Header
Composition/9a4bd04c-2e29-9fc6-12bd-f3dd3a4853ec
{
"date" : "2015-06-22",
"encounter" : {
"reference" : "urn:uuid:690487e1-3b05-37ea-c11f-fb3e15491628"
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"section" : [ {
"title" : "PROBLEMS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nActive Concerns\nProblem #1\n\t\t\t\t\t\t\t\t\n \nEssential hypertension (Disorder)\nProblem #2\n\t\t\t\t\t\t\t\t\n \nSevere Hypothyroidism (Disorder)\nProblem #3\n\t\t\t\t\t\t\t\t\n \nChronic rejection of renal transplant (disorder)\nProblem #4\n\t\t\t\t\t\t\t\t\n \nIron deficiency anemia (disorder))\nProblem #5\n\t\t\t\t\t\t\t\t\n \nInterstitial pneumonia (disorder)\nResolved Concerns\nProblem #6\n\t\t\t\t\t\t\t\t\n \nOverweight (finding)\n</div>\n",
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"text" : "PROBLEM LIST",
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}, {
"title" : "ASSESSMENTS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nThe patient was found to have Anemia and Dr Seven and his staff diagnosed the condition and treated Ms Alice for Anemia during the 2 day stay at Community Health Hospitals. Ms Alice recovered from Anemia during the stay and is being discharged in a stable condition. If there is fever greater than 101.5 F or onset of chest pain/breathlessness the patient is advised to contact emergency.\n</div>\n",
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}, {
"title" : "VITAL SIGNS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nDate / Time: \nJune 22, 2015\nHeight\n177 cm\nWeight\n88 kg\nBlood Pressure\n145/88 mm[Hg]\nHeart Rate\n80 beats per minute\nO2 Percentage BldC Oximetry\n95 percent\nBody Temperature\n38 degree celsius\nRespiratory Rate\n18 breaths per minute\n</table>\n</div>\n",
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"text" : "VITAL SIGNS",
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"code" : "8716-3",
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"system" : "http://loinc.org"
} ]
}
}, {
"title" : "PROCEDURES",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nProcedure\nDate\nBronchoscopy\nJune 22, 2015\nChest X-Ray, PA and Lateral Views\nJune 22, 2015\nIntroduction of cardiac pacemaker system via vein\nOctober 5, 2011\n</table>\n</div>\n",
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"display" : "HISTORY OF PROCEDURES",
"system" : "http://loinc.org"
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}, {
"title" : "ENCOUNTERS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nEncounter Diagnosis\nLocation\nDate\n Anemia in Chronic Kidney Disease\nCommunity Health and Hospitals\nJune 22, 2015 at 8:00am\n</table>\n</div>\n",
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"text" : "History of encounters",
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"code" : "46240-8",
"display" : "History of encounters",
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}, {
"title" : "HOSPITAL COURSE",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nMs. Rabecca Angeles is a 45 year old female with a history of Hypertension, Hypothyroidism, Iron deficiency and is a recipient of Renal Allograft is admitted on 6/22/2015 at 10 am EST to Community Health and Hospitals with history of intermittent fever for 2 days. The patient disclosed history of nausea, loose stools and weakness. She was found to have Anemia secondary to iron deficiency and CKD. After conducting multiple tests and administering necessary medications, the patient was discharged to Ambulatory facility to follow up with immunosuppression as an out-patient. The condition of the patient at discharge was stable, with controlled blood sugar levels and a pain score below 3. Additional follow up instructions have been provided to the patient.\n</div>\n",
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"text" : "HOSPITAL COURSE",
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}, {
"title" : "ADMISSION DIAGNOSIS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nAnemia\n</div>\n",
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},
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} ],
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"text" : "Hospital Admission Diagnosis",
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"display" : "Hospital Admission Diagnosis",
"system" : "http://loinc.org"
}, {
"code" : "42347-5",
"display" : "Admission Diagnosis",
"system" : "http://loinc.org"
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}
}, {
"title" : "Discharge Diagnosis",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nThe patient was discharged to Ambulatory facility to follow up with immunosuppression as an out-patient. The condition of the patient at discharge was stable, with controlled blood sugar levels and a pain score below 3. Additional follow up instructions have been provided to the patient.\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Hospital Discharge Diagnosis",
"coding" : [ {
"code" : "11535-2",
"display" : "Hospital Discharge Diagnosis",
"system" : "http://loinc.org"
}, {
"code" : "78375-3",
"display" : "Discharge Diagnosis",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "FUNCTIONAL STATUS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nFunctional Category\nEffective Dates\nDependence on Cane\nMay 01, 2005\n</table>\n</div>\n",
"status" : "generated"
},
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} ],
"code" : {
"text" : "Functional Status",
"coding" : [ {
"code" : "47420-5",
"display" : "Functional Status",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "TREATMENT PLAN",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n Hand-off Communication:\n<br>\n</br>\n<br>\n</br>\n<table width='100%' border='1'>\nPlanned Care\nStart Date\nUrinanalysis macro (dipstick) panel\nJune 29, 2015\nImmunosuppressive therapy\nJuly 1, 2015\nSchedule an appointment with Dr Seven after 1 week for Follow up with Outpatient facility for Immunosuppressive therapy.\nJuly 1, 2015\n</table>\n</div>\n",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:a5accdd9-f770-a662-b129-b4ca0571cd2c"
}, {
"reference" : "urn:uuid:fdcf9277-6807-5129-dbaf-928f8b3c380e"
}, {
"reference" : "urn:uuid:aff53d03-81d5-c502-66e1-6523e47f8b9e"
} ],
"code" : {
"text" : "Treatment plan",
"coding" : [ {
"code" : "18776-5",
"display" : "Treatment plan",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "MENTAL STATUS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nStatus\nDate\nAmnesia\nMay 05, 2005\n</table>\n</div>\n",
"status" : "generated"
},
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} ],
"code" : {
"text" : "MENTAL STATUS",
"coding" : [ {
"code" : "10190-7",
"display" : "MENTAL STATUS",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "IMMUNIZATIONS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nVaccine\nDate\nStatus\nSeries number\nInfluenza Virus Vaccine\n \nMay 10, 2014\nCompleted\nN/A\nTetanus and diphtheria toxoids\n \nJanuary 4, 2012\nCompleted\nN/A\ninfluenza, intradermal, quadrivalent, preservative free\n \nJune 22, 2015\nRefused\nN/A\n</table>\n</div>\n",
"status" : "generated"
},
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"reference" : "urn:uuid:96193893-d945-c9b9-374f-41fe52657427"
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"reference" : "urn:uuid:b9a0ac12-01b4-8229-6b27-43f9ce6fad8d"
}, {
"reference" : "urn:uuid:a0aa6527-7778-5454-6c2a-d63966273566"
} ],
"code" : {
"text" : "History of immunizations",
"coding" : [ {
"code" : "11369-6",
"display" : "History of immunizations",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Discharge Medications",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nNo Information\n</div>\n",
"status" : "generated"
},
"code" : {
"text" : "Hospital Discharge Medications",
"coding" : [ {
"code" : "10183-2",
"display" : "Hospital Discharge Medications",
"system" : "http://loinc.org"
}, {
"code" : "75311-1",
"display" : "Discharge Medications",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "ALLERGIES AND ADVERSE REACTIONS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nSubstance\nReaction\nSeverity\nStatus\nPenicillin G\nHives\nModerate\nActive\nAmpicillin\nHives\nModerate\nActive\n</table>\n</div>\n",
"status" : "generated"
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"reference" : "urn:uuid:aea7c259-3c0d-c306-06a0-5b3105360530"
} ],
"code" : {
"coding" : [ {
"code" : "48765-2",
"display" : "48765-2",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "HOSPITAL DISCHARGE INSTRUCTIONS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\nDiet: Diabetic low salt diet\nMedications: Take prescribed medications as advised.\nAppointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility for Immunosuppression treatment.\nFor Fever of > 101.5 F, or onset of chest pain/breathlessness contact Emergency.\n</div>\n",
"status" : "generated"
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"code" : {
"text" : "HOSPITAL DISCHARGE INSTRUCTIONS",
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"code" : "8653-8",
"display" : "HOSPITAL DISCHARGE INSTRUCTIONS",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Health Concerns Section",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nObservation\nStatus\nDate\nChronically ill\nActive\nJune 22, 2015\n</table>\n<br>\n</br>\n<table width='100%' border='1'>\nConcern\nStatus\nDate\nHyperTension problem concern\nActive\nJune 22, 2015\nHypoThyroidism problem concern\nActive\nJune 22, 2015\nAnemia problem concern\nActive\nJune 22, 2015\n</table>\n<br>\n</br>\n<table width='100%' border='1'>\nRelated observation\nDate\nVital Sign Weight Observation\nJune 22, 2015\n</table>\n<br>\n</br>\n</div>\n",
"status" : "generated"
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"reference" : "urn:uuid:ad4f24fd-0d03-6c57-b9f2-c0c31f546322"
} ],
"code" : {
"text" : "Health Concerns Document",
"coding" : [ {
"code" : "75310-3",
"display" : "Health Concerns Document",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "SOCIAL HISTORY",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nSocial History Observation\nDescription\nDates Observed\nSmoking Status\nHeavy tobacco smoker, ??-??/day\nMay 1, 2005 - February 27, 2011\nCurrent Smoking Status\nCurrent every day\nJune 22, 2015\nBirth Sex\nFemale\nJune 22, 2015\n</table>\n</div>\n",
"status" : "generated"
},
"entry" : [ {
"reference" : "urn:uuid:84f95ace-85c9-07fd-cfdb-f348d2e908fd"
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"reference" : "urn:uuid:581f645e-94ba-9c37-88e0-75d1eeada3ab"
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"reference" : "urn:uuid:b27b4f7f-b425-25a1-d1a7-46c82381017d"
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"reference" : "urn:uuid:499d0c99-d168-acd2-2066-16a1ea7c1c19"
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} ],
"code" : {
"text" : "Social History",
"coding" : [ {
"code" : "29762-2",
"display" : "Social History",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Implants",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table>\nImplanted\nArea\nUDI\nCardiac Pacemaker\nSubclavian Vein\n(01)00643169007222(17)160128(21)BLC200461H\n</table>\n</div>\n",
"status" : "generated"
},
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"reference" : "urn:uuid:fe24fc80-7415-f6da-686e-93b7daabc4fc"
} ],
"code" : {
"text" : "Medical Equipment",
"coding" : [ {
"code" : "46264-8",
"display" : "Medical Equipment",
"system" : "http://loinc.org"
} ]
}
}, {
"title" : "Goals Section",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nGoal\nValue\nDate\nNeed to gain more energy to do regular activities (Visual Inspection)\nN/A\nJune 23, 2015\nNegotiated Goal for Body Temperature\n98-99 degrees Fahrenheit\nJune 23, 2015\n</table>\n</div>\n",
"status" : "generated"
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"reference" : "urn:uuid:c4aabc92-3e7a-cb7f-7ed5-354b13c985f7"
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"code" : {
"text" : "Goals",
"coding" : [ {
"code" : "61146-7",
"display" : "Goals",
"system" : "http://loinc.org"
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}
}, {
"title" : "RESULTS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table>\nResult Type\nResult Value\nRelevant Reference Range\nInterpretation\nDate\nHGB\n10.2 g/dL\n06/22/2015\nWBC\n12.3 (10*3/uL)\nN/A - 500,000\n06/22/2015\nPLT\n123 (10*3/uL)\n06/22/2015\nEverolimus Blood\n10 ng/mL\n3.0-8.0 ng/ml\n06/22/2015\nColor of Urine\nYELLOW\nYELLOW\nNormal\n06/22/2015\nAppearance of Urine\nCLEAR\nCLEAR\nNormal\n06/22/2015\nSpecific gravity of Urine by Test strip\n1.015\n1.005 ? 1.030\nNormal\n06/22/2015\npH of Urine by Test strip\n5.0 [pH]\n5.0-8.0\nNormal\n06/22/2015\nGlucose [Mass/volume] in urine by test strip\n50 mg/dL\nNeg\n06/22/2015\nKetones [Mass/Volume] in urine by test strip\nNegative\nNegative\nNormal\n06/22/2015\nProtein[Mass/Volume] in urine by test strip\n100 mg/dL\nnegative\n06/22/2015\n</table>\n</div>\n",
"status" : "generated"
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"code" : {
"text" : "RESULTS",
"coding" : [ {
"code" : "30954-2",
"display" : "RESULTS",
"system" : "http://loinc.org"
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}, {
"title" : "MEDICATIONS",
"text" : {
"div" : "<div xmlns='http://www.w3.org/1999/xhtml'>\n<table width='100%' border='1'>\nMedication\nDirections\nStart Date\nCeftriaxone 100MG/ML\nTwo times daily\nJune 22, 2015\nVantin 200mg\nTwo Times daily\nJune 22, 2015\nTylenol 500mg\nAs needed\nJune 22, 2015\nDarbepoetin 0.5 MG/ML\nOnce a week\nJune 22, 2015\nClindamycin 300mg\nThree times daily\nJune 23, 2015\nTorsemide 20mg\nDaily\nJune 23, 2015\nLevothyroxine Sodium 1mg\nDaily\nJune 23, 2015\nPrednisolone 50mg\nDaily\nJune 23, 2015\nFenoFibric Acid 35mg\nAt the Hour of Sleep\nJune 24, 2015\nMycophenolic Acid 360mg\nTwo times daily\nJune 24, 2015\nEverolimus 0.5mg\nTwo times daily\nJune 24, 2015\nCiprofloxacin 250mg\nThree times daily\nJune 25, 2015\n</table>\n</div>\n",
"status" : "generated"
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"code" : {
"text" : "HISTORY OF MEDICATION USE",
"coding" : [ {
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"display" : "HISTORY OF MEDICATION USE",
"system" : "http://loinc.org"
} ]
}
} ],
"type" : {
"text" : "Discharge Summary",
"coding" : [ {
"code" : "18842-5",
"display" : "Discharge Summary",
"system" : "http://loinc.org"
} ]
},
"resourceType" : "Composition",
"title" : "170.315_b1_toc_inp_ds_r21_sample1 test data",
"author" : [ {
"reference" : "urn:uuid:de291f3e-f195-355e-2871-c189682f47b4"
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"custodian" : {
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"status" : "final",
"id" : "9a4bd04c-2e29-9fc6-12bd-f3dd3a4853ec",
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Patient/patient
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PractitionerRole/e214e9d5-ab94-8e6a-d3c1-9ac49b546f21
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Encounter/66fbf518-f24b-7819-c7d6-072df459eb10
{
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PROBLEMS (6 entries)
Active Concerns
Problem #1
Essential hypertension (Disorder)
Problem #2
Severe Hypothyroidism (Disorder)
Problem #3
Chronic rejection of renal transplant (disorder)
Problem #4
Iron deficiency anemia (disorder))
Problem #5
Interstitial pneumonia (disorder)
Resolved Concerns
Problem #6
Overweight (finding)
Condition/ec8a6ff8-jd4b-1f7e-87c3-e98e58b45de9
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Condition/ec8a6ff8-ed4b-4f7e-86c3-f98e59b45df9
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Condition/ec8a6ff8-ed4b-4f7e-84c3-e98e58b45de8
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Condition/ec8a6ff8-ed4b-4f7e-83c3-e98e58b45de7
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Condition/ec8a6ff8-ed4b-4f7e-88c3-e98e58b45df9
{
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Condition/ec8a6ff8-ed4b-4f7e-85c3-e98e58b45de9
{
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"id" : "ec8a6ff8-ed4b-4f7e-85c3-e98e58b45de9",
"code" : {
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"coding" : [ {
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},
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ASSESSMENTS (0 entries)
The patient was found to have Anemia and Dr Seven and his staff diagnosed the condition and treated Ms Alice for Anemia during the 2 day stay at Community Health Hospitals. Ms Alice recovered from Anemia during the stay and is being discharged in a stable condition. If there is fever greater than 101.5 F or onset of chest pain/breathlessness the patient is advised to contact emergency.
VITAL SIGNS (8 entries)
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
Observation/f4e729e2-a97f-4a7e-8e23-c92f9b6b55cf
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Observation/a0e39c70-9674-4b2a-9837-cdf74200d8d5
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Observation/a0e39c70-9675-4b2a-9838-cdf74200d8d5
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Observation/1c2748b7-e440-41ba-bc01-dde97d84a036
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Observation/ed9589fd-fda0-41f7-a3d0-dc537554f5c2
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Observation/a0e39c70-9675-4b2a-9841-cdf74200d8d5
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PROCEDURES (3 entries)
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
Procedure/d68b7e32-7812-4f5b-9cc2-acd54b0fd85d
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Procedure/d68b7e32-7811-4f5b-9cc2-acd54b0fd85d
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Procedure/d68b7e32-7810-4f5b-9cc2-acd54b0fd85e
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ENCOUNTERS (1 entries)
Encounter Diagnosis
Location
Date
Anemia in Chronic Kidney Disease
Community Health and Hospitals
June 22, 2015 at 8:00am
Encounter/2a620155-9d11-439e-92b3-5d9815ff4de8
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HOSPITAL COURSE (0 entries)
Ms. Rabecca Angeles is a 45 year old female with a history of Hypertension, Hypothyroidism, Iron deficiency and is a recipient of Renal Allograft is admitted on 6/22/2015 at 10 am EST to Community Health and Hospitals with history of intermittent fever for 2 days. The patient disclosed history of nausea, loose stools and weakness. She was found to have Anemia secondary to iron deficiency and CKD. After conducting multiple tests and administering necessary medications, the patient was discharged to Ambulatory facility to follow up with immunosuppression as an out-patient. The condition of the patient at discharge was stable, with controlled blood sugar levels and a pain score below 3. Additional follow up instructions have been provided to the patient.
ADMISSION DIAGNOSIS (1 entries)
Condition/5a784260-6856-4f38-9638-80c751aff2fb
{
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"code" : {
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Discharge Diagnosis (0 entries)
The patient was discharged to Ambulatory facility to follow up with immunosuppression as an out-patient. The condition of the patient at discharge was stable, with controlled blood sugar levels and a pain score below 3. Additional follow up instructions have been provided to the patient.
FUNCTIONAL STATUS (1 entries)
Functional Category
Effective Dates
Dependence on Cane
May 01, 2005
Observation/a7bc1062-8649-42a0-833d-eed65bd017c9
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"id" : "a7bc1062-8649-42a0-833d-eed65bd017c9",
"code" : {
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"status" : "final",
"subject" : {
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TREATMENT PLAN (3 entries)
Hand-off Communication:
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
Procedure/9a6d1bac-17d3-4195-89c4-1121bc809b5a
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}
Encounter/2.3.7.1.42424242.5.11111.1.1.1
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"reasonReference" : [ {
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Observation/b52bee94-c34b-4e2c-8c15-5ad9d6def513
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"code" : {
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},
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MENTAL STATUS (1 entries)
Status
Date
Amnesia
May 05, 2005
Observation/a7bc1062-8649-42a0-833d-ekd65bd013d1
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IMMUNIZATIONS (3 entries)
Vaccine
Date
Status
Series number
Influenza Virus Vaccine
May 10, 2014
Completed
N/A
Tetanus and diphtheria toxoids
January 4, 2012
Completed
N/A
influenza, intradermal, quadrivalent, preservative free
June 22, 2015
Refused
N/A
Immunization/e6f1ba43-c0ed-4b9b-9f12-f435d8ad8f92
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Immunization/e6f1ba43-c0ed-4b9b-9f12-f436d8ad8f92
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"id" : "e6f1ba43-c0ed-4b9b-9f12-f436d8ad8f92",
"lotNumber" : "2",
"occurrenceDateTime" : "2012-01-04"
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Immunization/de10790f-1496-4719-8fe6-f1b88b6219f7
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"occurrenceDateTime" : "2015-06-22"
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Discharge Medications (0 entries)
ALLERGIES AND ADVERSE REACTIONS (2 entries)
Substance
Reaction
Severity
Status
Penicillin G
Hives
Moderate
Active
Ampicillin
Hives
Moderate
Active
AllergyIntolerance/36e3e930-7b14-11db-9fe1-0800200c9a66
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"recordedDate" : "1980-05-01",
"id" : "36e3e930-7b14-11db-9fe1-0800200c9a66",
"code" : {
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},
"onsetDateTime" : "1980-05-01",
"reaction" : [ {
"manifestation" : [ {
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} ],
"onset" : "2010-03-15",
"severity" : "mild"
}, {
"manifestation" : [ {
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} ],
"severity" : "moderate"
} ]
}
AllergyIntolerance/b03805bd-2eb6-4ab8-a9ff-473c6653971a
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"recordedDate" : "1980-05-01",
"id" : "b03805bd-2eb6-4ab8-a9ff-473c6653971a",
"code" : {
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"onsetDateTime" : "1980-05-01",
"reaction" : [ {
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"severity" : "moderate"
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HOSPITAL DISCHARGE INSTRUCTIONS (0 entries)
Diet: Diabetic low salt diet
Medications: Take prescribed medications as advised.
Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility for Immunosuppression treatment.
For Fever of > 101.5 F, or onset of chest pain/breathlessness contact Emergency.
Health Concerns Section (2 entries)
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
List/4eab0e52-dd7d-4285-99eb-72d32ddb195c
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Observation/1eeb1e51-ee1d-1234-11xy-11z11ddb111z
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SOCIAL HISTORY (5 entries)
Social History Observation
Description
Dates Observed
Smoking Status
Heavy tobacco smoker, ??-??/day
May 1, 2005 - February 27, 2011
Current Smoking Status
Current every day
June 22, 2015
Birth Sex
Female
June 22, 2015
Observation/45efb604-7049-4a2e-ad33-d38556c9636c
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"code" : {
"text" : "History of tobacco use",
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}
Observation/3155d06c-8932-f32f-7040-a2ccd1a9b717
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"effectiveDateTime" : "2015-06-22",
"id" : "3155d06c-8932-f32f-7040-a2ccd1a9b717",
"code" : {
"text" : "Tobacco smoking status NHIS",
"coding" : [ {
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} ]
},
"subject" : {
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}
Observation/b1bf3416-3291-42e8-4b84-2449032f5ab5
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},
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Observation/0c14d19f-8158-b955-5bae-bd72067be64a
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Implants (1 entries)
Implanted
Area
UDI
Cardiac Pacemaker
Subclavian Vein
(01)00643169007222(17)160128(21)BLC200461H
Procedure/bee16ebf-3dce-08a6-3985-65f8d5ab066b
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"bodySite" : [ {
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"performedPeriod" : {
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Goals Section (2 entries)
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
Goal/3700b3b0-fbed-11e2-b778-0800200c9a66
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RESULTS (2 entries)
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
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MEDICATIONS (12 entries)
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 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
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MedicationStatement/6c844c75-aa34-421c-b7bd-5e4a9f206f44
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MedicationStatement/6c844c75-aa34-412c-b7bd-5e4a9f206f42
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MedicationStatement/6c844c75-aa34-423c-b7bd-5e4a9f206f44
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MedicationStatement/6c844c75-aa34-411c-b7bd-5e4a9f217f44
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