Referral 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 Nancy Nightingale RN Community Health and Hospitals Cardiac Stepdown Unit, 4B 1002 Healthcare Drive Ann Arbor MI 97857 US 17 Daws Rd. Ann Arbor MI 97857 US Mrs. Martha Jones
ADVANCE DIRECTIVES
Directive Description Verification Supporting Document(s)
Resuscitation status Do not resuscitate Dr. Patricia Primary, Feb 19, 2011 Advance directive
1004 Health Drive Portland OR 99123 US Dr. Patricia Primary
ALLERGIES AND ADVERSE REACTIONS
Substance Reaction
Penicillin Nausea
Codeine Wheezing
ASSESSMENT Uncontrolled brittle Type II diabetic. Obesity. Shortness of breath, mild wheezing. Pressure ulder on left knee.
CHIEF COMPLAINT(S) AND REASON FOR VISIT Diabetic Management and wound care follow up.
FAMILY HISTORY Father (deceased)
Diagnosis Age At Onset
Myocardial Infarction (cause of death) 57
Diabetes 40
FUNCTIONAL STATUS
Functional Category Effective Dates Results of Evaluation
Functional Assessment March 11, 2013 Independent Walking
ADL/IADL: Bathing March 11,2013 Independent
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 and is here for agressive wound care management. On admission she also presented with mild wheezing and dyspnea. Chest x-rays negative for infiltrates. Patient has a history of asthma and is morbidly obese. The patient is admitted at this time for for agressive wound care management, diabetic management, and asthma evaluation.
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
MEDICAL EQUIPMENT Medical Equipment Implanted Devices: Cardiac PaceMaker July 3, 2012 Implanted Devices: Upper GI Prosthesis, January 3, 2013 Cane, February 2, 2003 Biliary Stent, May 5, 2013 Implants Cardiac Pacemaker Good Health Durable Medical Equipment Upper GI Prosthesis Good Health Durable Medical Equipment Upper GI Prosthesis Good Health Durable Medical Equipment 1004 Health Care Drive Ann Arbor MI 02368 US Community Health and Hospitals 1003 Health Care Drive Ann Arbor MI 02368 US
MENTAL STATUS
Mental Status Findings Effective Dates Condition Status
Mental Function March 11, 2013 Impaired
Mental Function March 11, 2013 Agressive Behavior
Mental Function March 11, 2013 Difficulty understanding own emotions
Mental Function March 11, 2013 Difficulty communicating Thoughts
NUTRITION SECTION Nutritional Status: well nourished Diet: Low sodium diet, excessive carbohydrate Nutritional Status
Physical Examination Key Findings: 1. Type II diabetes, uncontrolled. 2. Slow healing Open wound on left knee. 3. Early signs of peripheral neuropathy.
SKIN, PHYSICAL FINDING Stage 3 Pressure Ulcer anterior aspect of knee
Measuring 1"W X 2"L Wound Characteristic: Offensive wound odor Three Stage 3 pressure ulcers. Worst pressure ulcer with necrotic eschar.
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 September 15, 2013 1st, Normal Priority 3rd, Normal Priority Dr. James Case
Treatment: Wound Care September 15, 2013 1st, Normal Priority 3rd, Normal Priority Caregiver: Mother
Nutrition Recommendation: Education September 15, 2013
Immunization: Influenza virus vaccine, IM November 15, 2013 1st, Normal Priority 3rd, Normal Priority Dr. Henry Seven
1006 Health Drive Ann Arbor MI 97867 US Nancy Nightingale RN 1006 Health Drive Ann Arbor MI 97867 US Dr. James Case Influenza virus vaccine 1 Possible flu-like symptoms for three days.
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]
Procedures
Procedure Date
Colonic polypectomy 1998
17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic
REASON FOR REFERRAL 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 March 11, 2013
Leukocytes 6.7 10*9/L Normal white blood cell count range 3.5-10.5 billion cells/L Normal March 11, 2013
Platelets 123 10*9/L Normal white blood cell count range 3.5-10.5 billion cells/L Low March 11, 2013
Hematocrit 35.3 % Normal hematocrit range for female: 34.9-44.5 percent Normal March 11, 2013
Erythrocytes 4.21 10*12/L Normal red blood cell count range 3.90-5.03 trillion cells/L Normal March 11, 2013
Urea nitrogen, Serum Pending Pending Pending March 11, 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