Summarization of Episode Note

Rebecca Larson
Patient Identifiers
OID: 43f651e4-75e3-71c4-62a0-264d65e10662

About

Date of Birth
05/1/1970
Sex
Female
Race
White
Ethnicity
Not Hispanic or Latino

Contact

Primary Home

1357 Amber Dr

Beaverton, OR

97006, USA

Tel : +1-555-777-1234

Service Event

Dr Henry Seven of Community Health Hospitals
06/22/2015 - 06/24/2015

Service Event

Mary McDonald
06/22/2015 - 06/24/2015

Author

Dr Henry Seven - Community Health Hospitals

Contact

Work Place

1002 Healthcare Dr

Portland, OR

97266, USA

Medications

Medications List
Medication Timing Route Freq Dose
Tylenol 500mg ~ Oral Oral, as needed, 1 unit 1
Aranesp 0.5 MG/ML ~ Injection Injectable, once a week, 1 unit 1
Clindamycin 300mg 06/23/2015 12:00AM UTC - 06/30/2015 12:00AM UTC Oral Oral, three times daily, 1 unit 1
Torsemide 20mg 06/23/2015 12:00AM UTC - 06/30/2015 12:00AM UTC Oral Oral, daily, 1 unit 1
FenoFibric Acid 35 mg 06/24/2015 12:00AM UTC - 07/04/2015 12:00AM UTC Oral At the hour of sleep 1
Mycophenolic Acid 360mg 06/24/2015 12:00AM UTC - 06/27/2015 12:00AM UTC Oral Oral, two times daily, 1 unit 1
Everolimus 0.5mg 06/24/2015 12:00AM UTC - 07/20/2015 12:00AM UTC Oral Oral, two times daily, 1 unit 1
Ciprofloxacin 250mg 06/24/2015 12:00AM UTC - 07/24/2015 12:00AM UTC Oral Oral, three times daily, 1 unit 1
Ceftriaxone 100 MG/ML ~ Injection ~ 1
Administered Medications
Medication Date Route Dose
No records

Problems

Active Problems
Problem Noted Date Diagnosed Date
Severe hypothyroidism 12/31/2006 12:00AM UTC ~
Chronic rejection of renal transplant 12/31/2011 12:00AM UTC ~
Iron deficiency anemia 06/22/2015 12:00AM UTC ~
Interstitial pneumonia 06/22/2015 12:00AM UTC ~
Essential hypertension 05/10/2015 12:00AM UTC ~
Resolved Problems
Problem Noted Date Diagnosed Date Resolved Date
Overweight 12/31/2006 12:00AM UTC ~ 06/01/2007 12:00AM UTC

Goals

a. Need to gain more energy to do regular activities. b. Negotiated Goal to keep Body Temperature at 98-99 degrees Fahrenheit with regular monitoring

Results

  • Urinanalysis macro (dipstick) panel, No performer ID, No Lab, No Lab Address:
    Code Value Date
    Color of urine YELLOW 06/22/2015 12:00AM UTC
    Appearance of urine CLEAR 06/22/2015 12:00AM UTC
    Specific gravity of urine by test strip 1.015 1 06/22/2015 12:00AM UTC
    pH of Urine by Test strip 5.0 [pH] 06/22/2015 12:00AM UTC
    Glucose [Mass/volume] in urine by test strip 50 mg/dL 06/22/2015 12:00AM UTC
    Ketones [Mass/Volume] in urine by test strip Negative 06/22/2015 12:00AM UTC
    Protein [Mass/Volume] in urine by test strip 100 mg/dL 06/22/2015 12:00AM UTC
  • CBC, No performer ID, No Lab, No Lab Address:
    Code Value Date
    HGB 10.2 g/dL 06/22/2015 12:00AM UTC
    WBC 12.3 10*3/uL 06/22/2015 12:00AM UTC
    PLT 123 10*3/ul 06/22/2015 12:00AM UTC
    Everolimus Blood 10 ng/mL 06/22/2015 12:00AM UTC

Social History

Element Date Value
Tobacco smoking status NHIS 06/22/2015 12:00AM UTC Current every day smoker
Sex Assigned At Birth ~ Female

Vital Signs

Vital sign Date Value and units
Blood Pressure Systolic 06/22/2015 3:08PM UTC 145 mm[Hg]
Blood Pressure Diastolic 06/22/2015 3:08PM UTC 88 mm[Hg]
Heart Rate 06/22/2015 3:10PM UTC 80 /min
Body Temperature 06/22/2015 3:15PM UTC 38 Cel
Respiratory Rate 06/22/2015 3:15PM UTC 18 /min
O2 % BldC Oximetry 06/22/2015 3:12PM UTC 95 %
Inhaled Oxygen Concentration 06/22/2015 3:12PM UTC 36 %
Weight 06/22/2015 3:05PM UTC 88 kg
Height 06/22/2015 3:05PM UTC 177 cm
BMI ~ ~
Head Occipital Circumference ~ ~

Allergies and Intolerances

Type Substance Onset Reactions Status
allergy Ampicillin 05/10/1980 12:00AM UTC

05/10/1980 12:00AM UTC - Hives - moderate

active
N/A Penicillin G 05/10/1980 12:00AM UTC

05/10/1980 12:00AM UTC - Hives - moderate

active

Encounters

Date Type Department CareTeam Description
No records

Functional Status

No data for section Functional Status

Immunizations

Vaccine Date Status Lot Notes
Tetanus and diphtheria toxoids 01/04/2012 12:00AM UTC completed N/A Immunization was not given - Patient rejected immunization
Influenza, intradermal, quadrivalent, preservative-free 06/22/2015 12:00AM UTC not-done No Lot number provided Immunization was not given - Patient rejected immunization

Medical Equipment

ID Assigning Auth Code Date
(01)00643169007222(17)160128(21)BLC200461H FDA Cardiac resynchronization therapy implantable pacemaker 10/05/2011 12:00AM UTC

Mental Status

No data for section Mental Status

Payers

No data for section Payers

Procedures

Procedures Date Status
Bronchoscopy 06/22/2015 12:00AM UTC completed
Chest X-Ray, PA and Lateral Views 06/22/2015 12:00AM UTC completed
Introduction of cardiac pacemaker system via vein 10/05/2011 12:00AM UTC completed

Hospital Course

Ms. Rebecca Larson 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.

Assesments

The patient was found to have Anemia and Dr Seven and his staff diagnosed the condition and treated Ms Rebecca for Anemia during the 2 day stay at Community Health Hospitals. Ms Rebecca 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

Procedures Notes

Henry Seven - 06/22/2015 12:00AM UTC: Dr Seven examined Ms Rebecca Larson and found that the pacemaker is operating properly and the breathlessness is due to high fever and anxiety.

History And Physical Notes

No data for section History And Physical Notes

Consultation Notes

No data for section Consultation Notes

Progress Notes

Henry Seven - 06/22/2015 12:00AM UTC: Ms Rebecca Larson got admitted due to developing high fever and since has shown considerable improvement and can be discharged shortly.

Plan of treatment

i. Schedule an appointment with Dr Seven after 1 week for Follow up with Outpatient facility for Immunosuppressive therapy.

Health Concerns

a. Chronic Sickness exhibited by patient b. HealthCare Concerns refer to underlying clinical facts i. Documented HyperTension problem ii. Documented HypoThyroidism problem iii. Watch Weight of patient iv. Documented Anemia problem

Laboratory Notes

Henry Seven - 06/22/2015 12:00AM UTC: Ms Rebecca Larson was tested for the Urinanalysis macro panel and CBC and the results have been found to be normal.

Discharge Instructions

a. Diet: Diabetic low salt diet b. Medications: Take prescribed medications as advised. c. Appointments: Schedule an appointment with Dr Seven after 1 week. Follow up with Outpatient facility for Immunosuppression treatment. d. For Fever of > 101.5 F, or onset of chest pain/breathlessness contact Emergency.

Discharge Summary

No data for section Discharge Summary

Document maintained by

Community Health Hospitals

Contact

1357, Amber Dr

Beaverton, OR

97006

Tel : +1-555-555-1002

Document Information

Document Identifier Document Created
OID: ee05e1da-df1b-7f7e-166c-e182e1d39f86 02/2/2023