--- a +++ b/data/text/Ira_Maggio_e1ef5e61-6054-6331-9e38-1aa109870389.txt @@ -0,0 +1,115 @@ +Ira Maggio +========== +Race: White +Ethnicity: Non-Hispanic +Gender: M +Age: 17 +Birth Date: 2005-02-11 +Marital Status: S +-------------------------------------------------------------------------------- +ALLERGIES: +No Known Allergies +-------------------------------------------------------------------------------- +MEDICATIONS: + 2022-02-10[STOPPED] : Ibuprofen 200 MG Oral Tablet + 2021-02-20[STOPPED] : Acetaminophen 325 MG Oral Tablet for Acute bronchitis (disorder) +-------------------------------------------------------------------------------- +CONDITIONS: + 2022-02-10 - 2022-02-28 : Laceration of forearm + 2021-02-20 - 2021-03-10 : Acute bronchitis (disorder) +-------------------------------------------------------------------------------- +CARE PLANS: + 2022-02-10[STOPPED] : Wound care + Reason: Laceration of forearm + Activity: Dressing change management + Activity: Behavior to prevent infection + 2021-02-20[STOPPED] : Respiratory therapy + Activity: Recommendation to avoid exercise + Activity: Deep breathing and coughing exercises +-------------------------------------------------------------------------------- +REPORTS: + 2022-04-01 : 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} + 2022-04-01 : Generalized anxiety disorder 7 item (GAD-7) + - Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 4.0 {score} + 2021-03-26 : Complete blood count (hemogram) panel - Blood by Automated count + - Leukocytes [#/volume] in Blood by Automated count 4.4 10*3/uL + - Erythrocytes [#/volume] in Blood by Automated count 5.4 10*6/uL + - Hemoglobin [Mass/volume] in Blood 12.5 g/dL + - Hematocrit [Volume Fraction] of Blood by Automated count 40.7 % + - MCV [Entitic volume] by Automated count 86.6 fL + - MCH [Entitic mass] by Automated count 27.5 pg + - MCHC [Mass/volume] by Automated count 33.4 g/dL + - Erythrocyte distribution width [Entitic volume] by Automated count 45.1 fL + - Platelets [#/volume] in Blood by Automated count 343.3 10*3/uL + - Platelet distribution width [Entitic volume] in Blood by Automated count 517.7 fL + - Platelet mean volume [Entitic volume] in Blood by Automated count 11.9 fL +-------------------------------------------------------------------------------- +OBSERVATIONS: + 2022-04-01 : Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen] 4.0 {score} + 2022-04-01 : Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 4.0 {score} + 2022-04-01 : Tobacco smoking status Ex-smoker (finding) + 2022-04-01 : Respiratory rate 16.0 /min + 2022-04-01 : Heart rate 73.0 /min + 2022-04-01 : Blood Pressure + - Diastolic Blood Pressure 82.0 mm[Hg] + - Systolic Blood Pressure 116.0 mm[Hg] + 2022-04-01 : Body mass index (BMI) [Percentile] Per age and gender 33.5 % + 2022-04-01 : Body Mass Index 20.2 kg/m2 + 2022-04-01 : Body Weight 65.6 kg + 2022-04-01 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 2.0 {score} + 2022-04-01 : Body Height 180.3 cm + 2021-03-26 : Tobacco smoking status Smokes tobacco daily (finding) + 2021-03-26 : Platelet mean volume [Entitic volume] in Blood by Automated count 11.9 fL + 2021-03-26 : Platelet distribution width [Entitic volume] in Blood by Automated count 517.7 fL + 2021-03-26 : Platelets [#/volume] in Blood by Automated count 343.3 10*3/uL + 2021-03-26 : Erythrocyte distribution width [Entitic volume] by Automated count 45.1 fL + 2021-03-26 : MCHC [Mass/volume] by Automated count 33.4 g/dL + 2021-03-26 : MCH [Entitic mass] by Automated count 27.5 pg + 2021-03-26 : MCV [Entitic volume] by Automated count 86.6 fL + 2021-03-26 : Hematocrit [Volume Fraction] of Blood by Automated count 40.7 % + 2021-03-26 : Hemoglobin [Mass/volume] in Blood 12.5 g/dL + 2021-03-26 : Erythrocytes [#/volume] in Blood by Automated count 5.4 10*6/uL + 2021-03-26 : Leukocytes [#/volume] in Blood by Automated count 4.4 10*3/uL + 2021-03-26 : Respiratory rate 15.0 /min + 2021-03-26 : Heart rate 83.0 /min + 2021-03-26 : Blood Pressure + - Diastolic Blood Pressure 84.0 mm[Hg] + - Systolic Blood Pressure 112.0 mm[Hg] + 2021-03-26 : Body mass index (BMI) [Percentile] Per age and gender 29.5 % + 2021-03-26 : Body Mass Index 19.3 kg/m2 + 2021-03-26 : Body Weight 61.6 kg + 2021-03-26 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 0.0 {score} + 2021-03-26 : Body Height 178.8 cm +-------------------------------------------------------------------------------- +PROCEDURES: + 2022-04-01 : Anticipatory guidance (procedure) + 2022-04-01 : Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (procedure) + 2022-04-01 : Assessment of substance use (procedure) + 2022-04-01 : Depression screening using Patient Health Questionnaire Nine Item score (procedure) + 2022-04-01 : Depression screening (procedure) + 2022-04-01 : Assessment of anxiety (procedure) + 2022-02-10 : Injection of tetanus antitoxin for Laceration of forearm + 2022-02-10 : Suture open wound for Laceration of forearm + 2021-03-26 : Anticipatory guidance (procedure) + 2021-03-26 : Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (procedure) + 2021-03-26 : Assessment of substance use (procedure) + 2021-02-20 : Sputum examination (procedure) for Acute bronchitis (disorder) +-------------------------------------------------------------------------------- +IMMUNIZATIONS: + 2022-04-01 : Influenza, seasonal, injectable, preservative free + 2021-05-21 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 30 mcg/0.3mL dose + 2021-04-30 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 30 mcg/0.3mL dose + 2021-03-26 : meningococcal MCV4P + 2021-03-26 : Influenza, seasonal, injectable, preservative free +-------------------------------------------------------------------------------- +ENCOUNTERS: +2022-04-01 (Dr. Clare Marquardt) : Encounter at HEALTHY CONCEPT FAMILY PRACTICE, LLC +2022-02-10 (Dr. Ramiro Llamas) : Encounter at OVERLOOK MASONIC HEALTH CENTER +2021-05-21 (Dr. Logan Fisher) : Encounter at BAYSTATE MEDICAL CENTER +2021-04-30 (Dr. Logan Fisher) : Encounter at BAYSTATE MEDICAL CENTER +2021-03-26 (Dr. Clare Marquardt) : Encounter at HEALTHY CONCEPT FAMILY PRACTICE, LLC +2021-02-20 (Dr. Logan Fisher) : Encounter at BAYSTATE MEDICAL CENTER : Encounter for Acute bronchitis (disorder) +-------------------------------------------------------------------------------- +IMAGING STUDIES: +--------------------------------------------------------------------------------