| Substance | Overall Severity | Reaction | Reaction Severity | Status |
| Cashew Nut | Severe | Anaphylactic reaction | Mild | Active |
This patient was only recently discharged for a recurrent GI bleed as described below.
He presented to the ER today c/o a dark stool yesterday but a normal brown stool today. On exam he was hypotensive in the 80?s resolved after .... .... ....
Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal. H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40.
He was transfused with 6 units of packed red blood cells with .... .... ....
GI evaluation 12 September: Colonoscopy showed single red clot in .... ........
| Problem Name | Type | Onset Date | Abatement Date | Status |
| Liveborn born in hospital | Condition | Complete |
| Name | Applies Period |
| Resuscitation | 2015/01/01 - 2016/12/31 |
Obesity.
Uncontrolled brittle Type II diabetic.
Shortness of breath, mild wheezing.
Pressure ulder on left knee.
Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy
Acute on chronic anemia secondary to #1.
Azotemia, acute renal failure with volume loss secondary tom#1.
Hyperkalemia secondary to #3 and on ACE and K+ supplement.
Other chronic diagnoses as noted above, currently stable.
Cramping, bloating, and constipation.
Dark Stools
| Relationship | Diagnosis | Age at Onset |
| Father | Myocardial Infarction(cause of Death) | 57 |
| Father | Diabetes | 40 |
| Functional or Cognitive Finding | Observation | Observation Date | Condition Status |
| Ambulation (Dependent to Independent | Independently able | 2010/03/11 | Active |
| Finding of Functional Performance and Activity | Dyspnea | 2008/02/16 | Active |
| Cognitive Function Finding | Memory Impairment | 2014/04/29 | Active |
Alert and in good spirits, no acute distress.
See History of Present Illness
| Vaccine | Date | Status |
| Fluvax (Influenza) | 2016-04-05 | Completed |
| Supply/Device | Date Supplied |
| Automatic Implantable cardioverter/defbrillator | 2008/11/16 |
| Wheelchair | 1999/12/01 |
| Medication | Directions | Start Date | Status | Indications | Fill Instructions |
| Amoxicillin | Amoxicillin Powder, for Suspension 250mg/5ml | 20160401 | Active | Pneumonia | Generic substitution allowed |
| Mental Status Findings | Effective Dates | Condition Status |
| Mental Function | July 31, 2013 | Impaired |
| Cognitive Abilities | July 31, 2013 | Judgement, Intact |
| Cognitive Function | July 31, 2013 | Aggressive Behavior |
| Cognitive Function | July 31, 2013 | Difficulty understanding own emotions |
| Cognitive Function | July 31, 2013 | Difficulty communicating Thoughts |
| Date | Nutritional Status | Diet |
| 2005/12/29 | Well nourished | Low sodium diet, excessive carbohydrate |
| 2010/05/26 | Slight dehydration | High protein, low fibre |
HEENT: All normal to examination.
>HEART: RRR, no murmur.
THORAX & LUNGS: Clear without rhonchi or wheeze.
ABDOMEN: Marked distension and tenderness, slightly obese, pos bowelsounds.
BACK: Normal to inspection and palpation, without tenderness; no presacral edema.
EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.
| Planned Activity | Period | Status |
| Colonoscopy | 2010/08/16 - 2010/08/16 | Completed |
| Recommendation to Exercise | 2015/10/29 | Ongoing |
| Procedure Name | Body Site | Performer | Date Performed | Reason |
| Appendectomy (Procedure) | Abdomen | Dr. Adam Everyman | 20160405 | Generalized abdominal pain 24 hours. Localized in RIF with rebound and guarding |
Tenderness of lower abdomen
| Result Type | Quantity Value | Date | Status |
| Glucose [Moles/volume] in Blood | 6.3 mmol/l | 2016/04/01 | Final |
Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. Several episodes of abdominal tenderness. No recent headaches. Positive for osteoarthritis in hips, knees and hands.
| Social History Element | Description | Effective Dates |
| Smoking | 1 pack tobacco per day | 2005/05/01 - 2010/02/28 |
| Vital Sign | Date | Value |
| Temperature | 2016/04/05 | 39 Degrees Celcius |