Community Health and Hospitals: Health Summary 1357 Amber Drive Beaverton OR 97006 US Myra Jones 1357 Amber Drive Beaverton OR 97006 US Ralph Jones Beaverton OR 97006 US Community Health and Hospitals 1002 Healthcare Dr Portland OR 97266 US 1002 Healthcare Drive Portland OR 97266 US Mary McDonald 1002 Healthcare Drive Portland OR 97266 US Henry Seven Frank Jones Community Health and Hospitals 1002 Healthcare Drive Portland OR 97266 US Henry Seven Community Health and Hospitals 1357 Amber Drive Beaverton OR 97006 US Mr. Ralph Jones 1357 Amber Drive Beaverton OR 97006 US Mr. Frank Jones Primary Care Provider 1002 Healthcare Dr Portland OR 97266 US Dr. Henry Seven Community Health and Hospitals 1002 Healthcare Drive Portland OR 97266 US Primary Care Provider 1002 Healthcare Dr Portland OR 97266 US Dr. Henry Seven Community Health and Hospitals 1002 Healthcare Drive Portland OR 97266 US Dr Henry Seven Dr Henry Seven
ALLERGIES, ADVERSE REACTIONS, ALERTS
Substance Reaction Severity Status
Penicillin G benzathine Hives Moderate to severe Inactive
Codeine Shortness of Breath Moderate Active
Aspirin Hives Mild to moderate Active
ENCOUNTERS
Encounter Performer Location Date
Pnuemonia Dr Henry Seven Community Health and Hospitals 20120806
Mild Fever 1002 Healthcare Dr Portland OR 97266 US Community Health and Hospitals
IMMUNIZATIONS
Vaccine Date Status
Influenza virus vaccine, IM May 2012 Completed
Tetanus and diphtheria toxoids, IM Apr 2012 Completed
Influenza virus vaccine Health LS - Immuno Inc. Possible flu-like symptoms for three days. Tetanus and diphtheria toxoids - preservative free Health LS - Immuno Inc. Possible flu-like symptoms for three days.
Medications
Medication Directions Start Date Status Indications Fill Instructions
Albuterol 0.09 MG/ACTUAT inhalant solution 0.09 MG/ACTUAT inhalant solution, 2 puffs once 20120806 Active Pneumonia (233604007 SNOMED CT) Generic Substitition Allowed
0.09 MG/ACTUAT inhalant solution, 2 puffs Medication Factory Inc. Community Health and Hospitals Aerosol Medication Factory Inc. 1002 Healthcare Dr Portland OR 97266 US label in spanish Medication Factory Inc.
CARE PLAN
Planned Activity Planned Date
Consultation with Dr George Potomac for Asthma 20120820
Chest X-ray 20120826
Sputum Culture 20120820
Follow up with Dr George Potomac for Asthma
HOSPITAL DISCHARGE MEDICATIONS
Medication Directions Start Date Status Indications Fill Instructions
120 ACTUAT Fluticasone propionate 0.11 MG/ACTUAT Metered Dose Inhaler 0.11 MG/ACTUAT Metered Dose Once Daily 20120813 Active Bronchitis (32398004 SNOMED CT) Generic Substitition Allowed
0.11 MG/ACTUAT Metered Dose Once Daily Medication Factory Inc. Community Health and Hospitals Aerosol Medication Factory Inc. 1002 Healthcare Dr Portland OR 97266 US Generic Substitution Allowed Medication Factory Inc.
REASON FOR REFERRAL Follow up with Dr George Potomac for Asthma
PROBLEMS Pneumonia : Status - Resolved Asthma : Status - Active
PROCEDURES
Procedure Date
Chest X-Ray 8/7/2012
1002 Healthcare Dr Portland OR 97266 US Community Health and Hospitals 1002 Healthcare Dr Portland OR 97266 US Community Health and Hospitals
FUNCTIONAL STATUS
Functional Condition Effective Dates Condition Status
Dependence on cane 2008 Active
Memory impairment 2008 Active
RESULTS
LABORATORY INFORMATION
Chemistries and drug levels
HGB (M 13-18 g/dl; F 12-16 g/dl) 13.2
WBC (4.3-10.8 10+3/ul) 6.7
PLT (135-145 meq/l) 123 (L)
M 13-18 g/dl; F 12-16 g/dl
SOCIAL HISTORY
Social History Element Description Effective Dates
smoking Former Smoker (1 pack per day 20050501 to 20110227
smoking Current Everyday Smoker 2 packs per day 20110227 - today
1 pack per day
VITAL SIGNS
Date / Time: Nov 1, 2011 August 6, 2012
Height 69 inches 69 inches
Weight 189 lbs 194 lbs
Blood Pressure 132/86 mmHg 145/88 mmHg
HOSPITAL DISCHARGE INSTRUCTIONS Ms. Jones, you have been seen by Dr. Henry Seven at Local Community Hospital from August 8th until August 13th 2012. You are currently being discharged from Local Community Hospital. Dr. Seven has provided the following instructions to you at this time; should you have any questions please contact a member of your healthcare team prior to discharge. If you have left the hospital and have questions, please contact Dr. Seven at 555-555-1002. Instructions: Take all medications as prescribed. Please monitor your peak flows. If your peak flows drop to 50% of normal, call my office immediately or return to the Emergency Room. If you experience any of the following symptoms, call my office immediately or return to the Emergency Room: Shortness of Breath Dizziness or Light-headedness Fever, chills, or diffuse body aches Pain or redness at the site of any previous intravenous catheter Any other unusual problem