Van MacGyver ============ Race: Asian Ethnicity: Non-Hispanic Gender: F Age: 10 Birth Date: 2012-03-11 Marital Status: S -------------------------------------------------------------------------------- ALLERGIES: 2013-01-16 - : Cow's milk (substance) 2013-01-16 - : Lisinopril 2013-01-16 - : Tree pollen (substance) 2013-01-16 - : Grass pollen (substance) 2013-01-16 - : Animal dander (substance) 2013-01-16 - : House dust mite (organism) 2013-01-16 - : Mold (organism) 2013-01-16 - : Latex (substance) -------------------------------------------------------------------------------- MEDICATIONS: 2022-03-20[CURRENT] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2022-03-20[CURRENT] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2022-01-23[STOPPED] : Acetaminophen 160 MG Chewable Tablet 2021-03-14[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2021-03-14[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2020-03-08[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2020-03-08[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2019-03-03[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2019-03-03[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2018-02-25[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2018-02-25[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2017-06-11[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2017-06-11[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2017-02-19[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2017-02-19[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2016-02-14[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2016-02-14[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2015-08-16[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2015-08-16[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2015-02-15[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2015-02-15[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2014-11-09[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2014-11-09[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2014-08-17[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2014-08-17[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2014-06-13[STOPPED] : NDA021457 200 ACTUAT albuterol 0.09 MG/ACTUAT Metered Dose Inhaler [ProAir] for Childhood asthma 2014-06-13[STOPPED] : 120 ACTUAT fluticasone propionate 0.044 MG/ACTUAT Metered Dose Inhaler [Flovent] for Childhood asthma 2013-01-16[CURRENT] : NDA020800 0.3 ML Epinephrine 1 MG/ML Auto-Injector 2013-01-16[CURRENT] : cetirizine hydrochloride 5 MG Oral Tablet -------------------------------------------------------------------------------- CONDITIONS: 2022-01-23 - 2022-02-12 : Facial laceration 2021-01-18 - 2021-09-17 : Child attention deficit disorder 2021-01-11 - 2021-02-17 : COVID-19 2021-01-11 - 2021-01-11 : Suspected COVID-19 2021-01-11 - 2021-02-17 : Joint pain (finding) 2021-01-11 - 2021-02-17 : Muscle pain (finding) 2021-01-11 - 2021-02-17 : Sore throat symptom (finding) 2021-01-11 - 2021-02-17 : Cough (finding) 2014-06-13 - : Childhood asthma -------------------------------------------------------------------------------- CARE PLANS: 2022-01-23[STOPPED] : Wound care Reason: Facial laceration Activity: Dressing change management Activity: Behavior to prevent infection 2021-01-18[STOPPED] : Overactivity/inattention behavior management Activity: Counseling Activity: Psychological assessment 2021-01-11[STOPPED] : Infectious disease care plan (record artifact) Activity: Airborne precautions (procedure) Activity: Isolation of infected patient (procedure) 2021-01-11[STOPPED] : Infectious disease care plan (record artifact) Activity: Airborne precautions (procedure) Activity: Personal protective equipment (physical object) 2014-06-13[CURRENT] : Asthma self management Reason: Childhood asthma Activity: Inhaled steroid therapy Activity: Home nebulizer therapy Activity: Breathing control 2013-01-03[CURRENT] : Self-care interventions (procedure) Activity: Food allergy diet Activity: Allergy education Activity: Allergy education -------------------------------------------------------------------------------- REPORTS: 2021-01-11 : SARS-CoV-2 RNA Pnl Resp NAA+probe - SARS-CoV-2 RNA Pnl Resp NAA+probe Detected (qualifier value) 2021-01-11 : Respiratory pathogens DNA and RNA panel - Respiratory specimen by NAA with probe detection - Influenza virus A RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) - Influenza virus B RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) - Respiratory syncytial virus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) - Parainfluenza virus 1 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) - Parainfluenza virus 2 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) - Parainfluenza virus 3 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) - Rhinovirus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) - Human metapneumovirus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) - Adenovirus A+B+C+D+E DNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) -------------------------------------------------------------------------------- OBSERVATIONS: 2022-03-20 : Tobacco smoking status Never smoked tobacco (finding) 2022-03-20 : Respiratory rate 15.0 /min 2022-03-20 : Heart rate 85.0 /min 2022-03-20 : Blood Pressure - Diastolic Blood Pressure 72.0 mm[Hg] - Systolic Blood Pressure 130.0 mm[Hg] 2022-03-20 : Body mass index (BMI) [Percentile] Per age and gender 66.4 % 2022-03-20 : Body Mass Index 17.9 kg/m2 2022-03-20 : Body Weight 30.5 kg 2022-03-20 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 1.0 {score} 2022-03-20 : Body Height 130.5 cm 2021-03-14 : Tobacco smoking status Never smoked tobacco (finding) 2021-03-14 : Respiratory rate 14.0 /min 2021-03-14 : Heart rate 69.0 /min 2021-03-14 : Blood Pressure - Diastolic Blood Pressure 77.0 mm[Hg] - Systolic Blood Pressure 114.0 mm[Hg] 2021-03-14 : Body mass index (BMI) [Percentile] Per age and gender 71.0 % 2021-03-14 : Body Mass Index 17.6 kg/m2 2021-03-14 : Body Weight 28.0 kg 2021-03-14 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 2.0 {score} 2021-03-14 : Body Height 126.0 cm 2021-01-11 : SARS-CoV-2 RNA Pnl Resp NAA+probe Detected (qualifier value) 2021-01-11 : Adenovirus A+B+C+D+E DNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) 2021-01-11 : Human metapneumovirus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) 2021-01-11 : Rhinovirus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) 2021-01-11 : Parainfluenza virus 3 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) 2021-01-11 : Parainfluenza virus 2 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) 2021-01-11 : Parainfluenza virus 1 RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) 2021-01-11 : Respiratory syncytial virus RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) 2021-01-11 : Influenza virus B RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) 2021-01-11 : Influenza virus A RNA [Presence] in Respiratory specimen by NAA with probe detection Negative (qualifier value) 2021-01-11 : Body Weight 27.3 kg 2021-01-11 : Blood Pressure - Diastolic Blood Pressure 73.0 mm[Hg] - Systolic Blood Pressure 123.0 mm[Hg] 2021-01-11 : Oxygen saturation in Arterial blood 75.5 % 2021-01-11 : Heart rate 69.5 /min 2021-01-11 : Respiratory rate 26.5 /min 2021-01-11 : Body temperature 41.0 Cel -------------------------------------------------------------------------------- PROCEDURES: 2022-01-23 : Suture open wound for Facial laceration 2021-09-17 : Cognitive and behavioral therapy for Child attention deficit disorder 2021-08-09 : Cognitive and behavioral therapy for Child attention deficit disorder 2021-06-29 : Cognitive and behavioral therapy for Child attention deficit disorder 2021-05-29 : Cognitive and behavioral therapy for Child attention deficit disorder 2021-04-19 : Cognitive and behavioral therapy for Child attention deficit disorder 2021-03-20 : Cognitive and behavioral therapy for Child attention deficit disorder 2021-03-14 : Medication Reconciliation (procedure) 2021-02-20 : Cognitive and behavioral therapy for Child attention deficit disorder 2021-01-11 : Face mask (physical object) for Suspected COVID-19 -------------------------------------------------------------------------------- IMMUNIZATIONS: 2022-03-20 : Influenza, seasonal, injectable, preservative free 2021-03-14 : Influenza, seasonal, injectable, preservative free -------------------------------------------------------------------------------- ENCOUNTERS: 2022-03-20 (Dr. Quentin Fritsch) : Encounter at RIVER'S EDGE PRIMARY CARE LLC 2022-01-23 (Dr. Burton Schoen) : Encounter at EXCEL HOME CARE SERVICES INC 2021-09-17 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS : Encounter for Child attention deficit disorder 2021-08-09 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS : Encounter for Child attention deficit disorder 2021-06-29 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS : Encounter for Child attention deficit disorder 2021-05-29 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS : Encounter for Child attention deficit disorder 2021-04-19 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS : Encounter for Child attention deficit disorder 2021-03-20 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS : Encounter for Child attention deficit disorder 2021-03-14 (Dr. Quentin Fritsch) : Encounter at RIVER'S EDGE PRIMARY CARE LLC 2021-02-20 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS : Encounter for Child attention deficit disorder 2021-01-18 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS : Encounter for Child attention deficit disorder 2021-01-11 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS 2020-03-08 (Dr. Quentin Fritsch) : Encounter at RIVER'S EDGE PRIMARY CARE LLC 2019-03-03 (Dr. Quentin Fritsch) : Encounter at RIVER'S EDGE PRIMARY CARE LLC 2018-02-25 (Dr. Quentin Fritsch) : Encounter at RIVER'S EDGE PRIMARY CARE LLC 2017-06-10 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS : Encounter for Viral sinusitis (disorder) 2017-02-19 (Dr. Quentin Fritsch) : Encounter at RIVER'S EDGE PRIMARY CARE LLC 2016-02-14 (Dr. Quentin Fritsch) : Encounter at RIVER'S EDGE PRIMARY CARE LLC 2015-08-16 (Dr. Quentin Fritsch) : Encounter at RIVER'S EDGE PRIMARY CARE LLC 2015-02-15 (Dr. Quentin Fritsch) : Encounter at RIVER'S EDGE PRIMARY CARE LLC 2014-11-09 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS 2014-08-17 (Dr. Quentin Fritsch) : Encounter at RIVER'S EDGE PRIMARY CARE LLC 2014-06-13 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS : Encounter for Childhood asthma 2013-01-16 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS 2013-01-03 (Dr. Cletus Paucek) : Encounter at ENCOMPASS HEALTH REHAB HOSPITAL OF WESTERN MASS -------------------------------------------------------------------------------- IMAGING STUDIES: --------------------------------------------------------------------------------