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| Condition | Onset Date | Status |
|---|---|---|
| Anemia | 22-May-2023 | active |
| Prediabetes | 16-May-2022 | active |
| Recurrent rectal polyp | 03-Jun-2020 | active |
| Polyp of colon | 06-May-2019 | active |
| Hyperlipidemia | 22-May-2017 | active |
| Chronic intractable migraine without aura | 20-Apr-1993 | active |
| Medication | Since | Form | Dosage | Reason |
|---|---|---|---|---|
| Simvastatin 10 mg oral tablet | 2025-06-10 | - | 1 tablet (10 mg) by mouth once daily | Hyperlipidemia |
| Vaccine | Date |
|---|---|
| Influenza virus antigen only vaccine product | 02-Jun-2025 |
| SARS-CoV-2 mRNA vaccine | 03-May-2021 |
| Clostridium tetani toxoid antigen adsorbed only vaccine product | 04-May-2020 |
| Live attenuated Human alphaherpesvirus 3 only vaccine product | 04-May-2020 |
| Procedure | Date | Reason |
|---|---|---|
| Postoperative care | 26-Jun-2020 | Overlapping malignant neoplasm of colon |
| Partial resection of colon | 20-Jun-2020 | Overlapping malignant neoplasm of colon |
| Assessment of health and social care needs | 24-Sep-2018 | - |
| Assessment of anxiety | 24-Sep-2018 | - |
| Assessment using AUDIT-C (Alcohol Use Disorders Identification Test - Consumption) | 24-Sep-2018 | - |
| Assessment of substance use | 24-Sep-2018 | - |
| Allergy/Intolerance | Onset Date | Status | Type | Reaction |
|---|---|---|---|---|
| ? | active | ? |
| Active Planned Care / Goals | Start Date | Reason |
|---|---|---|
| Diabetes self management plan | 16-May-2022 | Prediabetes |
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| Hyperlipidemia clinical management plan | 12-Jun-2017 | Hyperlipidemia |
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| Vital Signs | 2025-06-02 | 2024-05-27 |
|---|---|---|
| Body Height | 177 cm | 177 cm |
| Pain severity - 0-10 verbal numeric rating [Score] - Reported | 3 {score} | 3 {score} |
| Body Weight | 87.9 kg | 87.9 kg |
| Body mass index (BMI) [Ratio] | 28.1 kg/m2 | 28.1 kg/m2 |
| Diastolic Blood Pressure | 83 mm[Hg] | 84 mm[Hg] |
| Systolic Blood Pressure | 125 mm[Hg] | 123 mm[Hg] |
| Heart rate | 70 /min | 80 /min |
| Respiratory rate | 15 /min | 13 /min |
| Recent Lab Observations | 10-JUN-2025 | Reference Range | Unit |
|---|---|---|---|
| Glucose [Mass/volume] in Blood | 77.7 | 70 - 99 | mg/dL |
| Urea nitrogen [Mass/volume] in Blood | 11.5 | 7 - 20 | mg/dL |
| Creatinine [Mass/volume] in Blood | 2.8 H | 0.7 - 1.3 | mg/dL |
| Calcium [Mass/volume] in Blood | 9.3 | 8.5 - 10.5 | mg/dL |
| Sodium [Moles/volume] in Blood | 138.8 | 135 - 145 | mmol/L |
| Potassium [Moles/volume] in Blood | 4.9 | 3.5 - 5 | mmol/L |
| Chloride [Moles/volume] in Blood | 101.9 | 98 - 107 | mmol/L |
| Carbon dioxide, total [Moles/volume] in Blood | 27.5 | 24 - 29 | mmol/L |
| Protein [Mass/volume] in Serum or Plasma | 6.2 L | 6.6 - 8.3 | g/dL |
| Albumin [Mass/volume] in Serum or Plasma | 3.8 | 3.5 - 5.5 | g/dL |
| Globulin [Mass/volume] in Serum by calculation | 3.4 | 2 - 3.5 | g/L |
| Bilirubin.total [Mass/volume] in Serum or Plasma | 0.6 | 0.3 - 1.2 | mg/dL |
| Alkaline phosphatase [Enzymatic activity/volume] in Serum or Plasma | 65.3 | 39 - 136 | U/L |
| Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma | 40.7 | 7 - 52 | U/L |
| Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma | 12.3 | 10 - 40 | U/L |
| Cholesterol [Mass/volume] in Serum or Plasma | 200.4 H | 125 - 200 | mg/dL |
| Triglyceride [Mass/volume] in Serum or Plasma | 100.5 | 0 - 150 | mg/dL |
| Cholesterol in LDL [Mass/volume] in Serum or Plasma by Direct assay | 106.5 | 0 - 130 | mg/dL |
| Cholesterol in HDL [Mass/volume] in Serum or Plasma | 31.4 L | 40 - 100 | mg/dL |
| Device | Date (since) |
|---|---|
| Blood glucose meter (physical object) | 16-May-2022 |