Continuity of Care Document 1357 Amber Dr Beaverton OR 97006 US 1402 Dariy Dr Beaverton OR 97006 US Happy Always Kid Neighborhood Physicians Practice 2472 Rocky Place Beaverton OR 97006 1357 Amber Dr Beaverton OR 97006 US Matthew Newman 1357 Amber Dr Beaverton OR 97006 US Rick Holler Neighborhood Physicians Practice 2472 Rocky Place Beaverton OR 1357 Amber Dr Beaverton OR 97006 US Matthew Newman 1357 Amber Dr Beaverton OR 97006 US Rick Holler 2472 Rocky Place Beaverton OR 97006 Albert Davis Neighborhood Physicians Practice 2472 Rocky Place Beaverton OR 97006
ALLERGIES, ADVERSE REACTIONS, ALERTS
Substance Status Reaction
Ampicillin Active Adverse Reaction
Product containing benzodiazepine Active Adverse Reaction
MEDICATIONS
Medication Status Intent
Ceftriaxone 100 MG/ML Completed Order
Tylenol 500mg Completed Order
Aranesp 0.5 MG/ML Completed Order
Ceftriaxone 100 MG/ML Tylenol 500mg Aranesp 0.5 MG/ML
PROBLEMS LIST
Problem Status Clinical Status
Hypo Plastic Left Heart Syndrome Active active
PROCEDURES
Procedure Status
No Procedure information Completed
No Procedure information
DIAGNOSTIC TEST RESULTS
Lab Test Result Value Status
Portable Chest X-rays Lungs may be infected further tests needed. Final
Lungs may be infected further tests needed.
ASSESSMENT 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.
VITAL SIGNS
Vital Sign Value Date
Height 85 cm 20200622140500-0500
Weight 12 kg 20200622140500-0500
Blood Pressure Diastolic 88 mm[Hg] 20200622141000-0500
Blood Pressure Systolic 145 mm[Hg] 20200622141000-0500
Heart Rate 80 /min 20200622141000-0500
O2 % BldC Oximetry 95 % 20200622141200-0500
Inhaled Oxygen Concentration 36 % 20200622141200-0500
Body Temperature 38 Cel 20200622141500-0500
Respiratory Rate 18 /min 20200622141500-0500
BMI Percentile 56 % 20200622141500-0500
Weight for Length Percentile 51 % 20200622141500-0500
Head Occipital-frontal Circumference Percentile 18 % 20200622141500-0500
SOCIAL HISTORY
Social History Element Value Date
Sex Observation Female (finding) 20200622
PLAN OF TREATMENT
Planned Activity Status Target Date
Get an EKG done on 6/23/2020 Planned 20200622
Get a Chest X-ray done on 6/23/2020 showing the Lower Respiratory Tract Structure Planned 20200622
Take Clindamycin 300mg three times a day as needed if pain does not subside Planned 20200622
Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2020 Planned 20200622
i. Get an EKG done on 6/23/2020. ii. Get a Chest X-ray done on 6/23/2020 showing the Lower Respiratory Tract Structure. iii. Take Clindamycin 300mg three times a day as needed if pain does not subside. iv. Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2020. Get an EKG done on 6/23/2020 Get a Chest X-ray done on 6/23/2020 showing the Lower Respiratory Tract Structure Take Clindamycin 300mg three times a day as needed if pain does not subside Schedule follow on visit with Neighborhood Physicians Practice on 7/1/2020
GOALS
Goal Description Status
Get rid of intermittent fever that is occurring every few weeks Active
Need to gain more energy to do regular activities Active
a. Get rid of intermittent fever that is occurring every few weeks. b. Need to gain more energy to do regular activities
Notes section
Summary Written by: Date
Dr Albert Davis diagnosed Ms Happy Kid to be suffering from Fever and suspected Pneumonia and recommended admission to the Community Health Hospitals. The note was recorded on 22nd June at 11:00 am ET. Dr Albert Davis 06/22/2020
Dr Albert Davis diagnosed Ms Happy Kid to be suffering from Fever and suspected Pneumonia and recommended admission to the Community Health Hospitals. The note was recorded on 22nd June at 11:00 am ET.
HEALTH CONCERNS a. Chronic Sickness exhibited by patient b. HealthCare Concerns refer to underlying clinical factsi. Documented Hypertension problem
Health Concern Status Date
Chronic Sickness exhibited by patient Active 20200622
Documented HyperTension problem Active 20200622
REASON FOR REFERRAL Ms Happy Kid is being referred to Community Health Hospitals Inpatient facility because of the high fever noticed and suspected Anemia.