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--- a +++ b/data/text/Tabitha_Erdman_1783612e-6ffe-2eff-5575-d0e1666e0312.txt @@ -0,0 +1,205 @@ +Tabitha Erdman +============== +Race: White +Ethnicity: Non-Hispanic +Gender: F +Age: 47 +Birth Date: 1974-12-18 +Marital Status: M +-------------------------------------------------------------------------------- +ALLERGIES: +No Known Allergies +-------------------------------------------------------------------------------- +MEDICATIONS: +-------------------------------------------------------------------------------- +CONDITIONS: + 2022-01-10 - 2022-01-25 : Viral sinusitis (disorder) + 2021-01-06 - : Stress (finding) + 2021-01-06 - : Social isolation (finding) + 2019-01-02 - : Limited social contact (finding) + 2019-01-02 - : Anemia (disorder) + 2019-01-02 - : Prediabetes + 2016-12-28 - 2019-01-02 : Stress (finding) + 2012-03-07 - 2014-12-24 : Stress (finding) + 2008-10-08 - : Body mass index 30+ - obesity (finding) + 2003-07-23 - 2006-03-01 : Stress (finding) + 2000-12-06 - : Miscarriage in first trimester + 2000-02-23 - 2003-02-26 : Stress (finding) + 1999-01-16 - : Drug overdose + 1993-02-10 - 1994-02-16 : Stress (finding) + 1993-02-10 - 2016-12-28 : Limited social contact (finding) + 1993-02-10 - : Unemployed (finding) + 1993-02-10 - : Received certificate of high school equivalency (finding) + 1990-06-14 - : Chronic intractable migraine without aura + 1990-02-02 - : Impacted molars +-------------------------------------------------------------------------------- +CARE PLANS: + 2019-01-02[CURRENT] : Diabetes self management plan + Reason: Prediabetes + Activity: Diabetic diet + Activity: Exercise therapy + 2007-08-08[CURRENT] : Routine antenatal care + Activity: Antenatal education + Activity: Antenatal risk assessment + Activity: Antenatal blood tests + 2002-09-11[STOPPED] : Routine antenatal care + Activity: Antenatal education + Activity: Antenatal risk assessment + Activity: Antenatal blood tests + 1999-01-16[CURRENT] : Care plan (record artifact) + Activity: Drug addiction counseling + Activity: Drug detoxification + Activity: Drug addiction therapy + 1995-11-01[STOPPED] : Routine antenatal care + Activity: Antenatal education + Activity: Antenatal risk assessment + Activity: Antenatal blood tests + 1991-10-16[STOPPED] : Routine antenatal care + Activity: Antenatal education + Activity: Antenatal risk assessment + Activity: Antenatal blood tests +-------------------------------------------------------------------------------- +REPORTS: + 2021-01-07 : Patient Health Questionnaire 2 item (PHQ-2) [Reported] + - Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 1.0 {score} + 2021-01-07 : Humiliation, Afraid, Rape, and Kick questionnaire [HARK] + - Total score [HARK] 0.0 {score} + 2021-01-07 : Generalized anxiety disorder 7 item (GAD-7) + - Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 5.0 {score} + 2021-01-06 : Complete blood count (hemogram) panel - Blood by Automated count + - Leukocytes [#/volume] in Blood by Automated count 5.5 10*3/uL + - Erythrocytes [#/volume] in Blood by Automated count 4.6 10*6/uL + - Hemoglobin [Mass/volume] in Blood 12.2 g/dL + - Hematocrit [Volume Fraction] of Blood by Automated count 39.2 % + - MCV [Entitic volume] by Automated count 86.3 fL + - MCH [Entitic mass] by Automated count 29.7 pg + - MCHC [Mass/volume] by Automated count 35.1 g/dL + - Erythrocyte distribution width [Entitic volume] by Automated count 42.2 fL + - Platelets [#/volume] in Blood by Automated count 345.5 10*3/uL + - Platelet distribution width [Entitic volume] in Blood by Automated count 331.1 fL + - Platelet mean volume [Entitic volume] in Blood by Automated count 10.9 fL + 2021-01-06 : Lipid Panel + - Total Cholesterol 213.6 mg/dL + - Triglycerides 106.0 mg/dL + - Low Density Lipoprotein Cholesterol 136.7 mg/dL + - High Density Lipoprotein Cholesterol 55.7 mg/dL + 2021-01-06 : Basic Metabolic Panel + - Glucose 84.1 mg/dL + - Urea Nitrogen 18.5 mg/dL + - Creatinine 0.8 mg/dL + - Calcium 8.9 mg/dL + - Sodium 142.3 mmol/L + - Potassium 4.3 mmol/L + - Chloride 110.7 mmol/L + - Carbon Dioxide 23.3 mmol/L +-------------------------------------------------------------------------------- +OBSERVATIONS: + 2021-01-07 : Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 1.0 {score} + 2021-01-07 : Total score [HARK] 0.0 {score} + 2021-01-07 : Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 5.0 {score} + 2021-01-06 : Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE] + - In the past year, have you been afraid of your partner or ex-partner? No + - Do you feel physically and emotionally safe where you currently live? Yes + - Are you a refugee? No + - In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility? No + - Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you? Somewhat + - How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)? Less than once a week + - Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? No + - In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? Food + - During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any benefits. 4586 /a + - What is your main insurance? Medicaid + - What is your current work situation? Unemployed (finding) + - What is the highest level of school that you have finished? High school diploma or GED + - What address do you live at? 1086 Langworth Station + - Are you worried about losing your housing? No + - What is your housing situation today? I have housing + - How many family members, including yourself, do you currently live with? 5.0 {#} + - What language are you most comfortable speaking? English + - Have you been discharged from the armed forces of the United States? No + - At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income? No + - Which race(s) are you? White + - Are you Hispanic or Latino? No + 2021-01-06 : Hemoglobin A1c/Hemoglobin.total in Blood 6.2 % + 2021-01-06 : Tobacco smoking status Never smoked tobacco (finding) + 2021-01-06 : Platelet mean volume [Entitic volume] in Blood by Automated count 10.9 fL + 2021-01-06 : Platelet distribution width [Entitic volume] in Blood by Automated count 331.1 fL + 2021-01-06 : Platelets [#/volume] in Blood by Automated count 345.5 10*3/uL + 2021-01-06 : Erythrocyte distribution width [Entitic volume] by Automated count 42.2 fL + 2021-01-06 : MCHC [Mass/volume] by Automated count 35.1 g/dL + 2021-01-06 : MCH [Entitic mass] by Automated count 29.7 pg + 2021-01-06 : MCV [Entitic volume] by Automated count 86.3 fL + 2021-01-06 : Hematocrit [Volume Fraction] of Blood by Automated count 39.2 % + 2021-01-06 : Hemoglobin [Mass/volume] in Blood 12.2 g/dL + 2021-01-06 : Erythrocytes [#/volume] in Blood by Automated count 4.6 10*6/uL + 2021-01-06 : Leukocytes [#/volume] in Blood by Automated count 5.5 10*3/uL + 2021-01-06 : High Density Lipoprotein Cholesterol 55.7 mg/dL + 2021-01-06 : Low Density Lipoprotein Cholesterol 136.7 mg/dL + 2021-01-06 : Triglycerides 106.0 mg/dL + 2021-01-06 : Total Cholesterol 213.6 mg/dL + 2021-01-06 : Carbon Dioxide 23.3 mmol/L + 2021-01-06 : Chloride 110.7 mmol/L + 2021-01-06 : Potassium 4.3 mmol/L + 2021-01-06 : Sodium 142.3 mmol/L + 2021-01-06 : Calcium 8.9 mg/dL + 2021-01-06 : Creatinine 0.8 mg/dL + 2021-01-06 : Urea Nitrogen 18.5 mg/dL + 2021-01-06 : Glucose 84.1 mg/dL + 2021-01-06 : Respiratory rate 15.0 /min + 2021-01-06 : Heart rate 75.0 /min + 2021-01-06 : Blood Pressure + - Diastolic Blood Pressure 85.0 mm[Hg] + - Systolic Blood Pressure 121.0 mm[Hg] + 2021-01-06 : Body Mass Index 27.9 kg/m2 + 2021-01-06 : Body Weight 71.8 kg + 2021-01-06 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 2.0 {score} + 2021-01-06 : Body Height 160.3 cm +-------------------------------------------------------------------------------- +PROCEDURES: + 2021-01-07 : Depression screening using Patient Health Questionnaire Two-Item score (procedure) + 2021-01-07 : Depression screening (procedure) + 2021-01-07 : Screening for domestic abuse (procedure) + 2021-01-06 : Assessment of anxiety (procedure) + 2021-01-06 : Medication Reconciliation (procedure) + 2021-01-06 : Assessment of health and social care needs (procedure) +-------------------------------------------------------------------------------- +IMMUNIZATIONS: + 2022-01-12 : Influenza, seasonal, injectable, preservative free + 2021-02-10 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 30 mcg/0.3mL dose + 2021-01-20 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 30 mcg/0.3mL dose + 2021-01-06 : Influenza, seasonal, injectable, preservative free +-------------------------------------------------------------------------------- +ENCOUNTERS: +2022-12-02 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2022-11-02 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2022-10-03 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2022-01-10 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC : Encounter for Viral sinusitis (disorder) +2022-01-12 (Dr. Jewel Kassulke) : Encounter at BARRINGTON URGENT CARE PC +2021-12-25 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2021-11-25 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2021-10-26 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2021-09-26 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2021-08-27 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2021-07-28 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2021-06-28 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2021-02-10 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2021-01-20 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2021-01-06 (Dr. Erwin Stiedemann) : Encounter at NEW BEDFORD INTERNAL MEDICINE & GERIATRICS, LLC +2019-01-02 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC : Encounter for Anemia (disorder) +2019-01-02 (Dr. Erwin Stiedemann) : Encounter at NEW BEDFORD INTERNAL MEDICINE & GERIATRICS, LLC +2016-12-28 (Dr. Erwin Stiedemann) : Encounter at NEW BEDFORD INTERNAL MEDICINE & GERIATRICS, LLC +2012-03-07 (Dr. Erwin Stiedemann) : Encounter at NEW BEDFORD INTERNAL MEDICINE & GERIATRICS, LLC +2008-10-08 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC +2007-08-08 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC : Encounter for Normal pregnancy +2003-07-17 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC : Encounter for Streptococcal sore throat (disorder) +2002-09-11 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC : Encounter for Normal pregnancy +2000-12-06 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC : Encounter for Normal pregnancy +2000-02-23 (Dr. Erwin Stiedemann) : Encounter at NEW BEDFORD INTERNAL MEDICINE & GERIATRICS, LLC +1999-01-16 (Dr. Orpha Marks) : Encounter at HATHAWAY MANOR EXTENDED CARE : Encounter for Drug overdose +1995-11-01 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC : Encounter for Normal pregnancy +1993-02-10 (Dr. Erwin Stiedemann) : Encounter at NEW BEDFORD INTERNAL MEDICINE & GERIATRICS, LLC +1991-10-16 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC : Encounter for Normal pregnancy +1990-06-14 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC : Encounter for Chronic intractable migraine without aura +1990-02-02 (Dr. Jerónimo Berríos) : Encounter at AP MEDICAL LLC : Encounter for Impacted molars +-------------------------------------------------------------------------------- +IMAGING STUDIES: +--------------------------------------------------------------------------------