--- a +++ b/data/text/Dean_Lynch_a5889415-30d4-2332-2b15-58af5dfd7672.txt @@ -0,0 +1,104 @@ +Dean Lynch +========== +Race: White +Ethnicity: Non-Hispanic +Gender: M +Age: 17 +Birth Date: 2005-03-24 +Marital Status: S +-------------------------------------------------------------------------------- +ALLERGIES: +No Known Allergies +-------------------------------------------------------------------------------- +MEDICATIONS: + 2021-01-11[STOPPED] : Acetaminophen 325 MG Oral Tablet +-------------------------------------------------------------------------------- +CONDITIONS: + 2021-01-11 - 2021-01-27 : Sprain of wrist +-------------------------------------------------------------------------------- +CARE PLANS: + 2021-01-11[STOPPED] : Physiotherapy care plan (record artifact) + Reason: Sprain of wrist + Activity: Rest, ice, compression and elevation treatment programme + Activity: Stretching exercises +-------------------------------------------------------------------------------- +REPORTS: + 2022-05-12 : 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} + 2021-05-06 : 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} + 2021-05-06 : Generalized anxiety disorder 7 item (GAD-7) + - Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 3.0 {score} + 2021-05-06 : Complete blood count (hemogram) panel - Blood by Automated count + - Leukocytes [#/volume] in Blood by Automated count 7.0 10*3/uL + - Erythrocytes [#/volume] in Blood by Automated count 4.9 10*6/uL + - Hemoglobin [Mass/volume] in Blood 13.1 g/dL + - Hematocrit [Volume Fraction] of Blood by Automated count 43.2 % + - MCV [Entitic volume] by Automated count 84.9 fL + - MCH [Entitic mass] by Automated count 28.2 pg + - MCHC [Mass/volume] by Automated count 33.5 g/dL + - Erythrocyte distribution width [Entitic volume] by Automated count 42.7 fL + - Platelets [#/volume] in Blood by Automated count 439.0 10*3/uL + - Platelet distribution width [Entitic volume] in Blood by Automated count 314.7 fL + - Platelet mean volume [Entitic volume] in Blood by Automated count 10.2 fL +-------------------------------------------------------------------------------- +OBSERVATIONS: + 2022-05-12 : Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen] 1.0 {score} + 2022-05-12 : Tobacco smoking status Never smoked tobacco (finding) + 2022-05-12 : Respiratory rate 13.0 /min + 2022-05-12 : Heart rate 76.0 /min + 2022-05-12 : Blood Pressure + - Diastolic Blood Pressure 68.0 mm[Hg] + - Systolic Blood Pressure 125.0 mm[Hg] + 2022-05-12 : Body mass index (BMI) [Percentile] Per age and gender 70.6 % + 2022-05-12 : Body Mass Index 23.0 kg/m2 + 2022-05-12 : Body Weight 74.6 kg + 2022-05-12 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 1.0 {score} + 2022-05-12 : Body Height 180.1 cm + 2021-05-06 : Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen] 1.0 {score} + 2021-05-06 : Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 3.0 {score} + 2021-05-06 : Tobacco smoking status Never smoked tobacco (finding) + 2021-05-06 : Platelet mean volume [Entitic volume] in Blood by Automated count 10.2 fL + 2021-05-06 : Platelet distribution width [Entitic volume] in Blood by Automated count 314.7 fL + 2021-05-06 : Platelets [#/volume] in Blood by Automated count 439.0 10*3/uL + 2021-05-06 : Erythrocyte distribution width [Entitic volume] by Automated count 42.7 fL + 2021-05-06 : MCHC [Mass/volume] by Automated count 33.5 g/dL + 2021-05-06 : MCH [Entitic mass] by Automated count 28.2 pg + 2021-05-06 : MCV [Entitic volume] by Automated count 84.9 fL + 2021-05-06 : Hematocrit [Volume Fraction] of Blood by Automated count 43.2 % + 2021-05-06 : Hemoglobin [Mass/volume] in Blood 13.1 g/dL + 2021-05-06 : Erythrocytes [#/volume] in Blood by Automated count 4.9 10*6/uL + 2021-05-06 : Leukocytes [#/volume] in Blood by Automated count 7.0 10*3/uL + 2021-05-06 : Respiratory rate 16.0 /min + 2021-05-06 : Heart rate 78.0 /min + 2021-05-06 : Blood Pressure + - Diastolic Blood Pressure 72.0 mm[Hg] + - Systolic Blood Pressure 130.0 mm[Hg] + 2021-05-06 : Body mass index (BMI) [Percentile] Per age and gender 69.6 % + 2021-05-06 : Body Mass Index 22.2 kg/m2 + 2021-05-06 : Body Weight 70.8 kg + 2021-05-06 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 3.0 {score} + 2021-05-06 : Body Height 178.5 cm +-------------------------------------------------------------------------------- +PROCEDURES: + 2022-05-12 : Depression screening using Patient Health Questionnaire Nine Item score (procedure) + 2022-05-12 : Depression screening (procedure) + 2021-05-06 : Anticipatory guidance (procedure) + 2021-05-06 : Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (procedure) + 2021-05-06 : Assessment of substance use (procedure) + 2021-05-06 : Depression screening using Patient Health Questionnaire Nine Item score (procedure) + 2021-05-06 : Depression screening (procedure) + 2021-05-06 : Assessment of anxiety (procedure) +-------------------------------------------------------------------------------- +IMMUNIZATIONS: + 2022-05-12 : Influenza, seasonal, injectable, preservative free + 2021-05-06 : meningococcal MCV4P + 2021-05-06 : Influenza, seasonal, injectable, preservative free +-------------------------------------------------------------------------------- +ENCOUNTERS: +2022-05-12 (Dr. Shawn Padberg) : Encounter at RISE ABOVE WELLNESS HEALTH SERVICES LLC +2021-05-06 (Dr. Shawn Padberg) : Encounter at RISE ABOVE WELLNESS HEALTH SERVICES LLC +2021-01-11 (Dr. Kerrie Bergstrom) : Encounter at LIFE CARE CENTER OF ATTLEBORO +-------------------------------------------------------------------------------- +IMAGING STUDIES: +--------------------------------------------------------------------------------