# Demographics First Name: Ellen Last Name: Ross Gender: Female Martial Status: Married Religious Affiliation: Christian Ethnicity: Asian Language Spoken: English Address: 17 Daws Road, Portland, OR 97006 Telephone: 415-555-1229 Birthday: March 7, 1960 # Guardian Role: Sister First Name: Martha Last Name: Shan Address: 1357 Amber Drive, Beaverton, OR 97006 Telephone: 816-276-6909 # Provider Name of Provider: Ashby Medical Center Address: 1002 Healthcare Dr, Portland, OR 97266 Telephone: 415-555-1200 # Allergies Allergy Name: Penicillin Reaction: Hives Severity: Moderate to severe Allergy Name: Codeine Reaction: Shortness of Breath Severity: Moderate Allergy Name: Bee Stings Reaction: Anaphylactic Shock Severity: Severe # Immunizations Date: May 2001 Immunization Name: Influenza virus vaccine, IM Type: Intramuscular injection Dose Quantity (value / unit): 50 / mcg Education/Instructions: Possible flu-like symptoms for three days Date: April 2000 Immunization Name: Tetanus and diphtheria toxoids, IM Type: Intramuscular injection Dose Quantity (value / unit) 50 / mcg Education/Instructions: Mild pain or soreness in the local area # Medication Date: March 28, 2005 Type: Liquid Name of Medication: Acetaminophen with codiene Instructions: 2 puffs once a day Dose Quantity (value / unit): 2 / puffs Rate Quantity (value / unit): 1 / day Name of Prescriber: Ashby Medical Center Date: December 10, 2003 Type: Tablet Name of Medication: Indomethacin Instructions: 50mg bid with food Dose Quantity (value / unit): 50 / mg Rate Quantity (value / unit): 2 / day Name of Prescriber: Ashby Medical Center # Plan of Care Planned Activity Name: Office consultation Planned Date: May 28, 2007 Instructions: Consultation with Dr. George Potomac for Asthma Planned Activity Name: Chest X-Ray Planned Date: June 1, 2007 Instructions: Planned Activity Name: Sputum Culture Planned Date: May 28, 2007 Instructions: # Encounters Encounter: ED Visit for Ankle Sprain Provider: Dr. Henry Seven Location: Community Hospital Date: March 28, 2005 Encounter: Gall Bladder Surgery Provider: Dr. Bala Venktaraman Location: Ashby Medical Center Date: September 28, 2002 Encounter: Labor and Delivery Provider: Dr. Tiffany Martinez Location: Ashby Medical Center Date: March 21, 2002 Encounter: ED Visit for Acute Cholecystitis Provider: Dr. Tim Lee Location: Ashby Medical Center Date: October 28, 2001 # Problem List Observation: Ankle Sprain Status: Active Date: March 28, 2005 Comments: Slipped on ice and fell. Observation: Cholecystitis Status: Resolved Date: September 28, 2002 Comments: Surgery postponed until after delivery # Procedures Procedure: Laparoscopic Cholecystectomy Date: September 28, 2002 Provider: Dr. Bala Venktaraman Location: Ashby Medical Center Procedure: Cesarian Section Date: March 22, 2002 Provider: Dr. Tiffany Martinez Location: Ashby Medical Center