--- a +++ b/data/text/Trey_Fahey_08d860d1-77f3-8240-bda6-b893d6ad6c3b.txt @@ -0,0 +1,107 @@ +Trey Fahey +========== +Race: White +Ethnicity: Non-Hispanic +Gender: M +Age: 12 +Birth Date: 2010-04-17 +Marital Status: S +-------------------------------------------------------------------------------- +ALLERGIES: +No Known Allergies +-------------------------------------------------------------------------------- +MEDICATIONS: +-------------------------------------------------------------------------------- +CONDITIONS: + 2022-08-18 - 2022-08-30 : Acute viral pharyngitis (disorder) + 2022-05-07 - : Risk activity involvement (finding) + 2021-02-25 - 2021-03-08 : Viral sinusitis (disorder) +-------------------------------------------------------------------------------- +CARE PLANS: +-------------------------------------------------------------------------------- +REPORTS: + 2022-05-07 : 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} + 2022-05-07 : Generalized anxiety disorder 7 item (GAD-7) + - Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 4.0 {score} + 2021-05-01 : Complete blood count (hemogram) panel - Blood by Automated count + - Leukocytes [#/volume] in Blood by Automated count 5.7 10*3/uL + - Erythrocytes [#/volume] in Blood by Automated count 5.0 10*6/uL + - Hemoglobin [Mass/volume] in Blood 13.0 g/dL + - Hematocrit [Volume Fraction] of Blood by Automated count 47.3 % + - MCV [Entitic volume] by Automated count 91.9 fL + - MCH [Entitic mass] by Automated count 32.8 pg + - MCHC [Mass/volume] by Automated count 35.7 g/dL + - Erythrocyte distribution width [Entitic volume] by Automated count 44.9 fL + - Platelets [#/volume] in Blood by Automated count 340.3 10*3/uL + - Platelet distribution width [Entitic volume] in Blood by Automated count 426.8 fL + - Platelet mean volume [Entitic volume] in Blood by Automated count 10.7 fL +-------------------------------------------------------------------------------- +OBSERVATIONS: + 2022-08-18 : Body temperature 37.9 Cel + 2022-05-07 : Patient Health Questionnaire-9: Modified for Teens total score [Reported.PHQ.Teen] 1.0 {score} + 2022-05-07 : Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 4.0 {score} + 2022-05-07 : Tobacco smoking status Never smoked tobacco (finding) + 2022-05-07 : Respiratory rate 15.0 /min + 2022-05-07 : Heart rate 68.0 /min + 2022-05-07 : Blood Pressure + - Diastolic Blood Pressure 86.0 mm[Hg] + - Systolic Blood Pressure 145.0 mm[Hg] + 2022-05-07 : Body mass index (BMI) [Percentile] Per age and gender 45.5 % + 2022-05-07 : Body Mass Index 17.6 kg/m2 + 2022-05-07 : Body Weight 40.3 kg + 2022-05-07 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 0.0 {score} + 2022-05-07 : Body Height 151.6 cm + 2021-05-01 : Tobacco smoking status Never smoked tobacco (finding) + 2021-05-01 : Platelet mean volume [Entitic volume] in Blood by Automated count 10.7 fL + 2021-05-01 : Platelet distribution width [Entitic volume] in Blood by Automated count 426.8 fL + 2021-05-01 : Platelets [#/volume] in Blood by Automated count 340.3 10*3/uL + 2021-05-01 : Erythrocyte distribution width [Entitic volume] by Automated count 44.9 fL + 2021-05-01 : MCHC [Mass/volume] by Automated count 35.7 g/dL + 2021-05-01 : MCH [Entitic mass] by Automated count 32.8 pg + 2021-05-01 : MCV [Entitic volume] by Automated count 91.9 fL + 2021-05-01 : Hematocrit [Volume Fraction] of Blood by Automated count 47.3 % + 2021-05-01 : Hemoglobin [Mass/volume] in Blood 13.0 g/dL + 2021-05-01 : Erythrocytes [#/volume] in Blood by Automated count 5.0 10*6/uL + 2021-05-01 : Leukocytes [#/volume] in Blood by Automated count 5.7 10*3/uL + 2021-05-01 : Respiratory rate 12.0 /min + 2021-05-01 : Heart rate 86.0 /min + 2021-05-01 : Blood Pressure + - Diastolic Blood Pressure 89.0 mm[Hg] + - Systolic Blood Pressure 140.0 mm[Hg] + 2021-05-01 : Body mass index (BMI) [Percentile] Per age and gender 48.3 % + 2021-05-01 : Body Mass Index 17.1 kg/m2 + 2021-05-01 : Body Weight 36.4 kg + 2021-05-01 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 4.0 {score} + 2021-05-01 : Body Height 145.9 cm +-------------------------------------------------------------------------------- +PROCEDURES: + 2022-08-18 : Throat culture (procedure) for Acute viral pharyngitis (disorder) + 2022-05-07 : Health risks education (procedure) for Risk activity involvement (finding) + 2022-05-07 : Assessment using Car, Relax, Alone, Forget, Friends, Trouble Screening Test (procedure) + 2022-05-07 : Assessment of substance use (procedure) + 2022-05-07 : Depression screening using Patient Health Questionnaire Nine Item score (procedure) + 2022-05-07 : Depression screening (procedure) + 2022-05-07 : Medication Reconciliation (procedure) + 2022-05-07 : Assessment of anxiety (procedure) +-------------------------------------------------------------------------------- +IMMUNIZATIONS: + 2022-06-18 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 30 mcg/0.3mL dose + 2022-05-28 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 30 mcg/0.3mL dose + 2022-05-07 : HPV, quadrivalent + 2022-05-07 : Influenza, seasonal, injectable, preservative free + 2021-05-01 : meningococcal MCV4P + 2021-05-01 : HPV, quadrivalent + 2021-05-01 : Influenza, seasonal, injectable, preservative free + 2021-05-01 : Tdap +-------------------------------------------------------------------------------- +ENCOUNTERS: +2022-08-18 (Dr. Bennett Rippin) : Encounter at MILFORD REGIONAL MEDICAL CENTER : Encounter for Acute viral pharyngitis (disorder) +2022-06-18 (Dr. Bennett Rippin) : Encounter at MILFORD REGIONAL MEDICAL CENTER +2022-05-28 (Dr. Bennett Rippin) : Encounter at MILFORD REGIONAL MEDICAL CENTER +2022-05-07 (Dr. Bea Schiller) : Encounter at PRIMARY CARE FOR ADULTS PLLC +2021-05-01 (Dr. Bea Schiller) : Encounter at PRIMARY CARE FOR ADULTS PLLC +2021-02-25 (Dr. Bennett Rippin) : Encounter at MILFORD REGIONAL MEDICAL CENTER : Encounter for Viral sinusitis (disorder) +-------------------------------------------------------------------------------- +IMAGING STUDIES: +--------------------------------------------------------------------------------