Patient is overweight as shown by the vital sign height and weight observations (6/22/2015 at 10:05 EST) (Active) Start: 6/22/2015 |
• Goal: Keep weight under 95kg |
◦ Intervention: Nutrition: dietary regime (regime/therapy); nutrition education (procedure) |
◦ Outcome: a. Outcome Observation #1:i. Refers to Goal Observation for Weight; ii. Refers to the Intervention Act #1; iii. Progress Towards Goal of Weight – Goal Not Achieved as of 6/22/2015 |
Fever (6/22/2015 at 10:10 EST) (Active) Start: 6/22/2015 |
• Goal: Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit |
◦ Milestone: Get rid of intermittent fever that is occurring every few weeks. |
◦ Intervention: Medications: Tylenol 500 mg |
▪ Outcome: b. Outcome Observation #2: i. Refers to Goal Observation for Body Temperature; ii. Refers to Intervention Act #2 iii. Progress Towards Goal of Body Temperature – Goal Achieved as of 6/24/2015 |
◦ Outcome: b. Outcome Observation #2: i. Refers to Goal Observation for Body Temperature; ii. Refers to Intervention Act #2 iii. Progress Towards Goal of Body Temperature – Goal Achieved as of 6/24/2015 |
Increased body temperature as evidenced by Intermittent (recurrent) fever (Active) Start: 6/22/2015 |
• Goal: Get rid of intermittent fever that is occurring every few weeks. |
◦ Intervention: Medications: Ceftriaxone 100 MG/ML |
Fatigue (Active) Start: 12/31/2006 |
• Goal: Need to gain more energy to do regular activities. |
◦ Intervention: Medications: Levothyroxine Sodium 1 mg |
Hypertension: BP 145/88 (6/22/2015 at 10:08 EST) (Active) Start: 6/22/2015 |
Renal transplant rejection (Active) Start: 6/22/2015 |
• Goal: Improve renal function |
◦ Intervention: Medications: Aranesp 0.5 MG/ML |
Chronic sickness | 6/22/2015 |
Patient is overweight as shown by the vital sign height and weight observations (6/22/2015 at 10:05 EST) | Start: 6/22/2015 |
Status: Active Provider Concern |
Related To: | ||
•Overweight | Onset: 12/31/2006 |
Status: Active |
•Weight 110 kg | 22-Jun-2015 10:05 | |
•Height 177 cm | 22-Jun-2015 10:05 | |
Fever (6/22/2015 at 10:10 EST) | Start: 6/22/2015 |
Status: Active Provider Concern |
Related Health Concern: Increased body temperature as evidenced by Intermittent (recurrent) fever | ||
Related To: | ||
•Temperature 103 f | 22-Jun-2015 10:10 | |
Increased body temperature as evidenced by Intermittent (recurrent) fever | Start: 6/22/2015 |
Status: Active Provider Concern |
Associated Health Concern: Fever (6/22/2015 at 10:10 EST) | ||
Related To: | ||
•Intermittent (recurrent) fever | Onset: 6/22/2015 |
Status: Active |
•Encounter Diagnosis: Fever | Status: Active Onset: 6/22/2015 |
|
Fatigue | Start: 12/31/2006 |
Status: Active Provider Concern |
Related To: | ||
•Severe Hypothyroidism | Onset: 12/31/2006 |
Status: Active |
Hypertension: BP 145/88 (6/22/2015 at 10:08 EST) | Start: 6/22/2015 |
Status: Active Provider Concern |
Related To: | ||
•Hypertension | Onset: 10/5/2011 |
Status: Active |
•BP Systolic 145 mm[Hg] | 22-Jun-2015 10:05 | |
•BP Diastolic 88 mm[Hg] | 22-Jun-2015 10:05 | |
Renal transplant rejection | Start: 6/22/2015 |
Status: Active Provider Concern |
Related To: | ||
•Chronic rejection of renal transplant | Onset: 12/31/2011 |
Status: Active |
Get rid of intermittent fever that is occurring every few weeks. | Goal Set: 6/22/2015 | Patient and Provider Goal |
Related To: | ||
•Increased body temperature as evidenced by Intermittent (recurrent) fever | ||
Interventions | ||
•Ceftriaxone 100 MG/ML | ||
Need to gain more energy to do regular activities. | Goal Set: 6/22/2015 | Patient and Provider Goal |
Related To: | ||
•Fatigue | ||
Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit | Goal Set: 6/22/2015 | Patient and Provider Goal |
Related To: | ||
•Fever (6/22/2015 at 10:10 EST) | ||
Interventions | ||
•Tylenol 500 mg | ||
Milestones | ||
•Get rid of intermittent fever that is occurring every few weeks. | ||
Keep weight under 95kg | Goal Set: 6/22/2015 | Provider Goal |
Related To: | ||
•Patient is overweight as shown by the vital sign height and weight observations (6/22/2015 at 10:05 EST) | ||
Interventions | ||
•dietary regime (regime/therapy) | ||
•nutrition education (procedure) | ||
Improve renal function | Goal Set: 6/22/2015 | Patient and Provider Goal |
Related To: | ||
•Renal transplant rejection | ||
Interventions | ||
•Aranesp 0.5 MG/ML |
Intervention For: Keep weight under 95kg | ||
•dietary regime (regime/therapy) | Intent | |
•nutrition education (procedure) | Intent | |
Intervention For: Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit | ||
•Tylenol 500 mg; oral as needed | Start: 6/22/2015 End: 6/30/2015 |
Status: Complete |
Intervention For: Need to gain more energy to do regular activities. | ||
•Levothyroxine Sodium 1 mg; oral daily | Start: 6/23/2015 End: 6/30/2015 |
Status: Complete |
Intervention For: Get rid of intermittent fever that is occurring every few weeks. | ||
•Ceftriaxone 100 MG/ML; two times daily | Start: 6/22/2015 End: 7/22/2015 |
Status: Complete |
Intervention For: Improve renal function | ||
•Aranesp 0.5 MG/ML; Injectable Once a week | Start: 6/22/2015 End: 7/22/2015 |
Status: Complete |
a. Outcome Observation #1:i. Refers to Goal Observation for Weight; ii. Refers to the Intervention Act #1; iii. Progress Towards Goal of Weight – Goal Not Achieved as of 6/22/2015 |
||
Related Goal: | ||
•Keep weight under 95kg | ||
Progress: | ||
•Goal not achieved | 6/22/2015 | |
b. Outcome Observation #2: i. Refers to Goal Observation for Body Temperature; ii. Refers to Intervention Act #2 iii. Progress Towards Goal of Body Temperature – Goal Achieved as of 6/24/2015 |
||
Related Goal: | ||
•Negotiated Goal for Body Temperature 98-99 degrees Fahrenheit | ||
Interventions: | ||
•Tylenol 500 mg | ||
Progress: | ||
•Goal achieved | 6/22/2015 |