[ab5bfb]: / data / text / Germán_Meza_16edd53e-5409-27bf-549e-6c6216561301.txt

Download this file

316 lines (315 with data), 22.4 kB

  1
  2
  3
  4
  5
  6
  7
  8
  9
 10
 11
 12
 13
 14
 15
 16
 17
 18
 19
 20
 21
 22
 23
 24
 25
 26
 27
 28
 29
 30
 31
 32
 33
 34
 35
 36
 37
 38
 39
 40
 41
 42
 43
 44
 45
 46
 47
 48
 49
 50
 51
 52
 53
 54
 55
 56
 57
 58
 59
 60
 61
 62
 63
 64
 65
 66
 67
 68
 69
 70
 71
 72
 73
 74
 75
 76
 77
 78
 79
 80
 81
 82
 83
 84
 85
 86
 87
 88
 89
 90
 91
 92
 93
 94
 95
 96
 97
 98
 99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
Germán Meza
===========
Race: Asian
Ethnicity: Hispanic
Gender: M
Age: DECEASED
Birth Date: 1963-02-08
Marital Status: M
--------------------------------------------------------------------------------
ALLERGIES:
No Known Allergies
--------------------------------------------------------------------------------
MEDICATIONS:
2014-04-11[CURRENT] : lisinopril 10 MG Oral Tablet for Hypertension
2014-04-11[CURRENT] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
2013-06-17[STOPPED] : Amoxicillin 250 MG / Clavulanate 125 MG Oral Tablet for Viral sinusitis (disorder)
2013-04-05[CURRENT] : ferrous sulfate 325 MG Oral Tablet
2013-04-05[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension
2013-04-05[STOPPED] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
2013-04-05[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension
2013-04-05[STOPPED] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
2012-03-30[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension
2012-03-30[STOPPED] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
2011-03-25[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension
2011-03-25[STOPPED] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
2010-03-19[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension
2010-03-19[STOPPED] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
2009-03-13[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension
2009-03-13[STOPPED] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
2008-03-07[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension
2008-03-07[STOPPED] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
2007-03-02[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension
2007-03-02[STOPPED] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
2006-02-24[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension
2006-02-24[STOPPED] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
2005-03-20[STOPPED] : lisinopril 10 MG Oral Tablet for Hypertension
2005-02-18[STOPPED] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
2005-02-18[STOPPED] : Hydrochlorothiazide 25 MG Oral Tablet for Hypertension
--------------------------------------------------------------------------------
CONDITIONS:
2014-12-12 - : Bullet wound
2014-04-11 - : Full-time employment (finding)
2013-06-17 - 2013-07-03 : Viral sinusitis (disorder)
2013-04-05 - 2014-04-11 : Full-time employment (finding)
2013-04-05 - : Anemia (disorder)
2012-03-30 - 2013-04-05 : Severe anxiety (panic) (finding
2012-03-30 - 2013-04-05 : Full-time employment (finding)
2011-03-25 - 2012-03-30 : Full-time employment (finding)
2011-03-25 - : Prediabetes
2011-03-25 - : Metabolic syndrome X (disorder)
2009-03-13 - 2010-03-19 : Full-time employment (finding)
2008-03-07 - 2014-04-11 : Limited social contact (finding)
2008-03-07 - 2009-03-13 : Full-time employment (finding)
2007-03-02 - : Social isolation (finding)
2007-03-02 - 2008-03-07 : Full-time employment (finding)
2006-02-24 - 2007-03-02 : Full-time employment (finding)
2005-02-18 - 2006-02-24 : Full-time employment (finding)
2005-02-18 - : Hypertension
1997-04-25 - 2006-02-24 : Social isolation (finding)
1997-04-25 - 2000-04-28 : Full-time employment (finding)
1997-03-14 - 1997-04-25 : Full-time employment (finding)
1994-04-22 - 1997-03-14 : Full-time employment (finding)
1991-04-19 - : Refugee (person)
1991-04-19 - 1993-02-12 : Full-time employment (finding)
1988-04-15 - : Body mass index 30+ - obesity (finding)
1985-04-12 - 1988-04-15 : Full-time employment (finding)
1982-04-09 - 1982-12-24 : Full-time employment (finding)
1981-04-03 - 1982-04-09 : Full-time employment (finding)
1981-04-03 - : Received higher education (finding)
--------------------------------------------------------------------------------
CARE PLANS:
2011-03-25[CURRENT] : Diabetes self management plan
Reason: Prediabetes
Activity: Diabetic diet
Activity: Exercise therapy
2005-02-18[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:
2014-12-26 : U.S. standard certificate of death - 2003 revision
- Cause of Death [US Standard Certificate of Death] Bullet wound
2014-04-11 : Alcohol Use Disorder Identification Test - Consumption [AUDIT-C]
- Total score [AUDIT-C] 1.0 {score}
2014-04-11 : Patient Health Questionnaire 2 item (PHQ-2) [Reported]
- Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 2.0 {score}
2014-04-11 : Lipid Panel
- Total Cholesterol 136.2 mg/dL
- Triglycerides 141.5 mg/dL
- Low Density Lipoprotein Cholesterol 45.1 mg/dL
- High Density Lipoprotein Cholesterol 62.8 mg/dL
2014-04-11 : Basic Metabolic Panel
- Glucose 65.1 mg/dL
- Urea Nitrogen 16.1 mg/dL
- Creatinine 1.1 mg/dL
- Calcium 8.6 mg/dL
- Sodium 136.7 mmol/L
- Potassium 3.8 mmol/L
- Chloride 103.9 mmol/L
- Carbon Dioxide 28.3 mmol/L
2013-04-05 : Drug Abuse Screening Test-10 [DAST-10]
- Total score [DAST-10] 0.0 {score}
2013-04-05 : Patient Health Questionnaire 2 item (PHQ-2) [Reported]
- Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 2.0 {score}
2013-04-05 : Humiliation, Afraid, Rape, and Kick questionnaire [HARK]
- Total score [HARK] 0.0 {score}
2013-04-05 : Generalized anxiety disorder 7 item (GAD-7)
- Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 8.0 {score}
2013-04-05 : Complete blood count (hemogram) panel - Blood by Automated count
- Hemoglobin [Mass/volume] in Blood 11.7 g/dL
- Hematocrit [Volume Fraction] of Blood 34.2 %
- WBC Auto (Bld) [#/Vol] 4.4 10*3/uL
- RBC Auto (Bld) [#/Vol] 4.9 10*6/uL
- MCV [Entitic volume] by Automated count 93.5 fL
- MCH [Entitic mass] by Automated count 31.6 pg
- MCHC [Mass/volume] by Automated count 35.6 g/dL
- RDW - Erythrocyte distribution width Auto (RBC) [Entitic vol] 39.8 fL
- Platelets [#/volume] in Blood by Automated count 226.0 10*3/uL
- Platelet distribution width [Entitic volume] in Blood by Automated count 496.2 fL
- Platelet mean volume [Entitic volume] in Blood by Automated count 10.4 fL
2013-04-05 : Complete blood count (hemogram) panel - Blood by Automated count
- Leukocytes [#/volume] in Blood by Automated count 8.0 10*3/uL
- Erythrocytes [#/volume] in Blood by Automated count 4.1 10*6/uL
- Hemoglobin [Mass/volume] in Blood 12.3 g/dL
- Hematocrit [Volume Fraction] of Blood by Automated count 50.0 %
- MCV [Entitic volume] by Automated count 93.1 fL
- MCH [Entitic mass] by Automated count 27.3 pg
- MCHC [Mass/volume] by Automated count 34.5 g/dL
- Erythrocyte distribution width [Entitic volume] by Automated count 43.2 fL
- Platelets [#/volume] in Blood by Automated count 191.0 10*3/uL
- Platelet distribution width [Entitic volume] in Blood by Automated count 363.4 fL
- Platelet mean volume [Entitic volume] in Blood by Automated count 11.0 fL
2013-04-05 : Basic Metabolic Panel
- Glucose 88.1 mg/dL
- Urea Nitrogen 14.5 mg/dL
- Creatinine 1.1 mg/dL
- Calcium 9.1 mg/dL
- Sodium 137.6 mmol/L
- Potassium 3.8 mmol/L
- Chloride 105.1 mmol/L
- Carbon Dioxide 21.7 mmol/L
--------------------------------------------------------------------------------
OBSERVATIONS:
2014-12-26 : Cause of Death [US Standard Certificate of Death] Bullet wound
2014-04-11 : Total score [AUDIT-C] 1.0 {score}
2014-04-11 : Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 2.0 {score}
2014-04-11 : 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? Yes
- 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? Not at all
- 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)? 5 or more 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. 529290 /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? 1089 O'Keefe Knoll Unit 13
- 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? Language other than 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? Asian
- Are you Hispanic or Latino? No
2014-04-11 : Hemoglobin A1c/Hemoglobin.total in Blood 6.2 %
2014-04-11 : Tobacco smoking status Never smoked tobacco (finding)
2014-04-11 : High Density Lipoprotein Cholesterol 62.8 mg/dL
2014-04-11 : Low Density Lipoprotein Cholesterol 45.1 mg/dL
2014-04-11 : Triglycerides 141.5 mg/dL
2014-04-11 : Total Cholesterol 136.2 mg/dL
2014-04-11 : Carbon Dioxide 28.3 mmol/L
2014-04-11 : Chloride 103.9 mmol/L
2014-04-11 : Potassium 3.8 mmol/L
2014-04-11 : Sodium 136.7 mmol/L
2014-04-11 : Calcium 8.6 mg/dL
2014-04-11 : Creatinine 1.1 mg/dL
2014-04-11 : Urea Nitrogen 16.1 mg/dL
2014-04-11 : Glucose 65.1 mg/dL
2014-04-11 : Respiratory rate 14.0 /min
2014-04-11 : Heart rate 70.0 /min
2014-04-11 : Blood Pressure
- Diastolic Blood Pressure 88.0 mm[Hg]
- Systolic Blood Pressure 117.0 mm[Hg]
2014-04-11 : Body Mass Index 28.4 kg/m2
2014-04-11 : Body Weight 88.1 kg
2014-04-11 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 1.0 {score}
2014-04-11 : Body Height 176.1 cm
2013-04-05 : Total score [DAST-10] 0.0 {score}
2013-04-05 : Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 2.0 {score}
2013-04-05 : Total score [HARK] 0.0 {score}
2013-04-05 : Generalized anxiety disorder 7 item (GAD-7) total score [Reported.PHQ] 8.0 {score}
2013-04-05 : 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? Yes
- 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? Not at all
- 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)? 5 or more 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. 529290 /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? 1089 O'Keefe Knoll Unit 13
- 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? Language other than 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? Asian
- Are you Hispanic or Latino? No
2013-04-05 : Platelet mean volume [Entitic volume] in Blood by Automated count 10.4 fL
2013-04-05 : Platelet distribution width [Entitic volume] in Blood by Automated count 496.2 fL
2013-04-05 : Platelets [#/volume] in Blood by Automated count 226.0 10*3/uL
2013-04-05 : RDW - Erythrocyte distribution width Auto (RBC) [Entitic vol] 39.8 fL
2013-04-05 : MCHC [Mass/volume] by Automated count 35.6 g/dL
2013-04-05 : MCH [Entitic mass] by Automated count 31.6 pg
2013-04-05 : MCV [Entitic volume] by Automated count 93.5 fL
2013-04-05 : RBC Auto (Bld) [#/Vol] 4.9 10*6/uL
2013-04-05 : WBC Auto (Bld) [#/Vol] 4.4 10*3/uL
2013-04-05 : Hematocrit [Volume Fraction] of Blood 34.2 %
2013-04-05 : Hemoglobin [Mass/volume] in Blood 11.7 g/dL
2013-04-05 : Hemoglobin A1c/Hemoglobin.total in Blood 6.2 %
2013-04-05 : Tobacco smoking status Never smoked tobacco (finding)
2013-04-05 : Platelet mean volume [Entitic volume] in Blood by Automated count 11.0 fL
2013-04-05 : Platelet distribution width [Entitic volume] in Blood by Automated count 363.4 fL
2013-04-05 : Platelets [#/volume] in Blood by Automated count 191.0 10*3/uL
2013-04-05 : Erythrocyte distribution width [Entitic volume] by Automated count 43.2 fL
2013-04-05 : MCHC [Mass/volume] by Automated count 34.5 g/dL
2013-04-05 : MCH [Entitic mass] by Automated count 27.3 pg
2013-04-05 : MCV [Entitic volume] by Automated count 93.1 fL
2013-04-05 : Hematocrit [Volume Fraction] of Blood by Automated count 50.0 %
2013-04-05 : Hemoglobin [Mass/volume] in Blood 12.3 g/dL
2013-04-05 : Erythrocytes [#/volume] in Blood by Automated count 4.1 10*6/uL
2013-04-05 : Leukocytes [#/volume] in Blood by Automated count 8.0 10*3/uL
2013-04-05 : Carbon Dioxide 21.7 mmol/L
2013-04-05 : Chloride 105.1 mmol/L
2013-04-05 : Potassium 3.8 mmol/L
2013-04-05 : Sodium 137.6 mmol/L
2013-04-05 : Calcium 9.1 mg/dL
2013-04-05 : Creatinine 1.1 mg/dL
2013-04-05 : Urea Nitrogen 14.5 mg/dL
2013-04-05 : Glucose 88.1 mg/dL
2013-04-05 : Respiratory rate 14.0 /min
2013-04-05 : Heart rate 84.0 /min
2013-04-05 : Blood Pressure
- Diastolic Blood Pressure 85.0 mm[Hg]
- Systolic Blood Pressure 119.0 mm[Hg]
2013-04-05 : Body Mass Index 28.4 kg/m2
2013-04-05 : Body Weight 88.1 kg
2013-04-05 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 2.0 {score}
2013-04-05 : Body Height 176.1 cm
--------------------------------------------------------------------------------
PROCEDURES:
2014-04-11 : Assessment using Alcohol Use Disorders Identification Test - Consumption (procedure)
2014-04-11 : Assessment of substance use (procedure)
2014-04-11 : Depression screening using Patient Health Questionnaire Two-Item score (procedure)
2014-04-11 : Depression screening (procedure)
2014-04-11 : Medication Reconciliation (procedure)
2014-04-11 : Assessment of health and social care needs (procedure)
2013-04-05 : Brief general examination (procedure)
2013-04-05 : Medication Reconciliation (procedure)
2013-04-05 : Review of systems (procedure)
2013-04-05 : Screening for drug abuse (procedure)
2013-04-05 : Assessment of substance use (procedure)
2013-04-05 : Depression screening using Patient Health Questionnaire Two-Item score (procedure)
2013-04-05 : Depression screening (procedure)
2013-04-05 : Screening for domestic abuse (procedure)
2013-04-05 : Assessment of anxiety (procedure)
2013-04-05 : Peripheral blood smear interpretation
2013-04-05 : Assessment of health and social care needs (procedure)
--------------------------------------------------------------------------------
IMMUNIZATIONS:
2014-04-11 : Td (adult) preservative free
2014-04-11 : Influenza, seasonal, injectable, preservative free
2014-04-11 : zoster
2013-04-05 : Influenza, seasonal, injectable, preservative free
2013-04-05 : zoster
--------------------------------------------------------------------------------
ENCOUNTERS:
2014-12-26 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC : Encounter for Bullet wound
2014-12-12 (Dr. Rebeca Venegas) : Encounter at ALLIANCE HEALTH AT MARINA BAY
2014-04-11 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
2013-06-17 (Dr. Margaret Reinger) : Encounter at CARNEY HOSPITAL : Encounter for Viral sinusitis (disorder)
2013-04-05 (Dr. Margaret Reinger) : Encounter at CARNEY HOSPITAL : Encounter for Anemia (disorder)
2013-04-05 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
2012-03-30 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
2011-03-25 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
2010-03-19 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
2009-03-13 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
2008-03-07 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
2007-03-02 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
2006-02-24 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
2005-03-20 (Dr. Margaret Reinger) : Encounter at CARNEY HOSPITAL : Encounter for Hypertension
2005-02-18 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
1997-04-25 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
1997-03-08 (Dr. Margaret Reinger) : Encounter at CARNEY HOSPITAL : Encounter for Acute bronchitis (disorder)
1994-04-22 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
1991-04-19 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
1988-04-15 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
1985-04-12 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
1982-04-09 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
1981-04-03 (Dr. Eva Tamayo) : Encounter at HARBOR HEALTH SERVICES INC
--------------------------------------------------------------------------------
IMAGING STUDIES:
--------------------------------------------------------------------------------