--- a +++ b/data/text/Caleb_Jacobi_1b2a85df-dc1a-1993-87fb-e33914f3be4d.txt @@ -0,0 +1,83 @@ +Caleb Jacobi +============ +Race: White +Ethnicity: Non-Hispanic +Gender: M +Age: 12 +Birth Date: 2010-11-23 +Marital Status: S +-------------------------------------------------------------------------------- +ALLERGIES: +No Known Allergies +-------------------------------------------------------------------------------- +MEDICATIONS: +-------------------------------------------------------------------------------- +CONDITIONS: + 2022-09-28 - : Concussion with no loss of consciousness + 2020-08-16 - 2020-11-06 : Concussion with no loss of consciousness + 2018-03-09 - : Chronic sinusitis (disorder) +-------------------------------------------------------------------------------- +CARE PLANS: + 2022-09-28[CURRENT] : Head injury rehabilitation + Reason: Concussion with no loss of consciousness + Activity: Recommendation to rest + Activity: Alcohol-free diet + 2020-08-16[STOPPED] : Head injury rehabilitation + Reason: Concussion with no loss of consciousness + Activity: Recommendation to rest + Activity: Alcohol-free diet +-------------------------------------------------------------------------------- +REPORTS: + 2021-12-07 : Complete blood count (hemogram) panel - Blood by Automated count + - Leukocytes [#/volume] in Blood by Automated count 9.8 10*3/uL + - Erythrocytes [#/volume] in Blood by Automated count 4.5 10*6/uL + - Hemoglobin [Mass/volume] in Blood 12.9 g/dL + - Hematocrit [Volume Fraction] of Blood by Automated count 46.3 % + - MCV [Entitic volume] by Automated count 93.4 fL + - MCH [Entitic mass] by Automated count 32.0 pg + - MCHC [Mass/volume] by Automated count 35.0 g/dL + - Erythrocyte distribution width [Entitic volume] by Automated count 42.5 fL + - Platelets [#/volume] in Blood by Automated count 218.9 10*3/uL + - Platelet distribution width [Entitic volume] in Blood by Automated count 359.7 fL + - Platelet mean volume [Entitic volume] in Blood by Automated count 10.5 fL +-------------------------------------------------------------------------------- +OBSERVATIONS: + 2021-12-07 : Tobacco smoking status Never smoked tobacco (finding) + 2021-12-07 : Platelet mean volume [Entitic volume] in Blood by Automated count 10.5 fL + 2021-12-07 : Platelet distribution width [Entitic volume] in Blood by Automated count 359.7 fL + 2021-12-07 : Platelets [#/volume] in Blood by Automated count 218.9 10*3/uL + 2021-12-07 : Erythrocyte distribution width [Entitic volume] by Automated count 42.5 fL + 2021-12-07 : MCHC [Mass/volume] by Automated count 35.0 g/dL + 2021-12-07 : MCH [Entitic mass] by Automated count 32.0 pg + 2021-12-07 : MCV [Entitic volume] by Automated count 93.4 fL + 2021-12-07 : Hematocrit [Volume Fraction] of Blood by Automated count 46.3 % + 2021-12-07 : Hemoglobin [Mass/volume] in Blood 12.9 g/dL + 2021-12-07 : Erythrocytes [#/volume] in Blood by Automated count 4.5 10*6/uL + 2021-12-07 : Leukocytes [#/volume] in Blood by Automated count 9.8 10*3/uL + 2021-12-07 : Respiratory rate 14.0 /min + 2021-12-07 : Heart rate 63.0 /min + 2021-12-07 : Blood Pressure + - Diastolic Blood Pressure 74.0 mm[Hg] + - Systolic Blood Pressure 129.0 mm[Hg] + 2021-12-07 : Body mass index (BMI) [Percentile] Per age and gender 66.3 % + 2021-12-07 : Body Mass Index 18.2 kg/m2 + 2021-12-07 : Body Weight 34.6 kg + 2021-12-07 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 1.0 {score} + 2021-12-07 : Body Height 137.9 cm +-------------------------------------------------------------------------------- +PROCEDURES: +-------------------------------------------------------------------------------- +IMMUNIZATIONS: + 2021-12-07 : meningococcal MCV4P + 2021-12-07 : HPV, quadrivalent + 2021-12-07 : Influenza, seasonal, injectable, preservative free + 2021-12-07 : Tdap +-------------------------------------------------------------------------------- +ENCOUNTERS: +2022-09-28 (Dr. Maira Carter) : Encounter at ALLIANCE HEALTH AT MARIE ESTHER +2021-12-07 (Dr. Kayce Ondricka) : Encounter at COMPASSIONATE CARE INTERNAL MEDICINE, LLC +2020-08-16 (Dr. Maira Carter) : Encounter at ALLIANCE HEALTH AT MARIE ESTHER +2018-03-09 (Dr. Nickolas Schumm) : Encounter at ENCOMPASS HEALTH BRAINTREE HOSPITAL OF BRAINTREE : Encounter for Acute bacterial sinusitis (disorder) +-------------------------------------------------------------------------------- +IMAGING STUDIES: +--------------------------------------------------------------------------------