Transition of Care/Referral Summary 8745 W Willenow Rd Beaverton OR 97005- US Steve Williamson Male Black or African American Not Hispanic or Latino Local Community Hospital Organization 4000 Hospital Dr. Portland OR 97005- US Local Community Hospital Organization 4000 Hospital Dr. Portland OR 97005- US 1006 Healthcare Dr Portland OR 97005- US Aaron Admit MD Dale Owens 1004 Healthcare Dr. Get Well Clinic Portland OR 97005- US Nancy Nightengale RN 1006 Healthcare Dr Portland OR 97005- US Aaron Admit MD
Encounter
Dates Location Diagnoses Providers
07/10/2013 Local Community Hospital Organization
4000 Hospital Dr.
Portland, OR 97005- , USA		 Final: Exercise-induced angina

Final: Angina 		Owens , Dale
Admit MD, Aaron
Nightengale RN, Nancy
Inpatient Dale Owens 1004 Healthcare Dr. Get Well Clinic Portland OR 97005- US Nancy Nightengale RN 1006 Healthcare Dr Portland OR 97005- US Aaron Admit MD 4000 Hospital Dr. Portland OR 97005- US Local Community Hospital Organization Final Final
Vital Signs
Most recent to oldest [Reference Range]: 1
Systolic Blood Pressure [90-140 mmHg] 150 mmHg
*HI*
(07/10/2013 22:00:00 America/Chicago)
Diastolic Blood Pressure [60-90 mmHg] 95 mmHg
*HI*
(07/10/2013 22:00:00 America/Chicago)
Mean Arterial Pressure [70-100 mmHg] 113 mmHg
*>HHI*
(07/10/2013 22:00:00 America/Chicago)
Height/Length Measured 178 cm
(07/10/2013 22:00:00 America/Chicago)
Weight Measured 82 kg
(07/10/2013 22:00:00 America/Chicago)
BSA Measured 2.01 mm2
(07/10/2013 22:00:00 America/Chicago)
Body Mass Index Measured 25.88 m2
(07/10/2013 22:00:00 America/Chicago)
Body Mass Index Measured BSA Measured Mean Arterial Pressure Extreme High 70-100 mmHg Diastolic Blood Pressure High 60-90 mmHg Weight Measured Height/Length Measured Systolic Blood Pressure High 90-140 mmHg
Problem List
Condition Effective Dates Status Health Status Informant
Angina(Confirmed) 07/10/2013 Active
Diabetes mellitus type 2(Confirmed) 01/09/2009 Active
Hypercholesterolemia(Confirmed) 08/08/2008 Active

Diagnosis Diagnosis Type Effective Dates Health Status Clinical Service Informant
Angina Final 07/17/2013 Non-Specified
Exercise-induced angina Final 07/11/2013 Non-Specified
Allergies, Adverse Reactions, Alerts
Substance Reaction Severity Status
codeine Nausea Moderate Active
penicillin G benzathine Hives Moderate Active
Medications
Medication Instructions Start Date Stop Date Status
aspirin 81 mg oral tablet 81 mg = 1 tab(s), PO, Once Daily, 30 tab(s) 07/10/2013 Ordered
atorvastatin 40 mg oral tablet 40 mg = 1 tab(s), PO, Once Daily 08/08/2008 Ordered
Lantus 100 units/ml subcutaneous solution 30 units, Subcutaneous, At Bedtime, 10 mL 01/09/2009 Ordered
NovoLog 15 units, Subcutaneous, TIDAC, 10 mL 01/09/2009 Ordered
Subcutaneous units Ordered Oral Ordered Subcutaneous units Ordered Oral Ordered
Results CHEMISTRY
Most recent to oldest [Reference Range]: 1
Sodium Level [135-145 mmol/L] 135 mmol/L
(07/10/2013 22:25:00 America/Chicago)
Potassium Level [3.5-5.0 mmol/L] 3.5 mmol/L
(07/10/2013 22:25:00 America/Chicago)
Chloride [95-110 mmol/L] 95 mmol/L
(07/10/2013 22:25:00 America/Chicago)
CO2 [22-33 mmol/L] 23 mmol/L
(07/10/2013 22:25:00 America/Chicago)
Glucose, Random [65-110 mg/dL] 185 mg/dL
*HI*
(07/10/2013 22:25:00 America/Chicago)
BUN [4-18 mg/dL] 8 mg/dL
(07/10/2013 22:25:00 America/Chicago)
Creatinine [0.5-1.2 mg/dL] .8 mg/dL
(07/10/2013 22:25:00 America/Chicago)
Troponin-T [0.00-0.20 ng/mL] .01 ng/mL
(07/10/2013 22:25:00 America/Chicago)
Chemistry Troponin-T Normal 0.00-0.20 ng/mL Chemistry Potassium Level Normal 3.5-5.0 mmol/L BUN Normal 4-18 mg/dL CO2 Normal 22-33 mmol/L Sodium Level Normal 135-145 mmol/L Chloride Normal 95-110 mmol/L Glucose, Random HI 65-110 mg/dL Creatinine Normal 0.5-1.2 mg/dL
Immunizations
Vaccine Date Refusal Reason
influenza virus vaccine, inactivated 07/10/2013
Intramuscular 1004 Healthcare Dr. Get Well Clinic Portland OR 97005- US Nancy Nightengale RN
Procedures
Procedure Type Body Site Date of Procedure Related Diagnosis
Electrocardiographic procedure 07/10/2013 00:00:00 America/Chicago
Intranasal oxygen therapy 07/10/2013 00:00:00 America/Chicago
Social History
Social History Type Response
Smoking Status Never smoker
Functional Status FUNCTIONAL 07/10/2013
Functional Status : Dependence on walking stick
 COGNITIVE 07/10/2013
Cognitive Status : Memory impairment
Assessment and Plan Extracted from:
Title: Care Plan (Goals and Instructions) Author: Admit MD, Aaron Date: 07/10/2013
Goal: stress management surveillance
Instructions: counseling provided during visit
Hospital Discharge Instructions Discharge Instructions [Education and Patient Visual Aids] Discharge Instructions (b)(2) (Custom) You were admitted to Local Community Hospital on 7/10/2013 with a diagnosis of angina. You underwent and electrocardiogram and serial troponins drawn. Both tests were normal and your condition improved. You were discharged from Local Community Hospital on 7/11/2013 with instructions to follow-up with your primary care provider. Should you have any questions prior to discharge, please contact a member of your healthcare team. If you have left the hospital and have any questions, please contact your primary care physician.

Instructions:
1. Take all medications as prescribed
2. No vigorous exercise
3. If you experience any of the following symptoms, call your primary care physician or return to the emergency room:
- Chest pain
- Shortness of breath
- Dizziness or light-headedness
- Pain or redness at the site of any previous intravenous catheter
- Any other unusual symptoms
4. Schedule a follow up appointment with your primary care physician in one week.