--- a +++ b/data/text/Darin_Aufderhar_0edd2356-2fc3-4bc3-6aa5-05b69395296c.txt @@ -0,0 +1,171 @@ +Darin Aufderhar +=============== +Race: White +Ethnicity: Non-Hispanic +Gender: M +Age: 58 +Birth Date: 1964-10-15 +Marital Status: M +-------------------------------------------------------------------------------- +ALLERGIES: +No Known Allergies +-------------------------------------------------------------------------------- +MEDICATIONS: + 2020-12-15[STOPPED] : Naproxen sodium 220 MG Oral Tablet + 2014-03-25[CURRENT] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2014-02-01[CURRENT] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2012-04-05[CURRENT] : Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray + 2012-04-05[CURRENT] : 24 HR metoprolol succinate 100 MG Extended Release Oral Tablet + 2012-04-05[CURRENT] : Simvastatin 20 MG Oral Tablet + 2012-04-05[CURRENT] : Clopidogrel 75 MG Oral Tablet + 2012-03-29[CURRENT] : insulin human, isophane 70 UNT/ML / Regular Insulin, Human 30 UNT/ML Injectable Suspension [Humulin] for Prediabetes + 2012-03-29[CURRENT] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2011-03-24[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2010-03-18[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2009-03-12[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2008-03-06[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2007-03-01[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2006-02-23[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2005-02-17[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2004-02-12[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2003-02-06[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2002-01-31[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2001-01-25[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 2000-01-20[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 1999-01-14[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 1998-01-08[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 1997-01-02[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 1995-12-28[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension + 1995-12-28[STOPPED] : amLODIPine 2.5 MG Oral Tablet for Hypertension +-------------------------------------------------------------------------------- +CONDITIONS: + 2021-01-09 - 2021-02-01 : COVID-19 + 2021-01-09 - 2021-01-09 : Suspected COVID-19 + 2021-01-09 - 2021-02-01 : Fever (finding) + 2021-01-09 - 2021-02-01 : Sputum finding (finding) + 2021-01-09 - 2021-02-01 : Cough (finding) + 2020-12-15 - 2021-03-20 : Fracture of forearm + 2014-02-01 - : Chronic neck pain (finding) + 2014-02-01 - : Chronic low back pain (finding) + 2012-04-09 - : Abnormal findings diagnostic imaging heart+coronary circulat (finding) + 2012-03-29 - : Part-time employment (finding) + 2012-03-29 - : Diabetic renal disease (disorder) + 2012-03-29 - : Chronic kidney disease stage 1 (disorder) + 2012-03-29 - : Ischemic heart disease (disorder) + 2010-03-18 - 2011-03-24 : Part-time employment (finding) + 2007-03-01 - : Has a criminal record (finding) + 2006-02-23 - : Metabolic syndrome X (disorder) + 2005-02-17 - : Body mass index 30+ - obesity (finding) + 2003-02-06 - 2004-02-12 : Part-time employment (finding) + 2001-01-25 - 2002-01-31 : Part-time employment (finding) + 2000-01-20 - 2001-01-25 : Part-time employment (finding) + 1995-12-28 - : Hypertension + 1989-12-21 - 1992-12-24 : Part-time employment (finding) + 1989-12-21 - : Anemia (disorder) + 1989-12-21 - : Prediabetes + 1982-12-09 - : Received higher education (finding) +-------------------------------------------------------------------------------- +CARE PLANS: + 2021-01-09[STOPPED] : Infectious disease care plan (record artifact) + Activity: Airborne precautions (procedure) + Activity: Isolation of infected patient (procedure) + 2021-01-09[STOPPED] : Infectious disease care plan (record artifact) + Activity: Airborne precautions (procedure) + Activity: Personal protective equipment (physical object) + 2020-12-15[STOPPED] : Fracture care + Reason: Fracture of forearm + Activity: Recommendation to rest + Activity: Physical activity target light exercise + 2014-03-25[CURRENT] : Therapy (regime/therapy) + Activity: Physical therapy procedure (regime/therapy) + Activity: Cognitive and behavioral therapy (regime/therapy) + 1995-12-28[CURRENT] : Lifestyle education regarding hypertension + Reason: Hypertension + Activity: Prescribed activity/exercise education + Activity: Counseling about alcohol consumption + Activity: Dietary approaches to stop hypertension diet + Activity: Smoking cessation education + 1989-12-21[CURRENT] : Diabetes self management plan + Reason: Prediabetes + Activity: Diabetic diet + Activity: Exercise therapy +-------------------------------------------------------------------------------- +REPORTS: + 2021-01-09 : SARS-CoV-2 RNA Pnl Resp NAA+probe + - SARS-CoV-2 RNA Pnl Resp NAA+probe Detected (qualifier value) + 2021-01-09 : Respiratory pathogens DNA and RNA panel - Respiratory specimen by NAA with probe detection + - Influenza virus A RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + - Influenza virus B RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + - Respiratory syncytial virus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + - Parainfluenza virus 1 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + - Parainfluenza virus 2 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + - Parainfluenza virus 3 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + - Rhinovirus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + - Human metapneumovirus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + - Adenovirus A+B+C+D+E DNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) +-------------------------------------------------------------------------------- +OBSERVATIONS: + 2021-01-09 : SARS-CoV-2 RNA Pnl Resp NAA+probe Detected (qualifier value) + 2021-01-09 : Adenovirus A+B+C+D+E DNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + 2021-01-09 : Human metapneumovirus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + 2021-01-09 : Rhinovirus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + 2021-01-09 : Parainfluenza virus 3 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + 2021-01-09 : Parainfluenza virus 2 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + 2021-01-09 : Parainfluenza virus 1 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + 2021-01-09 : Respiratory syncytial virus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + 2021-01-09 : Influenza virus B RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + 2021-01-09 : Influenza virus A RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) + 2021-01-09 : Body Weight 91.4 kg + 2021-01-09 : Blood Pressure + - Diastolic Blood Pressure 88.0 mm[Hg] + - Systolic Blood Pressure 128.0 mm[Hg] + 2021-01-09 : Oxygen saturation in Arterial blood 85.3 % + 2021-01-09 : Heart rate 173.9 /min + 2021-01-09 : Respiratory rate 31.3 /min + 2021-01-09 : Body temperature 39.3 Cel + 2020-12-15 : DXA [T-score] Bone density 0.4 {T-score} +-------------------------------------------------------------------------------- +PROCEDURES: + 2021-01-09 : Face mask (physical object) for Suspected COVID-19 + 2020-12-15 : Bone density scan (procedure) for Fracture of forearm + 2020-12-15 : Bone immobilization for Fracture of forearm + 2020-12-15 : Upper arm X-ray +-------------------------------------------------------------------------------- +IMMUNIZATIONS: + 2021-03-04 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 100 mcg/0.5mL dose + 2021-02-04 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 100 mcg/0.5mL dose +-------------------------------------------------------------------------------- +ENCOUNTERS: +2021-03-20 (Dr. Rolande Gerlach) : Encounter at NEW ENGLAND BAPTIST HOSPITAL : Encounter for Fracture of forearm +2021-03-04 (Dr. Rolande Gerlach) : Encounter at NEW ENGLAND BAPTIST HOSPITAL +2021-02-04 (Dr. Rolande Gerlach) : Encounter at NEW ENGLAND BAPTIST HOSPITAL +2021-01-09 (Dr. Rolande Gerlach) : Encounter at NEW ENGLAND BAPTIST HOSPITAL +2020-12-15 (Dr. Lucina Moen) : Encounter at NEWBRIDGE ON THE CHARLES SKILLED NURSING FACILITY +2014-03-25 (Dr. Rolande Gerlach) : Encounter at NEW ENGLAND BAPTIST HOSPITAL +2014-02-01 (Dr. Rolande Gerlach) : Encounter at NEW ENGLAND BAPTIST HOSPITAL +2012-04-09 (Dr. Gabriel Reilly) : Encounter at Fitchburg Outpatient Clinic : Encounter for Ischemic heart disease (disorder) +2012-04-05 (Dr. Gabriel Reilly) : Encounter at Fitchburg Outpatient Clinic : Encounter for Ischemic heart disease (disorder) +2012-03-29 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2011-03-24 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2010-03-18 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2009-03-12 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2008-03-06 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2007-03-01 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2006-02-23 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2005-02-17 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2004-02-12 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2003-02-06 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2002-01-31 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2001-01-25 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +2000-01-20 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +1999-01-14 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +1998-01-08 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +1997-01-02 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +1995-12-28 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +1989-12-21 (Dr. Rolande Gerlach) : Encounter at NEW ENGLAND BAPTIST HOSPITAL : Encounter for Anemia (disorder) +1989-12-21 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +1982-12-09 (Dr. Eugenio Streich) : Encounter at GREATER BOSTON INTERNAL MEDICINE PC +-------------------------------------------------------------------------------- +IMAGING STUDIES: + 2020-12-15 : Digital Radiography, Arm +--------------------------------------------------------------------------------