--------------- MY HEALTHEVET PERSONAL INFORMATION REPORT --------------- *************CONFIDENTIAL************* Produced by the VA Blue Button (v12.4) 18 Mar 2013 @ 0719 This summary is a copy of information from your My HealtheVet Personal Health Record. Your summary may include: - information that you entered (self reported) - information from your VA health record - your military service information from the department of defense (DoD). ***Note: Your health care team may not have all of the information from your Personal Health Record unless you share it with them. Contact your health care team if you have questions about your health information.*** Name: MHVTESTVETERAN, ONE A Date of Birth: 01 Mar 1948 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 18 Mar 2013 @ 0719 File Name: mhv_MHVTESTVETERAN_20130318_0719.txt Date Range Selected: 18 Mar 2008 to 18 Mar 2013 Data Types Selected: My HealtheVet Account Summary Self Reported Demographics VA Demographics Self Reported Health Care Providers Self Reported Treatment Facilities Self Reported Health Insurance VA Wellness Reminders VA Appointments (Future) VA Appointments (Limited to past 2 years) VA Medication History Self Reported Medications and Supplements VA Allergies Self Reported Allergies VA Problem List VA Admissions and Discharges VA Notes Self Reported Medical Events VA Immunizations Self Reported Immunizations VA Laboratory Results: Chemistry/Hematology/Microbiology VA Pathology Reports: Surgical Pathology/Cytology/Electron Microscopy Self Reported Labs and Tests VA Vitals and Readings Self Reported Vitals and Readings VA Radiology Reports VA Electrocardiogram (EKG) Reports Self Reported Family Health History Self Reported Activity Journal Self Reported Food Journal Self Reported Military Health History DoD Military Service Information --------------------- MY HEALTHEVET ACCOUNT SUMMARY --------------------- Source: VA Authentication Status: Authenticated Authentication Date: 18 May 2011 Authentication Facility ID: 648 Authentication Facility Name: PORTLAND, OREGON VA MEDICAL CENTER VA Treating Facility Type ---------------------------- ----------- VA SOUTHERN OREGON REHABILITATION CENTERVAMC AUSTIN MHV OTHER AUSTIN PSIM OTHER PORTLAND, OREGON VA MEDICAL CENTER VAMC SPOKANE VAMC VAMC ---------------------- SELF REPORTED DEMOGRAPHICS ----------------------- Source: Self-Entered Your self-entered information saved in My HealtheVet is not shared with other sources. First Name: ONE Middle Initial: A Last Name: MHVTESTVETERAN Suffix: Alias: MHVVET Relationship to VA: Patient, Veteran Gender: Male Blood Type: AB+ Organ Donor: Yes Date of Birth: 01 Mar 1948 Marital Status: Married Current Occupation: Truck Driver Mailing or Destination Address: 123 Anywhere Road Mailing or Destination Address2: Apt. 123 Mailing or Destination City: Anywhere Mailing or Destination State: DC Mailing or Destination Country: United States Mailing or Destination Province: Mailing or Destination Zip/Postal Code: 20420 Home Phone Number: 000-010-0202 Work Phone Number: 000-010-0404 Pager Number: 000-010-0006 Cell Phone Number: 000-010-0303 FAX Number: 000-010-0005 Email Address: mhvveteran@emailaddress.com Preferred Method of Contact: Email EMERGENCY CONTACTS Contact First Name: Two Contact Last Name: MHVVeteran Relationship: Home Phone Number: 000-020-0001 Work Phone Number: 000-020-0002 Extension: Cell Phone Number: 000-020-0003 Address Line 1: 123 Anywhere Road Address Line 2: City: Anywhere State: DC Country: United States Province: Zip/Post Code: 20420 Email Address: mhvveterantwo@emailaddress.com Contact First Name: Three Contact Last Name: MHVVeteran Relationship: Home Phone Number: 000-030-0101 Work Phone Number: 000-030-0202 Extension: Cell Phone Number: 000-030-0303 Address Line 1: 123 Anywhere Road Address Line 2: Data Entered for Validation City: Data Entered for Validation State: DC Country: United States Province: Zip/Post Code: 20420 Email Address: mhvveteranthree@emailaddress.com ---------------------------- VA DEMOGRAPHICS ---------------------------- Source: VA Last Updated: 18 Mar 2013 @ 0634 Sorted By: VA Treating Facility Your information in My HealtheVet is not transferred to your VA Health Record. Also, VA Demographic information is not updated between VA treating facilities. If you have any questions or updates, please contact your VA health care team. ========================================================================= VA Treating Facility: VA SOUTHERN OREGON REHABILITATION CENTER CLINICS ------------------------------------------------------------------------- First Name: ONE Race: Middle Name: A Ethnicity: Last Name: MHVTESTVETERAN Religion: Date of Birth: 01 Mar 1948 Place of Birth: WASHINGTON, DISTRICT OF COLUMBIA Age: 65 Marital Status: DIVORCED Gender: Male ------------------------------------------------------------------------- PERMANENT ADDRESS AND CONTACT INFORMATION Street Address: 123 ANYWHERE RD Street Address 2: APT 123 City: WASHINGTON State: DISTRICT OF COLUMBIA Zip Code: 20420 County: 001 Country: USA Home Phone Number: Work Phone Number: Cell Phone Number: Email Address: MHVVETERAN@EMAILADDRESS.COM ------------------------------------------------------------------------- TEMPORARY ADDRESS AND CONTACT INFORMATION Active Start Date: Street Address: 123 ANYWHERE RD Active End Date: Street Address 2: APT 123 City: WASHINGTON State: DISTRICT OF COLUMBIA Zip Code: 20420 Country: USA Temporary Phone Number: ------------------------------------------------------------------------- ELIGIBILITY Service Connected Percentage: 70 Means Test Status: Primary Eligibility Code: RX Copay Status: ------------------------------------------------------------------------- EMPLOYMENT Occupation: Employment Status: NOT EMPLOYED Employer Name: ------------------------------------------------------------------------- PRIMARY NEXT OF KIN Name: MHVTESTVETERAN, TWO Relationship to Patient: Street Address: 123 ANYWHERE RD Home Phone Number: 000-000-0001 City: WASHINGTON Work Phone Number: State: DISTRICT OF COLUMBIA Zip Code: 20420 Country: ------------------------------------------------------------------------- EMERGENCY CONTACT Name: MHVTESTVETERAN, TWO Relationship to Patient: Street Address: 123 ANYWHERE RD Home Phone Number: 000-000-0001 City: WASHINGTON Work Phone Number: State: DISTRICT OF COLUMBIA Zip Code: 20420 Country: ------------------------------------------------------------------------- VA GUARDIAN Name: Relationship to Patient: Street Address: Home Phone Number: City: Work Phone Number: State: Zip Code: Country: ------------------------------------------------------------------------- CIVIL GUARDIAN Name: Relationship to Patient: Street Address: Home Phone Number: City: Work Phone Number: State: Zip Code: Country: ------------------------------------------------------------------------- ACTIVE INSURANCE Insurance Company: Effective Date: Group Name: Expiration Date: Group Number: Subscriber ID: Subscriber Name: Subscriber Relationship: ========================================================================= VA Treating Facility: SPOKANE VAMC ------------------------------------------------------------------------- First Name: ONE Race: Middle Name: A Ethnicity: Last Name: MHVTESTVETERAN Religion: Date of Birth: 01 Mar 1948 Place of Birth: WASHINGTON, DISTRICT OF COLUMBIA Age: 65 Marital Status: DIVORCED Gender: Male ------------------------------------------------------------------------- PERMANENT ADDRESS AND CONTACT INFORMATION Street Address: 123 ANYWHERE RD Street Address 2: APT 123 City: WASHINGTON State: DISTRICT OF COLUMBIA Zip Code: 20420 County: 001 Country: USA Home Phone Number: Work Phone Number: Cell Phone Number: Email Address: MHVVETERAN@EMAILADDRESS.COM ------------------------------------------------------------------------- TEMPORARY ADDRESS AND CONTACT INFORMATION Active Start Date: Street Address: 123 ANYWHERE RD Active End Date: Street Address 2: APT 123 City: WASHINGTON State: DISTRICT OF COLUMBIA Zip Code: 20420 Country: USA Temporary Phone Number: ------------------------------------------------------------------------- ELIGIBILITY Service Connected Percentage: 70 Means Test Status: Primary Eligibility Code: RX Copay Status: ------------------------------------------------------------------------- EMPLOYMENT Occupation: Employment Status: NOT EMPLOYED Employer Name: ------------------------------------------------------------------------- PRIMARY NEXT OF KIN Name: MHVTESTVETERAN, TWO Relationship to Patient: Street Address: 123 ANYWHERE RD Home Phone Number: 000-000-0001 City: WASHINGTON Work Phone Number: State: DISTRICT OF COLUMBIA Zip Code: 20420 Country: ------------------------------------------------------------------------- EMERGENCY CONTACT Name: MHVTESTVETERAN, TWO Relationship to Patient: Street Address: 123 ANYWHERE RD Home Phone Number: 000-000-0001 City: WASHINGTON Work Phone Number: State: DISTRICT OF COLUMBIA Zip Code: 20420 Country: ------------------------------------------------------------------------- VA GUARDIAN Name: Relationship to Patient: Street Address: Home Phone Number: City: Work Phone Number: State: Zip Code: Country: ------------------------------------------------------------------------- CIVIL GUARDIAN Name: Relationship to Patient: Street Address: Home Phone Number: City: Work Phone Number: State: Zip Code: Country: ------------------------------------------------------------------------- ACTIVE INSURANCE Insurance Company: Effective Date: Group Name: Expiration Date: Group Number: Subscriber ID: Subscriber Name: Subscriber Relationship: ========================================================================= VA Treating Facility: PORTLAND, OREGON VA MEDICAL CENTER ------------------------------------------------------------------------- First Name: ONE Race: Middle Name: A Ethnicity: Last Name: MHVTESTVETERAN Religion: Date of Birth: 01 Mar 1948 Place of Birth: WASHINGTON, DISTRICT OF COLUMBIA Age: 65 Marital Status: DIVORCED Gender: Male ------------------------------------------------------------------------- PERMANENT ADDRESS AND CONTACT INFORMATION Street Address: 123 ANYWHERE RD Street Address 2: APT 123 City: WASHINGTON State: DISTRICT OF COLUMBIA Zip Code: 20420 County: Country: USA Home Phone Number: Work Phone Number: Cell Phone Number: Email Address: MHVVETERAN@EMAILADDRESS.COM ------------------------------------------------------------------------- TEMPORARY ADDRESS AND CONTACT INFORMATION Active Start Date: Street Address: 123 ANYWHERE RD Active End Date: Street Address 2: APT 123 City: WASHINGTON State: DISTRICT OF COLUMBIA Zip Code: 20420 Country: USA Temporary Phone Number: ------------------------------------------------------------------------- ELIGIBILITY Service Connected Percentage: 0 Means Test Status: NO LONGER REQUIRED Primary Eligibility Code: RX Copay Status: ------------------------------------------------------------------------- EMPLOYMENT Occupation: Employment Status: NOT EMPLOYED Employer Name: ------------------------------------------------------------------------- PRIMARY NEXT OF KIN Name: MHVTESTVETERAN, TWO Relationship to Patient: Street Address: 123 ANYWHERE RD Home Phone Number: 000-000-0001 City: WASHINGTON Work Phone Number: State: DISTRICT OF COLUMBIA Zip Code: 20420 Country: ------------------------------------------------------------------------- EMERGENCY CONTACT Name: MHVTESTVETERAN, TWO Relationship to Patient: Street Address: 123 ANYWHERE RD Home Phone Number: 000-000-0001 City: WASHINGTON Work Phone Number: State: DISTRICT OF COLUMBIA Zip Code: 20420 Country: ------------------------------------------------------------------------- VA GUARDIAN Name: Relationship to Patient: Street Address: Home Phone Number: City: Work Phone Number: State: Zip Code: Country: ------------------------------------------------------------------------- CIVIL GUARDIAN Name: Relationship to Patient: Street Address: Home Phone Number: City: Work Phone Number: State: Zip Code: Country: ------------------------------------------------------------------------- ACTIVE INSURANCE Insurance Company: Effective Date: Group Name: Expiration Date: Group Number: Subscriber ID: Subscriber Name: Subscriber Relationship: ------------------ SELF REPORTED HEALTH CARE PROVIDERS ------------------ Source: Self-Entered Provider Name: John Doe Type of Provider: Primary Other Clinician Information: Phone Number: 000-000-0000 Ext: 1234 Email: provider@institution.org Comments: Dr. Doe can be reached on the weekend if needed by leaving a message with the clinic. Provider Name: Jane Smith Type of Provider: Specialist Other Clinician Information: Phone Number: 000-000-0001 Ext: 1234 Email: specialist@institution.org Comments: Dr. Smith should be notified of any changes in my medical condition. Requires a referral from my health insurance company. ------------------ SELF REPORTED TREATMENT FACILITIES-------------------- Source: Self-Entered Facility Name: Anywhere VA Medical Center Facility Type: VA VA Home Facility: Yes Phone Number: 000-000-0001 Ext: 1234 Mailing Address: 123 VA Drive Mailing Address2: Suite 4 Mailing City: Anywhere Mailing State: DC Mailing Country: United States Mailing Province: Mailing Zip/Postal Code: 00001 Comments: Contact clinic when calling to make my appointments. Facility Name: Health Care Inc. Facility Type: Non-VA VA Home Facility: No Phone Number: 000-000-0002 Ext: 5678 Mailing Address: 123 Anywhere Road Mailing Address2: B-Wing Mailing City: Anywhere Mailing State: DC Mailing Country: United States Mailing Province: Mailing Zip/Postal Code: 00001 Comments: Reminder to bring My HealtheVet printouts for all visits ------------------- SELF REPORTED HEALTH INSURANCE ---------------------- Source: Self-Entered Health Insurance Company: My Health Insurance Company Primary Insurance Provider: Yes ID Number: 0001234 Group Number: 0000000 Insured: One MHVveteran Start Date: 01 Jan 2009 Stop Date: Pre-Approval Phone Number: 000-000-0003 Health Insurance Company Phone Number: 000-000-0004 Comments: Need to get pre-authorization for special services. Health Insurance Company: My Other Health Insurance Company Primary Insurance Provider: No ID Number: 000567891010 Group Number: ABC123456789 Insured: One MHVveteran Start Date: 01 Jan 2009 Stop Date: Pre-Approval Phone Number: 000-000-0005 Health Insurance Company Phone Number: 000-000-0005 Comments: Coverage only for vision and dental. ---------------------------- VA WELLNESS REMINDERS ------------------------- Source: VA Last Updated: 18 Mar 2013 @ 0634 Wellness Reminder Due Date Last Completed Location ---------------------------------------------------------------------------- Pneumonia Vaccine 06 Mar 2011 PORTLAND, OR Body Mass Index more than 25 DUE NOW UNKNOWN PORTLAND, OR Control of Your Cholesterol DUE NOW UNKNOWN PORTLAND, OR Influenza Vaccine DUE NOW UNKNOWN PORTLAND, OR Colon Cancer Screening 01 Oct 2022 01 Oct 2012 PORTLAND, OR Influenza Vaccine DUE NOW UNKNOWN SPOKANE VAMC Colon Cancer Screening DUE NOW UNKNOWN SPOKANE VAMC Pneumonia Vaccine DUE NOW UNKNOWN SPOKANE VAMC Colon Cancer Screening DUE NOW UNKNOWN VA SOUTHERN Influenza Vaccine DUE NOW UNKNOWN VA SOUTHERN Pneumonia Vaccine DUE NOW UNKNOWN VA SOUTHERN Learn more about these Wellness Reminders by visiting My HealtheVet. Please contact your health care team with any questions about your VA Wellness Reminders. --------------------------- VA APPOINTMENTS ----------------------------- Source: VA Last Updated: 18 Mar 2013 @ 0627 Sort By: Date (Descending) All future VA Appointments are shown below. Past VA Appointments are limited to two years from the date of your download request. To cancel, change or request an appointment with your VA health care team, please contact your local VA facility. FUTURE APPOINTMENTS: -------------------- Date/Time: 09 Dec 2013 @ 0800 Location: PORTLAND Status: FUTURE Clinic: Provider One P2 Bldg 104 Phone Number: 5-5187 Date/Time: 16 May 2013 @ 0800 Location: PORTLAND Status: FUTURE Clinic: Provider One P2 Bldg 104 Phone Number: 5-5187 PAST APPOINTMENTS: -------------------- Date/Time: 07 Jan 2013 @ 0800 Location: PORTLAND Status: APPOINTMENT NOT KEPT Clinic: Provider One P2 Bldg 104 Phone Number: 5-5187 Date/Time: 30 May 2012 @ 1600 Location: PORTLAND Status: NOT APPLICABLE Clinic: Provider One P2 Bldg 104 Phone Number: 000-000-0001 Date/Time: 07 May 2012 @ 1100 Location: PORTLAND Status: NOT APPLICABLE Clinic: Provider One P2 Bldg 104 Phone Number: 000-000-0001 Date/Time: 27 Jan 2012 @ 1400 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 Note: This appointment has pre-appointment activity scheduled: Lab: 27 Jan 2012 @ 1000 Date/Time: 15 Dec 2011 @ 1300 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 Note: This appointment has pre-appointment activity scheduled: Lab: 15 Dec 2011 @ 0800 EKG: 15 Dec 2011 @ 1030 X-Ray: 15 Dec 2011 @ 0900 Date/Time: 03 Nov 2011 @ 1100 Location: PORTLAND Status: NOT APPLICABLE Clinic: 111A TEST NOTE LOCATION Phone Number: 000-000-0001 Note: This appointment has pre-appointment activity scheduled: X-Ray: 03 Nov 2011 @ 0800 -------------------------- VA MEDICATION HISTORY ---------------------- Source: VA Last Updated: 15 Feb 2013 @ 1315 Sorted By: Last Filled On (Descending) Remember to share all information about your medications or updates with your VA health care team. Also, check information in your VA Allergies and your Self Reported Allergies. This may let you know if you had a reaction to a medication you received. If you have any questions about your information please visit the FAQs or contact your VA health care team. Medication: HCTZ 25/TRIAMTERENE 37.5MG TAB Instructions: TAKE ONE-HALF TABLET (12.5/18.75 MG) BY MOUTH EVERY DAY Status: Active Refills Remaining: 3 Last Filled On: 11 Dec 2012 Initially Ordered On: 10 Dec 2012 Quantity: 45 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000001 Medication: FLUOXETINE HCL 10MG CAP Instructions: TAKE ONE CAPSULE BY MOUTH EVERY MORNING Status: Active Refills Remaining: 3 Last Filled On: 11 Dec 2012 Initially Ordered On: 10 Dec 2012 Quantity: 90 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000002 Medication: AMLODIPINE BESYLATE 5MG TAB Instructions: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY FOR BLOOD PRESSURE Status: Refill in Process Refills Remaining: 2 Last Filled On: 01 Mar 2013 Initially Ordered On: 10 Dec 2012 Quantity: 45 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000003 Medication: DONEPEZIL HCL 5MG TAB Instructions: TAKE ONE TABLET BY MOUTH EVERY MORNING Status: Submitted Refills Remaining: 11 Last Filled On: 11 Dec 2012 Initially Ordered On: 10 Dec 2012 Quantity: 30 Days Supply: 30 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000004 Medication: AMLODIPINE BESYLATE 10MG TAB Instructions: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY FOR BLOOD PRESSURE -- AVOID GRAPEFRUIT JUICE -- Status: Discontinued Refills Remaining: 3 Last Filled On: 15 Jul 2012 Initially Ordered On: 15 Jul 2012 Quantity: 45 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000005 Medication: COLON ELECTROLYTE LAVAGE PWD FOR SOLN Instructions: MIX 1 GALLON IN WATER AND DRINK AS DIRECTED FOR 1 DAY DISSOLVE 1 BOTTLE Status: Discontinued Refills Remaining: 0 Last Filled On: 15 Jul 2012 Initially Ordered On: 13 Jul 2012 Quantity: 1 Days Supply: 2 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000006 Medication: ACCU-CHEK AVIVA (GLUCOSE) TEST STRIP #50 Instructions: USE 1 STRIP FOR BLOOD GLUCOSE TESTING AS DIRECTED Status: Discontinued Refills Remaining: 2 Last Filled On: 09 Jul 2012 Initially Ordered On: 06 Jul 2012 Quantity: 200 Days Supply: 50 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000007 Medication: SODIUM CHLORIDE 0.65% SOLN NASAL Instructions: SPRAY 2 SPRAYS MOUTH MINUTE FOR 30 DAYS Status: Discontinued Refills Remaining: 3 Last Filled On: 09 Jul 2012 Initially Ordered On: 06 Jul 2012 Quantity: 10 Days Supply: 30 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000008 Medication: SIMVASTATIN 40MG TAB Instructions: TAKE ONE-HALF TABLET BY MOUTH AT BEDTIME TO LOWER YOUR CHOLESTEROL. AVOID CONSUMING GRAPEFRUIT PRODUCTS. CALL YOUR PROVIDER IF YOU HAVE UNEXPLAINED MUSCLE PAIN, TENDERNESS OR WEAKNESS. Status: Discontinued Refills Remaining: 2 Last Filled On: 09 Jul 2012 Initially Ordered On: 06 Jul 2012 Quantity: 45 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000009 Medication: NAPROXEN 500MG TAB Instructions: TAKE ONE TABLET BY MOUTH TWICE A DAY -- TAKE WITH FOOD IF GI Status: Discontinued Refills Remaining: 3 Last Filled On: 09 Jul 2012 Initially Ordered On: 06 Jul 2012 Quantity: 60 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000010 Medication: METFORMIN HCL 1000MG TAB Instructions: TAKE ONE TABLET BY MOUTH TWICE DAILY WITH MEALS FOR DIABETES. Status: Discontinued Refills Remaining: 2 Last Filled On: 09 Jul 2012 Initially Ordered On: 06 Jul 2012 Quantity: 180 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000011 Medication: LISINOPRIL 10MG TAB Instructions: TAKE ONE TABLET BY MOUTH EVERY DAY FOR BLOOD PRESSURE Status: Discontinued Refills Remaining: 3 Last Filled On: 09 Jul 2012 Initially Ordered On: 06 Jul 2012 Quantity: 30 Days Supply: 30 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000012 Medication: INSULIN,GLARGINE 100U/ML INJ 10ML VIAL Instructions: INJECT 25 UNITS SUBCUTANEOUSLY AT BEDTIME * DO NOT MIX OTHER INSULINS IN SAME SYRINGE AS GLARGINE. DISCARD VIAL 28 DAYS AFTER OPENING. EACH VIAL EXPIRES 28 DAYS AFTER FIRST OPENING. Status: Discontinued Refills Remaining: 2 Last Filled On: 09 Jul 2012 Initially Ordered On: 06 Jul 2012 Quantity: 3 Days Supply: 30 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000013 Medication: INSULIN NPH HUMAN 100 UNIT/ML NOVOLIN N Instructions: INJECT 16 UNITS SUBCUTANEOUSLY EVERY MORNING AND INJECT 18 UNITS AT BEDTIME EACH VIAL EXPIRES 30 DAYS AFTER FIRST OPENING. Status: Discontinued Refills Remaining: 1 Last Filled On: 09 Jul 2012 Initially Ordered On: 06 Jul 2012 Quantity: 3 Days Supply: 30 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000014 Medication: IBUPROFEN 600MG TAB Instructions: TAKE ONE TABLET BY MOUTH FOUR TIMES DAILY WITH MEALS AS NEEDED FOR PAIN Status: Discontinued Refills Remaining: 3 Last Filled On: 09 Jul 2012 Initially Ordered On: 06 Jul 2012 Quantity: 240 Days Supply: 60 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000015 Medication: DEXAMETHASONE 4MG TAB Instructions: TAKE TWO TABLETS BY MOUTH HOUR FOR 2 DAYS -- TAKE WITH FOOD -- Status: Discontinued Refills Remaining: 2 Last Filled On: 09 Jul 2012 Initially Ordered On: 06 Jul 2012 Quantity: 96 Days Supply: 30 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000016 Medication: BACITRACIN OINTMENT 1 OZ Instructions: APPLY SMALL AMOUNT TOPICALLY TO AFFECTED AREA TWICE A DAY TO THREE TIMES A DAY FOR 30 DAYS Status: Discontinued Refills Remaining: 1 Last Filled On: 09 Jul 2012 Initially Ordered On: 06 Jul 2012 Quantity: 10 Days Supply: 45 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000017 Medication: AMLODIPINE BESYLATE 10MG TAB Instructions: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY FOR BLOOD PRESSURE -- AVOID GRAPEFRUIT JUICE -- Status: Expired Refills Remaining: 2 Last Filled On: 17 May 2012 Initially Ordered On: 03 Jun 2011 Quantity: 45 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000018 Medication: IBUPROFEN 600MG TAB Instructions: TAKE ONE TABLET BY MOUTH FOUR TIMES DAILY WITH MEALS AS NEEDED FOR PAIN Status: Expired Refills Remaining: 2 Last Filled On: 17 Feb 2012 Initially Ordered On: 03 Jun 2011 Quantity: 240 Days Supply: 60 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000019 Medication: ACCU-CHEK AVIVA (GLUCOSE) TEST STRIP #50 Instructions: USE 1 STRIP FOR BLOOD GLUCOSE TESTING AS DIRECTED Status: Expired Refills Remaining: 1 Last Filled On: 05 Dec 2011 Initially Ordered On: 03 Jun 2011 Quantity: 200 Days Supply: 50 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000020 Medication: DEXAMETHASONE 4MG TAB Instructions: TAKE TWO TABLETS BY MOUTH HOUR FOR 2 DAYS -- TAKE WITH FOOD -- Status: Expired Refills Remaining: 2 Last Filled On: 03 Jun 2011 Initially Ordered On: 03 Dec 2010 Quantity: 96 Days Supply: 30 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000021 Medication: SODIUM CHLORIDE 0.65% SOLN NASAL Instructions: SPRAY 2 SPRAYS MOUTH MINUTE FOR 30 DAYS Status: Expired Refills Remaining: 3 Last Filled On: 03 Jun 2011 Initially Ordered On: 03 Dec 2010 Quantity: 10 Days Supply: 30 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000022 Medication: NAPROXEN 500MG TAB Instructions: TAKE ONE TABLET BY MOUTH TWICE A DAY -- TAKE WITH FOOD IF GI Status: Expired Refills Remaining: 3 Last Filled On: 03 Jun 2011 Initially Ordered On: 03 Dec 2010 Quantity: 60 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000023 Medication: INSULIN NOVOLIN NPH 100U/ML INJ 10ML VL Instructions: INJECT 16 UNITS SUBCUTANEOUSLY EVERY MORNING AND INJECT 18 UNITS AT BEDTIME EACH VIAL EXPIRES 30 DAYS AFTER FIRST OPENING. Status: Expired Refills Remaining: 1 Last Filled On: 03 Jun 2011 Initially Ordered On: 03 Jun 2011 Quantity: 3 Days Supply: 30 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000024 Medication: BACITRACIN OINTMENT 1 OZ Instructions: APPLY SMALL AMOUNT TOPICALLY TO AFFECTED AREA TWICE A DAY TO THREE TIMES A DAY FOR 30 DAYS Status: Expired Refills Remaining: 1 Last Filled On: 03 Jun 2011 Initially Ordered On: 03 Dec 2010 Quantity: 10 Days Supply: 45 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000025 Medication: LISINOPRIL 10MG TAB Instructions: TAKE ONE TABLET BY MOUTH EVERY DAY FOR BLOOD PRESSURE Status: Expired Refills Remaining: 3 Last Filled On: 03 Jun 2011 Initially Ordered On: 03 Dec 2010 Quantity: 30 Days Supply: 30 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000026 Medication: SIMVASTATIN 40MG TAB Instructions: TAKE ONE-HALF TABLET BY MOUTH AT BEDTIME TO LOWER YOUR CHOLESTEROL. AVOID CONSUMING GRAPEFRUIT PRODUCTS. CALL YOUR PROVIDER IF YOU HAVE UNEXPLAINED MUSCLE PAIN, TENDERNESS OR WEAKNESS. Status: Expired Refills Remaining: 2 Last Filled On: 03 Jun 2011 Initially Ordered On: 03 Jun 2011 Quantity: 45 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000027 Medication: METFORMIN HCL 1000MG TAB Instructions: TAKE ONE TABLET BY MOUTH TWICE DAILY WITH MEALS FOR DIABETES. Status: Expired Refills Remaining: 2 Last Filled On: 03 Jun 2011 Initially Ordered On: 03 Jun 2011 Quantity: 180 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000028 Medication: INSULIN,GLARGINE 100U/ML INJ 10ML VIAL Instructions: INJECT 25 UNITS SUBCUTANEOUSLY AT BEDTIME * DO NOT MIX OTHER INSULINS IN SAME SYRINGE AS GLARGINE. DISCARD VIAL 28 DAYS AFTER OPENING. EACH VIAL EXPIRES 28 DAYS AFTER FIRST OPENING. Status: Expired Refills Remaining: 2 Last Filled On: 03 Jun 2011 Initially Ordered On: 03 Jun 2011 Quantity: 3 Days Supply: 30 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000029 Medication: COLONIC LAVAGE SOLUTION (4 LITER) Instructions: MIX 1 GALLON IN WATER AND DRINK AS DIRECTED FOR 1 DAY DISSOLVE 1 BOTTLE Status: Expired Refills Remaining: 0 Last Filled On: 03 Jun 2011 Initially Ordered On: 03 Jun 2011 Quantity: 1 Days Supply: 2 Pharmacy: PORTLAND PHARMACY Prescription Number: 00000030 ------------------- SELF REPORTED MEDICATIONS AND SUPPLEMENTS --------------- Source: Self-Entered Remember to share all information about your medications or updates with your health care team. Category: OTC Drug Name: Cough Medicine Prescription Number: Strength: 1000mg Dose: 2 TBS Frequency: morning and night Start Date: 01 Feb 2010 Stop Date: 21 Feb 2010 Pharmacy Name: My Local Drugstore Pharmacy Phone: 000-010-0000 Reason for taking: Cough was keeping me up at night Comments: Cleared up after a few weeks Category: Supplement Drug Name: Multi-vitamin Prescription Number: Strength: 100% RDA Dose: 1 tablet daily Frequency: morning Start Date: 18 Mar 2010 Stop Date: Pharmacy Name: My Local Drugstore Pharmacy Phone: 000-010-0000 Reason for taking: To stay healthy Comments: Feeling more energetic since I started taking vitamin ----------------------------- VA ALLERGIES ------------------------------ Source: VA Last Updated: 18 Mar 2013 @ 0614 Remember to share all information about your allergies with your health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. Allergy Name: IMIPRAMINE Location: PORTLAND, OREGON VA MEDICAL CENTER Date Entered: 07 Dec 2012 Reaction: ANAPHYLAXIS Allergy Type: DRUG VA Drug Class: TRICYCLIC ANTIDEPRESSANTS Observed/Historical: OBSERVED Comments: severe Allergy Name: TRIMETHOPRIM Location: PORTLAND, OREGON VA MEDICAL CENTER Date Entered: 03 Jun 2011 Reaction: Allergy Type: DRUG VA Drug Class: ANTI-INFECTIVES,OTHER Observed/Historical: HISTORICAL Comments: the reaction to this allergy was MILD (NO SQUELAE) Allergy Name: TRAMADOL Location: PORTLAND, OREGON VA MEDICAL CENTER Date Entered: 03 Jun 2011 Reaction: RETENTION OF URINE Allergy Type: DRUG VA Drug Class: NON-OPIOID ANALGESICS Observed/Historical: HISTORICAL Comments: gradually worsening difficulty emptying bladder -- might try tramadol again cautiously because pt. reported pain relief Allergy Name: TERAZOSIN Location: PORTLAND, OREGON VA MEDICAL CENTER Date Entered: 03 Jun 2011 Reaction: DIZZINESS Allergy Type: DRUG VA Drug Class: ALPHA BLOCKERS/RELATED Observed/Historical: HISTORICAL Comments: Allergy Name: BACTRIM Location: PORTLAND, OREGON VA MEDICAL CENTER Date Entered: 03 Jun 2011 Reaction: Allergy Type: DRUG VA Drug Class: SULFONAMIDE/RELATED ANTIMICROBIALS Observed/Historical: HISTORICAL Comments: Causes Swelling of the Extremities Allergy Name: METHOCARBAMOL Location: PORTLAND, OREGON VA MEDICAL CENTER Date Entered: 03 Jun 2011 Reaction: DELIRIUM, DROWSY Allergy Type: DRUG VA Drug Class: SKELETAL MUSCLE RELAXANTS Observed/Historical: OBSERVED Comments: Drowsiness and hallucinations while on methocarbamol plus carbamazepine and other sedatives Remember to share all information about your allergies with your health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. Allergy information. ---------------------------- SELF REPORTED ALLERGIES ----------------------- Source: Self-Entered Allergy Name: Pollen Date: 18 Mar 2011 Severity: Mild Diagnosed: Yes Reaction: Watery eyes, itchy nose Comments: Took an over the counter antihistamine Allergy Name: Diovan Date: 07 Jan 2013 Severity: Mild Diagnosed: No Reaction: Dry cough Comments: I called my provider and told him the reaction I had. He is calling in a new Rx for my HTN ---------------------------- VA PROBLEM LIST ---------------------------- Source: VA Last Updated: 18 Mar 2013 @ 0634 Sorted By: Date/Time Entered (Descending) then alphabetically by Problem Your VA Problem List contains active health problems your VA providers are helping you to manage. This information is available 7 calendar days after it has been entered. It may not contain active problems managed by non-VA health care providers. If you have any questions about your information, visit the FAQs or contact your VA health care team. Problem: Posttraumatic Stress Disorder Date/Time Entered: 11 Feb 2013 @ 1200 Location: PORTLAND, OREGON VA MEDICAL CENTER Status: ACTIVE/CHRONIC Provider: PROVIDER, ONE Comments: AWAITING A COMP AND PEN EXAM Problem: MILD COGNITIVE IMPAIRMENT Date/Time Entered: 16 Jan 2013 @ 1200 Location: PORTLAND, OREGON VA MEDICAL CENTER Status: ACTIVE/CHRONIC Provider: PROVIDER, ONE Comments: this is only a test INDEPENDENT IN ADLs AND IADLs Problem: Diabetes with neurological Manifestations, type i [Juvenile type], not stated as Date/Time Entered: 07 Dec 2012 @ 1200 Location: PORTLAND, OREGON VA MEDICAL CENTER Status: ACTIVE Provider: PROVIDER, ONE Comments: Problem: Hyperlipidemia Date/Time Entered: 07 Dec 2012 @ 1200 Location: PORTLAND, OREGON VA MEDICAL CENTER Status: ACTIVE Provider: PROVIDER, ONE Comments: Problem: TRAUMATIC BRAIN INJURY Date/Time Entered: 07 Dec 2012 @ 1200 Location: PORTLAND, OREGON VA MEDICAL CENTER Status: ACTIVE Provider: PROVIDER, ONE Comments: --------------------- VA ADMISSIONS AND DISCHARGES ---------------------- Source: VA Last Updated: 18 Mar 2013 @ 0634 Sorted By: Admission Date/Time (Descending) Discharge summaries are available 7 calendar days after they are completed. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= Admission Date: 10 Dec 2012 @ 0935 Location: PORTLAND, OREGON VA MEDICAL CENTER Admitting Physician: PROVIDER, ONE Discharge Date: 11 Dec 2012 @ 1134 Discharge Physician: PROVIDER, TWO ----------------------------------------------------------------------------- DISCHARGE SUMMARY LOCAL TITLE: Discharge Summary STANDARD TITLE: DISCHARGE SUMMARY DICT DATE: DEC 10, 2012@10:40 ENTRY DATE: DEC 10, 2012@10:41:06 DICTATED BY: PROVIDER, ONE ATTENDING: PROVIDER, ONE URGENCY: routine STATUS: COMPLETED THIS IS ONLY A TEST ATTENDING PHYSICIAN: PRIMARY CARE PROVIDER AND FACILIITY: PRINCIPAL DIAGNOSIS: OTHER DIAGNOSES TREATED OR IMPACTING TREATMENT THIS ADMISSION: PROCEDURES PERFORMED AT THIS HOSPITAL DURING CURRENT ADMISSION: SUMMARY: (ABBREVIATED HPI, PE, AND PERTINENT LABS) HOSPITAL COURSE: FUNCTIONAL STATUS: (MAY INCLUDE ACTIVITY LEVEL, WORK RESTRICTIONS, OR DIET) DISCHARGE MEDICATIONS: (INDICATE ADDITIONS OR CHANGES WITH AN ASTERISK) MEDICATIONS THAT HAVE BEEN DISCONTINUED: CLINICAL ISSUES REQUIRING FOLLOW UP DURING PC PHONE APT: 1. 2. 3. ADDITIONAL FOLLOW UP APPOINTMENTS: SPECIALTY EXPECTED DATE SCHEDULED(Y/N) POINT OF CONTACT 1. 2. 3. FOLLOW UP LABS INCLUDING PATHOLOGY & MICROBIOLOGY: TEST ORDERED(Y/N) EXPECTED DATE IF NOT ORDERED 1. 2. 3. FOLLOW UP IMAGING AND PROCEDURES: PROCEDURE ORDERED(Y/N) EXPECTED DATE IF NOT ORDERED 1. 2. 3. /es/ PROVIDER, ONE ATTENDING PSYCHIATRIST Signed: 12/10/2012 16:15 for PROVIDER, TWO INTERNAL MEDICINE RESIDENT ------------------------------- VA NOTES -------------------------------- Source: VA Last Updated: 18 Mar 2013 @ 0634 Sorted By: Date/Time (Descending) VA Notes from January 1, 2013 are available 7 calendar days after they have been completed by members of your VA health care team. In the future more historical notes may be available. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= Date/Time: 25 Jan 2013 @ 0701 Note Title: CARDIOLOGY - FOLLOW-UP Location: PORTLAND, OREGON VA MEDICAL CENTER Signed By: PROVIDER,ONE Co-signed By: PROVIDER, TWO Date/Time Signed: 25 Jan 2013 @ 0701 ------------------------------------------------------------------------- LOCAL TITLE: CARDIOLOGY - FOLLOW-UP STANDARD TITLE: CARDIOLOGY OUTPATIENT NOTE DATE OF NOTE: JAN 25, 2013@07:01 ENTRY DATE: JAN 25, 2013@07:02:25 AUTHOR: PROVIDER, TWO EXP COSIGNER: PROVIDER, ONE URGENCY: STATUS: COMPLETED Mr. ONE A MHVTESTVETERAN is a 64 yo M with a PMHx as below who presents in routine follow-up. Past Cardiology History:Patient family history of cardiac stess and disease (uncle and older brother) all with diabetes. SUBJECTIVE: OBJECTIVE: Active Medications: 1) Amlodipine besylate 5mg tab take one-half tablet by mouth every day for blood pressure 2) Donepezil hcl 5mg tab take one tablet by mouth every morning 3) Fluoxetine hcl 10mg cap take one capsule by mouth every morning 4) Hctz 25/triamterene 37.5mg tab take one-half tablet (12.5/18.75 mg) by mouth every day active non-va medications status ========================================================================= 1) Non-va fish oil cap/tab 1 cap/tab mouth every day 2) Non-va ginkgo biloba small amount mouth every day 3) Non-va kava cap/tab 1 cap/tab mouth every day 4) Non-va lisinopril 5mg tab 2.5mg mouth every day 8 total medications) Physical Exam: Vitals: 98.5 F [36.9 C] (12/10/2012 09:24) 190/70 (01/07/2013 15:27) 88 (12/10/2012 09:24) No assessments on file. BSA : 2.569 sq. meters on 12/10/2012 09:24 BODY MASS INDEX DEC 10, 2012@09:24:38 46.7 GEN - NECK - CV - PULM - EXT - Lab Studies: Mixed dates for most recent tests of this panel No CBC in last year 145 H : 102 : 25 H / \ N/A / MCV: N/A ------ : ------ : ------ 150 H N/A ----- N/A SEGS: N/A 6.5 H*: 25 : 1.2 \ / N/A \ BANDS: N/A ASSESSMENT/PLAN: Mr. ONE A MHVTESTVETERAN is a 64 yo M with a PMHx as above who presents in routine follow-up. IMPRESSION: 1. 2. 3. 4. PLAN:Order a series of test to include a stress test and a series of cardiac lab panels. Will also review patient's current medication history and revise accordingly. FELLOW SUPERVISION: Staffed with Dr. Provider who agrees with my assessment and plan. /es/ PROVIDER, TWO Chief of Clinical Appl Coord Signed: 01/25/2013 07:07 /es/ ONE PROVIDER MD ATTENDING PSYCHIATRIST Cosigned: 02/11/2013 07:55 ========================================================================= Date/Time: 25 Jan 2013 @ 0655 Note Title: INPAT - MED - MS - PROGRESS Location: PORTLAND, OREGON VA MEDICAL CENTER Signed By: PROVIDER, TWO Co-signed By: PROVIDER, THREE Date/Time Signed: 25 Jan 2013 @ 0655 ------------------------------------------------------------------------- LOCAL TITLE: INPAT - MED - MS - PROGRESS STANDARD TITLE: STUDENT INPATIENT NOTE DATE OF NOTE: JAN 25, 2013@06:55 ENTRY DATE: JAN 25, 2013@06:56:26 AUTHOR: PROVIDER, TWO EXP COSIGNER: PROVIDER, ONE URGENCY: STATUS: COMPLETED *** INPAT - MED - MS - PROGRESS Has ADDENDA *** Patient presented and discussed at multi-disciplinary rounds today: Yes during patient interview< ia sked Mr. MHV if his family had a history of cardiac issues and diabetes, he replied that yes there was a history of both with his uncle and older brother. This new line of questioning was in response to a comment he made earlier to his RN. Plan to follow up with Dr. Provider, the resident which is providing care for Mr. MHV. The patient was staffed with Dr. Provider who agrees with my assessment and plan. /es/ TWO PROVIDER Chief of Clinical Appl Coord Signed: 01/25/2013 07:00 /es/ ONE PROVIDER MD CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Cosigned: 02/11/2013 07:55 01/25/2013 ADDENDUM STATUS: COMPLETED /es/ ONE PROVIDER MD CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/25/2013 11:48 ========================================================================= Date/Time: 24 Jan 2013 @ 1437 Note Title: PHYSICAL THERAPY - INPATIENT NOTE Location: PORTLAND, OREGON VA MEDICAL CENTER Signed By: PROVIDER, ONE Co-signed By: PROVIDER, TWO Date/Time Signed: 24 Jan 2013 @ 1437 ------------------------------------------------------------------------- LOCAL TITLE: PHYSICAL THERAPY - INPATIENT NOTE STANDARD TITLE: PHYSICAL THERAPY INPATIENT NOTE DATE OF NOTE: JAN 24, 2013@14:37 ENTRY DATE: JAN 24, 2013@14:38 AUTHOR: PROVIDER, ONE EXP COSIGNER: URGENCY: STATUS: COMPLETED S: Pain level: Pain location: O: A: (progress toward goals) P: THIS IS ONLY A TEST /es/ ONE PROVIDER MD CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/24/2013 14:38 ========================================================================= Date/Time: 24 Jan 2013 @ 1436 Note Title: INPAT - CT SURG - ADMIT Location: PORTLAND, OREGON VA MEDICAL CENTER Signed By: PROVIDER, ONE Co-signed By: PROVIDER, TWO Date/Time Signed: 24 Jan 2013 @ 1436 ------------------------------------------------------------------------- LOCAL TITLE: INPAT - CT SURG - ADMIT STANDARD TITLE: THORACIC SURGERY INPATIENT NOTE DATE OF NOTE: JAN 24, 2013@14:36 ENTRY DATE: JAN 24, 2013@14:37:02 AUTHOR: PROVIDER, ONE EXP COSIGNER: URGENCY: STATUS: COMPLETED I have seen and discussed the patient with my supervising practitioner, Dr.Three Provider, and Dr. Four Provider who is in agreement with the assesment and plan. Patient Name: MHVTESTVETERAN,ONE A S: THIS IS ONLY A TEST O: POD# s/p: No vitals data available in last 24 hours. I/O: Last CHEM 7 After 0500 JAN 24, 2013: N/A : N/A : N/A / ------ : ------ : ------ N/A N/A : N/A : N/A \ Last CBC w/Diff After 0500 JAN 24, 2013: \ N/A / MCV N/A N/A -------- N/A SEGS N/A / N/A \ BANDS N/A Active Medications: Neuro: AAO Pulm: CTAB CV: NRRR Abd: soft, NT, +BS Ext: Incision intact No hematoma A: P: /es/ ONE PROVIDER CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/24/2013 14:37 ========================================================================= Date/Time: 07 Jan 2013 @ 1428 Note Title: SECURE MESSAGING Location: PORTLAND, OREGON VA MEDICAL CENTER Signed By: PROVIDER, ONE Co-signed By: PROVIDER, ONE Date/Time Signed: 07 Jan 2013 @ 1428 ------------------------------------------------------------------------- LOCAL TITLE: SECURE MESSAGING STANDARD TITLE: MHV DIALOG NOTE DATE OF NOTE: JAN 07, 2013@14:28 ENTRY DATE: JAN 07, 2013@14:28:52 AUTHOR: PROVIDER, ONE EXP COSIGNER: URGENCY: STATUS: COMPLETED *** SECURE MESSAGING Has ADDENDA *** THIS IS A TEST /es/ ONE PROVIDER MD CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/07/2013 14:29 01/07/2013 ADDENDUM STATUS: COMPLETED CLINICAL REMINDER ACTIVITY *Annual OTC/Non-VA Med Review: Reviewed medication list with patient. New OTC/Non-VA medications to be added to list. DM NEPHROPATHY SCREENING: Angiotensin II receptor blocker therapy is contraindicated. Comment: test patient Eval of Positive Depression Screen: Rescreen with PHQ-2 if most recent previous screen is > 1 day old. A PHQ-2 screen was performed. The score was 0 which is a negative screen for depression. 1. Little interest or pleasure in doing things Not at all 2. Feeling down, depressed, or hopeless Not at all Are you feeling hopeless about the present or future? NO Have you had thoughts recently about taking your life? NO ASSESSMENT: Suicide risk screen is negative. PROVIDER EVALUATION The results of the PHQ depression screen have been reviewed. I have personally evaluated the patient including inquiry about feelings of hopelessness, suicidal thoughts, suicide plan if thoughts are present, and prior suicide attempts. Based on the evaluation, the following disposition plan will be implemented: No mental health condition requiring further intervention. Comment: test patient *Influenza Reminder: Patient was given influenza vaccination today for flu prevention. Influenza Dose: 0.5 ml Route/Site: IM Left Deltoid Lot Number: 1225 1P Exp. Date: May 31, 2013 (Manufacturer: Novartis) Given by: Staff Nurse Patient was given a copy of 2012-2013 Vaccine Information Statement for Influenza and verbalized an understanding of the document. Patient has been advised of possible side effects (rash, hives, nausea, difficulty breathing, redness, unusual pain, fever) and given the following instructions: *Notify the nurse immediately if any side effects are experienced. *If any urgent or emergent problems are experienced after leaving the clinical area report to the nearest emergency room or call 911. *Nurse/MA BP>=140/90: Repeat BP: 190/70 *Diabetes Foot Exam: Diabetic Visual Foot Exam: Visual foot exam is normal. Pedal Pulse Foot Exam: Pedal pulse foot exam is normal. Sensory Foot Exam by Monofilament: Monofilament sensory foot exam is normal. *Vitals: Pain: 3 What does your pain level need to be for you to experience rest and comfort: Elevated Pain Score: Latest pain score reported by patient: 8 (12/10/2012 09:24). *Diabetes-Retinal Exam: Retinal exam done within the past year at an outside location. Retinal exam done within the past year at an outside location. Result: No Retinopathy Verify month and year: January 2, 2013 Results: outside hospital CHF ACE/ARB Review: Medications reviewed for ACE inhibitor/Angiotensin II receptor blocker therapy. Current medications include ACE inhibitor/Angiotensin receptor blocker therapy. Diabetes or CVD Elevated LDL: No lipid treatment change is needed based on patient's current status. Comment: test patient Eval Positive AUDIT-C Screen: SCREEN FOR ALCOHOL (AUDIT-C) An alcohol screening test (AUDIT-C) was negative (score=0). 1. How often did you have a drink containing alcohol in the past year? Never 2. How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? Response not required due to responses to other questions. 3. How often did you have six or more drinks on one occasion in the past year? Response not required due to responses to other questions. The patient reports drinking below the recommended limits. The patient was advised to continue to drink within recommended limits, which were reviewed with patient. The medical risks of alcohol and the risks of drinking over the safe limits were reviewed. This issue will be addressed at the next yearly screening. HTN/DM BP>140/90: Repeat BP: 190/70 The patient's blood pressure is usually adequately controlled. No medication changes are indicated at this time. Comment: test patient Based on the patient's comorbidities and condition, no education to improve BP control is warranted at this time. Comment: test patient Evaluation of + Depression Screen: Are you feeling hopeless about the present or future? NO Have you had thoughts recently about taking your life? NO ASSESSMENT: Suicide risk screen is negative. PROVIDER EVALUATION The results of the PHQ depression screen have been reviewed. I have personally evaluated the patient including inquiry about feelings of hopelessness, suicidal thoughts, suicide plan if thoughts are present, and prior suicide attempts. Based on the evaluation, the following disposition plan will be implemented: No mental health condition requiring further intervention. Comment: test patient Evaluation of + PTSD Screen: Are you feeling hopeless about the present or future? NO Have you had thoughts recently about taking your life? NO ASSESSMENT: Suicide risk screen is negative. PROVIDER EVALUATION: The results of the PTSD screen have been reviewed. I have personally evaluated the patient including inquiry about feelings of hopelessness, suicidal thoughts, suicide plan if thoughts are present, and prior suicide attempts. Based on the evaluation, the following disposition plan will be implemented: No mental health condition requiring further intervention. Comment: test patient /es/ ONE PROVIDER CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/07/2013 15:31 ----------------------- SELF REPORTED MEDICAL EVENTS ------------------------ Source: Self-Entered Medical Event: Broken right arm Start Date: 04 Jan 2010 Stop Date: 17 Feb 2010 Response: Placed in cast from my hand to my elbow Comments: Went to community hospital emergency room since I was on vacation. Followed up with my VA doctor when I returned home. Medical Event: Rebroke R Arm Start Date: 07 Jan 2013 Stop Date: Response: Slipped and fell on ice. Placed in cast from my hand to my elbow Comments: Need to F/U with VA PCP ---------------------------- VA IMMUNIZATIONS ------------------------- Source: VA Last Updated: 18 Mar 2013 @ 0634 Your VA Immunizations list may not be complete. If you have any questions about your information, visit the FAQs or contact your VA health care team. ========================================================================== This section shows your five most recent immunization records. Sorted By: Date Received(Descending) Immunization Date Received -------------------------------------------------------------------------- INFLUENZA-H1N1-09, NOVEL (PANDEMIC) 07 Dec 2012 @ 1155 TETANUS DIPTHERIA (TD-ADULT) 07 Dec 2012 @ 1155 INFLUENZA-H1N1-09, NOVEL (PANDEMIC) 01 Oct 2012 @ 1200 PNEUMOCOCCAL 06 Mar 2011 @ 0900 PNEUMOVAX 06 Mar 2011 @ 0900 ========================================================================== This section shows all of the immunizations listed in your VA health record, grouped by immunization. Sorted By: Immunization Name, then Date (Descending) -------------------------------------------------------------------------- Immunization: INFLUENZA-H1N1-09, NOVEL (PANDEMIC) Date Received: 07 Dec 2012 @ 1155 Location: PORTLAND (OR) VAMC Reaction:* None Reported Comments: Novartis;#10127605;Feb 2010 Immunization: INFLUENZA-H1N1-09, NOVEL (PANDEMIC) Date Received: 01 Oct 2012 @ 1200 Location: PORTLAND (OR) VAMC Reaction:* None Reported Comments: -------------------------------------------------------------------------- Immunization: PNEUMOCOCCAL Date Received: 06 Mar 2011 @ 0900 Location: PORTLAND (OR) VAMC Reaction:* None Reported Comments: Inj type: IM, Site:Lt Deltoid -------------------------------------------------------------------------- Immunization: PNEUMOVAX Date Received: 06 Mar 2011 @ 0900 Location: PORTLAND (OR) VAMC Reaction:* None Reported Comments: Inj type: IM, Site:Lt Deltoid -------------------------------------------------------------------------- Immunization: TETANUS DIPTHERIA (TD-ADULT) Date Received: 07 Dec 2012 @ 1155 Location: PORTLAND (OR) VAMC Reaction:* None Reported Comments: 1234567 ========================================================================= Reaction Key: * = Check information in your VA Allergies and Adverse Reactions as well as your Self Reported Allergies. This may let you know if you had a reaction to an immunization you received. ---------------------- SELF REPORTED IMMUNIZATIONS -------------------------- Source: Self-Entered Immunization: Tetanus Other: Booster Method: Injection Date Received: 07 Jan 2013 Reactions: --------------------------------- Comments: Stepped on a board with rusty nails in it. Nail just broke the skin Immunization: Tetanus Other: Method: Injection Date Received: 18 Jul 2010 Reactions: --------------------------------- Pain Comments: stepped on a rusty nail Immunization: Flu Other: Method: Inhalant Date Received: 01 Sep 2009 Reactions: --------------------------------- Comments: Had no reaction ------------------------- VA LABORATORY RESULTS ------------------------- Source: VA Last Updated: 18 Mar 2013 @ 0634 Sorted By: Date Specimen Collected (Descending) Lab Test(Alphabetical Order), then Time Specimen Collected VA Laboratory Results are available 7 calendar days after they have been verified. For some tests, results slightly outside the reference range are not unusual. In addition, not all results are clinically significant. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= Lab Test: Potassium Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 17 Jan 2013 @ 1341 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: POTASSIUM Result: 6.5 Critical High Units: mmol/L Reference Range: (3.5-5.0) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: GRAM STAIN - MISC Lab Type: Microbiology Ordering Provider: Provider, One Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: LUNG Collection Sample: SPUTUM, EXPECTORATED Date/Time Collected: 12 Dec 2012 @ 1200 Collection Location: PORTLAND, OREGON VA MEDICAL CENTER Performing Location: PORTLAND, OREGON VA MEDICAL CENTER PO BOX 1034, PORTLAND 97207 Date/Time Completed: 07 Jan 2013 @ 1200 ------------------------------------------------------------------------- GRAM STAIN: POSITIVE CULTURE RESULTS: 250 STAPHYLOCOCCUS AUREUS Comment: TEST ANTIBIOTIC SUSCEPTIBILITY TEST RESULTS: STAPHYLOCOCCUS AUREUS : CEFAZOLIN S CIPROFLOXACIN S DOXYCYCLINE S LINEZOLID S MOXIFLOXACIN S OXACILLIN S PENICILLIN R TRIMETH/SULFA S PIPERACILLIN/TS CLINDAMYCIN S ERYTHROMYCIN S VANCOMYCIN S Bacteriology Remark(s): TEST ----------------------------------------------------------------------------- Result Key: SUSC = Susceptibility Result S = Susceptible INTP = Interpretation I = Intermediate MIC = Minimum Inhibitory Concentration R = Resistant ========================================================================= Lab Test: Glycohemoglobin A(1) C Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Whole blood Date/Time Collected: 12 Dec 2012 @ 0811 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: HEMOGLOBIN A1C/HEMOGLOBIN.TOTAL Result: 8.5 High Units: % Reference Range: (3.4-6.1) Interpretation: *** If Diabetic, recommended HgA1C should be <7% *** Hemoglobin A1c values reported after 1-1-95 are standardized in accordance with recommendations of the Diabetes Control and Complications Trial(DCCT). Based on these recommendations, a upward shift in reported results will be noted. A table depicting this shift is available in Chemistry on request. Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Cell Count Body Fluid Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Cerebral spinal fluid Date/Time Collected: 12 Dec 2012 @ 0810 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: APPEARANCE BODY FLUID Result: CLEAR Units: Reference Range: Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: COLOR Result: YELLOW Units: Reference Range: Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: ERYTHROCYTES Result: 10 High Units: #/cumm Reference Range: (0-0) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: LEUKOCYTES Result: 250 High Units: #/cumm Reference Range: (0-6) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: TUBE NUMBER Result: 1 Units: Reference Range: Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: XANTHOCHROMIA, CSF Result: NEG Units: Reference Range: Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Albumin/Creat Ratio Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Urine Date/Time Collected: 12 Dec 2012 @ 0810 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: ALBUMIN Result: 25 High Units: MG/DL Reference Range: (0-2) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: ALBUMIN/CREATININE Result: 20 Units: mg/g Reference Range: (<30) Interpretation: Reference range change per ADA Guidelines. Normal <30 mg/g Microalbuminuria 30 - 299 mg/g Clinical Albuminuria >300 mg/g Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CREATININE Result: 1.2 Units: mg/dL Reference Range: Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Lipid Panel Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0809 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: CHOLESTEROL Result: 165 Units: mg/dL Reference Range: (1-240) Interpretation: DESIRABLE VALUE: <200 BORDERLINE VALUE: 201-239 ELEVATED VALUE: >240 Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CHOLESTEROL.IN HDL Result: 45 Units: mg/dL Reference Range: (32-78) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CHOLESTEROL.IN LDL Result: 120 Units: MG/DL Reference Range: (43-161) Interpretation: ***If pt age < 75, recommended LDL-C < 100 mg/dl in diabetes and ischemic heart disease*** ACCORDING TO THE "NATIONAL CHOLESTEROL EDUCATION PROGRAM" LEVELS OF RISK ARE DEFINED AS FOLLOWS: LOW RISK: <130 MG/DL BORDERLINE HIGH RISK: 130-159 MG/DL HIGH RISK: >=160 MG/DL NOTE THAT NONFASTING RESULTS ARE SLIGHTLY LOWER THAN FASTING RESULTS. Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: TRIGLYCERIDE Result: 99 Units: mg/dL Reference Range: (35-160) Interpretation: DESIRABLE VALUE: <150 BORDERLINE VALUE: 150-199 ELEVATED VALUE: 200-499 Patient should be fasting at time of specimen collection for valid interpretation of triglyceride level. Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: VDRL Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Cerebral spinal fluid Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: REAGIN AB Result: NEG Units: Reference Range: (SEE INTERPRETATION) Interpretation: NORMAL REFERENCE RANGE = NONREACTIVE Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Carbon Dioxide Content Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: CARBON DIOXIDE Result: 25 Units: mmol/L Reference Range: (21-32) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Chloride Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: CHLORIDE Result: 102 Units: mmol/L Reference Range: (95-108) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Creatinine Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: CREATININE Result: 1.3 Units: mg/dL Reference Range: (0.8-1.5) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Creatinine eGFR Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: GLOMERULAR FILTRATION RATE.PREDICTED Result: 56 Low Units: Reference Range: (>60) Interpretation: An eGFR <60 is abnormal. Estimated glomerular filtration rate (eGFR) results >60 are imprecise. Many variables affect the calculated result. Interpretation of eGFR results >60 must be monitored over time. Units are mL/min/1.73m^2. Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Gen Chem Specimen Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: ANION GAP Result: 19 Units: mmol/L Reference Range: (10-22) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Glucose Quant Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: GLUCOSE Result: 150 High Units: mg/dL Reference Range: (71-109) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Lipid Panel Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: CHOLESTEROL Result: 150 Units: mg/dL Reference Range: (1-240) Interpretation: DESIRABLE VALUE: <200 BORDERLINE VALUE: 201-239 ELEVATED VALUE: >240 Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CHOLESTEROL.IN HDL Result: 23 Low Units: mg/dL Reference Range: (32-78) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CHOLESTEROL.IN LDL Result: 23 Low Units: MG/DL Reference Range: (43-161) Interpretation: ***If pt age < 75, recommended LDL-C < 100 mg/dl in diabetes and ischemic heart disease*** ACCORDING TO THE "NATIONAL CHOLESTEROL EDUCATION PROGRAM" LEVELS OF RISK ARE DEFINED AS FOLLOWS: LOW RISK: <130 MG/DL BORDERLINE HIGH RISK: 130-159 MG/DL HIGH RISK: >=160 MG/DL NOTE THAT NONFASTING RESULTS ARE SLIGHTLY LOWER THAN FASTING RESULTS. Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: TRIGLYCERIDE Result: 46 Units: mg/dL Reference Range: (35-160) Interpretation: DESIRABLE VALUE: <150 BORDERLINE VALUE: 150-199 ELEVATED VALUE: 200-499 Patient should be fasting at time of specimen collection for valid interpretation of triglyceride level. Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Potassium Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: POTASSIUM Result: 3.5 Units: mmol/L Reference Range: (3.5-5.0) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Sodium Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: SODIUM Result: 145 High Units: mmol/L Reference Range: (131-142) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Thyroid Stimulating Hormone Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: THYROTROPIN Result: 29 High Units: uIU/mL Reference Range: (0.27-4.20) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Transferase Aspartate SGOT Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: ASPARTATE AMINOTRANSFERASE Result: 12 Low Units: IU/L Reference Range: (14-44) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Urea Nitrogen Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 12 Dec 2012 @ 0808 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: UREA NITROGEN Result: 25 High Units: mg/dL Reference Range: (7-23) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: Glycohemoglobin A(1) C Lab Type: Chemistry/Hematology Ordering Provider: PROVIDER, ONE Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Whole blood Date/Time Collected: 12 Dec 2012 @ 0806 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: HEMOGLOBIN A1C/HEMOGLOBIN.TOTAL Result: 7.4 High Units: % Reference Range: (3.4-6.1) Interpretation: *** If Diabetic, recommended HgA1C should be <7% *** Hemoglobin A1c values reported after 1-1-95 are standardized in accordance with recommendations of the Diabetes Control and Complications Trial(DCCT). Based on these recommendations, a upward shift in reported results will be noted. A table depicting this shift is available in Chemistry on request. Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: TEST ========================================================================= Lab Test: INR Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: COAGULATION TISSUE FACTOR INDUCED.INR Result: 0.7 Low Units: Reference Range: (0.90-1.20) Interpretation: Therapeutic ranges may differ with individual clinical circumstances. INR therapeutic ranges for full anticoagulation: INR for venous thromboembolism, 2.0-3.0; INR for most patients with mechanical valves, 2.5-3.5. Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: PT. reported incorrectly as 9.0 by [104353-VA648]. Changed to 9.9 on Jun 06, 2011@12:08 by [87277-VA648]. ========================================================================= Lab Test: Prothrombin Time Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: COAGULATION TISSUE FACTOR INDUCED Result: 9.9 Low Units: SEC Reference Range: (11.9-14.5) Interpretation: SEE INR FOR CRITICAL VALUE CUT-OFF. Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Amended ------------------------------------------------------------------------- Comments: PT. reported incorrectly as 9.0 by [104353-VA648]. Changed to 9.9 on Jun 06, 2011@12:08 by [87277-VA648]. ========================================================================= Lab Test: Hemogram+Platelet Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Whole blood Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: ERYTHROCYTE DISTRIBUTION WIDTH Result: 10 Low Units: % Reference Range: (11.5-14.5) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ---------------------- Test Name: ERYTHROCYTE MEAN CORPUSCULAR HEMOGLOBIN Result: 32.2 Units: pg Reference Range: (27-33) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ---------------------- Test Name: ERYTHROCYTE MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION Result: 33.3 Units: g/dL Reference Range: (33-37) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ---------------------- Test Name: ERYTHROCYTES Result: 4.44 Units: M/cmm Reference Range: (4.3-5.6) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ---------------------- Test Name: HEMATOCRIT Result: 47.0 Units: % Reference Range: (41-51) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ---------------------- Test Name: HEMOGLOBIN Result: 15.5 Units: g/dL Reference Range: (13-18) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ---------------------- Test Name: LEUKOCYTES Result: 20.0 High Units: K/cmm Reference Range: (4.4-10.8) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ---------------------- Test Name: MEAN CORPUSCULAR VOLUME Result: 90 Units: fl Reference Range: (82-98) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ---------------------- Test Name: PLATELET MEAN VOLUME Result: 9 Units: fl Reference Range: (7.4-10.4) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ---------------------- Test Name: PLATELETS Result: 240 Units: K/cmm Reference Range: (150-400) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: Comments about the result for this test name ========================================================================= Lab Test: Calcium Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: CALCIUM Result: 9.0 Units: mg/dL Reference Range: (8.4-10.4) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= Lab Test: Carbon Dioxide Content Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: CARBON DIOXIDE Result: 25 Units: mmol/L Reference Range: (21-32) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= Lab Test: Chloride Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: CHLORIDE Result: 105 Units: mmol/L Reference Range: (95-108) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= Lab Test: Cholesterol Total Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: CHOLESTEROL Result: 152 Units: mg/dL Reference Range: (1-240) Interpretation: DESIRABLE VALUE: <200 BORDERLINE VALUE: 201-239 ELEVATED VALUE: >240 Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= Lab Test: Creatinine Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: CREATININE Result: 1.4 Units: mg/dL Reference Range: (0.8-1.5) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= Lab Test: Creatinine eGFR Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: GLOMERULAR FILTRATION RATE.PREDICTED Result: 51 Low Units: Reference Range: (>60) Interpretation: EGFR IS 5.9% LOWER THAN EGFR CALCULATIONS PERFORMED BEFORE 2/12/08 An eGFR <60 is abnormal. Estimated glomerular filtration rate (eGFR) results >60 are imprecise. Many variables affect the calculated result. Interpretation of eGFR results >60 must be monitored over time. Units are mL/min/1.73m^2. Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= Lab Test: Gen Chem Specimen Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: ANION GAP Result: 10.0 Units: mmol/L Reference Range: (10-22) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= Lab Test: Glucose Quant Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: GLUCOSE Result: 150 High Units: mg/dL Reference Range: (71-109) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Amended ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= Lab Test: Potassium Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: POTASSIUM Result: 4.5 Units: mmol/L Reference Range: (3.5-5.0) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= Lab Test: Sodium Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: SODIUM Result: 140 Units: mmol/L Reference Range: (131-142) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= Lab Test: Triglycerides w o extract Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: TRIGLYCERIDE Result: 250 High Units: mg/dL Reference Range: (35-160) Interpretation: DESIRABLE VALUE: <150 BORDERLINE VALUE: 150-199 ELEVATED VALUE: 200-499 Patient should be fasting at time of specimen collection for valid interpretation of triglyceride level. Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= Lab Test: Urea Nitrogen Lab Type: Chemistry/Hematology Ordering Provider: ZZZAATESTPHYSICIAN, EIGHTEEN Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Specimen: Plasma Date/Time Collected: 03 Jun 2011 @ 1024 Collected Location: PORTLAND, OREGON VA MEDICAL CENTER Test Name: UREA NITROGEN Result: 12 Units: mg/dL Reference Range: (7-23) Interpretation: Performing Location: PORTLAND, OREGON VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239 Status: Final ------------------------------------------------------------------------- Comments: GLUCOSE flagged incorrectly as normal GLUCOSE reported incorrectly as 110 by [104353-VA648]. Changed to 150 on Jun 03, 2011@10:31 by [104353-VA648]. ========================================================================= ------------------------- VA PATHOLOGY REPORTS -------------------------- Source: VA Last Updated: 18 Jan 2013 @ 0716 Sorted By: Date Obtained (Descending), Type of Report VA Pathology Reports are available 14 calendar days after they have been completed. Some studies done at a non-VA facility may not be available or they may not necessarily include an interpretation. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= Type of Report: Surgical Pathology Specimen: (A)GASTRIC FUNDUS BX. Date Obtained: 03 May 2004 Performing Location: DAYT29 Date Completed: 04 May 2004 ------------------------------------------------------------------------- SURGICAL PATHOLOGY REPORT Date Spec taken: May 03, 2004 Pathologist:Provider, One MD Date Spec rec'd: May 03, 2004 14:26 Resident: Date completed: May 04, 2004 Accession #: SP 04 1365 Submitted by: Provider, One MD Practitioner:Provider, One MD ------------------------------------------------------------------------------- Specimen: (A)GASTRIC FUNDUS BX. (B)RECTO-SIGMOID BXS. Brief Clinical History: |TAB||NOWRAP| A) HISTORY OF DYSPHAGIA - STATUS-POST EGD. B) SURVEILLANCE FOR COLON POLYP. Preoperative Diagnosis: |TAB||NOWRAP| A) RULE-OUT GASTRIC MALIGNANCY. B) RULE-OUT COLON POLYPS. Operative Findings: |TAB||NOWRAP| 1) GASTRIC FUNDUS NODULE. 2) PATCHY AREA OF ERYTHEMA IN RECTO-SIGMOID AREA. Postoperative Diagnosis: |TAB||NOWRAP| 1) RULE-OUT GASTRIC MALIGNANCY. 2) RULE-OUT COLITIS. Gross description: |TAB||NOWRAP| SPECIMEN (A) LABELED GASTRIC NODULE. RECEIVED IN FORMALIN ARE TWO PALE-BROWN TISSUE FRAGMENTS RANGING FROM 0.2 TO 0.3 CM IN DIAMETER. EMBEDDED IN ONE BLOCK. SPECIMEN (B) LABELED RECTO-SIGMOID BIOPSIES. RECEIVED IN FORMALIN IS A PALE BROWN TISSUE WHICH MEASURES 0.4 CM IN MAXIMUM DIMENSION. THE SURFACE IS VELVETY. THE SPECIMEN IS SLICED AND EMBEDDED ENTIRELY IN ONE BLOCK. Microscopic description: (Date Spec taken: May 03, 2004) SEE DOCUMENTATION IN DIAGNOSIS. Diagnosis: |TAB||NOWRAP| A) GASTRIC FUNDUS BIOPSY: HYPERPLASTIC POLYP WITH MANY MACROPHAGES. B) RECTOSIGMOID BIOPSIES: HYPERPLASTIC COLONIC MUCOSA. ========================================================================= Type of Report: Surgical Pathology Specimen: PROSTATE BXS. (A)LEFT LOBE (B)RIGHT LOBE Date Obtained: 20 Aug 2002 Performing Location: DAYT29 Date Completed: 21 Aug 2002 ------------------------------------------------------------------------- SURGICAL PATHOLOGY REPORT Date Spec taken: Aug 20, 2002 Pathologist:Provider, One MD Date Spec rec'd: Aug 20, 2002 10:24 Resident: Date completed: Aug 21, 2002 Accession #: SP 02 2089 Submitted by: Provider, One MD Practitioner:Provider, One MD ------------------------------------------------------------------------------- Specimen: PROSTATE BXS. (A)LEFT LOBE (B)RIGHT LOBE Brief Clinical History: ELEVATED PSA 20.38 Preoperative Diagnosis: R/O CANCER Gross description: |TAB||NOWRAP| SPECIMENS ARE RECEIVED IN TWO DIFFERENT CONTAINERS IN FORMALIN AND LABELED NEEDLE BIOPSY PROSTATE LEFT AND RIGHT. SPECIMEN (A) LABELED LEFT LOBE CONSISTS OF THREE SEGMENTS OF WHITISH TISSUE. EACH MEASURES 1 TO 1.5 CM IN LENGTH. THE ENTIRE SPECIMEN IS SUBMITTED IN ONE BLOCK. SPECIMEN (B) IS LABELED RIGHT LOBE. IT CONSISTS OF THREE SEGMENTS OF WHITISH TISSUE, EACH MEASURING 1 TO 1.5 CM IN LENGTH. ENTIRE SPECIMEN IS SUBMITTED IN ONE BLOCK. Microscopic description: (Date Spec taken: Aug 20, 2002) SEE DOCUMENTATION IN DIAGNOSIS. Diagnosis: |TAB||NOWRAP| PROSTATE BIOPSIES: A) LEFT LOBE: MODERATELY DIFFERENTIATED ADENOCARCINOMA. GLEASON GRADE 3+3=6 IN TWO OF THE THREE PIECES. B) RIGHT LOBE: BENIGN PROSTATIC HYPERPLASIA WITH A FOCUS OF ADENOCARCINOMA (3+3=6). NOTE: PA WAS NOTIFIED. |TAB||BLANK(3)||TAB||INDENT(40)||TAB|PATHOLOGISTS: Provider, One MD ========================================================================= Type of Report: Surgical Pathology Specimen: DESCENDING COLON POLYPS Date Obtained: 03 Jul 2000 Performing Location: DAYT29 Date Completed: 05 Jul 2000 ------------------------------------------------------------------------- SURGICAL PATHOLOGY REPORT Date Spec taken: Jul 03, 2000 Pathologist:Provider, One MD Date Spec rec'd: Jul 03, 2000 14:30 Resident: Provider, Two MD Date completed: Jul 05, 2000 Accession #: SP 00 1652 Submitted by: Provider, One MD Practitioner:Provider, One MD ------------------------------------------------------------------------------- Specimen: DESCENDING COLON POLYPS Brief Clinical History: 2 SESSILE POLYPS; NO FAMILY HISTORY OF CRC Gross description: RECEIVED IN FORMALIN AND LABELED "DESCENDING COLON POLYPS X 2" CONSISTS OF TWO 3 MM MEMBRANOUS FRAGMENTS OF GREY PINK TISSUE. SUBMITTED IN TOTO IN ONE BLOCK. Diagnosis: |TAB||NOWRAP| DESCENDING COLON POLYPS: TUBULOVILLOUS ADENOMA AND A FRAGMENT CONSISTENT WITH HYPERPLASTIC COLON POLYP. ========================================================================= Type of Report: Surgical Pathology Specimen: DEBRIDEMENT RIGHT KNEE Date Obtained: 15 Jun 2000 Performing Location: DAYT29 Date Completed: 19 Jun 2000 ------------------------------------------------------------------------- SURGICAL PATHOLOGY REPORT Date Spec taken: Jun 15, 2000 Pathologist:Provider, One MD Date Spec rec'd: Jun 16, 2000 12:11 Resident: Date completed: Jun 19, 2000 Accession #: SP 00 1521 Submitted by: Provider, One MD Practitioner:Provider, One MD ------------------------------------------------------------------------------- Specimen: DEBRIDEMENT RIGHT KNEE Brief Clinical History: S/P REIMPLANTATION RIGHT TOTAL KNEE 5-24-00, NOW WITH GAS INFECTION RIGHT TOTAL KNEE Preoperative Diagnosis: INFECTED RIGHT TOTAL KNEE Postoperative Diagnosis: INFECTED RIGHT TOTAL KNEE Gross description: SPECIMEN IS RECEIVED IN FORMALIN AND LABELED DEBRIDEMENT, RIGHT KNEE. IT CONSISTS OF MULTIPLE FRAGMENTS OF FIBRO ADIPOSE AND MUSCULAR TISSUE. SOME IS COVERED BY FIBRINOUS MATERIAL. FRAGMENTS OF CLOTTED BLOOD ARE PRESENT. REPRESENTATIVE SECTIONS ARE SUBMITTED IN TWO BLOCKS. Diagnosis: |TAB||NOWRAP| DEBRIDEMENT, RIGHT KNEE: SOFT TISSUE WITH CHRONIC AND ACUTE INFLAMMATION. SEE NOTE. NOTE: NECROTISING AND SUPPURATIVE INFLAMMATION WITH FOREIGN BODY GRANULOMA AND GRANULATION TISSUE. ========================================================================= ---------------------- SELF REPORTED LABS AND TESTS ------------------------- Source: Self-Entered Test Name: Blood Test Date: 06 Jun 2010 Location performed: Community Center Provider: Red Cross Blood Drive Results: Was not able to donate blood because iron was low Comments: Will ask doctor at next visit Test Name: Colonoscopy Date: 01 Jul 2010 Location performed: VAMC Provider: Provider One Results: No new polyps Comments: Keep high fiber diet Test Name: CBC Date: 08 Jan 2013 Location performed: Non VA Location Provider: Dr. Smith Results: GLUCOSE 144 K 4.1 CO2 26.9 CA 9.3 AST 31 ALT 35 ALK 86 Comments: This is an old lab test. I wanted the report in my record ------------------------ VA VITALS AND READINGS ------------------------- Source: VA Last Updated: 18 Mar 2013 @ 0634 VA Vitals and Readings displays your vital signs and other health measures. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= This section shows your most recent record for each vital sign. Vital Sign Measurement Date/Time Collected ---------------------------------------------------------------------------- Blood Pressure 190/70 mm[Hg] 07 Jan 2013 @ 1527 Pulse Rate 88 /min 10 Dec 2012 @ 0924 Respiration 16 /min 10 Dec 2012 @ 0924 Temperature 98.5 F 10 Dec 2012 @ 0924 Pain Level 3 07 Jan 2013 @ 1527 Height 70 in 10 Dec 2012 @ 0924 Weight 325 lb 10 Dec 2012 @ 0924 ========================================================================= This section shows all of the vital signs and health measures listed in your VA health record, grouped by the type of vital sign. Sorted By: Type of Vital Sign, then Date/Time (Descending) ----------------------------------------------------------- Vital Sign: Blood Pressure Measurement: 190/70 mm[Hg] Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 07 Jan 2013 @ 1527 Vital Sign: Blood Pressure Measurement: 200/120 mm[Hg] Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 10 Dec 2012 @ 0924 Vital Sign: Blood Pressure Measurement: 190/120 mm[Hg] Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 07 Dec 2012 @ 1201 Vital Sign: Blood Pressure Measurement: 150/70 mm[Hg] Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 11 Nov 2012 @ 0900 Vital Sign: Blood Pressure Measurement: 155/92 mm[Hg] Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 06 Jun 2011 @ 1247 ----------------------------------------------------------- Vital Sign: Temperature Measurement: 98.5 F Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 10 Dec 2012 @ 0924 Vital Sign: Temperature Measurement: 101.3 F Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 11 Nov 2012 @ 0900 ----------------------------------------------------------- Vital Sign: Circumference/Girth Measurement: 50 in Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 10 Dec 2012 @ 0924 ----------------------------------------------------------- Vital Sign: Height Measurement: 70 in Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 10 Dec 2012 @ 0924 Vital Sign: Height Measurement: 70 in Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 07 Dec 2012 @ 1201 Vital Sign: Height Measurement: 70 in Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 11 Nov 2012 @ 0900 Vital Sign: Height Measurement: 64 in Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 06 Jun 2011 @ 1237 ----------------------------------------------------------- Vital Sign: Pain Level Measurement: 3 Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 07 Jan 2013 @ 1527 Vital Sign: Pain Level Measurement: 8 Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 10 Dec 2012 @ 0924 Vital Sign: Pain Level Measurement: 7 Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 07 Dec 2012 @ 1201 Vital Sign: Pain Level Measurement: 6 Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 11 Nov 2012 @ 0900 Vital Sign: Pain Level Measurement: 1 Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 06 Jun 2011 @ 1247 ----------------------------------------------------------- Vital Sign: Pulse Oximetry Measurement: 98 % Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 10 Dec 2012 @ 0924 ----------------------------------------------------------- Vital Sign: Pulse Rate Measurement: 88 /min Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 10 Dec 2012 @ 0924 Vital Sign: Pulse Rate Measurement: 120 /min Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 11 Nov 2012 @ 0900 ----------------------------------------------------------- Vital Sign: Respiration Measurement: 16 /min Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 10 Dec 2012 @ 0924 Vital Sign: Respiration Measurement: 20 /min Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 11 Nov 2012 @ 0900 ----------------------------------------------------------- Vital Sign: Weight Measurement: 325 lb Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 10 Dec 2012 @ 0924 Vital Sign: Weight Measurement: 350 lb Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 07 Dec 2012 @ 1201 Vital Sign: Weight Measurement: 310 lb Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 11 Nov 2012 @ 0900 Vital Sign: Weight Measurement: 301 lb Comments: Location: PORTLAND, OREGON VA MEDICAL CENTER Date/Time Collected: 06 Jun 2011 @ 1237 ---------------------- SELF REPORTED VITALS AND READINGS -------------------- Source: Self-Entered Remember to share your self entered information with your VA health care team. =============================================================================== Measurement Type: Blood pressure Date: 02 Aug 2010 Time: 1720 Systolic: 130 Diastolic: 76 Comments: BP taken lying down =============================================================================== Measurement Type: Blood pressure Date: 02 Aug 2010 Time: 1730 Systolic: 132 Diastolic: 76 Comments: BP taken standing. PB continues at goal. Doctor says to continue BP medications as directed =============================================================================== Measurement Type: Blood pressure Date: 06 Jan 2013 Time: 1940 Systolic: 126 Diastolic: 82 Comments: Did not sleep well last night. Took a long nap this afternoon =============================================================================== Measurement Type: Blood pressure Date: 07 Jan 2013 Time: 2359 Systolic: 132 Diastolic: 76 Comments: Feeling fine =============================================================================== Measurement Type: Heart rate Date: 02 Jun 2010 Time: 1720 Heart Rate: 160 Comments: Started taking Beta-Blockers after visit with physician =============================================================================== Measurement Type: Heart rate Date: 06 Jan 2013 Time: 1900 Heart Rate: 86 Comments: Feel Fine =============================================================================== Measurement Type: Heart rate Date: 07 Jan 2013 Time: 2359 Heart Rate: 77 Comments: Feel OK =============================================================================== Measurement Type: Body weight Date: 02 Apr 2010 Time: 1720 Body Weight: 246 Measure: Pounds Comments: Talk to provider about weight management program at next visit =============================================================================== Measurement Type: Body weight Date: 02 May 2010 Time: 1720 Body Weight: 244 Measure: Pounds Comments: Lost a few pounds and feel better. Walking daily =============================================================================== Measurement Type: Body weight Date: 02 Jun 2010 Time: 1720 Body Weight: 242 Measure: Pounds Comments: still walking when I have time off from work =============================================================================== Measurement Type: Body weight Date: 06 Jan 2013 Time: 1900 Body Weight: 244 Measure: Pounds Comments: I can feel all those Christmas cookies I ate =============================================================================== Measurement Type: Body weight Date: 07 Jan 2013 Time: 2359 Body Weight: 242 Measure: Pounds Comments: Took a long walk with the dog today =============================================================================== Measurement Type: Body temperature Date: 02 Mar 2010 Time: 1720 Body temperature: 98.5 Measure: Fahrenheit Method: Mouth Comments: I wasn't feeling well but temperature is normal =============================================================================== Measurement Type: Body temperature Date: 06 Jan 2013 Time: 1900 Body temperature: 98.3 Measure: Fahrenheit Method: Mouth Comments: Not sure if this ear themo is working or if I am doing something work... =============================================================================== Measurement Type: Body temperature Date: 07 Jan 2013 Time: 2359 Body temperature: 98.1 Measure: Fahrenheit Method: Mouth Comments: Feel Fine =============================================================================== Measurement Type: Pain Date: 02 Jan 2010 Time: 1720 Pain Level: 7 Comments: Lower back pain - took 1 Ibuprofen with food for pain =============================================================================== Measurement Type: Pain Date: 06 Jan 2013 Time: 1900 Pain Level: 4 Comments: Feet are sore from the long walk I took with the Dog today =============================================================================== Measurement Type: Pain Date: 07 Jan 2013 Time: 2359 Pain Level: 3 Comments: General aches =============================================================================== Measurement Type: Blood sugar Date: 02 Jan 2010 Time: 1720 Method: Sterile Lancet Blood sugar count: 166 Comments: BS taken before meal =============================================================================== Measurement Type: Blood sugar Date: 06 Jan 2013 Time: 1900 Method: Sterile Lancet Blood sugar count: 174 Comments: I just ate. Need to leave the ice cream alone =============================================================================== Measurement Type: Blood sugar Date: 07 Jan 2013 Time: 2359 Method: Sterile Lancet Blood sugar count: 141 Comments: Feeling good! =============================================================================== Measurement Type: Cholesterol Date: 15 Aug 2009 Time: 2359 Total cholesterol: 142 HDL: 45 LDL: Comments: Lab result from community health fair. =============================================================================== Measurement Type: INR Date: 08 Jan 2013 Time: 2359 INR value: .8 Target range: No Target Location: Non VA Provider Provider: Dr. Smith Comments: PT Only 9.6 PTT only 13.3 -------------------------- VA RADIOLOGY REPORTS ------------------------- Source: VA Last Updated: 18 Mar 2013 @ 0634 Sorted By: Date/Time Exam Performed (Descending) VA Radiology Reports are available 7 calendar days after they have been completed. Some studies done at a non-VA facility may not be available or they may not necessarily include an interpretation. If you have any questions about your information please visit the FAQs or contact the provider who ordered the study or your primary care provider. ========================================================================= Procedure/Test Name: CT HEAD OR BRAIN W/O CONTRAST Date/Time Exam Performed: 10 Dec 2012 @ 1018 Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Requesting Provider: PROVIDER, ONE Reasons for Study: THIS IS ONLY A TEST Clinical History: THIS IS ONLY A TEST Performing Location: PORTLAND, OREGON VA MEDICAL CENTER PO BOX 1034 PORTLAND 97207 Radiologist: XRAY,MISSING -------------------------------------------------------------------------- RADIOLOGY REPORT Report: Impression: Test patient; no report necessary for dictation; ADMIN complete. Primary Diagnostic Code: ========================================================================= Procedure/Test Name: BONE DENSITY (DPX), AXIAL SKELETON, HIPS/PELVIS/SPINE Date/Time Exam Performed: 10 Dec 2012 @ 1017 Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Requesting Provider: PROVIDER, ONE Reasons for Study: THIS IS ONLY A TEST Clinical History: THIS IS ONLY A TEST Performing Location: PORTLAND, OREGON VA MEDICAL CENTER PO BOX 1034 PORTLAND 97207 Radiologist: XRAY,MISSING -------------------------------------------------------------------------- RADIOLOGY REPORT Report: Impression: Test patient; no report necessary for dictation; ADMIN complete. Primary Diagnostic Code: ========================================================================= Procedure/Test Name: *BONE IMAGING, WHOLE BODY Date/Time Exam Performed: 10 Dec 2012 @ 1016 Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Requesting Provider: PROVIDER, ONE Reasons for Study: THIS IS ONLY A TEST Clinical History: THIS IS ONLY A TEST Performing Location: PORTLAND, OREGON VA MEDICAL CENTER PO BOX 1034 PORTLAND 97207 Radiologist: XRAY,MISSING -------------------------------------------------------------------------- RADIOLOGY REPORT Report: Impression: Test patient; no report necessary for dictation; ADMIN complete. Primary Diagnostic Code: ========================================================================= Procedure/Test Name: CHEST 2 VIEWS PA&LAT Date/Time Exam Performed: 10 Dec 2012 @ 1014 Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Requesting Provider: PROVIDER, ONE Reasons for Study: THIS IS ONLY A TEST Clinical History: r/o pneumonia Performing Location: PORTLAND, OREGON VA MEDICAL CENTER PO BOX 1034 PORTLAND 97207 Radiologist: XRAY,MISSING -------------------------------------------------------------------------- RADIOLOGY REPORT Report: Test report Impression: Primary Diagnostic Code: ========================================================================= Procedure/Test Name: ULTRASOUND ABDOMEN COMPLETE Date/Time Exam Performed: 10 Dec 2012 @ 1013 Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER Requesting Provider: PROVIDER, ONE Reasons for Study: THIS IS ONLY A TEST Clinical History: THIS IS ONLY A TEST Performing Location: PORTLAND, OREGON VA MEDICAL CENTER PO BOX 1034 PORTLAND 97207 Radiologist: XRAY,MISSING -------------------------------------------------------------------------- RADIOLOGY REPORT Report: Impression: Test patient; no report necessary for dictation; ADMIN complete. Primary Diagnostic Code: ========================================================================= ------------------ VA ELECTROCARDIOGRAM (EKG) REPORTS ------------------- Source: VA Last Updated: 18 Mar 2013 @ 0634 Sorted By: Date/Time Exam Performed (Descending) Your EKG list may not be complete. Some studies done at a non-VA facility may not be available. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= Procedure/Test Name: Electrocardiogram (EKG) Date/Time Exam Performed: 10 Dec 2012 @ 1200 Ordering Location: PORTLAND, OREGON VA MEDICAL CENTER -------------------- SELF REPORTED FAMILY HEALTH HISTORY -------------------- Source: Self-Entered Relationship: Self First Name: ONE Last Name: MHVTESTVETERAN Living or Deceased: Living Health Issues: ----------------------------- Back Pain Insomnia >1 beer/wine a day Hearing Loss Pneumonia Allergies Chicken Pox Current Smoker Diabetics Type 2 Overweight High Blood Pressure Depression High Blood Cholesterol Stomach/Bowel Other Smoking >20 Years Other Health Issues: ----------------------------- trouble sleeping Comments: I sometimes have trouble sleeping when stress is high at work Relationship: Mother First Name: Four Last Name: MHVVeteranMother Living or Deceased: Deceased Health Issues: ----------------------------- Cancer Other Diabetics Type 2 Overweight Joint Pain Stroke Other Health Issues: ----------------------------- Chronic joint pain Comments: Mother died of cancer at age 40 -------------------- SELF REPORTED ACTIVITY JOURNAL --------------------- Source: Self-Entered ========================================================================= Date: 28 Aug 2012 Day of Week: Tuesday Comments: Started my new exercise program today ------------------------------------------------------------------------- Activity: Walked for 30 minutes Type: Aerobic/cardio Distance/Duration: 1 Measure: mile(s) Intensity: Moderate impact Time of Day: Morning ------------------------------------------------------------------------- Activity: Swam 20 laps Type: Aerobic/cardio Distance/Duration: 45 Measure: lap(s) Intensity: High impact Time of Day: Afternoon ------------------------------------------------------------------------- Activity: Lifted weights Type: Weights Distance/Duration: 15 Measure: pound(s) Intensity: Low impact Number of Sets: 2 Number of Reps: 10 Time of Day: Afternoon ------------------------------------------------------------------------- Activity: Yoga Type: Other Distance/Duration: 30 Measure: min(s) Intensity: Low impact Time of Day: Evening ========================================================================= Date: 27 Aug 2012 Day of Week: Monday Comments: I need to get back in shape ------------------------------------------------------------------------- Activity: Stretching Type: Other Distance/Duration: 1 Measure: hour(s) Intensity: Low impact Time of Day: Afternoon ----------------------- SELF REPORTED FOOD JOURNAL ---------------------- Source: Self-Entered ========================================================================= Date: 02 Jan 2013 Day of Week: Wednesday ------------------------------------------------------------------------- Water consumed (number of 8oz glasses): 4 ------------------------------------------------------------------------- Breakfast Food/Beverage Item: 3 eggs/cheese Quantity: 1 Serving Size: X-Large Method of Preparation: Fresh Food/Beverage Item: OJ Quantity: 1 Serving Size: 8 Method of Preparation: Fresh Food/Beverage Item: glasses of whole milk Quantity: 1 Serving Size: 8 Method of Preparation: Fresh ------------------------------------------------------------------------- Dinner Food/Beverage Item: Hot Dogs Quantity: 2 Serving Size: Large Method of Preparation: Boiled Food/Beverage Item: French Fries Quantity: 1 Serving Size: Large Method of Preparation: Fried ------------------------------------------------------------------------- Lunch Food/Beverage Item: Taco X 3 Quantity: 3 Serving Size: Large Method of Preparation: Fast Food Food/Beverage Item: Root Beers Quantity: 2 Serving Size: 8 Method of Preparation: Fresh ------------------------------------------------------------------------- Snack Food/Beverage Item: Strawberry Shake Quantity: 1 Serving Size: 8 Method of Preparation: Frozen ------------------------------------------------------------------------- Comments: Added Lemon ========================================================================= Date: 01 Jan 2013 Day of Week: Tuesday ------------------------------------------------------------------------- Water consumed (number of 8oz glasses): 2 ------------------------------------------------------------------------- Breakfast Food/Beverage Item: 3 glasses of whole milk Quantity: 3 Serving Size: Large Method of Preparation: Fresh Food/Beverage Item: Cheerios 1 large bowl Quantity: 1 Serving Size: Large Method of Preparation: Fresh ------------------------------------------------------------------------- Dinner Food/Beverage Item: Pizza medium cheese Quantity: 1 Serving Size: Small Method of Preparation: Baked ------------------------------------------------------------------------- Lunch Food/Beverage Item: Greek Salad Quantity: 1 Serving Size: 16 Method of Preparation: Fresh Food/Beverage Item: Root Beers Quantity: 2 Serving Size: 8 Method of Preparation: Fresh ------------------------------------------------------------------------- Snack Food/Beverage Item: Ice Cream Quantity: 1 Serving Size: 4 Method of Preparation: Frozen ------------------------------------------------------------------------- Comments: Ice Water ========================================================================= Date: 31 Dec 2012 Day of Week: Monday ------------------------------------------------------------------------- Water consumed (number of 8oz glasses): 0 ------------------------------------------------------------------------- Breakfast Food/Beverage Item: Orange Quantity: 1 Serving Size: Large Method of Preparation: Fresh Food/Beverage Item: Hamburger Quantity: .25 Serving Size: Large Method of Preparation: Fast Food Food/Beverage Item: Banana Quantity: 1 Serving Size: Large Method of Preparation: Fresh Food/Beverage Item: Apple Quantity: 1 Serving Size: Large Method of Preparation: Fresh ------------------------------------------------------------------------- Dinner Food/Beverage Item: French Fries Quantity: 1 Serving Size: X-Large Method of Preparation: Fast Food Food/Beverage Item: Coke Quantity: 1 Serving Size: 16 Method of Preparation: Other ------------------------------------------------------------------------- Lunch Food/Beverage Item: Coke Quantity: 1 Serving Size: 16 Method of Preparation: Other Food/Beverage Item: Chicken Sandwich Quantity: Serving Size: Method of Preparation: Fast Food Food/Beverage Item: French Fries Quantity: 1 Serving Size: X-Large Method of Preparation: Fast Food ------------------------------------------------------------------------- Comments: -------------------- SELF REPORTED MILITARY HEALTH HISTORY ------------------ Source: Self-Entered Event Title: Overseas Deployment Event Date: 07 Apr 2002 Service Branch: Army Rank: Colonel Exposures: Yes Location of Service: Overseas Onboard Ship: No Military Occupational Specialty: Infantry Assignment: 1st Recon Exposures: In Iraq, exposed to burning chemicals Military Service Description: Unit was in charge of security --------------------- DoD Military Service Information --------------------- Source: DoD Last Updated: 17 Jan 2013 @ 1527 NOTES: 1) This report may not show your complete DoD Military Service Information. For more information go to the FAQ tab. Data prior to establishment of DEERS and full service reporting (c. 1980) may not appear. 2) It is normal for the begin/end dates in DoD records, adjusted by the Personnel Center after separation, to vary slightly from the DD-214. 3) No peacetime deployments will be displayed. For Gulf War I, only one period will be displayed even if you deployed more than once. No conflict prior to Gulf War I will be displayed. Kosovo, Bosnia, and Southern Watch data is incomplete and may not display. 4) For Guard/Reserve, periods of active duty may not display. No periods of Active duty service less than 30 days will display. -- Regular Active Service Service Begin Date End Date Character of Service Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 06/11/2005 03/26/2007 Honorable COL Army 02/22/2009 02/21/2010 Honorable COL Army 04/10/2010 04/08/2011 Honorable COL -- Reserve/Guard Association Periods Service Begin Date End Date Character of Service Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Guard 01/11/1987 08/24/1993 Unknown Army Reserve 08/25/1993 10/25/2004 Unknown COL Army Reserve 03/27/2007 10/31/2008 Unknown COL -- Reserve/Guard Activation Periods Service Begin Date End Date Activated Under (Title 10, 32, etc.) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 11/10/2001 11/09/2002 Army Reserve 04/14/2003 10/13/2004 Army Reserve 10/24/2004 10/25/2004 Army Reserve 03/27/2007 10/24/2007 Army Reserve 02/04/2008 10/31/2008 -- Deployment Periods Service Begin Date End Date Conflict Location - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 03/01/2004 03/31/2004 OEF/OIF Unknown Army 01/01/2007 03/26/2007 OEF/OIF Iraq -- DoD MOS/Occupation Codes -- Note: Both Service and DoD Generic codes may not be present in all records Service Begin Date Enl/Off Type Svc Occ Code DoD Occ Code - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 01/16/1975 Officer Primary 35D00 3A Army Reserve 01/16/1975 Officer Duty 35B00 3A Army Reserve 03/31/2002 Officer Primary 35D 3A Army Reserve 03/31/2002 Officer Duty 35D 3A Army Reserve 06/30/2002 Officer Duty 00A 9E Army Reserve 11/30/2002 Officer Duty 01A 9E Army Reserve 10/31/2003 Officer Duty 35D 3A Army 06/11/2005 Officer Primary 35D5K 3A Army 05/31/2006 Officer Duty 35D 3A Army Reserve 03/27/2007 Officer Primary 35D5K 3A Army Reserve 06/27/2007 Officer Duty 35D5K 3A Army 02/22/2009 Officer Primary 35D5K 3A Army 02/22/2009 Officer Secondary 66HD5 6E18 Army 02/22/2009 Officer Duty 35D00 3A -- Military/Combat Pay Details Service Begin Date End Date Military Pay Type Location - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army Reserve 03/01/2004 03/31/2004 02 Army 01/01/2007 01 Iraq Army 01/01/2007 02 -- Separation Pay Details Service Begin Date End Date Separation Pay Type - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- Retirement Periods Service Begin Date End Date Retirement Type Rank - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 11/01/2008 02/21/2009 F COL Army 02/22/2010 04/09/2010 F COL Army 04/09/2011 F COL -- DoD Retirement Pay Service Begin Date End Date Dsblty % Pay Stat Term Rsn Stop Pay Rsn - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Army 10/31/2008 11/30/2008 00 1 C Z Army 12/01/2008 00 1 W Z Army 03/01/2010 07/31/2010 00 1 C Z Army 08/01/2010 00 5 W B Army 05/01/2011 05/31/2011 00 1 C Z Army 06/01/2011 11/30/2011 00 1 C Z Army 12/01/2011 00 1 W Z Translations of Codes Used in this Section: Service Occupation Codes 00A Officer Duties Unassigned 01A Officer Officer Generalist 35D Officer All Source Intelligence 35D Officer (obsolete) Air Traffic Control Equipment Repairer 35D Officer (obsolete) Meteorological Equipment Repairman DoD Occupation Codes 3A Officer Intelligence, General 9E Officer Other Military Pay Type Code 01 Combat Zone Tax Exclusion (CZTE) 02 Hostile Fire/Imminent Danger 03 Hazardous Duty incentive Separation Pay Type Code 01 Separation Pay 02 Readjustment Pay 03 Non-Disability Severance Pay 04 Disability Severance Pay 05 Discharge Gratuity 06 Death Gratuity 07 Special Separation Benefit 08 Voluntary Separation Incentive Pay 09 Voluntary Separation Pay (VSP) Retirement Type Code A Mandatory B Voluntary C Fleet Reserve D Temporary Disability Retirement List E Permanent Disability Retirement List F Title III G Special Act H Philippine Scouts Retired Pay Status Code 1 Receiving retired pay 2 Eligible, not receiving pay 3 Eligible, not receiving direct SBP remittance 4 Terminated 5 Suspended Retired Pay Termination Reason Code C Pay condition terminated S Pay terminated for the reason reported in the Stop Payment Reason Code W Not terminated Stop Payment Reason Code A Member died B Recalled to Active Duty C Removed from TDRL, returned to Active Duty D Removed from TDRL, returned to Civilian E Pay suspended, failure to report for TDRL physical F Civil Service retirement waiver G VA compensation waiver H Dual compensation, pay cap offset J Refused retired pay K Pay suspended, whereabouts unknown L Suspected death M Pay suspended, miscellaneous Z Not applicable -------------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------