Patient | Lindsey Pitt |
Date of birth | June 1, 1970 |
Sex | Female |
Race | White |
Ethnicity | Not Hispanic or Latino |
Contact info | Primary Home: 1006 Amber Dr Beaverton, OR 97266, US Tel: +1(555)-223-1234 |
Patient IDs | 117273338 2.16.840.1.113883.4.1 |
Document Id | ToC_10 2.16.840.1.113883.19.5.99999.1 |
Document Created: | June 22, 2015 |
Care provision | Anemia from June 22, 2015 to June 24, 2015 |
Performer (primary care physician) | Dr Henry Seven of Community Health and Hospitals |
Performer | Mary McDonald |
Author | Dr Henry Seven |
Contact info | 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002 |
Encounter Id | 9937012 2.16.840.1.113883.19 |
Encounter Date | From June 22, 2015, 10:00, EST to June 24, 2015 |
Personal relationship | Mr Ralph Issac |
Contact info | Primary Home: 1006 Amber Dr Beaverton, OR 97266, US Tel: +1(555)-224-1544 |
Personal relationship | Mr Franklin Pitt |
Contact info | Primary Home: 1006 Amber Dr Beaverton, OR 97266, US Tel: +1(555)-224-1544 |
Entered by | Mary McDonald |
Contact info | 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002 |
Signed | Dr Henry Seven at June 22, 2015 |
Contact info | 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002 |
Informant | Henry Seven |
Contact info | 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002 |
Informant | Franklin Pitt |
Information recipient: | Dr Henry Seven |
Legal authenticatorThis is not intended and not fully compliant with ONC Certification | Dr Henry Seven signed at June 22, 2015 |
Contact info | 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002 |
Document maintained by | Community Health and Hospitals |
Contact info | Work Place: 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002 |
Substance | Reaction | Severity | Status |
---|---|---|---|
Penicillin G | Hives | Moderate | Active |
Ampicillin | Hives | Moderate | Active |
Medication | Directions | Start Date |
---|---|---|
Ceftriaxone 100MG/ML | Two Times Daily | June 22, 2015 |
Vantin 200mg | Two Times Daily | June 22, 2015 |
Tylenol 500mg | As needed | June 22, 2015 |
Darbepoetin Alfa 0.5 MG/ML | Once a week | June 22, 2015 |
Clindamycin 300mg | Three Times Daily | June 23, 2015 |
Torsemide 20mg | Daily | June 23, 2015 |
Levothyroxine Sodium 1mg | Daily | June 23, 2015 |
Prednisolone 50mg | Daily | June 23, 2015 |
FenoFibric Acid 35mg | At the hour of sleep | June 24, 2015 |
Mycophenolic Acid 360mg | Two times daily | June 24, 2015 |
Everolimus 0.5mg | Two times daily | June 24, 2015 |
Ciprofloxacin 250mg | Three times daily | June 25, 2015 |
Active Concerns
Resolved Concerns
Encounter Diagnosis | Location | Date |
---|---|---|
Anemia in Chronic Kidney Disease | Community Health and Hospitals | June 22, 2015 at 10:00am EST |
Procedure | Date |
---|---|
Bronchoscopy | June 22, 2015 |
Chest X-Ray, PA and Lateral Views | June 22, 2015 |
Introduction of cardiac pacemaker system via vein | October 5, 2011 |
Implanted | Area | UDI |
---|---|---|
Cardiac Pacemaker | Subclavian Vein | (01)00643169007222(17)160128(21)BLC200461H |
Vaccine | Date | Status |
---|---|---|
Influenza Virus Vaccine | May 10, 2014 | Completed |
Tetanus and diphtheria toxoids | January 4, 2012 | Completed |
influenza, intradermal, quadrivalent, preservative free | June 22, 2015 | Refused |
Date / Time: | June 22, 2015 |
---|---|
Height | 177 cm |
Weight | 88 kg |
Blood Pressure | 145/88 mm[Hg] |
Heart Rate | 80 beats per minute |
O2 Percentage BldC Oximetry | 95 percent |
Body Temperature | 38 degree celsius |
Respiratory Rate | 18 breaths per minute |
Social History Observation | Description | Dates Observed |
---|---|---|
Smoking Status | Heavy tobacco smoker | May 1, 2005 - February 27, 2011 |
Current Smoking Status | Current every day | June 22, 2015 |
Birth Sex | Female | June 22, 2015 |
Result Type | Result Value | Relevant Reference Range | Interpretation | Date |
---|---|---|---|---|
HGB | 10.2 g/dL | 06/22/2015 | ||
WBC | 12.3 (10*3/uL) | N/A - 500,000 | 06/22/2015 | |
PLT | 123 (10*3/uL) | 06/22/2015 | ||
Everolimus Blood | 10 ng/mL | 3.0 - 8.0 ng/ml | 06/22/2015 | |
Color of Urine | YELLOW | YELLOW | Normal | 06/22/2015 |
Appearance of Urine | CLEAR | CLEAR | Normal | 06/22/2015 |
Specific gravity of Urine by Test strip | 1.015 | 1.005 - 1.030 | Normal | 06/22/2015 |
pH of Urine by Test strip | 5.0 [pH] | 5.0 - 8.0 | Normal | 06/22/2015 |
Glucose [Mass/volume] in urine by test strip | 50 mg/dL | Neg | 06/22/2015 | |
Ketones [Mass/Volume] in urine by test strip | Negative | Negative | Normal | 06/22/2015 |
Protein[Mass/Volume] in urine by test strip | 100 mg/dL | negative | 06/22/2015 |
Functional Category | Effective Dates |
---|---|
Dependence on Cane | May 01, 2005 |
Status | Date |
---|---|
Amnesia | May 05, 2005 |
Planned Care | Start Date |
---|---|
Urinanalysis macro (dipstick) panel | June 29, 2015 |
Immunosuppressive therapy | July 1, 2015 |
Schedule an appointment with Dr Seven after 1 week for Follow up with Outpatient facility for Immunosuppressive therapy. | July 1, 2015 |
Goal | Value | Date |
---|---|---|
Need to gain more energy to do regular activities (Visual Inspection) | N/A | June 23, 2015 |
Negotiated Goal for Body Temperature | 98-99 degrees Fahrenheit | June 23, 2015 |
Observation | Status | Date |
---|---|---|
Chronically ill | Active | June 22, 2015 |
Concern | Status | Date |
---|---|---|
HyperTension problem concern | Active | June 22, 2015 |
HypoThyroidism problem concern | Active | June 22, 2015 |
Anemia problem concern | Active | June 22, 2015 |
Related observation | Date |
---|---|
Vital Sign Weight Observation | June 22, 2015 |