Community Health and Hospitals: Discharge Summary 1357 Amber Drive Beaverton OR 97867 US Isabella Jones 1357 Amber Drive Beaverton OR 97867 US Ralph Jones Beaverton OR 97867 US Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US 1001 Village Avenue Portland OR 99123 US Henry Seven 1001 Village Avenue Portland OR 99123 US Henry Seven Frank Jones Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US Henry Seven Community Health and Hospitals 17 Daws Rd. Beaverton OR 97867 US Mrs. Martha Jones Primary Care Provider 1001 Village Avenue Portland OR 99123 US Dr. Henry Seven Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US Primary Care Provider 1001 Village Avenue Portland OR 99123 US Dr. Herman Eight Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US
ADMISSION DIAGNOSIS Appendicitis
ALLERGIES, ADVERSE REACTIONS, ALERTS
Substance Reaction Severity Status
Penicillin Nausea Moderate to severe Active
Codeine Wheezing Moderate Active
Eggs Hives Moderate Active
REASON FOR VISIT/CHIEF COMPLAINT Dark stools.
DISCHARGE DIAGNOSIS Appendicitis
DISCHARGE MEDICATIONS
Medication Instructions Dosage Effective Dates (start - stop) Status
Ibuprofen 600mg Oral Tablet take 1 tablet QID PRN 600 MG Sep-16-2014 - Active
FAMILY HISTORY Father (deceased)
Diagnosis Age At Onset
Myocardial Infarction (cause of death) 57
Diabetes 6
Functional Status
Functional Status Finding Observation Date Condition Status
Dyspnea February 2007 Active
PAST MEDICAL HISTORY See History of Present Illness.
HISTORY OF PRESENT ILLNESS This patient was only recently discharged for a recurrent GI pain .... She presented to the ER today c/o a dark stool yesterday but a normal brown stool today. On exam she reported lower quadrant abdominal pain .... .... .... Patient has previously reported functional limitations of trouble breathing ... Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal. H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40. Procedure: Appendectomy performed on ....
HOSPITAL CONSULTATIONS
Gastroenterology
Cardiology
Dietitian
HOSPITAL COURSE Patient presented with dark stools and pain lower left quadrant of abdomen. After examination and imaging, patient was diagnosed with acute appendicitis and scheduled for emergengent appendectomy. Appendix was removed with additional consults for cardiology and nurtition concerns during hsoptialization. Patient can ambulate with well-managed pain. Will discharge.
HOSPITAL DISCHARGE INSTRUCTIONS Take all of your prescription medication as directed. Make an appointment with your doctor to be seen two weeks from the date of your procedure. You may feel slightly bloated after the procedure because of air that was introduced during the examination. Call your physician if you notice:
Bleeding or black stools.
Abdominal pain.
Fever or chills.
Nausea or vomiting.
Any unusual pain or problem.
Pain or redness at the site where the intravenous needle was placed.
Do not drink alcohol for 24 hours. Alcohol amplifies the effect of the sedatives given. Do not drive or operate machinery for 24 hours.
HOSPITAL DISCHARGE PHYSICAL GENERAL: Slightly obese female with inflamed appendix.
HEART: Intermittent tachycardia without murmurs or gallops.
PULMONARY: Decreased breath sounds, but no clear-cut rales or wheezes.
EXTREMITIES: Free of edema.
HOSPITAL DISCHARGE STUDIES SUMMARY
Laboratory Information Chemistries and drug levels
Potasium 4.0
NA (135-145meq/l) 140

Other Tests Results
Abdominal CT Clear evidence of appendicitis.
IMMUNIZATIONS
Vaccine Date Status / Notes
Influenza virus vaccine, IM Sep 1, 2014 Completed. Possible flu-like symptoms for three days.
Tetanus and diphtheria toxoids, IM (NOT ADMINISTERED) Sep 1, 2014 Patient Refused
Influenza virus vaccine 11234654AA Health LS - Immuno Inc. Tetanus and diphtheria toxoids - preservative free Health LS - Immuno Inc.
PLAN OF CARE
Planned Activity Planned Date
Colonoscopy Oct 12, 2014
Problem List
Name Dates Status
Dark stools Onset: Sept 6 2014 Active
Appendicitis Onset: Sept 8 2014 Active
Procedures
Description Date and Time (Range) Status
Laparoscopic appendectomy (10 Sep 2014 09:22am- 10 Sep 2014 11:15am) Completed
REVIEW OF SYSTEMS Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. ....
Social History Smoking Status Never smoked Started: Stopped: Recorded Sept 10, 2014 12:54pm
VITAL SIGNS
Date / Time: Sept 16, 2014 8:45am
Height 177 cm
Weight 86 kg
Blood Pressure 80 / 55mm[Hg]