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: --------------------------------------------------------------------------------