--- a +++ b/data/text/Brett_Lang_0e11fbdf-a5f4-75fd-241c-039c9d4eedb2.txt @@ -0,0 +1,92 @@ +Brett Lang +========== +Race: Black +Ethnicity: Non-Hispanic +Gender: M +Age: 15 +Birth Date: 2007-04-25 +Marital Status: S +-------------------------------------------------------------------------------- +ALLERGIES: +No Known Allergies +-------------------------------------------------------------------------------- +MEDICATIONS: + 2021-02-07[STOPPED] : Naproxen sodium 220 MG Oral Tablet +-------------------------------------------------------------------------------- +CONDITIONS: + 2021-05-26 - : Risk activity involvement (finding) + 2021-02-07 - 2021-02-27 : Sprain of ankle + 2019-05-15 - 2020-05-20 : Risk activity involvement (finding) +-------------------------------------------------------------------------------- +CARE PLANS: + 2021-02-07[STOPPED] : Physiotherapy care plan (record artifact) + Reason: Sprain of ankle + Activity: Rest, ice, compression and elevation treatment programme + Activity: Stretching exercises +-------------------------------------------------------------------------------- +REPORTS: + 2022-06-01 : Patient Health Questionnaire-9: Modified for Teens [Reported.PHQ.Teen] + - Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen] 2.0 {score} + 2022-06-01 : Generalized anxiety disorder 7 item (GAD-7) + - Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 3.0 {score} + 2021-05-26 : Patient Health Questionnaire-9: Modified for Teens [Reported.PHQ.Teen] + - Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen] 1.0 {score} + 2021-05-26 : Generalized anxiety disorder 7 item (GAD-7) + - Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 1.0 {score} +-------------------------------------------------------------------------------- +OBSERVATIONS: + 2022-06-01 : Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen] 2.0 {score} + 2022-06-01 : Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 3.0 {score} + 2022-06-01 : Tobacco smoking status Never smoked tobacco (finding) + 2022-06-01 : Respiratory rate 12.0 /min + 2022-06-01 : Heart rate 87.0 /min + 2022-06-01 : Blood Pressure + - Diastolic Blood Pressure 81.0 mm[Hg] + - Systolic Blood Pressure 105.0 mm[Hg] + 2022-06-01 : Body mass index (BMI) [Percentile] Per age and gender 35.4 % + 2022-06-01 : Body Mass Index 19.0 kg/m2 + 2022-06-01 : Body Weight 48.1 kg + 2022-06-01 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 1.0 {score} + 2022-06-01 : Body Height 159.1 cm + 2021-05-26 : Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen] 1.0 {score} + 2021-05-26 : Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 1.0 {score} + 2021-05-26 : Tobacco smoking status Never smoked tobacco (finding) + 2021-05-26 : Respiratory rate 14.0 /min + 2021-05-26 : Heart rate 65.0 /min + 2021-05-26 : Blood Pressure + - Diastolic Blood Pressure 81.0 mm[Hg] + - Systolic Blood Pressure 116.0 mm[Hg] + 2021-05-26 : Body mass index (BMI) [Percentile] Per age and gender 32.3 % + 2021-05-26 : Body Mass Index 18.1 kg/m2 + 2021-05-26 : Body Weight 42.5 kg + 2021-05-26 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 3.0 {score} + 2021-05-26 : Body Height 153.2 cm +-------------------------------------------------------------------------------- +PROCEDURES: + 2022-06-01 : Depression screening using Patient Health Questionnaire Nine Item score (procedure) + 2022-06-01 : Depression screening (procedure) + 2022-06-01 : Assessment of anxiety (procedure) + 2021-05-26 : Health risks education (procedure) for Risk activity involvement (finding) + 2021-05-26 : Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (procedure) + 2021-05-26 : Assessment of substance use (procedure) + 2021-05-26 : Depression screening using Patient Health Questionnaire Nine Item score (procedure) + 2021-05-26 : Depression screening (procedure) + 2021-05-26 : Medication Reconciliation (procedure) + 2021-05-26 : Assessment of anxiety (procedure) +-------------------------------------------------------------------------------- +IMMUNIZATIONS: + 2022-06-01 : Influenza, seasonal, injectable, preservative free + 2021-11-03 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 30 mcg/0.3mL dose + 2021-10-13 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 30 mcg/0.3mL dose + 2021-05-26 : Influenza, seasonal, injectable, preservative free +-------------------------------------------------------------------------------- +ENCOUNTERS: +2022-06-01 (Dr. Odilia Mraz) : Encounter at FAMILY MEDICINE ASSOCIATES +2021-11-03 (Dr. Ahmed Feil) : Encounter at WESTERN MASSACHUSETTS HOSPITAL +2021-10-13 (Dr. Ahmed Feil) : Encounter at WESTERN MASSACHUSETTS HOSPITAL +2021-05-26 (Dr. Odilia Mraz) : Encounter at FAMILY MEDICINE ASSOCIATES +2021-02-07 (Dr. Cherry Hackett) : Encounter at MEMORY SUPPORT OF HERITAGE HALL +2019-05-15 (Dr. Odilia Mraz) : Encounter at FAMILY MEDICINE ASSOCIATES +-------------------------------------------------------------------------------- +IMAGING STUDIES: +--------------------------------------------------------------------------------