Community Health and Hospitals: Health Summary1357 Winterfell DriveWay NorthMN55425USAryaStark1357 Amber DriveBeavertonOR97006USRalphTestpatientBeavertonOR97006USCommunity Health and Hospitals1002 Healthcare DrPortlandOR97266US1002 Healthcare Drive PortlandOR97266USDrHenrySeven1002 Healthcare Drive PortlandOR97266USMaryMcDonald1002 Healthcare Drive PortlandOR97266USHenrySevenFrankTestpatientCommunity Health and Hospitals1002 Healthcare Drive PortlandOR97266USHenrySevenCommunity Health and Hospitals1002 Healthcare Drive PortlandOR97266USHenrySeven1002 Healthcare Drive PortlandOR97266USHenrySeven1357 Amber DriveBeavertonOR97006USMr.RalphTestpatient1357 Amber DriveBeavertonOR97006USMr.FrankTestpatientPrimary Care Provider1002 Healthcare DrPortlandOR97266USDr.HenrySevenCommunity Health and Hospitals1002 Healthcare Drive PortlandOR97266USPrimary Care Provider1002 Healthcare DrPortlandOR97266USDr.HenrySevenCommunity Health and Hospitals1002 Healthcare Drive PortlandOR97266USDrHenrySevenDrHenrySevenALLERGIES, ADVERSE REACTIONS, ALERTS
Substance
Reaction
Severity
Status
Penicillin G benzathine
Hives
Moderate to severe
Inactive
Codeine
Shortness of Breath
Moderate
Active
Aspirin
Hives
Mild to moderate
Active
ENCOUNTERS
Encounter
Performer
Location
Date
Pnuemonia
Dr Henry Seven
Community Health and Hospitals
20120806
Mild Fever 1002 Healthcare DrPortlandOR97266USCommunity Health and HospitalsIMMUNIZATIONS
Vaccine
Date
Status
Influenza virus vaccine, IM
May 2012
Completed
Tetanus and diphtheria toxoids, IM
Apr 2012
Completed
Influenza virus vaccineHealth LS - Immuno Inc.Possible flu-like symptoms for three days.Tetanus and diphtheria toxoids - preservative freeHealth LS - Immuno Inc.Possible flu-like symptoms for three days.Medications
Medication
Directions
Start Date
Status
Indications
Fill Instructions
Albuterol 0.09 MG/ACTUAT inhalant solution
0.09 MG/ACTUAT inhalant solution, 2 puffs once
20120806
Active
Pneumonia (233604007 SNOMED CT)
Generic Substitition Allowed
0.09 MG/ACTUAT inhalant solution, 2 puffs Medication Factory Inc.Community Health and HospitalsAerosolMedication Factory Inc.1002 Healthcare DrPortlandOR97266USDr.HenrySevenlabel in spanishMedication Factory Inc.1002 Healthcare DrPortlandOR97266USDr.HenrySevenCommunity Health and Hospitals.CARE PLAN
0.11 MG/ACTUAT Metered Dose Once Daily Medication Factory Inc.Community Health and HospitalsAerosolMedication Factory Inc.1002 Healthcare DrPortlandOR97266USDr.HenrySevenGeneric Substitution AllowedMedication Factory Inc.1002 Healthcare DrPortlandOR97266USDr.HenrySevenCommunity Health and HospitalsREASON FOR REFERRALFollow up with Dr George Potomac for AsthmaPROBLEMSPneumonia : Status - ResolvedAsthma : Status - ActivePROCEDURES
Procedure
Date
Chest X-Ray
8/7/2012
1002 Healthcare DrPortlandOR97266USCommunity Health and Hospitals1002 Healthcare DrPortlandOR97266USCommunity Health and HospitalsFUNCTIONAL STATUS
Functional Condition
Effective Dates
Condition Status
Dependence on cane
2008
Active
Memory impairment
2008
Active
RESULTS
LABORATORY INFORMATION
Chemistries and drug levels
HGB (M 13-18 g/dl; F 12-16 g/dl)
13.2
WBC (4.3-10.8 10+3/ul)
6.7
PLT (135-145 meq/l)
123 (L)
M 13-18 g/dl; F 12-16 g/dlSOCIAL HISTORY
Social History Element
Description
Effective Dates
smoking
Former Smoker (1 pack per day
20050501 to 20110227
smoking
Current Everyday Smoker 2 packs per day
20110227 - today
1 pack per dayVITAL SIGNS
Date / Time:
Nov 1, 2011
August 6, 2012
Height
69 inches
69 inches
Weight
189 lbs
194 lbs
Blood Pressure
132/86 mmHg
145/88 mmHg
HOSPITAL DISCHARGE INSTRUCTIONSMs. Testpatient, you have been seen by Dr. Henry Seven at Local Community Hospital from August 8th until August 13th 2012. You are currently being discharged from Local Community Hospital. Dr. Seven has provided the following instructions to you at this time; should you have any questions please contact a member of your healthcare team prior to discharge. If you have left the hospital and have questions, please contact Dr. Seven at 555-555-1002. Instructions: Take all medications as prescribed.Please monitor your peak flows. If your peak flows drop to 50% of normal, call my office immediately or return to the Emergency Room.If you experience any of the following symptoms, call my office immediately or return to the Emergency Room: Shortness of BreathDizziness or Light-headednessFever, chills, or diffuse body achesPain or redness at the site of any previous intravenous catheterAny other unusual problem
