170.315_b1_toc_inp_ds_r21_sample1 test data
Rabecca Angeles
Patient Identifiers
118283339 United States Social Security Number
About
Date of Birth
07/1/1970
Sex
Female
Race
White
Ethnicity
Mexican
Contact
Primary Home
1007 Amber Dr 1002 Oak Dr
Beaverton, OR
97266, US
Tel : +1(555)-225-1234
Care provision
Anemia from 06/22/2015 to 06/24/2015
Service Event
Dr Henry Seven of Community Health and Hospitals
06/22/2015 - 06/24/2015
Service Event
Mary McDonald
06/22/2015 - 06/24/2015
Author
Dr Henry Seven
Contact
1002 Healthcare Dr
Beaverton, OR
97266, US
Tel : +1(555)-555-1002
Encounter
Identifier
9937012 OID: 2.16.840.1.113883.19
Date
From: 06/22/2015, 10:00
To: 06/24/2015
Personal relationship
Mr Issac Wilmer
Contact
Primary Home
1007 Amber Dr
Beaverton, OR
97266, US
Tel : +1(555)-226-1544
Personal relationship
Mr Richard Angeles
Contact
Primary Home
1007 Amber Dr
Beaverton, OR
97266, US
Tel : +1(555)-226-1544
Informant
Henry Seven
Contact
1002 Healthcare Dr
Beaverton, OR
97266, US
Tel : +1(555)-555-1002
Informant
Richard Angeles
Information Recipient
Dr Henry Seven
Legal authenticator
Dr Henry Seven signed at 06/22/2015
Contact
1002 Healthcare Dr
Beaverton, OR
97266, US
Tel : +1(555)-555-1002
ALLERGIES AND ADVERSE REACTIONS
| Substance | Reaction | Severity | Status |
|---|---|---|---|
|
|
|
|
Active |
|
|
|
|
Active |
MEDICATIONS
| 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 |
Discharge Medications
No Information
PROBLEMS
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)
ENCOUNTERS
| Encounter Diagnosis | Location | Date |
|---|---|---|
| Anemia in Chronic Kidney Disease | Community Health and Hospitals | June 22, 2015 at 8:00am |
ADMISSION DIAGNOSIS
Anemia
PROCEDURES
| 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 |
Implants
| Implanted | Area | UDI |
|---|---|---|
| Cardiac Pacemaker | Subclavian Vein | (01)00643169007222(17)160128(21)BLC200461H |
IMMUNIZATIONS
| Vaccine | Date | Status | Series number |
|---|---|---|---|
|
|
May 10, 2014 | Completed | N/A |
|
|
January 4, 2012 | Completed | N/A |
|
|
June 22, 2015 | Refused | N/A |
VITAL SIGNS
| 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
| 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 |
RESULTS
| 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 STATUS
| Functional Category | Effective Dates |
|---|---|
| Dependence on Cane | May 01, 2005 |
MENTAL STATUS
| Status | Date |
|---|---|
| Amnesia | May 05, 2005 |
ASSESSMENTS
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.
TREATMENT PLAN
| 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 |
Goals Section
| 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 |
Health Concerns Section
| 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 |
HOSPITAL DISCHARGE INSTRUCTIONS
- 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.
HOSPITAL COURSE
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.
Discharge Diagnosis
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.
Signed
Dr Henry Seven at 06/22/2015
Contact
1002 Healthcare Dr
Beaverton, OR
97266, US
Tel : +1(555)-555-1002
Document maintained by
Community Health and Hospitals
Contact
Work Place
1002 Healthcare Dr
Beaverton, OR
97266, US
Tel : +1(555)-555-1002
Entered by
Mary McDonald
Contact
1002 Healthcare Dr
Beaverton, OR
97266, US
Tel : +1(555)-555-1002
Document Information
| Document Identifier | Document Created |
|---|---|
| TT107 OID: 2.16.840.1.113883.19.5.99999.1 | 06/22/2015 |