Transfer Summary 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. Rose Everyman Good Health HIE 1009 Healthcare Drive Portland OR 99123 US Sara Specialize M.D. The DoctorsApart Physician Group 17 Daws Rd. Ann Arbor MI 97857 US Mrs. Martha Jones Primary Care Provider 1004 Healthcare Drive Portland OR 99123 US Patricia Patty Primary M.D. Good Health Hospital 1004 Health Drive Portland OR 99123 US 1004 Healthcare Drive Ann Arbor MA 99123 US Rory Renal Primary M.D. Good Health Hospital 1036 Health Drive >Ann Arbor MA 99123 US
ALLERGIES AND ADVERSE REACTIONS
Substance Reaction
Penicillin Nausea
Codeine Wheezing
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
ASSESSMENT Flank pain. Pain on deep palpation of lower back. Other chronic diagnoses as noted above, currently stable.
ENCOUNTERS
Encounter Performer Location Date
Check-up, Inpatient Medical Ward Amanda Assigned, General Physician Good Health Clinic February 12, 2013
Checkup Examination 102 Health Drive Ann Arbor MI 99099 US Amanda Assigned Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic
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
GENERAL STATUS Alert and in good spirits, mild distress.
HISTORY OF PAST MEDICAL/SURGICAL ILLNESS In 2011, the patient experienced a minor stroke, which caused temporary paralysis on her left side. She was monitored in hospital for three weeks and recovered. She has been taking warfarin since then and is expected continue on with close monitoring. She has had type II diabetes, poorly controlled for many years. Since the diagnosis, her kidney functions are compromised and she is predisposed to developing peripheral neuropathy. occlusion. Two weeks prior to this current hospital admission, she was also diagnosed with hypercholesterolemia. She is currently taking Lipitor to manage this.
HISTORY OF PRESENT ILLNESS This is a 68-year-old white woman who went to the emergency room with sudden onset of severe left flank and left lower quadrant abdominal pain associated with gross hematuria. The patient had a CT stone profile which showed no evidence of renal calculi. She was referred for urologic evaluation. When seen in our office, the patient continued to have mild left flank pain and no difficultly voiding. Urinalysis showed 1+ occult blood. Intravenous pyelogram was done which demonstrated a low-lying malrotated right kidney. There was no evidence of renal or ureteral calculi or hydronephrosis. Urine cytology was negative for malignant cells. The patient subsequently had a CT renal scan with contrast. This showed what appeared to be an infarction of an area of the lower pole of the left kidney. It was suggested that a renal MRI be done for further delineation of this problem. She had a right kidney which was malrotated but was otherwise normal. The patient is admitted at this time for complete urologic evaluation.
Hospital Course of Care This is a 68-year-old white woman who went to the emergency room with sudden onset of severe left flank and left lower quadrant abdominal pain associated with gross hematuria. The patient had a CT stone profile which showed no evidence of renal calculi.
Hospital Discharge Diagnosis .Kidney Malrotation. Discharged August 1, 2013
IMMUNIZATIONS
Vaccine Date Status Series number
Influenza, seasonal, IM Nov 1999 Completed N/A
Influenza, seasonal, IM Dec 1998 Completed N/A
Pneumococcal polysaccharide vaccine, IM Dec 1998 Completed N/A
Tetanus and diphtheria toxoids, IM 1997 Refused N/A
Hepatitis B Aug 1, 2012 Completed 3rd
Influenza, seasonal, IM 1 Health LS - Immuno Inc. 102 Health Drive Ann Arbor MI 99099 US Amanda Assigned Good Health Clinic Possible flu-like symptoms for three days. 1 Health LS - Immuno Inc. 102 Health Drive Ann Arbor MI 99099 US Amanda Assigned Good Health Clinic Possible flu-like symptoms for three days. 1 Health LS - Immuno Inc. 102 Health Drive Ann Arbor MI 99099 US Amanda Assigned Good Health Clinic 1 Health LS - Immuno Inc. 102 Health Drive Ann Arbor MI 99099 US Amanda Assigned Good Health Clinic 1 102 Health Drive Ann Arbor MI 99099 US Amanda Assigned Good Health Clinic
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
MEDICATIONS
Current 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
Insurance Providers
Payer name Policy type / Coverage type Policy ID Covered party ID Policy Holder
Good Health Insurance Extended healthcare / Family Contract Number 1138345 Patient's Mother
123 Insurance Road Blue Bell MA 02368 US Good Health Insurance 17 Daws Rd. Blue Bell MA 02368 Mr. Frank A. Everyman 17 Daws Rd. Blue Bell MA 02368 US
Physical Examination Key Findings: In addition to Assessment finding above. 1. Type II diabetes, uncontrolled. 2. Slow healing Open wound on left knee. 3. Early signs of peripheral neuropathy. 4. Mild dysphagia. 5. Mild footdrop.
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 June 15, 2013 1st, Normal Priority 3rd, Normal Priority Dr. James Case
Care Goal: Pulse Oximetry 95% June 15, 2013 1st, Normal Priority 3rd, Normal Priority Caregiver: Mother
Treatment: Wound Care June 15, 2013 1st, Normal Priority 3rd, Normal Priority Caregiver: Mother
Nutrition Recommendation: Education June 13, 2013
Procedure: Colonoscopy June 15, 2013 1st, Normal Priority 3rd, Normal Priority Caregiver: Mother
Medication: Heparin 0.25 ml pre-filled syringe July 12, 2013 1st, Normal Priority 3rd, Normal Priority Caregiver: Mother
Supply: 0.25 ML Heparin sodium 10000 UNT/ML Prefilled Syringe June 15, 2013 Dr. Henry Seven
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 Heparin 0.25 ml Pre-filled Syringe Medication Factory Inc. Influenza virus vaccine 1 Possible flu-like symptoms for three days. Medication Factory Inc.
PROBLEMS Active Concerns Problem #1 malignant neoplasm of liver (onset July 3, 2013)[authored July 3, 2013] Prognosis: Presence of a life limiting condition(>50% possibility of death within 2 year Problem #2 Chest pain (onset Apr 14, 2007) [authored Apr 14, 2007] Angina (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] Pognosis Presence of a life limiting condition(>50% possibility of death within 2 year
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
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.
SOCIAL HISTORY
Social History Element Description Effective Dates
Alcohol Use 2 Drinks per Week March 12, 2013
Smoking Status Former smoker May 1, 2005 - Feb 27, 2009
Characteristics of Home Environment Unsatisfactory Living Conditions March 12, 2013
Cultural and Religious Observations Does not accept blood transfusions, or donates, or stores blood for transfusion. March 12, 2013
Does not accept blood transfusions, or donates, or stores blood for transfusion.
VITAL SIGNS
Date / Time: February 12, 2013 August 1, 2013
Height 177 cm 177 cm
Weight 86 kg 88 kg
Blood Pressure 132/88 128/80