Patient Chart Summary 456 Vaultina Dr. Dallas TX 75219 US Roger Rienman McBee Not Religious 456 Vaultina Dr. Dallas TX 75219 US Betty Bo McBee 4444 Home Street Beaverton TX 97867 US The DoctorsTogether Physician Group 1007 Health Drive Portland TX 99123 US 1007 Healthcare Drive Portland TX 99123 US Harold Hippocrates M.D. The DoctorsApart Physician Group 1025 Health Drive Portland TX 99123 US Ramsey Reaction M.D. The DoctorsApart Physician Group 1017 Health Drive Portland TX 99123 US William Bill Beaker Good Health Laboratory 1016 Health Drive Portland TX 99123 US Susan Script Pharm.D. People's Pharmacy 1027 Health Drive Portland TX 99123 US Patrick Pump M.D. The DoctorsApart Physician Group Betty Bo McBee Good Health HIE 1009 Healthcare Drive Portland TX 99123 US Sara Specialize M.D. The DoctorsApart Physician Group 456 Vaultina Dr. Dallas TX 75219 US Betty Bo McBee 456 Vaultina Dr. Dallas TX 75219 US Betty Bo McBee Primary Care Provider 1004 Healthcare Drive Portland TX 99123 US Patricia P. Primary M.D. The DoctorsTogether Physician Group 1004 Health Drive Portland TX 99123 US
ENCOUNTERS
Encounter Performer Location Date
PCP Follow-up Dr. Primary The DoctorsTogether Physician Group 8/15/2017 (10:00am) to 8/15/2017 (10:30am)
Inpatient Hospital Stay Dr. Hospitalist Community Memorial Hospital 8/7/2017 (1:00pm) to 8/12/2017 (3:00pm)
Outpatient Visit Dr. Jones Good Health Urgent Care September 27, 2012 at 1:00pm
Dr. Primary 100 Health Street Portland TX 99123 US The DoctorsTogether Physician Group Dr. Hospitalist 100 Health Street Portland TX 99123 US Community Memorial Hospital Dr. Jones 1007 Health Drive Portland TX 99123 US Good Health Urgent Care
ADVANCE DIRECTIVES Review of Patient Preferences
Associated Encounter: Inpatient Stay (8/7/2017- 8/10/2017)
(Documented by: Nancy Nightingale, RN August 07, 2017 4:30 pm)
Category of Directive: Established on: Supporting Document: Verified by: Time of Verification:
Personal Advance Care Plan August 11, 2016 PACP Document Link Dr. Patricia Primary (August 07, 2017 3:00 pm)
Type of Patient Preferences Available:
Healthcare agent appointment
Life support
Cardiopulmonary resuscitation
Palliative care
Organ donation
Autopsy
Other directives
Healthcare Agent Name: Contact Info: Named on date: Role: Status:
Jeff Zucker (Friend) zuckerjeff@gmail.com 02/19/2011 Primary Healthcare Agent Pending as of 1/23/2018
S. Leonard Susskind (Friend) sbrown@advaultinc.com 02/19/2011 First Alternate Healthcare Agent Accepted as of 11/8/2016
Jay Z Polkinghome (Friend) jzpolkinghome@gmail.com 02/19/2011 Second Alternate Healthcare Agent Accepted as of 2/14/2012
Obligation Instructions
Associated Encounter: Inpatient Stay (8/7/2017- 8/10/2017)
(Documented by: Nancy Nightingale, RN August 07, 2017 4:30 pm)
Type of Care Requested: As of: Signed by: Patient Care Decision Form
Palliative Care 8/7/2017 11:30am Jeff Zucker Signed Care Decision-Making Form for this enounter
Prohibition Instructions
Associated Encounter: Inpatient Stay (8/7/2017- 8/10/2017)
(Documented by: Nancy Nightingale, RN August 07, 2017 4:30 pm)
Type of Care Prohibited: As of: Signed by: Patient Care Decision Form
Cardiopulmonary resuscitation 8/7/2017 11:30am Jeff Zucker Signed Care Decision-Making Form for this enounter
Jeff Zucker S.LeonardSusskind JayZPolkinghome
PLAN OF TREATMENT
Planned Care: Status: Date of Service: Service Provider: Planned As of (by):
Advance Care Planning Consultation Scheduled Sept 15, 2017 2:00pm Patricia Primary, MD August 15, 2017 10:30am (Patricia Primary, MD)
Patricia Primary, MD
ALLERGIES AND ADVERSE REACTIONS
Substance Reaction
Penicillin Nausea
Codeine Wheezing
MEDICAL EQUIPMENT Medical Equipment Implanted Devices: Cardiac PaceMaker July 3, 2017 Implanted Devices: Upper GI Prosthesis, January 3, 2017 Cane, February 2, 2003 Biliary Stent, May 5, 2017 Implants Cardiac Pacemaker Good Health Durable Medical Equipment Upper GI Prosthesis Good Health Durable Medical Equipment Upper GI Prosthesis Good Health Durable Medical Equipment 1004 Health Care Drive Ann Arbor MI 02368 US Community Health and Hospitals 1003 Health Care Drive Ann Arbor MI 02368 US
PROBLEMS Active Concerns Problem #1 Pneumonia (onset July 3, 2017; resolution Aug 14, 2017) [authored Aug 14, 2017] Problem #2 Chest pain (onset Apr 14, 2007) [authored Apr 14, 2007] Angina (onset Apr 17, 2007) [authored Apr 17, 2007] Resolved Concerns Problem #3 Pneumonia - Left lower lobe (onset Mar 10, 1998; resolution Mar 16, 1998) [authored Mar 16, 1998]
FUNCTIONAL STATUS
Functional Category Effective Dates Results of Evaluation
Functional Assessment March 11, 2017 Independent Walking
ADL/IADL: Bathing March 11,2017 Independent
MEDICATIONS
Medication Directions Start Date Status Indications Fill Instructions
Proventil 0.09 MG/ACTUAT inhalant solution 2 puffs q6 hours PRN wheezing Jan 3, 2011 Active Asthma Generic Substitition Allowed
Atenolol 25 MG Oral Tablet 1 every 12 hours Orally Mar 18, 2012 Active Hypertension -none-
Medication Factory Inc. Community Health and Hospitals Aerosol Medication Factory Inc. label in spanish Medication Factory Inc. 1016 Health Drive Portland TX 99123 US Susan Script Pharm.D. People's Pharmacy
PROCEDURES
Procedure: Status: Date of Service: Service Provider: Documented by (time):
Advance Care Planning Consultation Completed August 15, 2017 10:00am Patricia Primary, MD Patricia Primary, MD (August 15, 2017 10:30am )


History of Procedures

Procedure Date
Colonic polypectomy 1998
Patricia Primary, MD 1001 Village Avenue Portland OR 99123 US Community Health and Hospitals 1001 Village Avenue Portland OR 99123 US
RESULTS
Result Type Result Value Relevant Reference Range Interpretation Date
Hemoglobin 13.2 g/dL Normal range for women is 12.0 to 15.5 grams per deciliter Normal 03/19/2008
Leukocytes 6.7 10*9/L Normal white blood cell count range 3.5-10.5 billion cells/L Normal 03/19/2008
Platelets 123 10*9/L Normal white blood cell count range 3.5-10.5 billion cells/L Low 03/19/2008
Hematocrit 35.3 % Normal hematocrit range for female: 34.9-44.5 percent Normal 03/19/2008
Erythrocytes 4.21 10*12/L Normal red blood cell count range 3.90-5.03 trillion cells/L Normal 03/19/2008
Urea nitrogen, Serum Pending Pending Pending March 20, 2008
6.7 billion per liter
VITAL SIGNS
Date / Time: Sept 10, 2012 Sept 1, 2011
Height 177 cm 177 cm
Weight 86 kg 88 kg
Blood Pressure 132/88 128/80
FAMILY HISTORY Father (deceased)
Diagnosis Age At Onset
Myocardial Infarction (cause of death) 57
Diabetes 40
SOCIAL HISTORY
Social History Observation Description Dates Observed
Current Smoking Status Former smoker September 10, 2012
Tobacco Use Moderate cigarette smoker, 10-19/day February, 2009 - February, 2011
Alcoholic drinks per day 12 Since February, 2012
IMMUNIZATIONS
Vaccine Date Status Series number
Influenza, seasonal, IM Nov 1999 Completed N/A
Influenza, seasonal, IM Dec 1998 Completed N/A
Pneumococcal polysaccharide vaccine, IM Dec 1998 Completed N/A
Tetanus and diphtheria toxoids, IM 1997 Refused N/A
Hepatitis B Aug 1, 2017 Completed 3rd
Influenza, seasonal, IM 1 Health LS - Immuno Inc. 1007 Health Drive Portland TX 99123 US Harold Hippocrates Good Health Clinic 1007 Health Drive Portland TX 99123 US Possible flu-like symptoms for three days. 1 Health LS - Immuno Inc. 1007 Health Drive Portland TX 99123 US Harold Hippocrates Good Health Clinic 1007 Health Drive Portland TX 99123 US Possible flu-like symptoms for three days. 1 Health LS - Immuno Inc. 1007 Health Drive Portland TX 99123 US Harold Hippocrates Good Health Clinic 1007 Health Drive Portland TX 99123 US 1 Health LS - Immuno Inc. 1007 Health Drive Portland TX 99123 US Harold Hippocrates Good Health Clinic 1 1007 Health Drive Portland TX 99123 US Harold Hippocrates Good Health Clinic 1007 Health Drive Portland TX 99123 US
INSURANCE PROVIDERS
Payer name Policy type / Coverage type Policy ID Covered party ID Policy Holder
Good Health Insurance Extended healthcare / Family Contract Number 1138345 Patient's Mother
9009 Health Drive Portland TX 99123 US Good Health Insurance 9009 Health Drive Portland TX 99123 2222 Home Street Beaverton TX 97867 USA Betty McBee 2222 Home Street Beaverton TX 97867 Betty McBee 2222 Home Street Beaverton TX 97867