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| No known problems or disabilities |
| Medication | Since | Form | Dosage | Reason |
|---|---|---|---|---|
| Fexofenadine hydrochloride 30 mg oral tablet | 2001-03-17 | - | 1 tablet (30 mg) twice daily | - |
| Epinephrine 1 mg/mL solution for injection | 2001-03-17 | - | 0.3 mg (1:1000) IM every 5 to 15 minutes as needed | - |
| Vaccine | Date |
|---|---|
| Hepatitis B virus antigen only vaccine product | 06-Oct-2022 |
| Clostridium tetani toxoid antigen adsorbed only vaccine product | 06-Oct-2022 |
| Neisseria meningitidis antigen-containing vaccine product | 06-Oct-2022 |
| Influenza virus antigen only vaccine product | 06-Oct-2022 |
| SARS-CoV-2 mRNA vaccine | 13-May-2021 |
| Procedure | Date | Reason |
|---|---|---|
| Medication reconciliation | 22-Sep-2016 | - |
| Depression screening | 21-Apr-2016 | - |
| Anticipatory guidance | 21-Apr-2016 | - |
| Assessment of anxiety | 21-Apr-2016 | - |
| Depression screening using PHQ-9 (Patient Health Questionnaire 9) score | 21-Apr-2016 | - |
| Assessment using Car | 21-Apr-2016 | - |
| Assessment of substance use | 21-Apr-2016 | - |
| Allergy/Intolerance | Onset Date | Status | Type | Reaction |
|---|---|---|---|---|
| Aspirin | 2001-03-17 | active | medication | Abdominal pain (finding) |
| Mold | 2001-03-17 | active | environment | |
| Eggs (edible) | 2001-03-17 | active | food | Wheal (finding) |
| Latex | 2001-03-17 | active | environment | Wheal (finding) |
| Grass pollen | 2001-03-17 | active | environment | |
| House dust mite | 2001-03-17 | active | environment | |
| Animal dander | 2001-03-17 | active | environment | Rhinoconjunctivitis (disorder) Wheal (finding) |
| Allergy to substance | 2001-03-17 | active | environment | |
| Fish | 2001-03-17 | active | food | Dyspnea (finding) Eruption of skin (disorder) |
| Tree pollen | 2001-03-17 | active | environment |
| Active Planned Care / Goals | Start Date | Reason |
|---|---|---|
| Self-care interventions | 05-Mar-2001 | - |
| Vital Signs | 2022-10-06 | 2020-07-17 |
|---|---|---|
| Body Height | 188.5 cm | - |
| Pain severity - 0-10 verbal numeric rating [Score] - Reported | 3 {score} | - |
| Body Weight | 88.1 kg | 84.4 kg |
| Body mass index (BMI) [Ratio] | 24.8 kg/m2 | - |
| Diastolic Blood Pressure | 88 mm[Hg] | 86 mm[Hg] |
| Systolic Blood Pressure | 110 mm[Hg] | 113 mm[Hg] |
| Heart rate | 83 /min | 178.2 /min |
| Respiratory rate | 14 /min | 26.4 /min |
| Body temperature | - | 41.7 Cel |
| Oxygen saturation in Arterial blood | - | 84.8 % |
| Recent Lab Observations | 06-OCT-2022 | Reference Range | Unit |
|---|---|---|---|
| Leukocytes [#/volume] in Blood by Automated count | 8.2 | 3.5 - 10.5 | 10*3/uL |
| Erythrocytes [#/volume] in Blood by Automated count | 4.0 L | 4.5 - 6.2 | 10*6/uL |
| Hemoglobin [Mass/volume] in Blood | 16.0 | 14 - 18 | g/dL |
| Hematocrit [Volume Fraction] of Blood by Automated count | 48.7 | 38 - 52 | % |
| MCV [Entitic volume] by Automated count | 86.5 | 80 - 98 | fL |
| MCH [Entitic mass] by Automated count | 29.8 | 27 - 33 | pg |
| MCHC [Mass/volume] by Automated count | 33.8 | 32 - 36 | g/dL |
| Erythrocyte distribution width [Entitic volume] by Automated count | 45.7 | 36 - 55 | fL |
| Platelets [#/volume] in Blood by Automated count | 251.7 | 150 - 350 | 10*3/uL |
| Platelet distribution width [Entitic volume] in Blood by Automated count | 377.3 | 150 - 450 | fL |
| Platelet mean volume [Entitic volume] in Blood by Automated count | 11.8 | 9.8 - 13.8 | fL |