Summarization of Episode Note
About
Contact
1357 Amber Dr
Beaverton, OR
97006, USA
Service Event
Service Event
Author
Contact
1002 Healthcare Dr
Portland, OR
97266, USA
Medications
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 |
Medication | Date | Route | Dose |
---|---|---|---|
No records |
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 | ~ |
Problem | Noted Date | Diagnosed Date | Resolved Date |
---|---|---|---|
Overweight | 12/31/2006 12:00AM UTC | ~ | 06/01/2007 12:00AM UTC |
Goals
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
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
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
Assesments
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
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
Health Concerns
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
Discharge Summary
Document maintained by
Contact
1357, Amber Dr
Beaverton, OR
97006
Document Information
Document Identifier | Document Created |
---|---|
OID: ee05e1da-df1b-7f7e-166c-e182e1d39f86 | 02/2/2023 |