Community Health and Hospitals: Health Summary 1357 Amber Drive Beaverton OR 97867 US Isabella Isa 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 1002 Healthcare Drive Portland OR 99123 US Henry Seven Community Health and Hospitals Primary Care Provider 1001 Village Avenue Portland OR 99123 US Dr. Henry Seven Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US
ADVANCE DIRECTIVES
Directive Description Verification Supporting Document(s)
Resuscitation status Do not resuscitate Dr. Robert Dolin, Feb 13, 2011 Advance directive
21 North Ave. Burlington MA 02368 US Dr. Dolin Robert
ALLERGIES, ADVERSE REACTIONS, ALERTS
Substance Overall Severity Reaction Reaction Severity Status
ALLERGENIC EXTRACT, PENICILLIN Moderate to Severe Nausea Mild Inactive
Codeine Mild Wheezing Moderate Active
Aspirin Mild Hives Mild to moderate Active
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.
ENCOUNTERS
Encounter Performer Location Date
Checkup Examination Performer Name Community Urgent Care Center 20090227130000+0500
Checkup Examination 17 Daws Rd. Blue Bell MA 02368 US Community Urgent Care Center
FAMILY HISTORY Father (deceased)
Diagnosis Age At Onset
Myocardial Infarction (cause of death) 57
Diabetes 40
Functional Status
Functional or Cognitive Finding Observation Observation Date Condition Status
Ambulation(Dependent to Independent) Independently able March 11, 2009 Active
Finding of Functional Performance and Activity Dyspnea February 2007 Active
Cognitive Function Finding Memory impairment April 2007 Active
Cognitive Function Finding(Non-Aggressive to Aggressive) Aggressive behavior March 11, 2009 Active
Text description of the calculation Text description of the calculation Non Aggressive to Aggressive
IMMUNIZATIONS
Vaccine Date Status
Influenza, seasonal, IM Nov 1999 Completed
Influenza, seasonal, IM Dec 1998 Completed
Pneumococcal polysaccharide vaccine, IM Dec 1998 Completed
Tetanus and diphtheria toxoids, IM 1997 Refused
1 Health LS - Immuno Inc. 1021 Health Drive Ann Arbor MI 99099 US Amanda Assigned Good Health Clinic Possible flu-like symptoms for three days. 1 Health LS - Immuno Inc. 1021 Health Drive Ann Arbor MI 99099 US Amanda Assigned Good Health Clinic Possible flu-like symptoms for three days. 1 Health LS - Immuno Inc. 1021 Health Drive Ann Arbor MI 99099 US Amanda Assigned Good Health Clinic 1 Health LS - Immuno Inc. 1021 Health Drive Ann Arbor MI 99099 US Amanda Assigned Good Health Clinic
INTERVENTIONS PROVIDED Therapeutic exercise intervention: knee extension, 3 sets, 10 repetitions, 10-lb weight. Therapeutic exercise intervention: arm curl, 3 sets, 10 repetitions, 15-lb weight
MEDICAL EQUIPMENT
Supply/Device Date Supplied
Automatic implantable cardioverter/defibrillator Nov 1999
Total hip replacement prosthesis 1998
Wheelchair 1999
Good Health Prostheses Company
Good Health Durable Medical Equipment
MEDICATIONS
Medication Directions Start Date Status Indications Fill Instructions
Proventil HFA 0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN wheezing 20070103 Active Pneumonia (233604007 SNOMED CT) Generic Substitition Allowed
Proventil HFA Medication Factory Inc. Community Health and Hospitals Aerosol Medication Factory Inc. 1001 Village Avenue Portland OR 99123 US label in spanish Medication Factory Inc.
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 123 Insurance Road Blue Bell MA 02368 US 17 Daws Rd. Blue Bell MA 02368 US Mr. Adam Frankie Everyman 17 Daws Rd. Blue Bell MA 02368 US Mr. Frank A. Everyman 17 Daws Rd. Blue Bell MA 02368 US
PLAN OF CARE
Planned Activity Planned Date
Colonoscopy 20120512
PROBLEMS Pneumonia Status: Resolved Asthma Status: Active
PROCEDURES
Procedure Date
Colonic polypectomy 1998
1001 Village Avenue Portland OR 99123 US Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US 17 Daws Rd. Blue Bell MA 02368 US Community Health and Hospitals 17 Daws Rd. Blue Bell MA 02368 US Community Gastroenterology Clinic 17 Daws Rd. Blue Bell MA 02368 US Community Health and Hospitals 17 Daws Rd. Blue Bell MA 02368 US Community Gastroenterology Clinic
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)
Liver Functions and Other Laboratory Values
ALT (SGPT) 31.0
AST (SGOT) 18.0
GGT 28.0 Alk
Phos 86.0
Total Bili 0.1
Albumin 3.2
Blood Count
White Count 7.7
Platelets 187.0
Hematocrit 23.7
Hemoglobin 8.1
ELECTROCARDIOGRAM (EKG) INFORMATION
EKG Sinus rhythm without acute changes
M 13-18 g/dl; F 12-16 g/dl
SOCIAL HISTORY
Social History Element Description Effective Dates
smoking 1 pack per day 20050501 to 20090227130000+0500
smoking None 20090227130000+0500 - today
Alcohol consumption None 20050501 -
1 pack per day None None
VITAL SIGNS
Date / Time: Nov 14, 1999 April 7, 2000
Height 177 cm 177 cm
Weight 86 kg 88 kg
Blood Pressure 132/86 mmHg 145/88 mmHg