# 170.315_b1_toc_inp_ccd_r21_sample1 test data

Patient | Lindsey Pitt
Date of birth | June 1, 1970
Sex | Female
Race | White
Ethnicity | Not Hispanic or Latino
Contact info | Primary Home: 1006 Amber Dr Beaverton, OR 97266, US Tel: +1(555)-223-1234
Patient IDs | 117273338 2.16.840.1.113883.4.1

Document Id | TT107 2.16.840.1.113883.19.5.99999.1
Document Created: | June 22, 2015

Care provision | Anemia from June 22, 2015 to June 24, 2015
Performer (primary care physician) | Dr Henry Seven of Community Health and Hospitals
Performer | Mary McDonald

Author | Dr Henry Seven
Contact info | 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002

Encounter Id | 9937012 2.16.840.1.113883.19
Encounter Date | From June 22, 2015, 10:00, EST to June 24, 2015

Personal relationship | Mr Ralph Issac
Contact info | Primary Home: 1006 Amber Dr Beaverton, OR 97266, US Tel: +1(555)-224-1544
Personal relationship | Mr Franklin Pitt
Contact info | Primary Home: 1006 Amber Dr Beaverton, OR 97266, US Tel: +1(555)-224-1544

Entered by | Mary McDonald
Contact info | 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002

Signed | Dr Henry Seven at June 22, 2015
Contact info | 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002

Informant | Henry Seven
Contact info | 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002
Informant | Franklin Pitt

Information recipient: | Dr Henry Seven

Legal authenticator | Dr Henry Seven signed at June 22, 2015
Contact info | 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002

Document maintained by | Community Health and Hospitals
Contact info | Work Place: 1002 Healthcare Dr Beaverton, OR 97266, US Tel: +1(555)-555-1002

## Table of Contents

- ALLERGIES AND ADVERSE REACTIONS
- MEDICATIONS
- Discharge Medications
- PROBLEMS
- ENCOUNTERS
- ADMISSION DIAGNOSIS
- PROCEDURES
- Implants
- IMMUNIZATIONS
- VITAL SIGNS
- SOCIAL HISTORY
- RESULTS
- FUNCTIONAL STATUS
- MENTAL STATUS
- ASSESSMENTS
- TREATMENT PLAN
- Goals Section
- Health Concerns Section
- HOSPITAL DISCHARGE INSTRUCTIONS

### ALLERGIES AND ADVERSE REACTIONS

Substance | Reaction | Severity | Status
--- | --- | --- | ---
Penicillin G | Hives | Moderate | Active

### MEDICATIONS

Medication | Directions | Start Date
--- | --- | ---
Ceftriaxone 100MG/ML | Two Times Daily | June 22, 2015
Vantin 200mg | Two Times Daily | June 22, 2015

### Discharge Medications

No Information

### PROBLEMS

Active Concerns

- Problem #1
  - Essential hypertension (Disorder)
- Problem #2
  - Severe Hypothyroidism (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 10:00am EST

### 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
--- | --- | ---
Influenza Virus Vaccine | May 10, 2014 | Completed
Tetanus and diphtheria toxoids | January 4, 2012 | Completed
influenza, intradermal, quadrivalent, preservative free | June 22, 2015 | Refused

### 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 | 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

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

### 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

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