170.315_b1_gold_sample1 test data 1357 Amber Dr Beaverton OR 97266 US Caroline Carrie Richard Helberg Community Health and Hospitals 1002 Healthcare Dr Beaverton OR 97266 US 1002 Healthcare Dr Beaverton OR 97266 US Mary McDonald 1002 Healthcare Dr Beaverton OR 97266 US Henry Seven Gabriel Helberg Community Health and Hospitals 1002 Healthcare Dr Beaverton OR 97266 US Dr Henry Seven Community Health and Hospitals 1357 Amber Dr Beaverton OR 97266 US Mr Ralph Issac 1357 Amber Dr Beaverton OR 97266 US Mr Gabriel Helberg Primary Care Provider 1002 Healthcare Dr Beaverton OR 97266 US Dr Henry Seven Community Health and Hospitals 1002 Healthcare Dr Beaverton OR 97266 US 1002 Healthcare Dr Beaverton OR 97266 US Mary McDonald
ALLERGIES AND ADVERSE REACTIONS
Substance Reaction Severity Status
Penicillin G benzathine Hives Moderate Active
Clindamycin Hydrochloride N/A N/A Completed
MEDICATIONS
Medication Directions Start Date
Vantin BID June 22, 2015
Tylenol 500mg As needed June 22, 2015
Darbepoetin 0.5 MG/ML Once a week June 22, 2015
Clindamycin 300mg TID June 23, 2015
Levothyroxine Sodium QD June 23, 2015
FenoFibric Acid 35mg QHS June 24, 2015
Discharge Medications No Information
PROBLEMS Active Concerns Problem #2 Severe Hypothyroidism (Disorder) Problem #5 Interstitial pneumonia (disorder) Resolved Concerns Problem #6 Overweight (finding) Problem #7 >Ruled out Diabetes
ENCOUNTERS
Encounter Diagnosis Location Date
Anemia in Chronic Kidney Disease Community Health and Hospitals June 22, 2015 at 8:00am
1002 Healthcare Dr Beaverton OR 97266 US Community Health and Hospitals
ADMISSION DIAGNOSIS Anemia 1002 Healthcare Dr Beaverton OR 97266 US Community Health and Hospitals
PROCEDURES
Procedure Date
Chest X-Ray, PA and Lateral Views June 22, 2015
Introduction of cardiac pacemaker system via vein October 5, 2011
1002 Healthcare Dr Portland OR 97266 US Community Health and Hospitals 1002 Healthcare Dr Portland OR 97266 US 1002 Healthcare Dr Portland OR 97266 US Community Health and Hospitals 1002 Healthcare Dr Portland OR 97266 US
IMMUNIZATIONS
Vaccine Date Status Series number
Tetanus and diphtheria toxoids January 4, 2012 Completed N/A
influenza, intradermal, quadrivalent, preservative free June 22, 2015 Refused N/A
2 Immuno Inc. 1 Immuno Inc.
VITAL SIGNS
Date / Time: June 22, 2015
Heart Rate 80 beats per minute
O2 Percentage BldC Oximetry 95 percent
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
RESULTS
Result Type Result Value Relevant Reference Range Interpretation Date
WBC 12.3 (10+3/ul) N/A - 500,000 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 50mg/dl Neg 06/22/2015
N/A - 500,000 YELLOW YELLOW CLEAR CLEAR
FUNCTIONAL STATUS
Functional Category Effective Dates
Dependence on Cane May 01, 2005
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.
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 Caroline for Anemia during the 2 day stay at Community Health Hospitals. Ms Caroline 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 22, 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
Schedule an appointment with Dr Seven after 1 week for Follow up with Outpatient facility for Immunosuppressive therapy.
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
Watch Weight Resolved June 1, 2007
Anemia problem concern Active 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.