Community Health Consult Note 2222 Home Street Beaverton OR 97867 US Eve Betterhalf Eve Everywoman 2222 Home Street Beaverton OR 97867 US Boris Bo Betterhalf 4444 Home Street Beaverton OR 97867 US The DoctorsTogether Physician Group 1007 Health Drive Portland OR 99123 US 1007 Healthcare Drive Portland OR 99123 US Ellen Enter 1007 Healthcare Drive Portland OR 99123 US Harold Hippocrates D.O. Good Health HIE 1009 Healthcare Drive Portland OR 99123 US Sara Specialize M.D. The DoctorsApart Physician Group
ALLERGIES AND ADVERSE REACTIONS
Substance Reaction
Penicillin Nausea
Codeine Wheezing
ASSESSMENT Uncontrolled brittle Type II diabetic. Obesity.
HISTORY OF PRESENT ILLNESS This is a 38-year-old white woman with years of uncontrolled diabetes who developed a pressure ulcer on her left knee that is slow to heal. Diet review from primary care provider shows a tendency for a high carbohydrate diet and little to no exercise. She was recently admitted to the hospital for diabetic management, wound care, and asthma management. Over the last 3 months her weight has increased by 20%.
FUNCTIONAL STATUS
Functional Category Effective Dates Results of Evaluation
Functional Assessment July 31, 2013 Independent Walking
ADL/IADL: Bathing July 31,2013 Independent
MEDICATIONS
Medication Directions Start Date Status Indications Monitored by
Proventil 0.09 MG/ACTUAT inhalant solution 2 puffs q6 hours PRN wheezing Jan 3, 2013 Active Asthma Penny Puffer, MD
Atenolol 25 MG Oral Tablet 1 every 12 hours Orally Mar 18, 2013 Active Hypertension
Medication Factory Inc. Community Health and Hospitals Aerosol Puffer Penny DR
MENTAL STATUS
Mental Status Findings Effective Dates Condition Status
Mental Function July 31, 2013 Impaired
Mental Status July 31, 2013 Aggressive Behavior
Mental Function July 31, 2013 Difficulty understanding own emotions
Mental Function July 31, 2013 Difficulty communicating Thoughts
NUTRITION SECTION Nutritional Status: well nourished Diet: Low sodium diet, excessive carbohydrate Nutritional Status
Physical Examination Key Findings: 1. Obesity. 2. Slow healing Open wound on left knee. 3. Early signs of peripheral neuropathy.
TREATMENT PLAN Hand-off Communication: Nurse Florence, RN to Nancy Nightingale, RN

Planned Care Start Date Patient Provider Rating Provider Provider Rating Provider Patient Support/Caregiver
Encounter for Check-up October 15, 2013 1st, Normal Priority 3rd, Normal Priority Dr. James Case
Care Goal: Weight loss from baseline weight 10% October 15, 2013 1st, Normal Priority 3rd, Normal Priority
Nutrition Recommendation: Education July 31, 2013
1006 Health Drive Ann Arbor MI 97867 US Nancy Nightingale RN 1006 Health Drive Ann Arbor MI 97867 US Dr. James Case Care Goal: Weight loss from baseline weight 10%
PROBLEMS Active Concerns Problem #1 Type II diabetes mellitus with ulcer (onset July 3, 2000)[authored Aug 14, 2013] Problem #2 Mixed Asthma (onset Apr 14, 2007) [authored Apr 14, 2007] Acute Asthma (onset Apr 17, 2007) [authored Apr 17, 2007] Resolved Concerns Problem #3 Pneumonia - Left lower lobe (onset Mar 10, 1998; resolution Mar 16, 1998) [authored Mar 16, 1998]
REASON FOR REFERRAL Request for consultation for weight management. Patient referral for consultation for full care. Referral Nurse: Nurse Florence,RN
RESULTS
Result Type Result Value Relevant Reference Range Interpretation Date
Hemoglobin 13.2 g/dL Normal range for women is 12.0 to 15.5 grams per deciliter Normal July 31, 2013
Leukocytes 6.7 10*9/L Normal white blood cell count range 3.5-10.5 billion cells/L Normal July 31, 2013
Platelets 123 10*9/L Normal white blood cell count range 3.5-10.5 billion cells/L Low July 31, 2013
Hematocrit 35.3 % Normal hematocrit range for female: 34.9-44.5 percent Normal July 31, 2013
Erythrocytes 4.21 10*12/L Normal red blood cell count range 3.90-5.03 trillion cells/L Normal July 31, 2013
Urea nitrogen, Serum Pending Pending Pending July 31, 2013
6.7 billion per liter
VITAL SIGNS
Date / Time: Sept 10, 2012 Sept 1, 2011
Height 177 cm 177 cm
Weight 86 kg 88 kg
Blood Pressure 132/88 128/80