--- a +++ b/data/text/Elana_Goodwin_f8f30359-d447-d395-af25-568820325e55.txt @@ -0,0 +1,110 @@ +Elana Goodwin +============= +Race: White +Ethnicity: Non-Hispanic +Gender: F +Age: 16 +Birth Date: 2006-05-22 +Marital Status: S +-------------------------------------------------------------------------------- +ALLERGIES: +No Known Allergies +-------------------------------------------------------------------------------- +MEDICATIONS: + 2021-08-31[STOPPED] : Naproxen sodium 220 MG Oral Tablet + 2021-05-03[STOPPED] : Naproxen sodium 220 MG Oral Tablet + 2021-05-03[STOPPED] : Amoxicillin 250 MG Oral Capsule +-------------------------------------------------------------------------------- +CONDITIONS: + 2021-08-31 - 2021-10-05 : Sprain of ankle + 2021-05-03 - 2021-06-28 : Otitis media +-------------------------------------------------------------------------------- +CARE PLANS: + 2021-08-31[STOPPED] : Physiotherapy care plan (record artifact) + Reason: Sprain of ankle + Activity: Rest, ice, compression and elevation treatment programme + Activity: Stretching exercises +-------------------------------------------------------------------------------- +REPORTS: + 2022-07-04 : Patient Health Questionnaire-9: Modified for Teens [Reported.PHQ.Teen] + - Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen] 4.0 {score} + 2022-07-04 : Complete blood count (hemogram) panel - Blood by Automated count + - Leukocytes [#/volume] in Blood by Automated count 4.6 10*3/uL + - Erythrocytes [#/volume] in Blood by Automated count 4.7 10*6/uL + - Hemoglobin [Mass/volume] in Blood 15.4 g/dL + - Hematocrit [Volume Fraction] of Blood by Automated count 36.8 % + - MCV [Entitic volume] by Automated count 90.8 fL + - MCH [Entitic mass] by Automated count 30.6 pg + - MCHC [Mass/volume] by Automated count 34.1 g/dL + - Erythrocyte distribution width [Entitic volume] by Automated count 44.8 fL + - Platelets [#/volume] in Blood by Automated count 156.6 10*3/uL + - Platelet distribution width [Entitic volume] in Blood by Automated count 252.7 fL + - Platelet mean volume [Entitic volume] in Blood by Automated count 11.2 fL + 2021-06-28 : Generalized anxiety disorder 7 item (GAD-7) + - Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 1.0 {score} +-------------------------------------------------------------------------------- +OBSERVATIONS: + 2022-07-04 : Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen] 4.0 {score} + 2022-07-04 : Tobacco smoking status Never smoked tobacco (finding) + 2022-07-04 : Platelet mean volume [Entitic volume] in Blood by Automated count 11.2 fL + 2022-07-04 : Platelet distribution width [Entitic volume] in Blood by Automated count 252.7 fL + 2022-07-04 : Platelets [#/volume] in Blood by Automated count 156.6 10*3/uL + 2022-07-04 : Erythrocyte distribution width [Entitic volume] by Automated count 44.8 fL + 2022-07-04 : MCHC [Mass/volume] by Automated count 34.1 g/dL + 2022-07-04 : MCH [Entitic mass] by Automated count 30.6 pg + 2022-07-04 : MCV [Entitic volume] by Automated count 90.8 fL + 2022-07-04 : Hematocrit [Volume Fraction] of Blood by Automated count 36.8 % + 2022-07-04 : Hemoglobin [Mass/volume] in Blood 15.4 g/dL + 2022-07-04 : Erythrocytes [#/volume] in Blood by Automated count 4.7 10*6/uL + 2022-07-04 : Leukocytes [#/volume] in Blood by Automated count 4.6 10*3/uL + 2022-07-04 : Respiratory rate 14.0 /min + 2022-07-04 : Heart rate 73.0 /min + 2022-07-04 : Blood Pressure + - Diastolic Blood Pressure 86.0 mm[Hg] + - Systolic Blood Pressure 123.0 mm[Hg] + 2022-07-04 : Body mass index (BMI) [Percentile] Per age and gender 78.4 % + 2022-07-04 : Body Mass Index 23.5 kg/m2 + 2022-07-04 : Body Weight 62.0 kg + 2022-07-04 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 2.0 {score} + 2022-07-04 : Body Height 162.6 cm + 2021-06-28 : Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 1.0 {score} + 2021-06-28 : Tobacco smoking status Never smoked tobacco (finding) + 2021-06-28 : Respiratory rate 13.0 /min + 2021-06-28 : Heart rate 92.0 /min + 2021-06-28 : Blood Pressure + - Diastolic Blood Pressure 87.0 mm[Hg] + - Systolic Blood Pressure 132.0 mm[Hg] + 2021-06-28 : Body mass index (BMI) [Percentile] Per age and gender 78.0 % + 2021-06-28 : Body Mass Index 22.8 kg/m2 + 2021-06-28 : Body Weight 59.8 kg + 2021-06-28 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 1.0 {score} + 2021-06-28 : Body Height 162.0 cm +-------------------------------------------------------------------------------- +PROCEDURES: + 2022-07-04 : Anticipatory guidance (procedure) + 2022-07-04 : Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (procedure) + 2022-07-04 : Assessment of substance use (procedure) + 2022-07-04 : Depression screening using Patient Health Questionnaire Nine Item score (procedure) + 2022-07-04 : Depression screening (procedure) + 2021-06-28 : Anticipatory guidance (procedure) + 2021-06-28 : Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (procedure) + 2021-06-28 : Assessment of substance use (procedure) + 2021-06-28 : Assessment of anxiety (procedure) +-------------------------------------------------------------------------------- +IMMUNIZATIONS: + 2022-07-04 : meningococcal MCV4P + 2022-07-04 : Influenza, seasonal, injectable, preservative free + 2021-12-06 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 100 mcg/0.5mL dose + 2021-11-08 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 100 mcg/0.5mL dose + 2021-06-28 : Influenza, seasonal, injectable, preservative free +-------------------------------------------------------------------------------- +ENCOUNTERS: +2022-07-04 (Dr. Erwin Stiedemann) : Encounter at NEW BEDFORD INTERNAL MEDICINE & GERIATRICS, LLC +2021-12-06 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2021-11-08 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2021-08-31 (Dr. Orpha Marks) : Encounter at HATHAWAY MANOR EXTENDED CARE +2021-06-28 (Dr. Erwin Stiedemann) : Encounter at NEW BEDFORD INTERNAL MEDICINE & GERIATRICS, LLC +2021-05-03 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC : Encounter for Otitis media +-------------------------------------------------------------------------------- +IMAGING STUDIES: +--------------------------------------------------------------------------------