Judson Luettgen =============== Race: White Ethnicity: Non-Hispanic Gender: M Age: 23 Birth Date: 1999-02-18 Marital Status: S -------------------------------------------------------------------------------- ALLERGIES: No Known Allergies -------------------------------------------------------------------------------- MEDICATIONS: -------------------------------------------------------------------------------- CONDITIONS: 2021-07-31 - 2021-08-19 : Viral sinusitis (disorder) 2021-04-22 - : Full-time employment (finding) 2020-03-05 - : Unhealthy alcohol drinking behavior (finding) 2020-03-05 - 2021-04-22 : Reports of violence in the environment (finding) 2020-03-05 - 2021-04-22 : Limited social contact (finding) 2020-03-05 - 2021-04-22 : Part-time employment (finding) 2018-04-19 - : Prediabetes 2017-04-13 - 2018-04-19 : Full-time employment (finding) 2017-04-13 - : Received certificate of high school equivalency (finding) -------------------------------------------------------------------------------- CARE PLANS: 2020-02-24[STOPPED] : Respiratory therapy Activity: Recommendation to avoid exercise Activity: Deep breathing and coughing exercises 2018-04-19[CURRENT] : Diabetes self management plan Reason: Prediabetes Activity: Diabetic diet Activity: Exercise therapy -------------------------------------------------------------------------------- REPORTS: 2021-04-22 : Drug Abuse Screening Test-10 [DAST-10] - Total score [DAST-10] 1.0 {score} 2021-04-22 : Patient Health Questionnaire 2 item (PHQ-2) [Reported] - Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 1.0 {score} 2021-04-22 : Complete blood count (hemogram) panel - Blood by Automated count - Leukocytes [#/volume] in Blood by Automated count 10.2 10*3/uL - Erythrocytes [#/volume] in Blood by Automated count 4.5 10*6/uL - Hemoglobin [Mass/volume] in Blood 12.5 g/dL - Hematocrit [Volume Fraction] of Blood by Automated count 43.7 % - MCV [Entitic volume] by Automated count 89.6 fL - MCH [Entitic mass] by Automated count 32.4 pg - MCHC [Mass/volume] by Automated count 34.9 g/dL - Erythrocyte distribution width [Entitic volume] by Automated count 41.1 fL - Platelets [#/volume] in Blood by Automated count 216.6 10*3/uL - Platelet distribution width [Entitic volume] in Blood by Automated count 440.4 fL - Platelet mean volume [Entitic volume] in Blood by Automated count 11.1 fL 2021-04-22 : Basic Metabolic Panel - Glucose 64.1 mg/dL - Urea Nitrogen 17.3 mg/dL - Creatinine 1.5 mg/dL - Calcium 8.7 mg/dL - Sodium 137.3 mmol/L - Potassium 4.4 mmol/L - Chloride 107.5 mmol/L - Carbon Dioxide 23.5 mmol/L -------------------------------------------------------------------------------- OBSERVATIONS: 2021-04-22 : Total score [DAST-10] 1.0 {score} 2021-04-22 : Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 1.0 {score} 2021-04-22 : 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? 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. 48361 /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? High school diploma or GED - What address do you live at? 820 Wilderman Quay Apt 61 - 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? 6.0 {#} - 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 2021-04-22 : Hemoglobin A1c/Hemoglobin.total in Blood 5.8 % 2021-04-22 : Tobacco smoking status Never smoked tobacco (finding) 2021-04-22 : Platelet mean volume [Entitic volume] in Blood by Automated count 11.1 fL 2021-04-22 : Platelet distribution width [Entitic volume] in Blood by Automated count 440.4 fL 2021-04-22 : Platelets [#/volume] in Blood by Automated count 216.6 10*3/uL 2021-04-22 : Erythrocyte distribution width [Entitic volume] by Automated count 41.1 fL 2021-04-22 : MCHC [Mass/volume] by Automated count 34.9 g/dL 2021-04-22 : MCH [Entitic mass] by Automated count 32.4 pg 2021-04-22 : MCV [Entitic volume] by Automated count 89.6 fL 2021-04-22 : Hematocrit [Volume Fraction] of Blood by Automated count 43.7 % 2021-04-22 : Hemoglobin [Mass/volume] in Blood 12.5 g/dL 2021-04-22 : Erythrocytes [#/volume] in Blood by Automated count 4.5 10*6/uL 2021-04-22 : Leukocytes [#/volume] in Blood by Automated count 10.2 10*3/uL 2021-04-22 : Carbon Dioxide 23.5 mmol/L 2021-04-22 : Chloride 107.5 mmol/L 2021-04-22 : Potassium 4.4 mmol/L 2021-04-22 : Sodium 137.3 mmol/L 2021-04-22 : Calcium 8.7 mg/dL 2021-04-22 : Creatinine 1.5 mg/dL 2021-04-22 : Urea Nitrogen 17.3 mg/dL 2021-04-22 : Glucose 64.1 mg/dL 2021-04-22 : Respiratory rate 15.0 /min 2021-04-22 : Heart rate 94.0 /min 2021-04-22 : Blood Pressure - Diastolic Blood Pressure 93.0 mm[Hg] - Systolic Blood Pressure 136.0 mm[Hg] 2021-04-22 : Body Mass Index 28.9 kg/m2 2021-04-22 : Body Weight 92.2 kg 2021-04-22 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 1.0 {score} 2021-04-22 : Body Height 178.7 cm -------------------------------------------------------------------------------- PROCEDURES: 2021-04-22 : Screening for drug abuse (procedure) 2021-04-22 : Assessment of substance use (procedure) 2021-04-22 : Depression screening using Patient Health Questionnaire Two-Item score (procedure) 2021-04-22 : Depression screening (procedure) 2021-04-22 : Assessment of health and social care needs (procedure) -------------------------------------------------------------------------------- IMMUNIZATIONS: 2021-09-23 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 30 mcg/0.3mL dose 2021-09-02 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 30 mcg/0.3mL dose 2021-04-22 : Hep B, adult 2021-04-22 : Influenza, seasonal, injectable, preservative free -------------------------------------------------------------------------------- ENCOUNTERS: 2021-09-23 (Dr. Bennett Rippin) : Encounter at MILFORD REGIONAL MEDICAL CENTER 2021-09-02 (Dr. Bennett Rippin) : Encounter at MILFORD REGIONAL MEDICAL CENTER 2021-07-31 (Dr. Bennett Rippin) : Encounter at MILFORD REGIONAL MEDICAL CENTER : Encounter for Viral sinusitis (disorder) 2021-04-22 (Dr. Bea Schiller) : Encounter at PRIMARY CARE FOR ADULTS PLLC 2020-03-05 (Dr. Bennett Rippin) : Encounter at MILFORD REGIONAL MEDICAL CENTER 2020-02-24 (Dr. Bennett Rippin) : Encounter at MILFORD REGIONAL MEDICAL CENTER : Encounter for Acute bronchitis (disorder) 2018-04-19 (Dr. Bea Schiller) : Encounter at PRIMARY CARE FOR ADULTS PLLC 2017-04-13 (Dr. Bea Schiller) : Encounter at PRIMARY CARE FOR ADULTS PLLC -------------------------------------------------------------------------------- IMAGING STUDIES: --------------------------------------------------------------------------------