Generated Narrative: ServiceRequest example-referral-summary-sr-myhix-sample

ExtensionAttester (MY Core)

• mode: professional
• time: 2022-10-05 07:14:38+0800
• party: Murusamy A/L Atharv (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/43217)

identifier: http://fhir.hie.moh.gov.my/sid/service-request-id/HTJ-REF-2304000005

status: Active

intent: Proposal

category: Patient referral

priority: Routine

code: Hospital Referral Summary

subject: Bundle: type = transaction

encounter: Bundle: type = transaction

authoredOn: 2022-08-30 08:00:46+0800

requester: Wong Ah Liu (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/76212)

performerType: Internal

performer:

• ​Organization/11-05060009
• Arumugan A/L Aryan (Identifier: http://fhir.hie.moh.gov.my/sid/mmc-no/12345)

reasonReference: Bundle: type = transaction

supportingInfo: Zuraidah Binti Abu

note: <div xmlns="http://www.w3.org/1999/xhtml"><h2><strong>Allergies</strong></h2><ul><li><strong>Allergies and Other Adverse Reactions:</strong><p>Patient allergic to:</p><p>1. Paracetamol</p><p>2. Peanut</p></li></ul><h2><strong>Reason for Care</strong></h2><ul><li><strong>Hospital Admission Diagnosis:</strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li></ol></li><li><p><strong>History of Present Illness</strong></p><p>72 year old thin white male presented to emergency on 8 JAN 14 with shortness of breath, weakness and dehydration. Chest X-ray showed right lower lobe infiltrate, ABGs unremarkable. Pulse ox on RA was 79%25.</p><ol><li>Pneumonia: treated with ceftriaxone and azithromycin iv. Switched to PO after 72 hours.&nbsp;</li><li>Exacerbation of COPD: patient treated with inhaled and oral steroids, O2 at 2l/nc. On RA at time of discharge&nbsp;</li><li>Weakness and dehydration: secondary to pneumonia and COPD. Responded well to strengthening with PT and regular meals.&nbsp;</li></ol></li></ul><h2><strong>Other Condition Histories</strong></h2><ul><li><strong><strong>Active Problems:</strong></strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li><li>mild CHF</li><li>osteoarthritis</li></ol></li><li><strong>Discharge Diagnosis:</strong><ol><li>RLL pneumonia</li><li>COPD exacerbation</li><li>mild CHF</li><li>osteoarthritis</li></ol></li><li><strong>Resolved Problems:</strong>&nbsp;none</li><li><strong>List of Surgeries:</strong><ol><li>Craniotomy</li><li>Lumbar Puncture</li></ol></li></ul><h2><strong>Medication</strong></h2><ul><li><strong>Medications: </strong>Zithromycin daily until gone, inhalers #of puffs</li></ul><h2><strong>Relevant Studies</strong></h2><ul><li><strong>Results:</strong>&nbsp;</li></ul><p>Doctor : DR NURUL FAUZAN BIN MOHD PAUZI<br />Registration : 11 OCT 2022 11:48:16 D.O.B. : 10 NOV 2020<br />Clinic : KLINIK PAKAR<br />Completion : 11 OCT 2022 14:53:54</p><p>Validated &amp; Reported By: Siti Zarinawati Binti Johari (Juruteknologi Makmal Perubatan U29)<br />Validated On: 11 OCT 2022 14:53:54<br />Accessed &amp; Printed By: (10.29.194.218) Accessed On: 11 OCT 2022, 17:26:13</p><table><tbody><tr><th>Full Blood Count</th><th>Result</th><th>Unit</th><th>Ref Range</th></tr><tr><td>White Blood Cell Count</td><td>H 16.97</td><td>x 10^3uL</td><td>( 4.078 - 11.370 )</td></tr><tr><td>Red Blood Cell Count</td><td>L 3.85</td><td>x 10^6uL</td><td>( 4.53 - 5.95 )</td></tr><tr><td>Haemoglobin</td><td>LL 6.7</td><td>g/dL</td><td>( 13.5 - 17.4 )</td></tr><tr><td>Hematocrit</td><td>L 20.5</td><td>%25</td><td>( 40.1 - 50.6 )</td></tr><tr><td>Mean Cell Volume</td><td>L 53.2</td><td>fL</td><td>( 80.6 - 95.5 )</td></tr><tr><td>Mean Cell Haemoglobin</td><td>L 17.4</td><td>pg</td><td>( 26.9 - 32.3 )</td></tr><tr><td>Mean Cell Haemoglobin Concentration</td><td>32.7</td><td>g/dL</td><td>( 31.9 - 35.3 )</td></tr></tbody></table><ul><li><strong>Hospital Discharge:</strong>&nbsp;none</li><li><strong>Studies Summary:</strong>&nbsp;none</li></ul><h2><strong>Plans of Care</strong></h2><ul><li><strong>Care Plan:&nbsp;</strong>No activity restriction, regular diet, follow up in two to three weeks with regular physician.</li></ul></div>