2023
ALBUMIN/GLOBULIN RATIO
1.7
08/16/2023
BILIRUBIN, TOTAL
0.6
08/16/2023
ALKALINE PHOSPHATASE
65
08/16/2023
AST
14
08/16/2023
ALT
14
08/16/2023
WHITE BLOOD CELL COUNT
10.0
08/16/2023
RED BLOOD CELL COUNT
5.19
08/16/2023
HEMOGLOBIN
15.1
08/16/2023
HEMATOCRIT
43.8
08/16/2023
MCV
84.4
08/16/2023
MCH
29.1
08/16/2023
MCHC
34.5
08/16/2023
RDW
12.2
08/16/2023
PLATELET COUNT
344
08/16/2023
MPV
9.4
08/16/2023
ABSOLUTE NEUTROPHILS
8910
08/16/2023
ABSOLUTE LYMPHOCYTES
660
08/16/2023
ABSOLUTE MONOCYTES
400
08/16/2023
ABSOLUTE EOSINOPHILS
20
08/16/2023
ABSOLUTE BASOPHILS
10
08/16/2023
NEUTROPHILS
89.1
08/16/2023
LYMPHOCYTES
6.6
08/16/2023
MONOCYTES
4.0
08/16/2023
EOSINOPHILS
0.2
08/16/2023
BASOPHILS
0.1
08/16/2023PositivePositivePositivePositivePositiveNegativePositiveNegativedark/cleartea coloredNegativeNegativeNegativeSEE NOTE:PLAN 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
Maxalt-MLT 10 mg disintegrating tablet, [RxNorm: 828537]	03/16/2022	PLACE 1 TABLET (10 MG) ON TOP OF TONGUE, ALLOW TO DISSOLVE THEN SWALLOW BY TRANSLINGUAL ROUTE ONCE, MAY REPEAT EVERY 2 HRS; MAX 30 MG/24HRS	Active
ibuprofen 800 mg tablet, [RxNorm: 202098]	03/16/2022	TAKE 1 TABLET (800 MG) BY ORAL ROUTE 3 TIMES PER DAY WITH FOOD as needed for pain	Active
amoxicillin 875 mg-potassium clavulanate 125 mg tablet, [RxNorm: 824194]	03/10/2023	TAKE 1 TABLET BY ORAL ROUTE EVERY 12 HOURS FOR 7 DAYS	Active
Bromfed DM 2 mg-30 mg-10 mg/5 mL oral syrup, [RxNorm: 1358993]	03/10/2023	TAKE 10 MILLILITERS BY ORAL ROUTE EVERY 4 HOURS AS NEEDED FOR COUGH/CONGESTION. DO NOT EXCEED 40 ML/DAY	Active
fluticasone propionate 50 mcg/actuation nasal spray,suspension, [RxNorm: 1797909]	03/10/2023	SPRAY 1 - 2 SPRAYS (50 - 100 MCG) IN EACH NOSTRIL BY INTRANASAL ROUTE DAILY	Active
ondansetron HCl 4 mg tablet, [RxNorm: 104895]	08/15/2023	take 1 tablet PO every 8 hrs as needed for nausea/vomiting	Active

Procedure	Date
STREP A, [LOINC: 18481-2]	03/10/2023
UA, [CPT-4: 81003]	08/15/2023
COMP METABOLIC PANEL (QUEST), [CPT-4: 10231]	08/15/2023
CBC W/ DIFF (QUEST), [CPT-4: 6399]	08/15/2023
INFLUENZA Rapid Test, [CPT-4: 87804]	03/10/2023
INFLUENZA Rapid Test, [CPT-4: 87804]	03/16/2022
THERAPEUTIC INJECTION ADMIN, [CPT-4: 96372]	03/16/2022
Toradol 60 MG , [CPT-4: J1885]	03/16/2022
Toradol 60 MG , [CPT-4: J1885]	03/10/2023
Ear Irrigation, [CPT-4: 69209]	03/10/2023
Ondansetron 4mg/ml, [CPT-4: J2405]	08/15/2023
Dexamethasone 4mg/ml, [CPT-4: J1100]	03/10/2023
Abbott Binax Now Rapid COVID , [CPT-4: 87426]	03/16/2022
COVID-19, mRNA, LNP-S, PF, [CPT-4: 91300]	02/15/2021
COVID-19, mRNA, LNP-S, PF, [CPT-4: 91300]	03/08/2021
IV START WITH MEDS, [LOINC: 96365]	08/15/2023
Normal saline 1L Bolus, [CPT-4: 90774]	08/15/2023
Abbott COVID Rapid Test, [CPT-4: ABBO]	03/10/2023

Name	Date	Status
COVID-19, mRNA, LNP-S, PF	02/15/2021	Completed
COVID-19, mRNA, LNP-S, PF	03/08/2021	Completed

Date	Height	Weight	BMI	Blood Pressure	Temperature	Pulse	Pulse Oximetry	Respiratory Rate
03/16/2022	160 cm	65 kg	25.5	132/80 mm[Hg]	37 Cel	124 bpm	96 pct	16 bpm
03/10/2023	160 cm	71 kg	27.91	124/82 mm[Hg]	36 Cel	103 bpm	97 pct	16 bpm
08/15/2023	160 cm	72 kg	28.04	102/73 mm[Hg]	36 Cel	114 bpm	98 pct	16 bpm

Result Type	Result Value	Date
Leukocytes-Urine	Positive	08/15/2023
Urobilinogen-Urine	Positive	08/15/2023
Protein [Mass/Volume] in Urine by Test strip	Positive mg/dL	08/15/2023
pH of Urine by Test strip	5 [pH]	08/15/2023
Blood-Urine	Positive	08/15/2023
Ketones [Mass/Volume] in Urine by Test strip	Positive mg/dL	08/15/2023
Glucose [Mass/Volume] in Urine by Test strip	Negative mg/dL	08/15/2023
Specific Gravity of Urine by Test strip	1.020	08/15/2023
Bilirubin-Urine	Positive	08/15/2023
Nitrites-Urine	Negative	08/15/2023
Appearance of Urine	dark/clear	08/15/2023
Color of Urine	tea colored	08/15/2023
STREP A	Negative	03/10/2023
INFLUENZA Rapid Test	Negative	03/16/2022
INFLUENZA Rapid Test	Negative	03/10/2023
GLUCOSE	93	08/16/2023
UREA NITROGEN (BUN)	16	08/16/2023
CREATININE	0.87	08/16/2023
EGFR	88	08/16/2023
BUN/CREATININE RATIO	SEE NOTE:	08/16/2023
SODIUM	137	08/16/2023
POTASSIUM	3.7	08/16/2023
CHLORIDE	99	08/16/2023
CARBON DIOXIDE	25	08/16/2023
CALCIUM	9.4	08/16/2023
PROTEIN, TOTAL	7.5	08/16/2023
ALBUMIN	4.7	08/16/2023
GLOBULIN	2.8	08/16/2023
ALBUMIN/GLOBULIN RATIO	1.7	08/16/2023
BILIRUBIN, TOTAL	0.6	08/16/2023
ALKALINE PHOSPHATASE	65	08/16/2023
AST	14	08/16/2023
ALT	14	08/16/2023
WHITE BLOOD CELL COUNT	10.0	08/16/2023
RED BLOOD CELL COUNT	5.19	08/16/2023
HEMOGLOBIN	15.1	08/16/2023
HEMATOCRIT	43.8	08/16/2023
MCV	84.4	08/16/2023
MCH	29.1	08/16/2023
MCHC	34.5	08/16/2023
RDW	12.2	08/16/2023
PLATELET COUNT	344	08/16/2023
MPV	9.4	08/16/2023
ABSOLUTE NEUTROPHILS	8910	08/16/2023
ABSOLUTE LYMPHOCYTES	660	08/16/2023
ABSOLUTE MONOCYTES	400	08/16/2023
ABSOLUTE EOSINOPHILS	20	08/16/2023
ABSOLUTE BASOPHILS	10	08/16/2023
NEUTROPHILS	89.1	08/16/2023
LYMPHOCYTES	6.6	08/16/2023
MONOCYTES	4.0	08/16/2023
EOSINOPHILS	0.2	08/16/2023
BASOPHILS	0.1	08/16/2023