--------------- MY HEALTHEVET PERSONAL INFORMATION REPORT --------------- *************CONFIDENTIAL************* Produced by the VA Blue Button (v12.10) 08 Aug 2017 @ 0937 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 ealthPersonal Health Record unless you share it with them. Contact your health care team if you have questions about your health information.*** Key: Double dashes (--) mean there is no information to display. Name: MHVTESTVETERAN, ONE A Date of Birth: 01 Mar 1948 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 08 Aug 2017 @ 0937 File Name: mhv_MHVTESTVETERAN_20170808_0937.txt Date Range Selected: 08 Aug 2016 to 08 Aug 2017 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 Allergies Self Reported Allergies VA Medication History Self Reported Medications and Supplements 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 Military Health History Self Reported Activity Journal Self Reported Food Journal DoD Military Service Information Self Reported My Goals Current Self Reported My Goals Completed --------------------- MY HEALTHEVET ACCOUNT SUMMARY --------------------- Source: VA Authentication Status: Authenticated Authentication Date: 18 May 2011 Authentication Facility ID: 648 Authentication Facility Name: Portland OR VAMC VA Treating Facility Type -------------------- ------ Spokane WA VAMC na Portland OR VAMC na WHITE CITY VAMC na AUSTIN MHV na ENROLLMENT SYSTEM REENGINEERING na ---------------------- 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: 1515 Main Street Mailing or Destination Address2: Apt. 123 Mailing or Destination City: Mc Lean Mailing or Destination State: VA Mailing or Destination Country: United States Mailing or Destination Province: Mailing or Destination Zip/Postal Code: 20151 Home Phone Number: 703-555-2123 Work Phone Number: 703-555-4100 Pager Number: 703-555-2020 Cell Phone Number: 202-555-0303 FAX Number: 703-555-4110 Email Address: mhvveteran@emailaddress.com Preferred Method of Contact: Email EMERGENCY CONTACTS Contact First Name: Sam Contact Last Name: Arnold Relationship: Home Phone Number: 703-555-2121 Work Phone Number: 703-555-1000 Extension: Cell Phone Number: 202-555-1855 Address Line 1: 1342 Hilldale Ave Address Line 2: City: Chantilly State: VA Country: United States Province: Zip/Post Code: 20151 Email Address: mhvveterantwo@emailaddress.com Contact First Name: Bethany Contact Last Name: Simpson Relationship: Home Phone Number: 708-555-2339 Work Phone Number: 708-555-5000 Extension: Cell Phone Number: 312-555-1458 Address Line 1: 21040 95th Street Address Line 2: City: Hickory Hills State: IL Country: United States Province: Zip/Post Code: 62402 Email Address: mhvveteranthree@emailaddress.com ---------------------------- VA DEMOGRAPHICS ---------------------------- Source: VA Last Updated: 01 Aug 2017 @ 1332 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: WHITE CITY VAMC ------------------------------------------------------------------------- First Name: ONE Middle Name: A Last Name: MHVTESTVETERAN Religion: -- Ethnicity: -- Date of Birth: 01 Mar 1948 Place of Birth: COLUMBUS, OHIO Age: 69 Gender: Male Marital Status: DIVORCED ------------------------------------------------------------------------- PERMANENT ADDRESS AND CONTACT INFORMATION Street Address: 123 ANYWHERE RD Street Address 2: APT 123 Work Phone Number: -- 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 ------------------------------------------------------------------------- ELIGIBILITY Primary Eligibility Code: -- Service Connected Percentage: 70 EMPLOYMENT Employment Status: NOT EMPLOYED Employer Name: -- ------------------------------------------------------------------------- ACTIVE INSURANCE Insurance Company: -- Effective Date: -- Expiration Date: -- Group Name: -- Group Number: -- Subscriber ID: -- Subscriber Name: -- Subscriber Relationship: -- ------------------------------------------------------------------------- PRIMARY NEXT OF KIN Name: ANDERSON,ORLEN Street Address: 403 E. STEWART City: COLUMBUS State: OHIO Zip Code: 43232 Home Phone Number: 614-444-1952 Work Phone Number: -- ------------------------------------------------------------------------- EMERGENCY CONTACT Name: ANDERSON,ORLEN Street Address: 403 E. STEWART City: COLUMBUS State: OHIO Zip Code: 43232 Home Phone Number: 614-444-1952 Work Phone Number: -- ------------------------------------------------------------------------- VA GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- CIVIL GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- ------------------------------------------------------------------------- ========================================================================= VA Treating Facility: Spokane WA VAMC ------------------------------------------------------------------------- First Name: ONE Middle Name: A Last Name: MHVTESTVETERAN Religion: -- Ethnicity: -- Date of Birth: 01 Mar 1948 Place of Birth: HOLLYWOOD, CALIFORNIA Age: 69 Gender: Male Marital Status: DIVORCED ------------------------------------------------------------------------- PERMANENT ADDRESS AND CONTACT INFORMATION Street Address: 123 ANYWHERE RD Street Address 2: APT 123 Work Phone Number: -- 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 ------------------------------------------------------------------------- ELIGIBILITY Primary Eligibility Code: -- Service Connected Percentage: 70 EMPLOYMENT Employment Status: NOT EMPLOYED Employer Name: -- ------------------------------------------------------------------------- ACTIVE INSURANCE Insurance Company: -- Effective Date: -- Expiration Date: -- Group Name: -- Group Number: -- Subscriber ID: -- Subscriber Name: -- Subscriber Relationship: -- ------------------------------------------------------------------------- PRIMARY NEXT OF KIN Name: ANDERSON,ORLEN Street Address: 403 E. STEWART City: COLUMBUS State: OHIO Zip Code: 43232 Home Phone Number: 614-444-1952 Work Phone Number: -- ------------------------------------------------------------------------- EMERGENCY CONTACT Name: ANDERSON,ORLEN Street Address: 403 E. STEWART City: COLUMBUS State: OHIO Zip Code: 43232 Home Phone Number: 614-444-1952 Work Phone Number: -- ------------------------------------------------------------------------- VA GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- CIVIL GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- ------------------------------------------------------------------------- ========================================================================= VA Treating Facility: Portland OR VAMC ------------------------------------------------------------------------- First Name: ONE Middle Name: A Last Name: MHVTESTVETERAN Religion: -- Ethnicity: -- Date of Birth: 01 Mar 1948 Place of Birth: COLUMBUS, OHIO Age: 69 Gender: Male Marital Status: DIVORCED ------------------------------------------------------------------------- PERMANENT ADDRESS AND CONTACT INFORMATION Street Address: 123 ANYWHERE RD Street Address 2: APT 123 Work Phone Number: -- 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 ------------------------------------------------------------------------- ELIGIBILITY Primary Eligibility Code: -- Service Connected Percentage: 0 EMPLOYMENT Employment Status: NOT EMPLOYED Employer Name: -- ------------------------------------------------------------------------- ACTIVE INSURANCE Insurance Company: -- Effective Date: -- Expiration Date: -- Group Name: -- Group Number: -- Subscriber ID: -- Subscriber Name: -- Subscriber Relationship: -- ------------------------------------------------------------------------- PRIMARY NEXT OF KIN Name: ANDERSON,ORLEN Street Address: 403 E. STEWART City: COLUMBUS State: OHIO Zip Code: 43232 Home Phone Number: 614-444-1952 Work Phone Number: -- ------------------------------------------------------------------------- EMERGENCY CONTACT Name: ANDERSON,ORLEN Street Address: 403 E. STEWART City: COLUMBUS State: OHIO Zip Code: 43232 Home Phone Number: 614-444-1952 Work Phone Number: -- ------------------------------------------------------------------------- VA GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- CIVIL GUARDIAN Name: -- Street Address: -- City: -- State: -- Zip Code: -- Home Phone Number: -- Work Phone Number: -- ------------------------------------------------------------------------- ------------------ SELF REPORTED HEALTH CARE PROVIDERS ------------------ Source: Self-Entered Provider Name: Provider One Type of Provider: Specialist Other Clinician Information: Phone Number: 254-222-2525 Ext: Email: Comments: Provider Name: Provider One Type of Provider: Primary Other Clinician Information: Phone Number: 703-285-2220 Ext: 1485 Email: Provider One@institution.org Comments: Provider one can be reached on the weekend if needed by leaving a message with the clinic. ------------------ SELF REPORTED TREATMENT FACILITIES-------------------- Source: Self-Entered Facility Name: Fredericksburg CBOC Facility Type: VA VA Home Facility: Yes Phone Number: 540-370-4468 Ext: Mailing Address: 130 Executive Center Pkwy Mailing Address2: Mailing City: Fredericksburg Mailing State: VA Mailing Country: United States Mailing Province: Mailing Zip/Postal Code: 22401 Comments: Contact clinic when calling to make my appointments. Facility Name: Northern Virginia Physicians LLC Facility Type: Non-VA VA Home Facility: No Phone Number: 703-555-3062 Ext: Mailing Address: 123 Charlotte Drive Mailing Address2: B-Wing Mailing City: Chantilly Mailing State: VA Mailing Country: United States Mailing Province: Mailing Zip/Postal Code: 20151 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: ADC-30105-1 Group Number: 23010 Insured: One MHVveteran Start Date: 01 Jan 2014 Stop Date: Pre-Approval Phone Number: 855-555-2101 Health Insurance Company Phone Number: 800-555-3100 Comments: Need to get pre-authorization for special services. Health Insurance Company: Apex Dental Primary Insurance Provider: No ID Number: 030131-9942 Group Number: ABC123456789 Insured: One MHVveteran Start Date: 01 Jan 2014 Stop Date: Pre-Approval Phone Number: 800-555-8949 Health Insurance Company Phone Number: 800-555-1502 Comments: Dental Coverage --------------------------- VA WELLNESS REMINDERS ----------------------- Source: VA Last Updated: 01 Aug 2017 @ 1329 Wellness Reminder Due Date Last Completed Location ------------------------------------------------------------------------- Influenza Vaccine DUE NOW UNKNOWN Portland OR Influenza Vaccine DUE NOW UNKNOWN Spokane WA V Pneumonia Vaccine DUE NOW UNKNOWN Spokane WA V Colon Cancer Screening DUE NOW UNKNOWN Spokane WA V Pneumonia Vaccine DUE NOW UNKNOWN Portland OR Colon Cancer Screening 01 Oct 2022 01 Oct 2012 Portland OR Colon Cancer Screening DUE NOW UNKNOWN WHITE CITY V Influenza Vaccine DUE NOW UNKNOWN WHITE CITY V Pneumonia Vaccine DUE NOW UNKNOWN WHITE CITY V 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: 08 Aug 2017 @ 0936 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. ***Please remember to bring your insurance information with you to your appointment. FUTURE APPOINTMENTS: -------------------- Date/Time: 21 Nov 2017 @ 0800 Location: PORTLAND VA MEDICAL CENTER Status: CANCELLED Clinic: MH1 Provider One P2 Bldg 104 Phone Number: 503-220-8262 Date/Time: 14 Nov 2017 @ 0800 Location: PORTLAND VA MEDICAL CENTER Status: CANCELLED Clinic: MH1 Provider One P2 Bldg 104 Phone Number: 503-220-8262 Date/Time: 01 Nov 2017 @ 0800 Location: PORTLAND VA MEDICAL CENTER Status: CANCELLED Clinic: MH1 Provider One P2 Bldg 104 Phone Number: 503-220-8262 PAST APPOINTMENTS: -------------------- Date/Time: 08 May 2017 @ 0800 Location: PORTLAND VA MEDICAL CENTER Status: CANCELLED Clinic: CARDIOLOGY STRESS OUTPT-4A103 Phone Number: 503-273-5299 Date/Time: 08 May 2017 @ 0730 Location: PORTLAND VA MEDICAL CENTER Status: CANCELLED Clinic: ECHOCARDIOGRAM 4A-103 Phone Number: 503-273-5299 Date/Time: 02 Mar 2017 @ 0800 Location: PORTLAND VA MEDICAL CENTER Status: UPDATE IN PROGRESS Clinic: JIM B S FAKE CLINIC-AREA A Phone Number: 503-220-8262 Date/Time: 23 Feb 2017 @ 0800 Location: PORTLAND VA MEDICAL CENTER Status: UPDATE IN PROGRESS Clinic: JIM B S FAKE CLINIC-AREA A Phone Number: 503-220-8262 Date/Time: 16 Feb 2017 @ 0800 Location: PORTLAND VA MEDICAL CENTER Status: UPDATE IN PROGRESS Clinic: JIM B S FAKE CLINIC-AREA A Phone Number: 503-220-8262 Date/Time: 09 Jan 2017 @ 1100 Location: PORTLAND VA MEDICAL CENTER Status: CANCELLED Clinic: CARDIOLOGY STRESS OUTPT-4A103 Phone Number: 503-273-5299 Date/Time: 09 Jan 2017 @ 1000 Location: PORTLAND VA MEDICAL CENTER Status: CANCELLED Clinic: ECHOCARDIOGRAM 4A-103 Phone Number: 503-273-5299 ----------------------------- VA ALLERGIES ------------------------------ Source: VA Last Updated: 08 Aug 2017 @ 0936 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: TRIHEXYPHENIDYL Location: Portland OR VAMC Date Entered: 05 May 2017 Reaction: GENERALIZED RASH Allergy Type: DRUG VA Drug Class: PARASYMPATHOLYTICS Observed/Historical: HISTORICAL Comments: -- Allergy Name: OXYCODONE Location: Portland OR VAMC Date Entered: 04 Jan 2017 Reaction: -- Allergy Type: DRUG VA Drug Class: OPIOID ANALGESICS Observed/Historical: HISTORICAL Comments: -- Allergy Name: PENICILLIN Location: Portland OR VAMC Date Entered: 04 Jan 2017 Reaction: GENERALIZED RASH Allergy Type: DRUG VA Drug Class: PENICILLIN-G RELATED PENICILLINS Observed/Historical: HISTORICAL Comments: -- Allergy Name: TETRACYCLINE Location: Portland OR VAMC Date Entered: 15 Jan 2016 Reaction: ANAPHYLAXIS Allergy Type: DRUG VA Drug Class: ANTIACNE AGENTS,TOPICAL, ANTIBACTERIALS,TOPICAL OPHTHALMIC, TETRACYCLINES Observed/Historical: OBSERVED Comments: this is only a test Allergy Name: IMIPRAMINE Location: Portland OR VAMC 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 OR VAMC 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 OR VAMC Date Entered: 03 Jun 2011 Reaction: RETENTION OF URINE Allergy Type: DRUG VA Drug Class: 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 OR VAMC 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 OR VAMC Date Entered: 03 Jun 2011 Reaction: -- Allergy Type: DRUG VA Drug Class: SULFONAMIDE/RELATED ANTIMICROBIAL S Observed/Historical: HISTORICAL Comments: Causes Swelling of the Extremitie s 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 No information was available that matched your selection. -------------------------- VA MEDICATION HISTORY ---------------------- Source: VA Last Updated: 13 Jun 2017 @ 1033 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: FOLIC ACID 1MG TAB Instructions: TAKE ONE TABLET BY MOUTH EVERY DAY Status: Active Refills Remaining: 3 Last Filled On: 05 May 2017 Initially Ordered On: 05 May 2017 Quantity: 100 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 12788033 Medication: VITAMIN A 10000 UNT CAP Instructions: TAKE 10000UNT BY MOUTH EVERY DAY DOSES OVER 25,000 UNITS/DAY ARE Status: Active Refills Remaining: 3 Last Filled On: 05 May 2017 Initially Ordered On: 05 May 2017 Quantity: 90 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 12788035 Medication: ALLOPURINOL 300MG TAB Instructions: TAKE ONE TABLET BY MOUTH EVERY DAY TO LOWER URIC ACID LEVELS IN BLOOD Status: Active Refills Remaining: 3 Last Filled On: 05 Jan 2017 Initially Ordered On: 05 Jan 2017 Quantity: 90 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 12659470 Medication: FERROUS SULFATE 325MG TAB Instructions: TAKE ONE TABLET BY MOUTH TWICE A DAY Status: Active Refills Remaining: 3 Last Filled On: 05 Jan 2017 Initially Ordered On: 05 Jan 2017 Quantity: 200 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 12659471 Medication: ASCORBIC ACID 500MG TAB Instructions: TAKE ONE TABLET BY MOUTH EVERY DAY TAKE WITH IRON (FERROUS SULFATE) Status: Discontinued Refills Remaining: 3 Last Filled On: 05 May 2017 Initially Ordered On: 05 May 2017 Quantity: 100 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 12788031 Medication: VITAMIN E 200 UNT CAP Instructions: TAKE 200UNT BY MOUTH EVERY DAY Status: Expired Refills Remaining: 0 Last Filled On: 05 May 2017 Initially Ordered On: 05 May 2017 Quantity: 100 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 12788039 Medication: GLIPIZIDE 5MG TAB Instructions: TAKE ONE TABLET BY MOUTH EVERY DAY FOR DIABETES. TAKE 30 MINUTES Status: Discontinued Refills Remaining: 3 Last Filled On: 05 Jan 2017 Initially Ordered On: 05 Jan 2017 Quantity: 90 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 12659467 Medication: SIMVASTATIN 20MG TAB Instructions: TAKE ONE TABLET BY MOUTH EVERY EVENING TO LOWER YOUR CHOLESTEROL. Status: Expired Refills Remaining: 3 Last Filled On: 05 Jan 2017 Initially Ordered On: 05 Jan 2017 Quantity: 90 Days Supply: 90 Pharmacy: PORTLAND PHARMACY Prescription Number: 12659474 ----------------- SELF REPORTED MEDICATIONS AND SUPPLEMENTS ------------- Source: Self-Entered No information was available that matched your selection. ---------------------------- VA PROBLEM LIST ---------------------------- Source: VA Last Updated: 01 Aug 2017 @ 1332 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 3 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: Ankylosing spondylitis (SCT 9631008) Date/Time Entered: 05 May 2017 @ 1200 Location: Portland OR VAMC Status: ACTIVE Provider: Provider One Comments: -- Problem: Temporal lobectomy behavior syndrome (SCT 10651001) Date/Time Entered: 05 Jan 2017 @ 1200 Location: Portland OR VAMC Status: ACTIVE Provider: Provider One Comments: -- Problem: Ehlers-Danlos syndrome, type 8 (SCT 50869007) Date/Time Entered: 04 Jan 2017 @ 1200 Location: Portland OR VAMC Status: ACTIVE Provider: Provider One Comments: -- Problem: Mild cognitive impairment (SCT 386805003) Date/Time Entered: 20 Jan 2016 @ 1200 Location: Portland OR VAMC Status: ACTIVE Provider: Provider One Comments: INDEPENDENT IN ADLs AND IADLs this is only a test Problem: Wolff-Parkinson-White pattern (SCT 74390002) Date/Time Entered: 20 Jan 2016 @ 1200 Location: Portland OR VAMC Status: ACTIVE Provider: Provider One Comments: -- Problem: Congestive heart failure (SCT 42343007) Date/Time Entered: 15 Jan 2016 @ 1200 Location: Portland OR VAMC Status: ACTIVE Provider: Provider One Comments: -- Problem: Posttraumatic Stress Disorder (ICD-9-CM 309.81) Date/Time Entered: 11 Feb 2013 @ 1200 Location: Portland OR VAMC Status: ACTIVE Provider: Provider One Comments: comment #3 Comment #2 comment #1 AWAITING A COMP AND PEN EXAM Problem: Diabetes with neurological Manifestations, type i [Juvenile type], not stated as (ICD-9-CM 250.61) Date/Time Entered: 07 Dec 2012 @ 1200 Location: Portland OR VAMC Status: ACTIVE Provider: Provider One Comments: -- Problem: Hyperlipidemia (ICD-9-CM 272.4) Date/Time Entered: 07 Dec 2012 @ 1200 Location: Portland OR VAMC Status: ACTIVE Provider: Provider One Comments: -- Problem: TRAUMATIC BRAIN INJURY (ICD-9-CM 799.9) Date/Time Entered: 07 Dec 2012 @ 1200 Location: Portland OR VAMC Status: ACTIVE Provider: Provider One Comments: -- --------------------- VA ADMISSIONS AND DISCHARGES ---------------------- Source: VA Last Updated: 01 Aug 2017 @ 1332 Sorted By: Admission Date/Time (Descending) Discharge summaries are available 3 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: 05 May 2017 @ 1204 Location: Portland OR VAMC Admitting Physician: Provider One Discharge Date: -- Discharge Physician: Provider One ----------------------------------------------------------------------------- DISCHARGE SUMMARY LOCAL TITLE: Discharge Summary STANDARD TITLE: DISCHARGE SUMMARY DICT DATE: MAY 05, 2017@12:05 ENTRY DATE: MAY 05, 2017@12:06:05 DICTATED BY: Provider One ATTENDING: Provider One URGENCY: routine STATUS: COMPLETED 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 CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 05/05/2017 12:06 Admission Date: 05 Jan 2017 @ 1237 Location: Portland OR VAMC Admitting Physician: Provider One Discharge Date: -- Discharge Physician: Provider One ----------------------------------------------------------------------------- DISCHARGE SUMMARY LOCAL TITLE: Discharge Summary STANDARD TITLE: DISCHARGE SUMMARY DICT DATE: JAN 05, 2017@12:39 ENTRY DATE: JAN 05, 2017@12:39:19 DICTATED BY: Provider One ATTENDING: Provider One URGENCY: routine STATUS: COMPLETED 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 CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 12:39 Admission Date: 05 Jan 2017 @ 1235 Location: Portland OR VAMC Admitting Physician: Provider One Discharge Date: -- Discharge Physician: Provider One ----------------------------------------------------------------------------- DISCHARGE SUMMARY LOCAL TITLE: Discharge Summary STANDARD TITLE: DISCHARGE SUMMARY DICT DATE: JAN 05, 2017@12:36 ENTRY DATE: JAN 05, 2017@12:37:04 DICTATED BY: Provider One ATTENDING: Provider One URGENCY: routine STATUS: COMPLETED 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 CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 12:37 ------------------------------- VA NOTES -------------------------------- Source: VA Last Updated: 01 Aug 2017 @ 1332 Sorted By: Date/Time (Descending) VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed and signed by all required members of your VA health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. ========================================================================= Date/Time: 08 May 2017 @ 0914 Note Title: FIM - WEEKLY UP DATE Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 08 May 2017 @ 0915 ------------------------------------------------------------------------- LOCAL TITLE: FIM - WEEKLY UP DATE STANDARD TITLE: PHYSICAL MEDICINE REHAB NOTE DATE OF NOTE: MAY 08, 2017@09:14 ENTRY DATE: MAY 08, 2017@09:14:57 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED Therapy Start Date: 3/27/2017 Admission Class: 1-Initial Rehabilitation Discharge Date: 5/8/2017 DIAGNOSIS Impairment Group: 9 Cardiac Date of Onset: 3/22/2017 FUNCTIONAL INDEPENDENCE MEASURE (FIM) ADMISSION DISCHARGE Self-Care Eating 7 7 Grooming 6 7 Bathing 5 6 Dressing-Upper Body 6 6 Dressing-Lower Body 4 6 Toileting 6 6 Sphincter Control Bladder Management 6 7 Bowel Management 6 6 Mobility Bed, Chair, Wheelchair 5 6 Toilet 6 6 Tub, Shower 1 6 Locomotion Walk/Wheelchair walk 5 walk 6 Stairs 1 6 Motor Subtotal Score: 64 81 Communication Comprehension aud 6 aud 6 Expression voc 6 vocal 6 Social Cognition Social Interaction 6 6 Problem Solving 6 6 Memory 7 7 Cognitive Subtotal Score: 31 31 Total Motor and Cognitive Score: 95 112 * FIM MEASUREMENT DEFINITIONS NO HELPER 7. Complete Independence (Timely, Safely) 6. Modified Independence (Device) HELPER (Modified Dependence) 5. Supervision 4. Minimal Assistance (Subject = 75% +) 3. Moderate Assistance (Subject = 50% +) HELPER (Complete Dependence) 2. Maximal Assistance (Subject = 25% +) 1. Total Assistance (Subject = 0% +) /es/ Provider One MS,BSN,CRRN,CNL Restorative Coordinator Signed: 05/08/2017 09:15 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 May 2017 @ 1214 Note Title: GEN SURG - CONSULT REQUESTED Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 May 2017 @ 1214 ------------------------------------------------------------------------- LOCAL TITLE: GEN SURG - CONSULT REQUESTED STANDARD TITLE: SURGERY CONSULT DATE OF NOTE: MAY 05, 2017@12:14 ENTRY DATE: MAY 05, 2017@12:14:16 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED I have seen and discussed the patient with my supervising practitioner, Provider One, and Provider Two. who is in agreement with the assesment and plan. /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 05/05/2017 12:14 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 May 2017 @ 1213 Note Title: MEDICATION OTC ALERT Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 May 2017 @ 1213 ------------------------------------------------------------------------- LOCAL TITLE: MEDICATION OTC ALERT STANDARD TITLE: NURSING NOTE DATE OF NOTE: MAY 05, 2017@12:13 ENTRY DATE: MAY 05, 2017@12:13:45 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED Your patient MHVTESTVETERAN,ONE A had "Over the Counter" medications entered into CPRS today. While entering this information a "medication reaction ALERT" was relayed to this author. This could have Significant or critical importance. Please review the patient's active and OTC medications for any concerns you may have. Items marked with a * indicate potential adverse reactions. TERAZOSIN, BACTRIM, TRAMADOL, TRIMETHOPRIM, IMIPRAMINE, TETRACYCLINE PENICILLIN, OXYCODONE, TRIHEXYPHENIDYL Active Outpatient Medications (including Supplies): Active Outpatient Medications Status ========================================================================= 1) ALLOPURINOL 300MG TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE DAY TO LOWER URIC ACID LEVELS IN BLOOD 2) CHOLECALCIFEROL (VIT D3) 400UNIT TAB TAKE 400UNT BY HOLD MOUTH EVERY DAY 3) FERROUS SULFATE 325MG TAB TAKE ONE TABLET BY MOUTH ACTIVE TWICE A DAY 4) FOLIC ACID 1MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE 5) LEVOTHYROXINE NA (SYNTHROID) 0.025MG TAB TAKE ONE HOLD TABLET BY MOUTH EVERY DAY ON AN EMPTY STOMACH AND AT LEAST 4 HOURS BEFORE PRODUCTS CONTAINING CALCIUM, IRON OR VITAMINS 6) VITAMIN A 10000 UNT CAP TAKE 10000UNT BY MOUTH EVERY ACTIVE DAY DOSES OVER 25,000 UNITS/DAY ARE CONTRAINDICATED IN PREGNANCY Active Non-VA Medications Status ========================================================================= 1) Non-VA FISH OIL CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE 2) Non-VA GINKGO BILOBA SMALL AMOUNT MOUTH EVERY DAY ACTIVE 3) Non-VA KAVA CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE 4) Non-VA LISINOPRIL 5MG TAB 2.5MG MOUTH EVERY DAY ACTIVE 5) Non-VA SAW PALMETTO CAP/TAB 1 TAB MOUTH AT BEDTIME ACTIVE 6) Non-VA ST. JOHN'S WART CAP/TAB 1 CAP/TAB MOUTH AT ACTIVE BEDTIME 12 Total Medications /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 05/05/2017 12:13 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 May 2017 @ 1212 Note Title: MHD - INDIVIDUAL NOTE Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 May 2017 @ 1213 ------------------------------------------------------------------------- LOCAL TITLE: MHD - INDIVIDUAL NOTE STANDARD TITLE: MENTAL HEALTH OUTPATIENT NOTE DATE OF NOTE: MAY 05, 2017@12:12 ENTRY DATE: MAY 05, 2017@12:12:37 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED this is only a test /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 05/05/2017 12:13 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 May 2017 @ 1207 Note Title: INPAT - MED - HIST&PHYS Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 May 2017 @ 1207 ------------------------------------------------------------------------- LOCAL TITLE: INPAT - MED - HIST&PHYS STANDARD TITLE: INTERNAL MEDICINE H & P NOTE DATE OF NOTE: MAY 05, 2017@12:07 ENTRY DATE: MAY 05, 2017@12:07:16 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED ID: ONE A MHVTESTVETERAN is a 69 year old MALE PRIMARY CARE PROVIDER: Provider One ASSOCIATE PROVIDERS: Provider One _______________________________________________________ CC: MHVTESTVETERAN,ONE A presented with a chief complaint of HISTORY OF PRESENT ILLNESS: PERTINENT ED COURSE: PAST MEDICAL HISTORY: 1. 2. 3. REVIEW OF SYSTEMS: SOCIAL HISTORY: NEXT OF KIN/FAMILY CONTACTS: HABITS: FAMILY HISTORY: _______________________________________________________ MEDICATION HISTORY Active Outpatient Medications Active Outpatient Medications (including Supplies): Outpatient Medications Status ======================================================================== = 1) ALLOPURINOL 300MG TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE DAY TO LOWER URIC ACID LEVELS IN BLOOD 2) CHOLECALCIFEROL (VIT D3) 400UNIT TAB TAKE 400UNT BY HOLD MOUTH EVERY DAY 3) FERROUS SULFATE 325MG TAB TAKE ONE TABLET BY MOUTH ACTIVE TWICE A DAY 4) FOLIC ACID 1MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE 5) LEVOTHYROXINE NA (SYNTHROID) 0.025MG TAB TAKE ONE HOLD TABLET BY MOUTH EVERY DAY ON AN EMPTY STOMACH AND AT LEAST 4 HOURS BEFORE PRODUCTS CONTAINING CALCIUM, IRON OR VITAMINS 6) VITAMIN A 10000 UNT CAP TAKE 10000UNT BY MOUTH EVERY ACTIVE DAY DOSES OVER 25,000 UNITS/DAY ARE CONTRAINDICATED IN PREGNANCY Non-VA Medications Status ======================================================================== = 1) Non-VA FISH OIL CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE 2) Non-VA GINKGO BILOBA SMALL AMOUNT MOUTH EVERY DAY ACTIVE 3) Non-VA KAVA CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE 4) Non-VA LISINOPRIL 5MG TAB 2.5MG MOUTH EVERY DAY ACTIVE 5) Non-VA SAW PALMETTO CAP/TAB 1 TAB MOUTH AT BEDTIME ACTIVE 6) Non-VA ST. JOHN'S WART CAP/TAB 1 CAP/TAB MOUTH AT ACTIVE BEDTIME 12 Total Medications -------------------------------------- Active/Pending/Expired Medications: Active and Recently Expired Outpatient Medications (excluding Supplies): Active Outpatient Medications Status ======================================================================== = 1) ALLOPURINOL 300MG TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE DAY TO LOWER URIC ACID LEVELS IN BLOOD 2) CHOLECALCIFEROL (VIT D3) 400UNIT TAB TAKE 400UNT BY HOLD MOUTH EVERY DAY 3) FERROUS SULFATE 325MG TAB TAKE ONE TABLET BY MOUTH ACTIVE TWICE A DAY 4) FOLIC ACID 1MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE 5) LEVOTHYROXINE NA (SYNTHROID) 0.025MG TAB TAKE ONE HOLD TABLET BY MOUTH EVERY DAY ON AN EMPTY STOMACH AND AT LEAST 4 HOURS BEFORE PRODUCTS CONTAINING CALCIUM, IRON OR VITAMINS 6) VITAMIN A 10000 UNT CAP TAKE 10000UNT BY MOUTH EVERY ACTIVE DAY DOSES OVER 25,000 UNITS/DAY ARE CONTRAINDICATED IN PREGNANCY Inactive Outpatient Medications Status ======================================================================== = 1) ACETAMINOPHEN 325MG TAB TAKE 325-650MG BY MOUTH EVERY EXPIRED 4 TO 6 HOURS AS NEEDED *PATIENTS WITHOUT LIVER DISEASE, MAXIMUM DOSE IS 4 GM/DAY OF ACETAMINOPHEN. FOR PAIN. THIS IS ONLY A TEST 2) FUROSEMIDE 20MG TAB TAKE ONE-HALF TABLET BY MOUTH EXPIRED EVERY DAY FOR HEART FAILURE THIS IS ONLY A TEST 3) SIMVASTATIN 20MG TAB TAKE ONE TABLET BY MOUTH EVERY EXPIRED EVENING TO LOWER YOUR CHOLESTEROL. AVOID CONSUMING GRAPEFRUIT PRODUCTS. 4) VITAMIN E 200 UNT CAP TAKE 200UNT BY MOUTH EVERY DAY EXPIRED Active Non-VA Medications Status ======================================================================== = 1) Non-VA FISH OIL CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE 2) Non-VA GINKGO BILOBA SMALL AMOUNT MOUTH EVERY DAY ACTIVE 3) Non-VA KAVA CAP/TAB 1 CAP/TAB MOUTH EVERY DAY ACTIVE 4) Non-VA LISINOPRIL 5MG TAB 2.5MG MOUTH EVERY DAY ACTIVE 5) Non-VA SAW PALMETTO CAP/TAB 1 TAB MOUTH AT BEDTIME ACTIVE 6) Non-VA ST. JOHN'S WART CAP/TAB 1 CAP/TAB MOUTH AT ACTIVE BEDTIME 16 Total Medications Remote Medications HDRM - Remote Active Meds No Active Remote Medications for this patient RART - Remote ADR No Remote Allergy/ADR Data available for this patient -------------------------------------- Medication Reconciliation: Medications were reviewed with the patient and/or caregiver, and the above list is accurate, with any exceptions noted. ALLERGIES: TERAZOSIN, BACTRIM, TRAMADOL, TRIMETHOPRIM, IMIPRAMINE, TETRACYCLINE PENICILLIN, OXYCODONE, TRIHEXYPHENIDYL _______________________________________________________ PHYSICAL: VITALS SIGNS Blood pressure: 82/40 (01/05/2017 06:46) Pulse: 120 (01/05/2017 06:46) Temperature: 102.2 F [39.0 C] (01/05/2017 06:46) Respirations: 22 (01/05/2017 06:46) Weight: 180 lb [81.8 kg] (01/05/2017 06:43) Height: 72 in [182.9 cm] (01/05/2017 06:43) EXAM: General: HEENT: Neck: Chest: Cardiac: Abdomen: Back/Extrem: GU/Rectal: Neuro: Skin: _________________________________________________ LABORATORY DATA: WBC canc 01/05/2017 10:00 HCT canc 01/05/2017 10:00 MCV canc 01/05/2017 10:00 AUTO DIFF 01/05/2017 10:00 LY% 29.6 LY# 2.5 NE# 5.0 NE% 59.7 MO# 0.7 MO% 7.8 EO# 0.1 BA# 0.1 EO% 1.8 BA% 1.1 SODIUM 145 H 01/05/2017 10:00 POTASSIUM 3.9 01/05/2017 10:00 CHLORIDE 121 H 01/05/2017 10:00 CO2 32 UREA NITROGEN 20 01/05/2017 10:00 CREATININE 2.0 H 01/05/2017 10:00 Cardiac Enzymes last 72 hours: No Results last 72 hours _______________________________________________________ IMAGING: OTHER DATA: ______________________________________________ IMPRESSION: _______________________________________________________ ASSESMENT AND PLAN: PROBLEM 1: PLAN: PROBLEM 2: PLAN: PROBLEM 3: PLAN: PROPHYLAXIS ISSUES: _______________________________________________________ CODE STATUS: The patient will be staffed with Dr. within 24 hours. /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 05/05/2017 12:07 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 1238 Note Title: ORTHOPEDICS - HISTORY & PHYSICAL Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 1238 ------------------------------------------------------------------------- LOCAL TITLE: ORTHOPEDICS - HISTORY & PHYSICAL STANDARD TITLE: ORTHOPEDIC SURGERY H & P NOTE DATE OF NOTE: JAN 05, 2017@12:38 ENTRY DATE: JAN 05, 2017@12:38:38 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED HISTORY AND PHYSICAL /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 12:38 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 1236 Note Title: MHD - HISTORY & PHYSICAL EXAM Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 1236 ------------------------------------------------------------------------- LOCAL TITLE: MHD - HISTORY & PHYSICAL EXAM STANDARD TITLE: MENTAL HEALTH OUTPATIENT NOTE DATE OF NOTE: JAN 05, 2017@12:36 ENTRY DATE: JAN 05, 2017@12:36:30 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED HISTORY AND PHYSICAL /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 12:36 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 0931 Note Title: C&P MENTAL DISORDERS Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 0933 ------------------------------------------------------------------------- LOCAL TITLE: C&P MENTAL DISORDERS STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JAN 05, 2017@09:31 ENTRY DATE: JAN 05, 2017@09:32:01 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED this is a test /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 09:33 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 0930 Note Title: CARDIOLOGY - CONSULT Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 0930 ------------------------------------------------------------------------- LOCAL TITLE: CARDIOLOGY - CONSULT STANDARD TITLE: CARDIOLOGY CONSULT DATE OF NOTE: JAN 05, 2017@09:30 ENTRY DATE: JAN 05, 2017@09:30:30 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED this is a test /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 09:30 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 0929 Note Title: C&P MENTAL DISORDERS Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 0929 ------------------------------------------------------------------------- LOCAL TITLE: C&P MENTAL DISORDERS STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JAN 05, 2017@09:29 ENTRY DATE: JAN 05, 2017@09:29:17 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED this is a test /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 09:29 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 0928 Note Title: C&P EXAMINATION Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 0928 ------------------------------------------------------------------------- LOCAL TITLE: C&P EXAMINATION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: JAN 05, 2017@09:28 ENTRY DATE: JAN 05, 2017@09:28:21 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED this is a test /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 09:28 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 0718 Note Title: CLC - CLINICAL PHARMACY F/U Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 0719 ------------------------------------------------------------------------- LOCAL TITLE: CLC - CLINICAL PHARMACY F/U STANDARD TITLE: PHARMACY INPATIENT NOTE DATE OF NOTE: JAN 05, 2017@07:18 ENTRY DATE: JAN 05, 2017@07:18:55 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED Note #7 /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 07:19 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 0717 Note Title: PHYSICAL THERAPY - DAILY NOTE Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 0718 ------------------------------------------------------------------------- LOCAL TITLE: PHYSICAL THERAPY - DAILY NOTE STANDARD TITLE: PHYSICAL THERAPY NOTE DATE OF NOTE: JAN 05, 2017@07:17 ENTRY DATE: JAN 05, 2017@07:18:19 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED Note #6 /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 07:18 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 0717 Note Title: ED NURSING OBS - PROGRESS NOTE Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 0717 ------------------------------------------------------------------------- LOCAL TITLE: ED NURSING OBS - PROGRESS NOTE STANDARD TITLE: EMERGENCY DEPT NOTE DATE OF NOTE: JAN 05, 2017@07:17 ENTRY DATE: JAN 05, 2017@07:17:36 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED Note #5 /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 07:17 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 0716 Note Title: GEN SURG - ATTENDING Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 0717 ------------------------------------------------------------------------- LOCAL TITLE: GEN SURG - ATTENDING STANDARD TITLE: SURGERY ATTENDING NOTE DATE OF NOTE: JAN 05, 2017@07:16 ENTRY DATE: JAN 05, 2017@07:16:37 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED Note #4 /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 07:17 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 0715 Note Title: MHD - PRIMARY CARE - NEW Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 0716 ------------------------------------------------------------------------- LOCAL TITLE: MHD - PRIMARY CARE - NEW STANDARD TITLE: MENTAL HEALTH OUTPATIENT NOTE DATE OF NOTE: JAN 05, 2017@07:15 ENTRY DATE: JAN 05, 2017@07:16:05 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED Note #3 /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 07:16 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 0715 Note Title: DEMENTIA CLINIC - FOLLOW-UP Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 0715 ------------------------------------------------------------------------- LOCAL TITLE: DEMENTIA CLINIC - FOLLOW-UP STANDARD TITLE: NEUROLOGY OUTPATIENT NOTE DATE OF NOTE: JAN 05, 2017@07:15 ENTRY DATE: JAN 05, 2017@07:15:21 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED Note #2 /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 07:15 ------------------------------------------------------------------------- ========================================================================= Date/Time: 05 Jan 2017 @ 0655 Note Title: MHD - INDIVIDUAL NOTE Location: Portland OR VAMC Signed By: Provider One Co-signed By: Provider One Date/Time Signed: 05 Jan 2017 @ 0657 ------------------------------------------------------------------------- LOCAL TITLE: MHD - INDIVIDUAL NOTE STANDARD TITLE: MENTAL HEALTH OUTPATIENT NOTE DATE OF NOTE: JAN 05, 2017@06:55 ENTRY DATE: JAN 05, 2017@06:55:53 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED Here are NEW AND/OR CHANGED MEDICATIONS that your provider has prescribed: 1) Allopurinol 300Mg Tab Take One Tablet By Mouth Every Day 2) Ferrous Sulfate 325Mg Tab Take One Tablet By Mouth Twice A Day 3) Glipizide 5Mg Tab Take One Tablet By Mouth Every Day For Diabetes. Take 30 Minutes Before A Meal. 4) Levothyroxine Na (Synthroid) 0.025Mg Tab Take One Tablet By Mouth Every Day On An Empty Stomach And At Least 4 Hours Before Products Containing Calcium, Iron Or Vitamins 5) Simvastatin 20Mg Tab Take One Tablet By Mouth Every Evening _______________________________________________________________________ Your provider has NOT discontinued any of your medications today. /es/ Provider One CHIEF HEALTH INFORMATICS OFFICER/ATTENDING PSYCHIATRIST Signed: 01/05/2017 06:57 ------------------------------------------------------------------------- --------------------- SELF REPORTED MEDICAL EVENTS ---------------------- Source: Self-Entered No information was available that matched your selection. ----------------------------- VA IMMUNIZATIONS -------------------------- Source: VA Last Updated: 01 Aug 2017 @ 1332 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 ------------------------------------------------------------------------- VARICELLA 05 May 2017 @ 1207 JAPANESE ENCEPHALITIS IM 05 Jan 2017 @ 0650 TD (ADULT) 05 Jan 2017 @ 0650 TD (ADULT) 15 Jan 2016 @ 1000 PNEUMOCOCCAL POLYSACCHARIDE PPV23 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: JAPANESE ENCEPHALITIS IM Date Received: 05 Jan 2017 @ 0650 Location: ACCESS CENTER-X Reaction:* None Reported Comments: -- ------------------------------------------------------------------------- Immunization: NOVEL INFLUENZA-H1N1-09, ALL FORMULATIONS Date Received: 07 Dec 2012 @ 1155 Location: 111A TEST NOTE LOCATION Reaction:* None Reported Comments: Novartis;#10127605;Feb 2010 Immunization: NOVEL INFLUENZA-H1N1-09, ALL FORMULATIONS Date Received: 01 Oct 2012 @ 1200 Location: PORTLAND VA MEDICAL CENTER Reaction:* None Reported Comments: -- ------------------------------------------------------------------------- Immunization: PNEUMOCOCCAL POLYSACCHARIDE PPV23 Date Received: 06 Mar 2011 @ 0900 Location: 111A TEST NOTE LOCATION Reaction:* None Reported Comments: Inj type: IM, Site:Lt Deltoid ------------------------------------------------------------------------- Immunization: PNEUMOCOCCAL, UNSPECIFIED FORMULATION Date Received: 06 Mar 2011 @ 0900 Location: 111A TEST NOTE LOCATION Reaction:* None Reported Comments: Inj type: IM, Site:Lt Deltoid ------------------------------------------------------------------------- Immunization: TD (ADULT) Date Received: 05 Jan 2017 @ 0650 Location: ACCESS CENTER-X Reaction:* None Reported Comments: -- Immunization: TD (ADULT) Date Received: 15 Jan 2016 @ 1000 Location: FAKE CLINIC AREA 1475 Reaction:* NONE Comments: this is a test ------------------------------------------------------------------------- Immunization: TD(ADULT) UNSPECIFIED FORMULATION Date Received: 07 Dec 2012 @ 1155 Location: 111A TEST NOTE LOCATION Reaction:* None Reported Comments: 1234567 ------------------------------------------------------------------------- Immunization: VARICELLA Date Received: 05 May 2017 @ 1207 Location: 9CANS-O Reaction:* None Reported Comments: -- ======================================================================== 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 No information was available that matched your selection. ------------------------- VA LABORATORY RESULTS ------------------------- Source: VA Last Updated: 08 Aug 2017 @ 0936 Sorted By: Date Specimen Collected (Descending) Lab Test(Alphabetical Order), then Time Specimen Collected VA Laboratory Results are available 3 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: Hemogram+PLT+Diff Lab Type: Chemistry/Hematology Ordering Provider: Provider One Ordering Location: PORTLAND VA MEDICAL CENTER Specimen: Blood (substance) Date/Time Collected: 05 May 2017 @ 1242 Collected Location: PORTLAND VA MEDICAL CENTER ------------------------------------------------------------------------- Test Name: BA# Result: 2 High Units: 10*3/uL Reference Range: (0-0.2) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: BA% Result: 2 Units: % Reference Range: (0-2) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: EO# Result: 3 High Units: 10*3/uL Reference Range: (0-0.5) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: EO% Result: 3 Units: % Reference Range: (0-6) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: HCT Result: 45 Units: % Reference Range: (41-51) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: HGB Result: 14.6 Units: g/dL Reference Range: (13-17.4) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: LY# Result: 25 High Units: 10*3/uL Reference Range: (1.0-4.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: LY% Result: 25 Units: % Reference Range: (15-42) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: MCH Result: 25 Low Units: pg Reference Range: (28-34.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: MCHC Result: 33 Units: g/dL Reference Range: (33-37) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: MCV Result: 90 Units: fl Reference Range: (82.0-98.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: MO# Result: 14 High Units: 10*3/uL Reference Range: (0.2-1.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: MO% Result: 14 High Units: % Reference Range: (3-12) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: MPV Result: 8 Units: fl Reference Range: (7.4-10.4) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: NE# Result: 55 High Units: 10*3/uL Reference Range: (2.5-7.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: NE% Result: 55 Units: % Reference Range: (44-78) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: PLT Result: 568 High Units: 10*3/uL Reference Range: (150-400) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: RBC Result: 4.0 Low Units: 10*6/uL Reference Range: (4.3-5.6) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: RDW Result: 14 Units: % Reference Range: (11.5-14.5) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: WBC Result: 45 High Units: 10*3/uL Reference Range: (4.4-10.8) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ========================================================================= Lab Test: Chemistry Analysis Profile Lab Type: Chemistry/Hematology Ordering Provider: Provider One Ordering Location: PORTLAND VA MEDICAL CENTER Specimen: Plasma (substance) Date/Time Collected: 05 May 2017 @ 1242 Collected Location: PORTLAND VA MEDICAL CENTER ------------------------------------------------------------------------- Test Name: ALBUMIN Result: 6.0 High Units: g/dL Reference Range: (3.4-5.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: ALKALINE PHOSPHATASE Result: 249 High Units: IU/L Reference Range: (45-129) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: ANION GAP Result: 5 Low Units: mmol/L Reference Range: (10-22) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: BILIRUBIN, TOTAL Result: 2.3 High Units: mg/dL Reference Range: (0.2-1.1) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CALCIUM Result: 8.8 Units: mg/dL Reference Range: (8.4-10.4) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CHLORIDE Result: 118 High Units: mmol/L Reference Range: (95-108) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CHOLESTEROL Result: 600 High Units: mg/dL Reference Range: (1-240) Interpretation: DESIRABLE VALUE: <200 BORDERLINE VALUE: 201-239 ELEVATED VALUE: >240 Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CO2 Result: 45 Critical High Units: mmol/L Reference Range: (21-32) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CREATININE Result: 3.4 High Units: mg/dL Reference Range: (0.8-1.5) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: EGFR Result: 18 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. The following is the IDMS traceable MDRD Study equation (for creatinine methods calibrated to an IDMS reference method) EGFR (Ml/min/1.73m^2) = 175 x S^-1.154 x (AGE^-.203) x (0.742 if female) x (1.212 if African American) The equation does not require weight or height variables because the results are reported normalized to 1.73 m^2 body surface area, which is an accepted average adult surface area. Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: GLUCOSE Result: 397 High Units: mg/dL Reference Range: (71-109) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: PHOSPHATE Result: 3.4 Units: mg/dL Reference Range: (2.5-4.5) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: POTASSIUM Result: 4.0 Units: mmol/L Reference Range: (3.5-5.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: PROTEIN,TOTAL Result: 4.5 Low Units: g/dL Reference Range: (6.5-8.2) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: SGOT (AST) Result: 500 High Units: IU/L Reference Range: (14-44) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: SODIUM Result: 140 Units: mmol/L Reference Range: (131-142) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: UREA NITROGEN Result: 50 High Units: mg/dL Reference Range: (7-23) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: Called Critical CO2 ========================================================================= Lab Test: Chemistry Analysis Profile Lab Type: Chemistry/Hematology Ordering Provider: Provider One Ordering Location: PORTLAND VA MEDICAL CENTER Specimen: Plasma (substance) Date/Time Collected: 05 Jan 2017 @ 1200 Collected Location: PORTLAND VA MEDICAL CENTER ------------------------------------------------------------------------- Test Name: ALBUMIN Result: 3.2 Low Units: g/dL Reference Range: (3.4-5.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: ALKALINE PHOSPHATASE Result: 125 Units: IU/L Reference Range: (45-129) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: ANION GAP Result: 11 Units: mmol/L Reference Range: (10-22) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: BILIRUBIN, TOTAL Result: 1.0 Units: mg/dL Reference Range: (0.2-1.1) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CALCIUM Result: 10.0 Units: mg/dL Reference Range: (8.4-10.4) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CHLORIDE Result: 121 High Units: mmol/L Reference Range: (95-108) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CHOLESTEROL Result: 189 Units: mg/dL Reference Range: (1-240) Interpretation: DESIRABLE VALUE: <200 BORDERLINE VALUE: 201-239 ELEVATED VALUE: >240 Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CO2 Result: 32 Units: mmol/L Reference Range: (21-32) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: CREATININE Result: 2.0 High Units: mg/dL Reference Range: (0.8-1.5) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: EGFR Result: 33 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. The following is the IDMS traceable MDRD Study equation (for creatinine methods calibrated to an IDMS reference method) EGFR (Ml/min/1.73m^2) = 175 x S^-1.154 x (AGE^-.203) x (0.742 if female) x (1.212 if African American) The equation does not require weight or height variables because the results are reported normalized to 1.73 m^2 body surface area, which is an accepted average adult surface area. Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: GLUCOSE Result: 156 High Units: mg/dL Reference Range: (71-109) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: PHOSPHATE Result: 6.0 High Units: mg/dL Reference Range: (2.5-4.5) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: POTASSIUM Result: 3.9 Units: mmol/L Reference Range: (3.5-5.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: PROTEIN,TOTAL Result: 5.6 Low Units: g/dL Reference Range: (6.5-8.2) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: SGOT (AST) Result: 56 High Units: IU/L Reference Range: (14-44) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: SODIUM Result: 145 High Units: mmol/L Reference Range: (131-142) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: UREA NITROGEN Result: 20 Units: mg/dL Reference Range: (7-23) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ------------------------------------------------------------------------- Comments: Test patient for Provider One. ========================================================================= Lab Test: Hemogram+PLT+Diff Lab Type: Chemistry/Hematology Ordering Provider: Provider One Ordering Location: PORTLAND VA MEDICAL CENTER Specimen: Blood (substance) Date/Time Collected: 05 Jan 2017 @ 1200 Collected Location: PORTLAND VA MEDICAL CENTER ------------------------------------------------------------------------- Test Name: BA# Result: 0.1 Units: 10*3/uL Reference Range: (0-0.2) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: BA% Result: 1.1 Units: % Reference Range: (0-2) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: EO# Result: 0.1 Units: 10*3/uL Reference Range: (0-0.5) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: EO% Result: 1.8 Units: % Reference Range: (0-6) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: HCT Result: canc Units: % Reference Range: (41-51) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Amended ---------------------- Test Name: HGB Result: canc Units: g/dL Reference Range: (13-17.4) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Amended ---------------------- Test Name: LY# Result: 2.5 Units: 10*3/uL Reference Range: (1.0-4.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: LY% Result: 29.6 Units: % Reference Range: (15-42) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: MCH Result: canc Units: pg Reference Range: (28-34.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Amended ---------------------- Test Name: MCHC Result: canc Units: g/dL Reference Range: (33-37) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Amended ---------------------- Test Name: MCV Result: canc Units: fl Reference Range: (82.0-98.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Amended ---------------------- Test Name: MO# Result: 0.7 Units: 10*3/uL Reference Range: (0.2-1.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: MO% Result: 7.8 Units: % Reference Range: (3-12) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: MPV Result: canc Units: fl Reference Range: (7.4-10.4) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Amended ---------------------- Test Name: NE# Result: 5.0 Units: 10*3/uL Reference Range: (2.5-7.0) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: NE% Result: 59.7 Units: % Reference Range: (44-78) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Final ---------------------- Test Name: PLT Result: canc Units: 10*3/uL Reference Range: (150-400) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Amended ---------------------- Test Name: RBC Result: canc Units: 10*6/uL Reference Range: (4.3-5.6) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Amended ---------------------- Test Name: RDW Result: canc Units: % Reference Range: (11.5-14.5) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Amended ---------------------- Test Name: WBC Result: canc Units: 10*3/uL Reference Range: (4.4-10.8) Interpretation: -- Performing Location: PORTLAND VA MEDICAL CENTER 3710 SW US VETERANS HOSPTL RD , PORTLAND, OR 97239-2964 Status: Amended ------------------------------------------------------------------------- Comments: Test patient for Provider One. WBC reported incorrectly as 8.4 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. RBC reported incorrectly as 3.59 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. RBC flagged incorrectly as L by [197557-VA648]. Abnormal flag removed on Jan 09, 2017@08:04 by [256510-VA648]. HGB reported incorrectly as 11.1 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. HGB flagged incorrectly as L by [197557-VA648]. Abnormal flag removed on Jan 09, 2017@08:04 by [256510-VA648]. HCT reported incorrectly as 33.8 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. HCT flagged incorrectly as L by [197557-VA648]. Abnormal flag removed on Jan 09, 2017@08:04 by [256510-VA648]. MCV reported incorrectly as 94.0 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. MCH reported incorrectly as 31.0 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. MCHC reported incorrectly as 33.0 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. RDW reported incorrectly as 13.3 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. PLT reported incorrectly as 186 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. MPV reported incorrectly as 9.5 by [197557-VA648]. Changed to canc on Jan 09, 2017@08:04 by [256510-VA648]. ========================================================================= ------------------------- VA PATHOLOGY REPORTS -------------------------- Source: VA Last Updated: 01 Aug 2017 @ 1332 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: TONSIL Date Obtained: 05 May 2017 Performing Location: Portland OR VAMCPO BOX 1034, PORTLAND 97207 Date Completed: 05 May 2017 ------------------------------------------------------------------------- SURGICAL PATHOLOGY REPORT LOCAL TITLE: LR SURGICAL PATHOLOGY REPORT DATE OF NOTE: MAY 05, 2017@12:05:55 ENTRY DATE: MAY 05, 2017@12:05:55 AUTHOR: Provider One EXP COSIGNER: URGENCY: STATUS: COMPLETED $APHDR - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - MEDICAL RECORD | SURGICAL PATHOLOGY - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PATHOLOGY REPORT Accession No. SP 17 17000 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - $TEXT Submitted by: Date obtained: May 05, 2017 11:57 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Specimen (Received May 05, 2017 11:57): TONSIL - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - BRIEF CLINICAL HISTORY: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PREOPERATIVE DIAGNOSIS: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - OPERATIVE FINDINGS: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - POSTOPERATIVE DIAGNOSIS: Surgeon/physician: Provider One =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-= - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PATHOLOGY REPORT Accession No. SP 17 17000 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - GROSS DESCRIPTION: Received labled with the patient name, medical record number and "left tonsil" is a 2.5 x 1.5 x 1.0 cm piece of brown-tan soft tissue. On cut section there is an ill-defined white-tan 0.7 cm nodule noted. Representative samples are submitted in one block. BC 5/5/17 MICROSCOPIC EXAM: DIAGNOSIS AFTER MICROSCOPIC EXAMINATION: TONSIL, LEFT, TONSILLECTOMY, TEST CASE: - MODERATELY DIFFERENTIATED SQUAMOUS CELL CARCINOMA. - NEOPLASTIC CELLS DIFFUSELY POSITIVE FOR P16. Comment: The hypothetical H&E stain sections demonstrate an invasive moderately differentiated nonkeratinizing squamous cell carcinoma. Immunohistochemical stain p16 shows diffuse strong staining within the hypothetical malignant cells. This case received intradepartmental consultation by Provider One who concurs with the above diagnosis. NOTE: "The Immunohistochemical staining test was developed and its performance characteristics determined by Pathology & Laboratory Medicine, PVAMC. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) as qualified to perform high complexity clinical laboratory testing." Slide(s) reviewed and diagnosis rendered by: /es/ Provider One MD Signed May 05, 2017@12:05 Performing Laboratory: Surgical Pathology Report Performed By: PORTLAND VA MEDICAL CENTER [CLIA# 38D0988131] 3710 SW US VETERANS HOSPTL RD PORTLAND, OR 97239-2964 $FTR - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (End of report) Provier One bgc| Date May 05, 2017 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - MHVTESTVETERAN,ONE A STANDARD FORM 515 ID:666-66-1948 SEX:M DOB:03/01/1948 AGE: 69 LOC:AAALAB ADM:MAY 5,2017 DX:PTSD PCP: /es/ Provider One MD Signed: 05/05/2017 12:05 ========================================================================= Type of Report: Surgical Pathology Specimen: POLYPS Date Obtained: 05 Jan 2017 Performing Location: Portland OR VAMCPO BOX 1034, PORTLAND 97207 Date Completed: 05 Jan 2017 ------------------------------------------------------------------------- SURGICAL PATHOLOGY REPORT Date Spec taken: Jan 05, 2017 11:15 Pathologist:Provider One Date Spec rec'd: Jan 05, 2017 11:15 Resident: Date completed: Jan 05, 2017 Accession #: SP 17 113 Submitted by: Provider One Practitioner:0 ------------------------------------------------------------------------------- Specimen: POLYPS GROSS DESCRIPTION: No specimen received. Report only for test patient. MICROSCOPIC EXAM: (Date Spec taken: Jan 05, 2017 11:15) DIAGNOSIS AFTER MICROSCOPIC EXAMINATION: POLYPS: - NO DIAGNOSIS. - TEST PATIENT REPORT ONLY. Diagnosis rendered by: Provider One STAFF PATHOLOGIST PATHOLOGY AND LAB MED =--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=--=-- Performing Laboratory: Surgical Pathology Report Performed By: PORTLAND VA MEDICAL CENTER [CLIA# 38D0988131] 3710 SW US VETERANS HOSPTL RD PORTLAND, OR 97239-2964 ========================================================================= -------------------- SELF REPORTED LABS AND TESTS ----------------------- Source: Self-Entered No information was available that matched your selection. ------------------------ VA VITALS AND READINGS ------------------------- Source: VA Last Updated: 01 Aug 2017 @ 1332 VA Vitals and Readings displays your vital signs and other health readings. 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 and health reading. Vital Sign or Health Reading Measurement Date/Time Collected ------------------------------------------------------------------------- Blood Pressure 90/60 mm[Hg] 05 May 2017 @ 1208 Pulse Rate 120 /min 05 May 2017 @ 1208 Respiration 23 /min 05 May 2017 @ 1208 Temperature 101.5 F 05 May 2017 @ 1208 Pain Level 10 05 May 2017 @ 1208 Height 76 in 05 May 2017 @ 1208 Weight 180 lb 05 May 2017 @ 1208 ========================================================================= This section shows all of the vital signs and health readings listed in your VA health record based on the dates you selected when you requested your VA Blue Button. They are grouped by the type of vital sign or health reading. Sorted By: Type of Vital Sign or Health Reading, then Date/Time (Descending) ----------------------------------------------------------- Vital Sign: Blood Pressure Measurement: 90/60 mm[Hg] Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Blood Pressure Measurement: 120/80 mm[Hg] Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Blood Pressure Measurement: 82/40 mm[Hg] Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0646 Vital Sign: Blood Pressure Measurement: 153/95 mm[Hg] Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0643 ----------------------------------------------------------- Vital Sign: Temperature Measurement: 101.5 F Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Temperature Measurement: 98.1 F Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Temperature Measurement: 102.2 F Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0646 Vital Sign: Temperature Measurement: 97.9 F Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0643 ----------------------------------------------------------- Vital Sign: Height Measurement: 76 in Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Height Measurement: 72 in Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Height Measurement: 72 in Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0643 ----------------------------------------------------------- Vital Sign: Pain Level Measurement: 10 Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Pain Level Measurement: 1 Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Pain Level Measurement: 10 Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0646 Vital Sign: Pain Level Measurement: 1 Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0643 ----------------------------------------------------------- Vital Sign: Pulse Oximetry Measurement: 98 % Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Pulse Oximetry Measurement: 99 % Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Pulse Oximetry Measurement: 75 % Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0646 Vital Sign: Pulse Oximetry Measurement: 98 % Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0643 ----------------------------------------------------------- Vital Sign: Pulse Rate Measurement: 120 /min Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Pulse Rate Measurement: 100 /min Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Pulse Rate Measurement: 120 /min Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0646 Vital Sign: Pulse Rate Measurement: 62 /min Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0643 ----------------------------------------------------------- Vital Sign: Respiration Measurement: 23 /min Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Respiration Measurement: 16 /min Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Respiration Measurement: 22 /min Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0646 Vital Sign: Respiration Measurement: 14 /min Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0643 ----------------------------------------------------------- Vital Sign: Weight Measurement: 180 lb Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Weight Measurement: 177 lb Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 May 2017 @ 1208 Vital Sign: Weight Measurement: 180 lb Comments: -- Location: Portland OR VAMC Date/Time Collected: 05 Jan 2017 @ 0643 -------------------- SELF REPORTED VITALS AND READINGS ------------------ Source: Self-Entered No information was available that matched your selection. -------------------------- VA RADIOLOGY REPORTS ------------------------- Source: VA Last Updated: 01 Aug 2017 @ 1332 Sorted By: Date/Time Exam Performed (Descending) VA Radiology Reports are available 3 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: CHEST 2 VIEWS PA&LAT Date/Time Exam Performed: 05 May 2017 @ 1200 Ordering Location: Portland OR VAMC Requesting Provider: Provider One Reasons for Study: Rule out pneumonia Clinical History: please result this test radiology order for VACO Performing Location: Portland OR VAMC PO BOX 1034, PORTLAND 97207 Radiologist: Provider One -------------------------------------------------------------------------- RADIOLOGY REPORT Report: Impression: Test patient; no report necessary for dictation; ADMIN complete. Primary Diagnostic Code: ========================================================================= Procedure/Test Name: UL ABDOMINAL LIMITED (BILE DUCTS/GB/LIVER/PANCREAS/SPLEEN) Date/Time Exam Performed: 05 Jan 2017 @ 0927 Ordering Location: Portland OR VAMC Requesting Provider: Provider One Reasons for Study: this is a test Clinical History: this is only a test Performing Location: Portland OR VAMC PO BOX 1034, PORTLAND 97207 Radiologist: Provider One -------------------------------------------------------------------------- RADIOLOGY REPORT Report: Impression: Test patient; no report necessary for dictation; ADMIN complete. Primary Diagnostic Code: ========================================================================= Procedure/Test Name: ABDOMEN 3 OR MORE VIEWS Date/Time Exam Performed: 05 Jan 2017 @ 0926 Ordering Location: Portland OR VAMC Requesting Provider: Provider One Reasons for Study: abdominal pain Clinical History: r/o obstruction Performing Location: Portland OR VAMC PO BOX 1034, PORTLAND 97207 Radiologist: Provider One -------------------------------------------------------------------------- RADIOLOGY REPORT Report: Impression: Test patient; no report necessary for dictation; ADMIN complete. Primary Diagnostic Code: ========================================================================= ------------------ VA ELECTROCARDIOGRAM (EKG) REPORTS ------------------- Source: VA Last Updated: 01 Aug 2017 @ 1332 No information was available that matched your selection. ------------------ 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 MILITARY HEALTH HISTORY ---------------- Source: Self-Entered Event Title: Overseas Deployment Event Date: 07 Apr 2002 Service Branch: Army Rank: COL 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 -------------------- SELF REPORTED ACTIVITY JOURNAL --------------------- Source: Self-Entered No information was available that matched your selection. ----------------------- SELF REPORTED FOOD JOURNAL ---------------------- Source: Self-Entered No information was available that matched your selection. -------------------- DoD Military Service Information ------------------- Source: DoD No information was available that matched your selection. -------------------- SELF REPORTED MY GOALS: CURRENT GOALS --------------- Source: Self-Entered Sorted By: Priority, then by Goal Start Date (Descending) Remember to share your self-entered information with your VA health care team. This section contains your My Goals: Current Goals information included in the date range selected when you requested your VA Blue Button. ========================================================================== ALL CURRENT GOALS - SUMMARY LIST (BY PRIORITY) -------------------------------------------------------------------------- None Entered ---------------- SELF REPORTED MY GOALS: COMPLETED GOALS -------------- Source: Self-Entered Sorted By: Date Goal Completed (Descending) Remember to share your self-entered information with your VA health care team. This section contains your My Goals: Completed Goals information included in the date range selected when you requested your VA Blue Button. ========================================================================== COMPLETED GOALS - SUMMARY LIST (BY DATE GOAL COMPLETED) -------------------------------------------------------------------------- None Entered ----------- END OF MY HEALTHEVET PERSONAL INFORMATION REPORT ----------