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샘플 결과 / 의료 기록 시간순 정리

샘플 결과

샘플 결과: 의료 기록 시간순 정리

의료 기록 시간순 정리이(가) 가상의 데모 파일로 만든 결과를 수정 없이 그대로 보여드려요. 아래 다운로드는 결제한 고객이 받는 파일과 같은 종류예요.

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교통사고를 당한 가상 환자의 60페이지짜리 가상 진료 기록입니다. 병원, 가정의, 물리치료, MRI, 정형외과, 검사실, 약국 기록으로 이루어져 있으며 21페이지는 스캔본이고 5개월의 공백과 날짜가 없는 페이지도 있습니다.

  • · Santos medical records (sample).pdf

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결과

Santos medical records (sample)

Chronology
Date Provider / facility Type Findings (as written) Diagnoses Medications Source page
2025-01-14 Springfield General Hospital visit Patient presents with neck pain and headache after a motor vehicle collision. Reports immediate posterior neck pain, 7/10, worse with rotation, and a dull occipital headache. Albuterol inhaler as needed p. 2
2025-01-14 Springfield General Hospital visit Midline cervical tenderness absent; bilateral paraspinal tenderness C3 to C7 with muscle spasm. Range of motion limited by pain in rotation and extension. Acute cervical strain (whiplash), S13.4XXA; Post-traumatic headache, G44.309 p. 3
2025-01-14 Carlos Mendes, MD · Springfield General Hospital visit Discharged home in stable condition at 11:15. Soft collar not recommended; follow up with primary care in 1 week. Cyclobenzaprine 5 mg; Ibuprofen 600 mg p. 4
2025-01-14 Priya Natarajan, MD · Springfield General Hospital imaging XR Cervical Spine, 3 views showed no acute fracture. Straightening/loss of lordosis, likely spasm, and mild degenerative change at C5-C6. p. 5
2025-01-14 C. Mendes · Maple Pharmacy #112 medication Prescription fill history records Cyclobenzaprine 5 mg tab (Qty 15) and Ibuprofen 600 mg tab (Qty 28). Cyclobenzaprine 5 mg tab; Ibuprofen 600 mg tab p. 40
2025-01-14 Springfield General Hospital Emergency Department other Itemized billing statement for ED visit level 4 (99284) and XR cervical spine 3 views (72040). p. 59
2025-01-21 Dr. Helen Park, MD · Riverside Family Practice visit Follow-up after ED visit on 01/14/2025 with persistent neck pain at 6/10 after a rear-end collision. Paraspinal tenderness C4 to C7, neurologically intact, Spurling test negative. p. 6
2025-01-21 Dr. Helen Park, MD · Riverside Family Practice visit Cervical strain with myofascial pain, improving slowly. Post-traumatic headache. Cervical strain with myofascial pain; Post-traumatic headache ibuprofen 600 mg; cyclobenzaprine p. 7
2025-01-28 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Physical Therapy Initial Evaluation. Subjective pain 6/10 at rest, 8/10 with computer work over 30 minutes, with Neck Disability Index 42%. cervical strain S13.4XXA p. 8
2025-01-28 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Cervical rotation 50 / 55 degrees, extension 30 degrees with pain. Forward head posture, bilateral upper trapezius and levator scapulae hypertonicity, and deep neck flexor endurance 12 seconds. p. 9
2025-01-28 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Plan of care: manual therapy, therapeutic exercise, posture training and home exercise program, 2 times a week for 6 weeks. Goals include rotation over 70 degrees, NDI below 20%, sit at computer 60 minutes with pain under 3/10. p. 10
2025-01-30 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 6/10 today with headache twice since last visit. Cervical rotation 52 degrees bilaterally; tolerated treatment well. p. 13
2025-02-04 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 6/10 today; slept better. Cervical rotation 54 degrees bilaterally; tolerated treatment well. p. 14
2025-02-06 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 6/10 today, stiff after a long drive. Cervical rotation 56 degrees bilaterally; tolerated treatment well. p. 15
2025-02-11 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 5/10 today with right forearm tingling with computer use. Cervical rotation 58 degrees bilaterally; tolerated treatment well. p. 16
2025-02-13 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Physical Therapy Daily Note, visit 6 of 12. Pain 5/10 with headache twice since last visit; cervical rotation 60 degrees bilaterally and tolerated treatment well. p. 17
2025-02-18 City Imaging Center imaging C4-C5: mild disc bulge, no stenosis. C5-C6: small right paracentral disc protrusion contacting the ventral cord without cord signal change, mild right foraminal narrowing. p. 11
2025-02-18 Daniel Levin, MD, Neuroradiology · City Imaging Center imaging Small right paracentral disc protrusion at C5-C6 with mild right foraminal narrowing, which may correlate with right C6 symptoms. No fracture or ligament injury. p. 12
2025-02-20 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 5/10 today; slept better. Cervical rotation 62 degrees bilaterally; tolerated treatment well. p. 18
2025-02-25 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 4/10 today; stiff after a long drive. Cervical rotation 64 degrees bilaterally; tolerated treatment well. p. 19
2025-02-27 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 4/10 today with right forearm tingling with computer use. Cervical rotation 66 degrees bilaterally, and tolerated treatment well. p. 20
2025-03-04 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 4/10 today; headache twice since last visit. Cervical rotation 68 degrees bilaterally; tolerated treatment well. p. 21
2025-03-05 Dr. Samuel Okoye, MD, FAAOS · Lakeside Orthopedics visit Orthopedic spine consultation for neck pain and right arm paresthesia after MVC on 01/14/2025, with MRI showing C5-C6 protrusion. Reports six weeks of physical therapy with partial improvement and intermittent tingling into the right thumb and index finger. p. 25
2025-03-05 Dr. Samuel Okoye, MD, FAAOS · Lakeside Orthopedics visit Spurling test positive on the right reproducing thumb paresthesia, and sensation slightly decreased in the right C6 dermatome. Reviewed MRI 02/18/2025 showing right paracentral C5-C6 disc protrusion with mild foraminal narrowing. p. 26
2025-03-05 Dr. Samuel Okoye, MD, FAAOS · Lakeside Orthopedics visit Plan to continue physical therapy 4 more weeks and referral to pain management for right C5-C6 epidural steroid injection. Recommended desk duty with breaks every 45 minutes. Right C6 radiculopathy secondary to C5-C6 disc protrusion, M54.12; Cervical strain Gabapentin 300 mg at night, increase to twice daily after one week if tolerated p. 27
2025-03-05 Valley Clinical Laboratories lab Glucose, fasting was elevated at 104 mg/dL. WBC 7.2 x10^3/uL, Hemoglobin 12.9 g/dL, Platelets 262 x10^3/uL, Sodium 139 mmol/L, Potassium 4.1 mmol/L, Creatinine 0.78 mg/dL, eGFR 96 mL/min/1.73m2, ALT 22 U/L, and AST 19 U/L. p. 28
2025-03-06 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 3/10 today; slept better. Cervical rotation 70 degrees bilaterally and tolerated treatment well. p. 22
2025-03-06 S. Okoye · Maple Pharmacy #112 medication Prescription fill history records Gabapentin 300 mg cap (Qty 60). Gabapentin 300 mg cap p. 40
2025-03-11 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 3/10 today, stiff after a long drive. Cervical rotation 72 degrees bilaterally; tolerated treatment well. p. 23
2025-03-13 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 3/10 today with right forearm tingling with computer use. Cervical rotation 74 degrees bilaterally, and tolerated treatment well. p. 24
2025-04-07 S. Okoye · Maple Pharmacy #112 medication Prescription fill history records Gabapentin 300 mg cap (Qty 60). Gabapentin 300 mg cap p. 40
2025-04-10 Dr. Aisha Rahman, MD · Springfield Pain & Spine Center procedure Right C6-C7 interlaminar epidural steroid injection under fluoroscopic guidance using loss of resistance technique. Contrast spread confirmed in the epidural space. Right C6 radiculopathy; C5-C6 disc protrusion dexamethasone 10 mg; preservative-free saline 2 mL p. 29
2025-04-10 Dr. Aisha Rahman, MD · Springfield Pain & Spine Center procedure Patient tolerated the procedure well with no complications. Pre-procedure pain was 6/10 and post-procedure pain was 2/10. p. 30
2025-05-20 Dr. Helen Park, MD · Riverside Family Practice visit Epidural injection on 04/10/2025 helped about 60%, with tingling now only after long drives and back to full duty since 05/01/2025. Rotation 70 degrees bilaterally, Spurling negative, and strength 5/5. p. 31
2025-05-20 Helen Park, MD · Riverside Family Practice visit Cervical radiculopathy, improving after injection. Continue home exercises. Cervical radiculopathy Gabapentin 300 mg at night only p. 32
2025-05-21 H. Park · Maple Pharmacy #112 medication Gabapentin 300 mg cap filled, quantity 30. Gabapentin 300 mg cap p. 41
2025-06-03 Dr. Samuel Okoye, MD, FAAOS · Lakeside Orthopedics visit Improved after epidural injection, with occasional neck pain 3/10 at the end of the work day. Examination showed full strength, Spurling negative, and sensation intact. p. 33
2025-06-03 Dr. Samuel Okoye, MD, FAAOS · Lakeside Orthopedics visit Discharged from active orthopedic care. Maximum medical improvement not yet reached; re-evaluate in 6 months. p. 34
2025-11-18 Dr. Helen Park, MD · Riverside Family Practice visit Neck pain returned in October, 5/10, with right arm tingling again for two weeks. Rotation 55 degrees right, 65 left, Spurling positive on the right, and grip 4+/5 right. p. 37
2025-11-18 Dr. Helen Park, MD · Riverside Family Practice visit Assessment noted recurrent right C6 radiculopathy. Plan to restart physical therapy, repeat orthopedic evaluation, and consider repeat MRI if no improvement in 6 weeks. Recurrent right C6 radiculopathy Gabapentin 300 mg twice daily p. 38
2025-11-18 H. Park · Maple Pharmacy #112 medication Gabapentin 300 mg cap filled, quantity 60. Gabapentin 300 mg cap p. 41
2025-11-25 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 5/10. Tingling in the right thumb in the morning. p. 42
2025-11-27 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 5/10, better after last session. Treatment included cervical traction 10 minutes, nerve glides, deep neck flexor training, scapular stabilization. p. 43
2025-12-02 Dr. Samuel Okoye, MD, FAAOS · Lakeside Orthopedics letter Patient has been under care since 03/05/2025 for right C6 radiculopathy following a motor vehicle collision on 01/14/2025, with symptoms recurring in October 2025. She may work with restrictions until re-evaluation on 01/13/2026: no lifting over 20 lb, no overhead work, and a 10-minute break every hour of computer work. right C6 radiculopathy p. 39
2025-12-02 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Physical Therapy Daily Note, second episode, visit 3. Pain 5/10 with headache yesterday; treatment included cervical traction 10 minutes, nerve glides, deep neck flexor training, and scapular stabilization. p. 44
2025-12-04 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 4/10, with tingling in the right thumb in the morning. Treatment included cervical traction 10 minutes, nerve glides, deep neck flexor training, scapular stabilization. p. 45
2025-12-09 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 4/10, reported better after last session. Treatment included cervical traction 10 minutes, nerve glides, deep neck flexor training, and scapular stabilization. p. 46
2025-12-11 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 4/10 with headache yesterday. Treatment included cervical traction 10 minutes, nerve glides, deep neck flexor training, and scapular stabilization. p. 47
2025-12-16 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Physical Therapy Daily Note, second episode, visit 7. Pain 3/10; tingling in the right thumb in the morning. p. 48
2025-12-18 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 3/10; better after last session. Treatment included cervical traction 10 minutes, nerve glides, deep neck flexor training, and scapular stabilization. p. 49
2025-12-23 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 3/10, with headache yesterday. Treatment included cervical traction for 10 minutes, nerve glides, deep neck flexor training, and scapular stabilization. p. 50
2025-12-30 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 2/10. Tingling in the right thumb in the morning. p. 51
2026-01-06 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Physical Therapy Daily Note, second episode, visit 11. Pain 2/10, better after last session; treatment included cervical traction 10 minutes, nerve glides, deep neck flexor training, and scapular stabilization. p. 52
2026-01-08 Jordan Reyes, PT, DPT · Northside Physical Therapy visit Pain 2/10 with headache yesterday. Treatment included cervical traction 10 minutes, nerve glides, deep neck flexor training, and scapular stabilization. p. 53
2026-01-09 City Imaging Center imaging MRI Cervical Spine without Contrast compared to 02/18/2025 shows C5-C6 right paracentral disc protrusion slightly larger than on prior study, now with moderate right foraminal narrowing. No cord compression or signal change; other levels unchanged. p. 54
2026-01-09 Daniel Levin, MD, Neuroradiology · City Imaging Center imaging Interval mild enlargement of the right C5-C6 disc protrusion with moderate right foraminal stenosis. p. 55
2026-01-13 Dr. Samuel Okoye, MD, FAAOS · Lakeside Orthopedics visit Symptoms recurred in October 2025 with twelve physical therapy visits since 11/25/2025 providing partial relief, and repeat MRI 01/09/2026 reviewed. Examination showed Spurling positive right, grip 4+/5 right, and decreased sensation right thumb. p. 56
2026-01-13 Dr. Samuel Okoye, MD, FAAOS · Lakeside Orthopedics visit Assessment noted recurrent right C6 radiculopathy with enlarging C5-C6 protrusion. Plan includes repeat epidural injection and surgical consultation for anterior cervical discectomy and fusion if symptoms persist after 6 weeks. Recurrent right C6 radiculopathy with enlarging C5-C6 protrusion, M50.121 p. 57
2026-01-13 Dr. Samuel Okoye, MD, FAAOS · Lakeside Orthopedics visit Risks and benefits of injection and surgery discussed. Patient wishes to try injection first. p. 58
undated Dr. Helen Park, MD · Riverside Family Practice other Current symptoms reported: neck pain, headaches, tingling right hand. Symptoms started after the car accident in January. ibuprofen; gabapentin at night; albuterol p. 35
Gaps
Last record before the gap Next record Days without a record
2025-06-03 2025-11-18 168
Providers
Provider or facility Clinicians named First record Last record Rows Source pages
Maple Pharmacy #112 C. Mendes; S. Okoye; H. Park 2025-01-14 2025-11-18 5 40–41
Springfield General Hospital Carlos Mendes, MD; Priya Natarajan, MD 2025-01-14 2025-01-14 4 2–5
Springfield General Hospital Emergency Department 2025-01-14 2025-01-14 1 59
Riverside Family Practice Dr. Helen Park, MD; Helen Park, MD 2025-01-21 2025-11-18 7 6–7, 31–32, 35, 37–38
Northside Physical Therapy Jordan Reyes, PT, DPT 2025-01-28 2026-01-08 27 8–10, 13–24, 42–53
City Imaging Center Daniel Levin, MD, Neuroradiology 2025-02-18 2026-01-09 4 11–12, 54–55
Lakeside Orthopedics Dr. Samuel Okoye, MD, FAAOS 2025-03-05 2026-01-13 9 25–27, 33–34, 39, 56–58
Valley Clinical Laboratories 2025-03-05 2025-03-05 1 28
Springfield Pain & Spine Center Dr. Aisha Rahman, MD 2025-04-10 2025-04-10 2 29–30

데모 작업으로 October 22, 2026에 생성됨. · 의료 기록 시간순 정리 소개

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