170.315_b1_toc_amb_ccd_r21_sample1 test data

Substance	Reaction	Severity	Status
Penicillin G	Hives	Moderate	Active
Ampicillin	Hives	Moderate	Active

Medication	Directions	Start Date
Ceftriaxone 100 MG/ML	Two Times Daily	June 22, 2015
Tylenol 500mg	As needed for 10 days	June 22, 2015
Darbepoetin 0.5 MG/ML	Once a week	June 22, 2015

Active Concerns

• Problem #1
  • Essential hypertension (Disorder)
• Problem #2
  • Severe Hypothyroidism (Disorder)
• Problem #3
  • Chronic rejection of renal transplant (disorder)
• Problem #4
  • Fever (finding)

Resolved Concerns

• Problem #5
  • Overweight (finding)

Encounter Diagnosis	Location	Date
Fever	Neighborhood Physicians Practice	June 22, 2015 at 10am EST

Vaccine	Date	Status
Influenza Virus Vaccine	May 10, 2014	Completed
Tetanus and diphtheria toxoids	January 4, 2012	Completed
influenza, intradermal, quadrivalent, preservative free	June 22, 2015	Refused by Patient

Date / Time:	June 22, 2015
Height	177 cm
Weight	88 kg
Blood Pressure	145/88 mm[Hg]
Heart Rate	80 beats per minute
O2 Percentage BldC Oximetry	95 percent
Body Temperature	38 degree celsius
Respiratory Rate	18 breaths per minute

Social History Observation	Description	Dates Observed
Smoking Status	Heavy tobacco smoker	May 1, 2005 - February 27, 2011
Current Smoking Status	Current every day smoker	June 22, 2015
Birth Sex	Female	June 22, 2015

Procedure	Date
Nebulizer Therapy	June 22, 2015
Introduction of cardiac pacemaker system via vein	October 5, 2011

Implanted	Area	UDI
Cardiac Pacemaker	Subclavian Vein	(01)00643169007222(17)160128(21)BLC200461H

Result Type	Result Value	Relevant Reference Range	Interpretation	Date
Color of Urine	YELLOW	YELLOW	Normal	06/22/2015
Appearance of Urine	CLEAR	CLEAR	Normal	06/22/2015
Specific gravity of Urine by Test strip	1.015	1.005 – 1.030	Normal	06/22/2015
pH of Urine by Test strip	5.0 [pH]	5.0-8.0	Normal	06/22/2015
Glucose [Mass/volume] in urine by test strip	50 mg/dL	Neg		06/22/2015
Ketones [Mass/Volume] in urine by test strip	Negative	Negative		06/22/2015
Protein[Mass/Volume] in urine by test strip	100 mg/dL	negative		06/22/2015

Functional Category	Effective Dates
Dependence on Cane	May 01, 2005

The patient was found to have fever and Dr Davis is suspecting Anemia based on the patient history. So Dr Davis asked the patient to closely monitor the temperature and blood pressure and get admitted to Community Health Hospitals if the fever does not subside within a day.

Hand-off Communication:

Planned Care	Start Date
Urinanalysis macro (dipstick) panel	June 29, 2015
Get an EKG done on 6/23/2015.	June 23, 2015
Get a Chest X-ray done on 6/23/2015 showing the Lower Respiratory Tract Structure.	June 23, 2015
Take Clindamycin 300mg three times a day as needed if pain does not subside.	June 23, 2015 three times a day as needed
Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2015.	July 7, 2015

Goal	Value	Date
Get rid of intermittent fever that is occurring every few weeks (Visual Inspection)	N/A	June 22, 2015
Need to gain more energy to do regular activities (Visual Inspection)	N/A	June 22, 2015

Observation	Status	Date
Chronic Sickness exhibited by patient	Active	June 22, 2015

Concern	Status	Date
Documented HyperTension problem	Active	June 22, 2015
Documented HypoThyroidism problem	Active	June 22, 2015
Watch Weight of patient	Active	June 22, 2015

Ms Myra Banks is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia.

Status	Date
Amnesia	May 05, 2005