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| Condition | Onset Date | Status |
|---|---|---|
| Prediabetes | 05-Oct-2008 | active |
| Anemia | 05-Oct-2008 | active |
| Medication | Since | Form | Dosage | Reason |
|---|---|---|---|---|
| Acetaminophen 325 mg oral tablet | 2025-04-20 | - | 1 tablet (325 mg) every 4 to 6 hours as needed | - |
| Tramadol hydrochloride 50 mg oral tablet | 2025-04-20 | - | 1 tablet (50 mg) by mouth every 4 to 6 hours as needed for pain | - |
| Vaccine | Date |
|---|---|
| Influenza virus antigen only vaccine product | 20-Apr-2025 |
| SARS-CoV-2 mRNA vaccine | 11-Apr-2021 |
| Clostridium tetani toxoid antigen adsorbed only vaccine product | 11-Mar-2018 |
| Procedure | Date | Reason |
|---|---|---|
| Depression screening | 02-Jul-2023 | - |
| Assessment of health and social care needs | 02-Jul-2023 | - |
| Assessment of anxiety | 02-Jul-2023 | - |
| Screening for drug abuse | 02-Jul-2023 | - |
| Assessment of substance use | 02-Jul-2023 | - |
| Depression screening using Patient Health Questionnaire Two-Item score (procedure) | 02-Jul-2023 | - |
| Allergy/Intolerance | Onset Date | Status | Type | Reaction |
|---|---|---|---|---|
| ? | active | ? |
| Active Planned Care / Goals | Start Date | Reason |
|---|---|---|
| Therapy | 30-Mar-2014 | - |
| Diabetes self management plan | 05-Oct-2008 | Prediabetes |
|
| Vital Signs | 2025-04-20 | 2024-04-14 |
|---|---|---|
| Body Height | 186.8 cm | 186.8 cm |
| Pain severity - 0-10 verbal numeric rating [Score] - Reported | 1 {score} | 3 {score} |
| Body Weight | 100.3 kg | 98.9 kg |
| Body mass index (BMI) [Ratio] | 28.7 kg/m2 | 28.3 kg/m2 |
| Diastolic Blood Pressure | 75 mm[Hg] | 74 mm[Hg] |
| Systolic Blood Pressure | 123 mm[Hg] | 112 mm[Hg] |
| Heart rate | 98 /min | 71 /min |
| Respiratory rate | 15 /min | 15 /min |
| Recent Lab Observations | 20-APR-2025 | Reference Range | Unit |
|---|---|---|---|
| Hemoglobin A1c/Hemoglobin.total in Blood | 5.9 | 4 - 6 | % |
| Glucose [Mass/volume] in Blood | 64.8 L | 70 - 99 | mg/dL |
| Urea nitrogen [Mass/volume] in Blood | 10.3 | 7 - 20 | mg/dL |
| Creatinine [Mass/volume] in Blood | 1.4 H | 0.6 - 1.3 | mg/dL |
| Calcium [Mass/volume] in Blood | 9.5 | 8.5 - 10.5 | mg/dL |
| Sodium [Moles/volume] in Blood | 137.8 | 135 - 145 | mmol/L |
| Potassium [Moles/volume] in Blood | 4.4 | 3.5 - 5.2 | mmol/L |
| Chloride [Moles/volume] in Blood | 108.2 | 98 - 114 | mmol/L |
| Carbon dioxide, total [Moles/volume] in Blood | 25.7 | 24 - 29 | mmol/L |
| Device | Date (since) |
|---|---|
| Blood glucose meter (physical object) | 05-Oct-2008 |