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--- a +++ b/data/text/Wilmer_Von_760a4b17-1dc2-75ca-d26e-0e01dcf0d41d.txt @@ -0,0 +1,322 @@ +Wilmer Von +========== +Race: White +Ethnicity: Non-Hispanic +Gender: M +Age: 30 +Birth Date: 1992-12-06 +Marital Status: M +-------------------------------------------------------------------------------- +ALLERGIES: +No Known Allergies +-------------------------------------------------------------------------------- +MEDICATIONS: + 2022-08-14[CURRENT] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2022-08-14[CURRENT] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2022-08-14[CURRENT] : lisinopril 10 MG Oral Tablet for Hypertension + 2022-04-03[STOPPED] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2022-04-03[STOPPED] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2022-04-03[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2021-03-28[STOPPED] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2021-03-28[STOPPED] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2021-03-28[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2020-11-15[STOPPED] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2020-11-15[STOPPED] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2020-11-15[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2020-03-22[STOPPED] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2020-03-22[STOPPED] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2020-03-22[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2019-03-17[STOPPED] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2019-03-17[STOPPED] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2019-03-17[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2018-03-11[STOPPED] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2018-03-11[STOPPED] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2018-03-11[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2017-03-05[STOPPED] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2017-03-05[STOPPED] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2017-03-05[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2016-02-28[STOPPED] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2016-02-28[STOPPED] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2016-02-28[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2015-02-22[STOPPED] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2015-02-22[STOPPED] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2015-02-22[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2014-03-17[STOPPED] : 12 HR Hydrocodone Bitartrate 10 MG Extended Release Oral Capsule + 2014-02-16[STOPPED] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2014-02-16[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2014-02-04[STOPPED] : Acetaminophen 300 MG / Hydrocodone Bitartrate 5 MG Oral Tablet + 2013-02-10[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2013-02-10[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2012-02-05[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension + 2012-02-05[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension +-------------------------------------------------------------------------------- +CONDITIONS: + 2022-08-14 - : Reports of violence in the environment (finding) + 2022-08-14 - : Part-time employment (finding) + 2022-08-07 - 2022-08-15 : Acute viral pharyngitis (disorder) + 2022-04-03 - 2022-08-14 : Full-time employment (finding) + 2021-03-28 - : Stress (finding) + 2021-03-28 - 2022-08-14 : Limited social contact (finding) + 2021-03-28 - 2022-04-03 : Part-time employment (finding) + 2020-11-15 - 2021-03-28 : Part-time employment (finding) + 2020-03-22 - 2020-11-15 : Part-time employment (finding) + 2019-03-17 - 2020-11-15 : Stress (finding) + 2016-02-28 - 2018-03-11 : Stress (finding) + 2014-02-04 - : Chronic neck pain (finding) + 2013-02-10 - : Anemia (disorder) + 2013-02-10 - : Prediabetes + 2012-02-05 - 2013-02-10 : Part-time employment (finding) + 2012-02-05 - : Hypertension + 2011-01-30 - 2013-02-10 : Stress (finding) + 2011-01-30 - : Received higher education (finding) + 2007-01-07 - : Risk activity involvement (finding) +-------------------------------------------------------------------------------- +CARE PLANS: + 2020-11-05[STOPPED] : Respiratory therapy + Activity: Recommendation to avoid exercise + Activity: Deep breathing and coughing exercises + 2014-03-17[CURRENT] : Therapy (regime/therapy) + Activity: Physical therapy procedure (regime/therapy) + Activity: Cognitive and behavioral therapy (regime/therapy) + 2013-02-10[CURRENT] : Diabetes self management plan + Reason: Prediabetes + Activity: Diabetic diet + Activity: Exercise therapy + 2012-02-05[CURRENT] : Lifestyle education regarding hypertension + Reason: Hypertension + Activity: Prescribed activity/exercise education + Activity: Counseling about alcohol consumption + Activity: Dietary approaches to stop hypertension diet + Activity: Smoking cessation education +-------------------------------------------------------------------------------- +REPORTS: + 2022-08-14 : Alcohol Use Disorder Identification Test - Consumption [AUDIT-C] + - Total score [AUDIT-C] 2.0 {score} + 2022-08-14 : Patient Health Questionnaire 2 item (PHQ-2) [Reported] + - Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 1.0 {score} + 2022-08-14 : Generalized anxiety disorder 7 item (GAD-7) + - Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 1.0 {score} + 2022-08-14 : Basic Metabolic Panel + - Glucose 72.0 mg/dL + - Urea Nitrogen 8.4 mg/dL + - Creatinine 1.6 mg/dL + - Calcium 9.1 mg/dL + - Sodium 138.4 mmol/L + - Potassium 3.9 mmol/L + - Chloride 104.8 mmol/L + - Carbon Dioxide 21.2 mmol/L + 2022-04-04 : Drug Abuse Screening Test-10 [DAST-10] + - Total score [DAST-10] 1.0 {score} + 2022-04-04 : Patient Health Questionnaire 2 item (PHQ-2) [Reported] + - Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 1.0 {score} + 2022-04-03 : Humiliation, Afraid, Rape, and Kick questionnaire [HARK] + - Total score [HARK] 0.0 {score} + 2022-04-03 : Generalized anxiety disorder 7 item (GAD-7) + - Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 1.0 {score} + 2022-04-03 : Basic Metabolic Panel + - Glucose 95.6 mg/dL + - Urea Nitrogen 19.0 mg/dL + - Creatinine 1.5 mg/dL + - Calcium 10.1 mg/dL + - Sodium 139.1 mmol/L + - Potassium 3.8 mmol/L + - Chloride 101.3 mmol/L + - Carbon Dioxide 28.3 mmol/L + 2021-03-28 : Alcohol Use Disorder Identification Test - Consumption [AUDIT-C] + - Total score [AUDIT-C] 0.0 {score} + 2021-03-28 : Generalized anxiety disorder 7 item (GAD-7) + - Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 1.0 {score} + 2021-03-28 : Basic Metabolic Panel + - Glucose 78.8 mg/dL + - Urea Nitrogen 13.2 mg/dL + - Creatinine 1.5 mg/dL + - Calcium 9.7 mg/dL + - Sodium 141.1 mmol/L + - Potassium 3.9 mmol/L + - Chloride 103.1 mmol/L + - Carbon Dioxide 21.0 mmol/L +-------------------------------------------------------------------------------- +OBSERVATIONS: + 2022-08-14 : Total score [AUDIT-C] 2.0 {score} + 2022-08-14 : Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 1.0 {score} + 2022-08-14 : Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 1.0 {score} + 2022-08-14 : 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? No + - 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? A little bit + - 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)? 3 to 5 times 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? Medicine or Any Health Care + - 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. 175139 /a + - What is your main insurance? Private insurance + - What is your current work situation? Part-time or temporary work + - What is the highest level of school that you have finished? More than high school + - What address do you live at? 750 Gutkowski Boulevard + - 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? 2.0 {#} + - 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 + 2022-08-14 : Hemoglobin A1c/Hemoglobin.total in Blood 5.9 % + 2022-08-14 : Tobacco smoking status Ex-smoker (finding) + 2022-08-14 : Carbon Dioxide 21.2 mmol/L + 2022-08-14 : Chloride 104.8 mmol/L + 2022-08-14 : Potassium 3.9 mmol/L + 2022-08-14 : Sodium 138.4 mmol/L + 2022-08-14 : Calcium 9.1 mg/dL + 2022-08-14 : Creatinine 1.6 mg/dL + 2022-08-14 : Urea Nitrogen 8.4 mg/dL + 2022-08-14 : Glucose 72.0 mg/dL + 2022-08-14 : Respiratory rate 15.0 /min + 2022-08-14 : Heart rate 78.0 /min + 2022-08-14 : Blood Pressure + - Diastolic Blood Pressure 96.0 mm[Hg] + - Systolic Blood Pressure 127.0 mm[Hg] + 2022-08-14 : Body Mass Index 29.4 kg/m2 + 2022-08-14 : Body Weight 98.8 kg + 2022-08-14 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 3.0 {score} + 2022-08-14 : Body Height 183.4 cm + 2022-08-07 : Body temperature 37.2 Cel + 2022-04-04 : Total score [DAST-10] 1.0 {score} + 2022-04-04 : Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 1.0 {score} + 2022-04-03 : Total score [HARK] 0.0 {score} + 2022-04-03 : Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 1.0 {score} + 2022-04-03 : 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)? 3 to 5 times 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? I choose not to answer this question + - 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. 175139 /a + - What is your main insurance? Private insurance + - What is your current work situation? Full-time work + - What is the highest level of school that you have finished? More than high school + - What address do you live at? 750 Gutkowski Boulevard + - 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? 2.0 {#} + - 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 + 2022-04-03 : Hemoglobin A1c/Hemoglobin.total in Blood 5.8 % + 2022-04-03 : Tobacco smoking status Ex-smoker (finding) + 2022-04-03 : Carbon Dioxide 28.3 mmol/L + 2022-04-03 : Chloride 101.3 mmol/L + 2022-04-03 : Potassium 3.8 mmol/L + 2022-04-03 : Sodium 139.1 mmol/L + 2022-04-03 : Calcium 10.1 mg/dL + 2022-04-03 : Creatinine 1.5 mg/dL + 2022-04-03 : Urea Nitrogen 19.0 mg/dL + 2022-04-03 : Glucose 95.6 mg/dL + 2022-04-03 : Respiratory rate 15.0 /min + 2022-04-03 : Heart rate 79.0 /min + 2022-04-03 : Blood Pressure + - Diastolic Blood Pressure 95.0 mm[Hg] + - Systolic Blood Pressure 121.0 mm[Hg] + 2022-04-03 : Body Mass Index 29.1 kg/m2 + 2022-04-03 : Body Weight 97.9 kg + 2022-04-03 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 1.0 {score} + 2022-04-03 : Body Height 183.4 cm + 2021-03-28 : Total score [AUDIT-C] 0.0 {score} + 2021-03-28 : Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 1.0 {score} + 2021-03-28 : 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? Quite a bit + - 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)? 1 or 2 times 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? Utilities + - 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. 175139 /a + - What is your main insurance? Private insurance + - What is your current work situation? Part-time or temporary work + - What is the highest level of school that you have finished? More than high school + - What address do you live at? 750 Gutkowski Boulevard + - 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? 2.0 {#} + - 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 + 2021-03-28 : Hemoglobin A1c/Hemoglobin.total in Blood 6.4 % + 2021-03-28 : Tobacco smoking status Ex-smoker (finding) + 2021-03-28 : Carbon Dioxide 21.0 mmol/L + 2021-03-28 : Chloride 103.1 mmol/L + 2021-03-28 : Potassium 3.9 mmol/L + 2021-03-28 : Sodium 141.1 mmol/L + 2021-03-28 : Calcium 9.7 mg/dL + 2021-03-28 : Creatinine 1.5 mg/dL + 2021-03-28 : Urea Nitrogen 13.2 mg/dL + 2021-03-28 : Glucose 78.8 mg/dL + 2021-03-28 : Respiratory rate 16.0 /min + 2021-03-28 : Heart rate 88.0 /min + 2021-03-28 : Blood Pressure + - Diastolic Blood Pressure 86.0 mm[Hg] + - Systolic Blood Pressure 125.0 mm[Hg] + 2021-03-28 : Body Mass Index 28.4 kg/m2 + 2021-03-28 : Body Weight 95.5 kg + 2021-03-28 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 1.0 {score} + 2021-03-28 : Body Height 183.4 cm +-------------------------------------------------------------------------------- +PROCEDURES: + 2022-08-14 : Assessment using Alcohol Use Disorders Identification Test - Consumption (procedure) + 2022-08-14 : Assessment of substance use (procedure) + 2022-08-14 : Depression screening using Patient Health Questionnaire Two-Item score (procedure) + 2022-08-14 : Depression screening (procedure) + 2022-08-14 : Assessment of anxiety (procedure) + 2022-08-14 : Assessment of health and social care needs (procedure) + 2022-08-07 : Throat culture (procedure) for Acute viral pharyngitis (disorder) + 2022-04-04 : Screening for drug abuse (procedure) + 2022-04-04 : Assessment of substance use (procedure) + 2022-04-03 : Depression screening using Patient Health Questionnaire Two-Item score (procedure) + 2022-04-03 : Depression screening (procedure) + 2022-04-03 : Screening for domestic abuse (procedure) + 2022-04-03 : Assessment of anxiety (procedure) + 2022-04-03 : Assessment of health and social care needs (procedure) + 2021-03-28 : Assessment using Alcohol Use Disorders Identification Test - Consumption (procedure) + 2021-03-28 : Assessment of substance use (procedure) + 2021-03-28 : Assessment of anxiety (procedure) + 2021-03-28 : Medication Reconciliation (procedure) + 2021-03-28 : Assessment of health and social care needs (procedure) +-------------------------------------------------------------------------------- +IMMUNIZATIONS: + 2022-08-14 : Influenza, seasonal, injectable, preservative free + 2022-04-03 : Influenza, seasonal, injectable, preservative free +-------------------------------------------------------------------------------- +ENCOUNTERS: +2022-08-14 (Dr. Lynn Cassin) : Encounter at BAYSTATE NOBLE HOSPITAL CORPORATION +2022-08-07 (Dr. Lynn Cassin) : Encounter at BAYSTATE NOBLE HOSPITAL CORPORATION : Encounter for Acute viral pharyngitis (disorder) +2022-04-03 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2021-03-28 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2020-11-15 (Dr. Lynn Cassin) : Encounter at BAYSTATE NOBLE HOSPITAL CORPORATION +2020-11-05 (Dr. Lynn Cassin) : Encounter at BAYSTATE NOBLE HOSPITAL CORPORATION : Encounter for Acute bronchitis (disorder) +2020-03-22 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2019-03-17 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2018-03-11 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2017-03-05 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2016-02-28 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2015-02-22 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2014-03-17 (Dr. Lynn Cassin) : Encounter at BAYSTATE NOBLE HOSPITAL CORPORATION +2014-02-16 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2014-02-04 (Dr. Lynn Cassin) : Encounter at BAYSTATE NOBLE HOSPITAL CORPORATION +2013-02-10 (Dr. Lynn Cassin) : Encounter at BAYSTATE NOBLE HOSPITAL CORPORATION : Encounter for Anemia (disorder) +2013-02-10 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2012-02-05 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2011-01-30 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +2007-01-07 (Dr. Eloisa Arellano) : Encounter at PRIMARY CARE MEDICINE AND PEDIATRICS, LLC +-------------------------------------------------------------------------------- +IMAGING STUDIES: +--------------------------------------------------------------------------------