Progress Note 17 Daws Rd. Blue Bell MA 02368 US Mr. Adam Frankie Everyman 17 Daws Rd. Blue Bell MA 02368 US Ralph Relative MA 02368 USA Good Health Clinic 21 North Ave Burlington MA 02368 USA 21 North Ave. Burlington MA 02368 USA Henry Seven 21 North Ave. Burlington MA 02368 USA Henry Seven Rose Everyman Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 USA Henry Seven Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 USA Mrs. Abigail Ruth Primary Care Provider Dr. Pseudo Physician-1 NIST HL7 Test Laboratory Primary Care Provider Dr. Pseudo Physician-3 HL7 Test Laboratory
ALLERGIES AND ADVERSE REACTIONS
Substance Reaction
Penicillin Nausea
Codeine Wheezing
ASSESSMENT Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy. Acute on chronic anemia secondary to #1. Azotemia, acute renal failure with volume loss secondary to #1. Hyperkalemia secondary to #3 and on ACE and K+ supplement. Other chronic diagnoses as noted above, currently stable.
REASON FOR VISIT/CHIEF COMPLAINT Dark stools.
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
OBJECTIVE DATA Chest: clear to ausc. No rales, normal breath sounds Heart: RR, PMI in normal location and no heave or evidence of cardiomegaly,normal heart sounds, no murm or gallop
PHYSICAL EXAMINATION HEENT: All normal to examination. Heart: RRR, no murmur. THORAX & LUNGS: Clear without rhonchi or wheeze. ABDOMEN: No distension, tenderness, or guarding, obese, pos bowel sounds. BACK: Normal to inspection and palpation, without tenderness; no presacral edema. EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.
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 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]
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
REVIEW OF SYSTEMS Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. One episode of melena. No recent headaches. Positive for osteoarthritis in hips, knees and hands.
SUBJECTIVE DATA Complaints of rectal bleeding, fatigue and a change in bowel patterns. Has several days of constipation alternating with diarrhea.
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