From 7cc33c9268b4252877d8bb10dabe3939b853fc2d Mon Sep 17 00:00:00 2001 From: Angela The Date: Fri, 27 Sep 2024 08:59:31 -0700 Subject: [PATCH] Update eICR Details section (#2618) * fix device resource, add eicr release version to composition * update eicr details and remove sender details * update snapshot & unit tests * remove eicr sender details from loading view * update data.sql * update snapshot test and bundle --- .../ecr-viewer/seed-scripts/sql/data.sql | 242 +++++++++--------- .../ecr-viewer/src/app/api/fhirPath.yml | 4 +- .../src/app/services/ecrMetadataService.ts | 74 ++---- .../app/tests/assets/BundleEcrMetadata.json | 46 ++++ .../app/tests/components/EcrMetadata.test.tsx | 31 +-- .../app/tests/components/Unavailable.test.tsx | 2 +- .../AccordionContent.test.tsx.snap | 103 +------- .../__snapshots__/EcrMetadata.test.tsx.snap | 59 +---- .../LoadingComponent.test.tsx.snap | 71 ----- .../__snapshots__/Unavailable.test.tsx.snap | 2 +- .../tests/services/ecrMetadataService.test.ts | 44 +--- .../view-data/components/AccordionContent.tsx | 6 +- .../app/view-data/components/EcrMetadata.tsx | 13 +- .../view-data/components/LoadingComponent.tsx | 3 +- .../eCR/Resource/_Composition.liquid | 8 + .../Templates/eCR/Resource/_Device.liquid | 9 - 16 files changed, 225 insertions(+), 492 deletions(-) diff --git a/containers/ecr-viewer/seed-scripts/sql/data.sql b/containers/ecr-viewer/seed-scripts/sql/data.sql index 46a3eae8f0..fb61bb6192 100644 --- a/containers/ecr-viewer/seed-scripts/sql/data.sql +++ b/containers/ecr-viewer/seed-scripts/sql/data.sql @@ -1,124 +1,124 @@ -INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.297.3.7.8.688883.567418', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.297.3.7.8.688883.567418", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.297.3.7.8.688883.567418", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "91fbf46a-4fcf-11ed-9f87-c301d81100b2", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "18"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-12-23T11:35:35-08:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "b7a7ed08-af88-4a31-cc4e-8dddd58b7fc8", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "F8F801F2-82F8-11ED-BEE8-C301D81100B2", "title": "Immunizations", "text": {"status": "generated", "div": "Not on file documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "F8F967CC-82F8-11ED-BEE8-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "5dd88b3d-f94a-27b1-0a18-79c39698376d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Drugs Of Abuse Comprehensive Screen, UrLabSTAT12/23/2022 11:13 AM PST
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
Drugs Of Abuse Comprehensive Screen, UrLabRoutineOne Time for 1 Occurrences starting 12/23/22 until 12/23/22
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/62c205fb-325f-10a1-324f-7d92c46f2bfd"}]}, {"id": "F9000D2A-82F8-11ED-BEE8-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "No known active problemsdocumented as of this encounter (statuses as of 12/23/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Condition/bb410dc7-007f-c649-1bed-2c00e676edfb"}]}, {"id": "2cfa1813-6ae8-c2d9-e243-2a17fef007cb", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "F9239DE4-82F8-11ED-BEE8-C301D81100B2", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Phencyclidine Screen, Urine", "reference": "Observation/ec338cfe-dc27-b775-0d99-2a09beaf59e3"}, {"display": "Benzodiazepines Screen, Urine", "reference": "Observation/f5df7c4a-4b02-d5f7-e071-d0c5141d6ba1"}, {"display": "Cocaine Screen, Urine", "reference": "Observation/2937e958-dcc7-d35c-768a-399ed135fdcc"}, {"display": "Barbiturates Screen, Urine", "reference": "Observation/bca062c5-9e12-a4f3-481c-ca4e20df1b14"}, {"display": "Amphetamine Screen, Urine", "reference": "Observation/d9ad8664-e771-0cf1-c8e7-8c6849184c56"}, {"display": "Cannabinoids Screen, Urine", "reference": "Observation/be258389-0971-1470-a4f1-d97d202de898"}, {"display": 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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "1f3f7b09-a1fb-199e-34cf-7749685a6c55", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
10/11/22EmergencyHOAG MEMORIAL HOSPITAL NEWPORT EMERGENCY CENTER1 HOAG DRNEWPORT BEACH, CA 92663-4162949-764-8372
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Reportability Response Information Section
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Unconfirmed screening results must not be used for non-medical purposes (e.g., employment testing).
Only positive maternal and neonatal screening results reflex for confirmation and are reported separately.
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Active ProblemsNoted Date
Coronavirus infection12/14/22
PregnantEstimated Date of DeliveryComments
Yes3/13/23
documented as of this encounter (statuses as of 12/20/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Coronavirus infection", "reference": "Condition/bf5669b6-650b-a7f4-b6b0-ef3c12a61432"}]}, {"id": "73e873d9-5336-4470-02cf-abb2740c876d", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "622C60F2-80B3-11ED-9CEB-005056AC13DC", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Lab Interpretation", "reference": "Observation/d679042c-0029-f362-cbfa-d650a9e1823d"}]}, {"id": "04039dfb-0a38-d275-fcaa-ac28731e342e", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
Travel HistoryTravel StartTravel End
Mexico12/15/2212/17/22
Brazil11/30/2212/7/22
COVID-19 ExposureResponseDate Recorded
In the last 10 days, have you been in contact with someone who was confirmed or suspected to have Coronavirus/COVID-19?No / Unsure12/20/2022 2:07 PM PST
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DateTypeDepartmentCare TeamDescription
12/20/22Office VisitFAMILY CARE SPECIALISTS MEDICAL CORPORATION1701 CESAR E. CHAVEZ AVE., STE 230LOS ANGELES, CA 90033-2642323-226-1100Castro, Edward, MD1701 CESAR E. CHAVEZ AVE., STE 230LOS ANGELES, CA 90033-2642323-226-1100 (Work)323-226-1101 (Fax)Coronavirus infection (Primary Dx)
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Reportability Response Information Section
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.....DRUG...... \u00a0 \u00a0 \u00a0 \u00a0 THRESHOLD DETECTION LIMIT
AMPH/METHAMPHET \u00a0 \u00a0 \u00a0 \u00a0 >1000 ng/mL
BARBITUATES \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 200 ng/mL
BENZODIAZEPINES \u00a0 \u00a0 \u00a0 \u00a0 > 200 ng/mL
COCAINE \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 300 ng/mL
OPIATES \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 300 ng/mL
PCP \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a025 ng/mL
THC \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a050 ng/mL
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TESTPHYS AAAprimary care physicianActive
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Ed Bakeradmitting physicianActive
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DR DEBRA A ALEXANDER JR, PHDFAMILYActive
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Is patient pregnant?NMarch 31st, 2022 12:06pm
Assigned Birth SexFemale
Gender Identityunknown
Sexual OrientationDo not know
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AnthraxActive
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Recent DiagnosisOnset Date
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HOYT HEPATITIS LOINC 22314-9April 1st, 2022 4:26pmApril 8th, 2022
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Crohn''s disease of perianal regionActive
Colostomy in placeActive
Ileostomy prolapse (disorder)Active
Anxiety (finding)Active
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Lab Test NameLab Test Result ValueLab Test Result Date
SARS-CoV-2, NAA CLPOS
Symptomatic as defined by CDC?YES
In ICU?NO
Group care resident?NO
Employed in healthcare?NO
Estimated Creatinine Clearance75.63|http://unitsofmeasure.org|mL/min
U Beta hCG QlNegative.
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Ur BloodSmall
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Ur Leuk EstNegative
Ur ProteinTrace mg/dL
Ur NitriteNegative
Ur KetonesTrace mg/dL
UR GlucoseNegative mg/dL
eGFR PediatricNot Reported
Calc Osmo273|http://unitsofmeasure.org|mOsmol/kg
A/G RatioUnknown
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eGFR African American60.0|http://unitsofmeasure.org|mL/min/1.73m2
Sodium138|http://unitsofmeasure.org|mmol/L
Potassium3.2|http://unitsofmeasure.org|mmol/L
Albumin. Level4.1|http://unitsofmeasure.org|gm/dL
Calcium8.7|http://unitsofmeasure.org|mg/dL
RDW-CV13.0|http://unitsofmeasure.org|%
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MCV85.8|http://unitsofmeasure.org|Femtoliters
MCHC34.0|http://unitsofmeasure.org|gm/dL
MCH29.2|http://unitsofmeasure.org|pg
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Hct34.4|http://unitsofmeasure.org|%
Glucose Level95|http://unitsofmeasure.org|mg/dL
CO225|http://unitsofmeasure.org|mmol/L
T Bili0.1|http://unitsofmeasure.org|mg/dL
AST16|http://unitsofmeasure.org|Intl_units/L
ALT21|http://unitsofmeasure.org|Intl_units/L
Alk Phos53|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio7|http://unitsofmeasure.org|Ratio
Anion Gap11|http://unitsofmeasure.org|mmol/L
Creatinine0.76|http://unitsofmeasure.org|mg/dL
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Travel HistoryCOVID- 19 Testing Reason-Screening
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Travel HistoryTB Risk Score-
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Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
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MULTIPLE COMPLAINTS
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Reportability Response Information Section
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Adam Sheradmitting physicianActive
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MCUTLERattending physicianActive
Start: March 12th, 2022
DR MEDITECHprimary care physicianActive
Start: March 12th, 2022
AMANDA NOELREFERRINGActive
Start: March 12th, 2022
AMANDA PARLATOFAMILYActive
Start: March 12th, 2022
Rickey RobertsOTHERActive
Start: March 12th, 2022
Stephen NewtonCONSULTINGActive
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Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
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RIGRAPID HEART BEAT
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Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
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[{"system": "urn:ietf:rfc:3986", "value": "urn:uuid:17867d44-a3bf-11ec-81e0-9e7eef92c510"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "vital-signs"}]}], "status": "final", "code": {"coding": [{"code": "39156-5", "display": "BMI (Body Mass Index)", "system": "http://loinc.org"}]}, "effectiveDateTime": "2022-03-14T13:48:00-04:00", "valueQuantity": {"value": 25.0, "unit": "kg/m2"}, "subject": {"reference": "Patient/565affad-487e-4a67-94a1-d60395f4544b"}}, "request": {"method": "PUT", "url": "Observation/dcd0af93-2eca-0d28-f1fe-5f2b65c7d182"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}, {"fullUrl": "urn:uuid:2d1c8280-bfde-5e93-e96e-2300eb5cfc2d", "resource": {"resourceType": "Immunization", "id": 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vaccine?"}]}, "manufacturer": {"reference": "Organization/81335318-8424-a5e6-822b-3f53ce03b63f"}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/81ff4e99-dc85-a8a8-80ec-46788c03571e"}}, {"fullUrl": "urn:uuid:6a8ae7b7-e46b-7b29-8082-bf332be553dd", "resource": {"resourceType": "Immunization", "id": "6a8ae7b7-e46b-7b29-8082-bf332be553dd", "identifier": [{"system": "urn:ietf:rfc:3986", "value": "urn:uuid:f388d4f9-a451-11ec-81e0-9e7eef92c510"}], "protocolApplied": [{"doseNumberPositiveInt": "1"}], "occurrenceDateTime": "2022-03-15T07:20:00-04:00", "note": {"text": "anthrax"}, "vaccineCode": {"coding": [{"code": "24", "display": "anthrax", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "LOT9911Z", "manufacturer": {"reference": "Organization/1e2d10a1-e4d3-ac11-3b25-56396aee4ba2"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/565affad-487e-4a67-94a1-d60395f4544b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/6a8ae7b7-e46b-7b29-8082-bf332be553dd"}}, {"fullUrl": "urn:uuid:1e2d10a1-e4d3-ac11-3b25-56396aee4ba2", "resource": {"resourceType": "Organization", "id": "1e2d10a1-e4d3-ac11-3b25-56396aee4ba2", "name": "PFIZER & OTHER CHARACTERS", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/1e2d10a1-e4d3-ac11-3b25-56396aee4ba2"}}, {"fullUrl": "urn:uuid:efc69dae-16b1-10e2-e609-82bfdf6dd46a", "resource": {"resourceType": "Immunization", "id": "efc69dae-16b1-10e2-e609-82bfdf6dd46a", "identifier": [{"system": "urn:ietf:rfc:3986", "value": "urn:uuid:8bdb0ffa-a9d2-11ec-81e0-9e7eef92c510"}], "occurrenceString": "Unknown", "note": {"text": "RIG"}, "vaccineCode": {"coding": [{"code": "34", "display": "RIG", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "manufacturer": {"reference": "Organization/81335318-8424-a5e6-822b-3f53ce03b63f"}, "status": "completed", "primarySource": true, "patient": 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"Immunization/c859a2f6-86ea-d524-4025-2416fc8b90e7"}}, {"fullUrl": "urn:uuid:fb121477-4011-40b3-40fe-f884cdfecd6a", "resource": {"resourceType": "Organization", "id": "fb121477-4011-40b3-40fe-f884cdfecd6a", "name": "JOHNSON AND JOHNSON", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/fb121477-4011-40b3-40fe-f884cdfecd6a"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('f14889a0-e28f-47b2-9260-c73d38133938', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:f14889a0-e28f-47b2-9260-c73d38133938", "resource": {"resourceType": "Composition", "id": "f14889a0-e28f-47b2-9260-c73d38133938", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "28109659|65128172"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "2"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-05-21T12:01:02Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "28c67070-3e59-9749-0b22-75c480826ad3", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Ineffective airway clearanceActive
Alteration in nutrition (finding)Active
Rheumatoid arthritis (disorder)Active
At risk for injury due to fall (finding)Active
Chronic obstructive lung disease (disorder)Active
Aortic stenosisActive
Bowel dysfunction (disorder)Active
Diabetes mellitus (disorder)Active
Systolic heart failure (disorder)Active
History of malignant neoplasm of prostate (situation)Active
DiabetesActive
At risk for fallsActive
Atrial fibrillation (disorder)Active
Hypertensive disorder, systemic arterial (disorder)Active
Acute painActive
HypertensionActive
Bloody stoolsActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Ineffective airway clearance (finding)", "reference": "Condition/64a739b3-2854-5868-df1d-1949f6ae1fef"}, {"display": "Problem - Alteration in nutrition (finding)", "reference": "Condition/52280af5-612d-3140-4080-0d23a0f571c7"}, {"display": "Problem - Rheumatoid arthritis (disorder)", "reference": "Condition/cda5ae1c-47c3-d7ff-6501-8672df4b125a"}, {"display": "Problem - At risk for injury due to fall (finding)", "reference": "Condition/6e2fd739-7997-b985-78f9-623466d140d2"}, {"display": "Problem - Chronic obstructive lung disease (disorder)", "reference": "Condition/82e380a6-0cc6-dc4f-0978-e3bbbddcbb59"}, {"display": "Problem - Aortic valve stenosis (disorder)", "reference": "Condition/d139d835-2bea-d850-3233-a16e55ae6593"}, {"display": "Problem - Bowel dysfunction (disorder)", "reference": "Condition/1cf1659e-01ea-32e6-8cd3-c623b9779ea9"}, {"display": "Problem - Diabetes mellitus (disorder)", "reference": "Condition/1f6f997e-1bb6-76ca-e106-6ae9c5037326"}, {"display": "Problem - Systolic heart failure (disorder)", "reference": "Condition/19373c76-4df9-50e6-5155-685adcab5620"}, {"display": "Problem - History of malignant neoplasm of prostate (situation)", "reference": "Condition/66b26b96-a776-d0a6-fd03-10ddc85ce037"}, {"display": "Problem - Diabetes mellitus (disorder)", "reference": "Condition/be49290f-4769-1d4d-1873-4c7ce57afb34"}, {"display": "Problem - At risk for falls (finding)", "reference": "Condition/d1822e79-d8fb-2cd9-b4d7-ba2df3571c1f"}, {"display": "Problem - Atrial fibrillation (disorder)", "reference": "Condition/b6660c4a-4a09-1dac-2388-ca50c6904a87"}, {"display": "Problem - Hypertensive disorder, systemic arterial (disorder)", "reference": "Condition/c54a639a-0084-07aa-4518-88148d9a7df6"}, {"display": "Problem - Acute pain (finding)", "reference": "Condition/1a2bcef3-7fc6-027f-3fff-d532981e0efd"}, {"display": "Problem - Hypertensive disorder, systemic arterial (disorder)", "reference": "Condition/6f7712f7-a0ed-d5b0-50b7-c3ccd7522943"}, {"display": "Problem - Hematochezia (finding)", "reference": "Condition/2cee354e-d907-b2fa-bf84-f9f2f1df5a0d"}]}, {"id": "e919e7ad-f6f5-981c-8402-0f3b330d9bf4", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
inpatient encounter20220514125500+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "e2d758a5-40fc-2c8a-0c22-0e82b14db6e5", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
POC Glucose223|http://unitsofmeasure.org|mg/dL
POC Glucose148|http://unitsofmeasure.org|mg/dL
POC Glucose120|http://unitsofmeasure.org|mg/dL
POC Glucose90|http://unitsofmeasure.org|mg/dL
POC Glucose264|http://unitsofmeasure.org|mg/dL
POC Glucose133|http://unitsofmeasure.org|mg/dL
Plt MorphologyNormal
eGFR PediatricNot Reported
Magnesium S LC2.1 mg/dL
Calc Osmo288|http://unitsofmeasure.org|mOsmol/L
Eos # Man1.04|http://unitsofmeasure.org|x10e3/mcL
Segs # Man3.17|http://unitsofmeasure.org|x10e3/mcL
Mono # Man1.38|http://unitsofmeasure.org|x10e3/mcL
Lymphs # Man1.10|http://unitsofmeasure.org|x10e3/mcL
Mono Man20|http://unitsofmeasure.org|%
Lymphs Man16|http://unitsofmeasure.org|%
eGFR Non-African American42.87 mL/min/1.73m2
eGFR African American49.69 mL/min/1.73m2
RBC MorphAbnormal
Sodium140|http://unitsofmeasure.org|mmol/L
Potassium3.5|http://unitsofmeasure.org|mmol/L
Ferritin Lvl260|http://unitsofmeasure.org|ng/mL
Myelo # Man0.21|http://unitsofmeasure.org|x10e3/mcL
Segs Man46|http://unitsofmeasure.org|%
Calcium8.3|http://unitsofmeasure.org|mg/dL
Plt GiantPresent
Schistocytes1+
RDW-CV18.7|http://unitsofmeasure.org|%
Chloride105|http://unitsofmeasure.org|mmol/L
BUN35|http://unitsofmeasure.org|mg/dL
Plt126|http://unitsofmeasure.org|x10e3/mcL
WBC6.9|http://unitsofmeasure.org|x10e3/mcL
RBC3.52|http://unitsofmeasure.org|x10e6/mcL
Myelo Man3|http://unitsofmeasure.org|%
MPV10.7|http://unitsofmeasure.org|Femtoliters
MCV94.0|http://unitsofmeasure.org|Femtoliters
MCHC30.8|http://unitsofmeasure.org|gm/dL
MCH29.0|http://unitsofmeasure.org|pg
Mg LvlTNP mg/dL
Hgb10.2|http://unitsofmeasure.org|gm/dL
Hct33.1|http://unitsofmeasure.org|%
Glucose Level108|http://unitsofmeasure.org|mg/dL
Eos Man15|http://unitsofmeasure.org|%
D Dimer1.15|http://unitsofmeasure.org|mg/L
CRP5.5|http://unitsofmeasure.org|mg/dL
CO226.8|http://unitsofmeasure.org|mmol/L
BUN/Creat Ratio25.0|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Ovalocytes1+
EchinocytesPresent
Plt LargePresent
Plt EstAdequate
Aniso1+
Acanthocyte1+
Hypo1+
Polychrom1+
Macro1+
Creatinine1.4|http://unitsofmeasure.org|mg/dL
POC Glucose233|http://unitsofmeasure.org|mg/dL
POC Glucose107|http://unitsofmeasure.org|mg/dL
POC Glucose266|http://unitsofmeasure.org|mg/dL
POC Glucose120|http://unitsofmeasure.org|mg/dL
Estimated Creatinine Clearance34.37|http://unitsofmeasure.org|mL/min
eGFR PediatricNot Reported
Calc Osmo286|http://unitsofmeasure.org|mOsmol/L
eGFR Non-African American41.80 mL/min/1.73m2
eGFR African American48.45 mL/min/1.73m2
Sodium138|http://unitsofmeasure.org|mmol/L
Potassium3.5|http://unitsofmeasure.org|mmol/L
Baso # Auto0.02|http://unitsofmeasure.org|x10e3/mcL
Mono # Auto1.4|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto5.2|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.2|http://unitsofmeasure.org|%
Eos % Auto7.0|http://unitsofmeasure.org|%
Lymph % Auto12.3|http://unitsofmeasure.org|%
Neut % Auto62.7|http://unitsofmeasure.org|%
Calcium8.6|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.10|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto1.0|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto16.6|http://unitsofmeasure.org|%
RDW-CV19.0|http://unitsofmeasure.org|%
Immature Grans %1.2|http://unitsofmeasure.org|%
Eos # Auto0.6|http://unitsofmeasure.org|x10e3/mcL
Chloride105|http://unitsofmeasure.org|mmol/L
BUN38|http://unitsofmeasure.org|mg/dL
Plt118|http://unitsofmeasure.org|x10e3/mcL
WBC8.3|http://unitsofmeasure.org|x10e3/mcL
RBC3.33|http://unitsofmeasure.org|x10e6/mcL
MPV10.9|http://unitsofmeasure.org|Femtoliters
MCV92.5|http://unitsofmeasure.org|Femtoliters
MCHC31.2|http://unitsofmeasure.org|gm/dL
MCH28.8|http://unitsofmeasure.org|pg
Mg Lvl1.8|http://unitsofmeasure.org|mg/dL
Hgb9.6|http://unitsofmeasure.org|gm/dL
Hct30.8|http://unitsofmeasure.org|%
Glucose Level122|http://unitsofmeasure.org|mg/dL
CO226.8|http://unitsofmeasure.org|mmol/L
BUN/Creat Ratio27.1|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine1.4|http://unitsofmeasure.org|mg/dL
POC Glucose180|http://unitsofmeasure.org|mg/dL
POC Glucose158|http://unitsofmeasure.org|mg/dL
POC Glucose199|http://unitsofmeasure.org|mg/dL
eGFR PediatricNot Reported
Calc Osmo293|http://unitsofmeasure.org|mOsmol/L
eGFR Non-African American34.24 mL/min/1.73m2
eGFR African American39.69 mL/min/1.73m2
Sodium140|http://unitsofmeasure.org|mmol/L
Potassium3.6|http://unitsofmeasure.org|mmol/L
Ferritin Lvl221|http://unitsofmeasure.org|ng/mL
Baso # Auto0.04|http://unitsofmeasure.org|x10e3/mcL
Mono # Auto0.8|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto7.2|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.4|http://unitsofmeasure.org|%
Eos % Auto2.5|http://unitsofmeasure.org|%
Lymph % Auto13.1|http://unitsofmeasure.org|%
Neut % Auto74.7|http://unitsofmeasure.org|%
Calcium8.6|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.12|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto1.3|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.0|http://unitsofmeasure.org|%
RDW-CV19.3|http://unitsofmeasure.org|%
Immature Grans %1.3|http://unitsofmeasure.org|%
Eos # Auto0.2|http://unitsofmeasure.org|x10e3/mcL
Chloride108|http://unitsofmeasure.org|mmol/L
BUN47|http://unitsofmeasure.org|mg/dL
Plt127|http://unitsofmeasure.org|x10e3/mcL
WBC9.6|http://unitsofmeasure.org|x10e3/mcL
RBC3.29|http://unitsofmeasure.org|x10e6/mcL
MPV11.0|http://unitsofmeasure.org|Femtoliters
MCV90.0|http://unitsofmeasure.org|Femtoliters
MCHC32.4|http://unitsofmeasure.org|gm/dL
MCH29.2|http://unitsofmeasure.org|pg
Mg Lvl1.7|http://unitsofmeasure.org|mg/dL
Hgb9.6|http://unitsofmeasure.org|gm/dL
Hct29.6|http://unitsofmeasure.org|%
Glucose Level115|http://unitsofmeasure.org|mg/dL
D Dimer3.17|http://unitsofmeasure.org|mg/L
CRP10.5|http://unitsofmeasure.org|mg/dL
CO224.0|http://unitsofmeasure.org|mmol/L
BUN/Creat Ratio27.6|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine1.7|http://unitsofmeasure.org|mg/dL
POC Glucose125|http://unitsofmeasure.org|mg/dL
POC Glucose220|http://unitsofmeasure.org|mg/dL
POC Glucose129|http://unitsofmeasure.org|mg/dL
POC Glucose195|http://unitsofmeasure.org|mg/dL
POC Glucose235|http://unitsofmeasure.org|mg/dL
Symptomatic as defined by CDC?Yes
In ICU?Yes
Group care resident?No
Employed in healthcare?No
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRPositive
Flu B PCRNot Detected
Flu A PCRNot Detected
POC Glucose158|http://unitsofmeasure.org|mg/dL
Ur pHUnknown
Ur Spec GravUnknown
Ur Urobilinogen<2.0 mg/dL
Ur Blood3+ mg/dL
Ur BiliNegative mg/dL
Ur Leuk EstTrace
Ur ColorRed
Ur MucousRare /LPF
Ur Squam Epithelial1|http://unitsofmeasure.org|/HPF
Ur WBC33|http://unitsofmeasure.org|/HPF
Ur RBC182|http://unitsofmeasure.org|/HPF
Ur Protein1+ mg/dL
Ur NitriteNegative
Ur KetonesNegative mg/dL
UR GlucoseNegative mg/dL
Ur BacteriaNone Seen /HPF
Ur ClarityCloudy
Estimated Creatinine Clearance28.30|http://unitsofmeasure.org|mL/min
POC Glucose177|http://unitsofmeasure.org|mg/dL
eGFR PediatricNot Reported
Calc Osmo295|http://unitsofmeasure.org|mOsmol/L
A/G Ratio0.9|http://unitsofmeasure.org|Ratio
eGFR Non-African American34.98 mL/min/1.73m2
eGFR African American40.55 mL/min/1.73m2
Sodium141|http://unitsofmeasure.org|mmol/L
Potassium4.4|http://unitsofmeasure.org|mmol/L
Ferritin Lvl192|http://unitsofmeasure.org|ng/mL
Albumin. Level3.0|http://unitsofmeasure.org|gm/dL
Calcium9.1|http://unitsofmeasure.org|mg/dL
RDW-CV18.9|http://unitsofmeasure.org|%
Chloride111|http://unitsofmeasure.org|mmol/L
BUN40|http://unitsofmeasure.org|mg/dL
Plt114|http://unitsofmeasure.org|x10e3/mcL
WBC15.6|http://unitsofmeasure.org|x10e3/mcL
TP6.5|http://unitsofmeasure.org|gm/dL
RBC3.28|http://unitsofmeasure.org|x10e6/mcL
MPV10.8|http://unitsofmeasure.org|Femtoliters
MCV93.0|http://unitsofmeasure.org|Femtoliters
MCHC31.5|http://unitsofmeasure.org|gm/dL
MCH29.3|http://unitsofmeasure.org|pg
Mg Lvl1.6|http://unitsofmeasure.org|mg/dL
Hgb9.6|http://unitsofmeasure.org|gm/dL
Hct30.5|http://unitsofmeasure.org|%
Glucose Level178|http://unitsofmeasure.org|mg/dL
CRP12.5|http://unitsofmeasure.org|mg/dL
CO221.6|http://unitsofmeasure.org|mmol/L
T Bili0.8|http://unitsofmeasure.org|mg/dL
AST19|http://unitsofmeasure.org|Intl_units/L
ALT21|http://unitsofmeasure.org|Intl_units/L
Alk Phos88|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio23.5|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine1.7|http://unitsofmeasure.org|mg/dL
POC Glucose169|http://unitsofmeasure.org|mg/dL
POC Glucose213|http://unitsofmeasure.org|mg/dL
POC Glucose225|http://unitsofmeasure.org|mg/dL
Troponin TNIH258.7|http://unitsofmeasure.org|ng/L
POC Glucose207|http://unitsofmeasure.org|mg/dL
Troponin TNIH137.1|http://unitsofmeasure.org|ng/L
HCO3 Art21.3|http://unitsofmeasure.org|mmol/L
POC PEEP5|http://unitsofmeasure.org|cm H2O
POC PIP24|http://unitsofmeasure.org|cm H2O
POC Pt Temp37.0|http://unitsofmeasure.org|DegC
POC Set RR24|http://unitsofmeasure.org|br/min
POC Total RR24|http://unitsofmeasure.org|br/min
POC FIO270|http://unitsofmeasure.org|%
POC Allen TestPOS
Art Base Excess-3.7|http://unitsofmeasure.org|mmol/L
Art sO298|http://unitsofmeasure.org|%
Art pO2112.0|http://unitsofmeasure.org|mmHg
pH ArterialUnknown
Art pCO237.5|http://unitsofmeasure.org|mmHg
Estimated Creatinine Clearance32.08|http://unitsofmeasure.org|mL/min
Troponin TNIH72.4|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
Calc Osmo294|http://unitsofmeasure.org|mOsmol/L
A/G Ratio1.0|http://unitsofmeasure.org|Ratio
eGFR Non-African American41.46 mL/min/1.73m2
eGFR African American48.05 mL/min/1.73m2
Sodium142|http://unitsofmeasure.org|mmol/L
Potassium3.5|http://unitsofmeasure.org|mmol/L
Albumin. Level2.8|http://unitsofmeasure.org|gm/dL
Calcium7.7|http://unitsofmeasure.org|mg/dL
Chloride112|http://unitsofmeasure.org|mmol/L
BUN32|http://unitsofmeasure.org|mg/dL
TP5.7|http://unitsofmeasure.org|gm/dL
Glucose Level171|http://unitsofmeasure.org|mg/dL
CO221.1|http://unitsofmeasure.org|mmol/L
T Bili1.8|http://unitsofmeasure.org|mg/dL
AST17|http://unitsofmeasure.org|Intl_units/L
ALT19|http://unitsofmeasure.org|Intl_units/L
Alk Phos99|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio21.3|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine1.5|http://unitsofmeasure.org|mg/dL
Lactic Acid Lvl1.8|http://unitsofmeasure.org|mmol/L
HCO3 Art19.0|http://unitsofmeasure.org|mmol/L
POC PEEP5|http://unitsofmeasure.org|cm H2O
POC PIP27|http://unitsofmeasure.org|cm H2O
POC Pt Temp37.0|http://unitsofmeasure.org|DegC
POC Set RR18|http://unitsofmeasure.org|br/min
POC Total RR18|http://unitsofmeasure.org|br/min
POC FIO280|http://unitsofmeasure.org|%
POC Allen TestPOS
Art Base Excess-6.7|http://unitsofmeasure.org|mmol/L
Art sO298|http://unitsofmeasure.org|%
Art pO2130.0|http://unitsofmeasure.org|mmHg
pH ArterialUnknown
Art pCO257.3|http://unitsofmeasure.org|mmHg
POC Glucose172|http://unitsofmeasure.org|mg/dL
Troponin TNIH18.0|http://unitsofmeasure.org|ng/L
NT-ProBNP1846|http://unitsofmeasure.org|pg/mL
Baso # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Mono # Auto0.5|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto10.2|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.2|http://unitsofmeasure.org|%
Eos % Auto1.4|http://unitsofmeasure.org|%
Lymph % Auto23.9|http://unitsofmeasure.org|%
Neut % Auto70.2|http://unitsofmeasure.org|%
Immature Grans # Auto0.16|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto3.5|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto3.2|http://unitsofmeasure.org|%
RDW-CV18.9|http://unitsofmeasure.org|%
Immature Grans %1.1|http://unitsofmeasure.org|%
Eos # Auto0.2|http://unitsofmeasure.org|x10e3/mcL
Plt167|http://unitsofmeasure.org|x10e3/mcL
WBC14.6|http://unitsofmeasure.org|x10e3/mcL
RBC3.68|http://unitsofmeasure.org|x10e6/mcL
PTT27.2|http://unitsofmeasure.org|Seconds
PT11.0|http://unitsofmeasure.org|Seconds
MPV10.7|http://unitsofmeasure.org|Femtoliters
MCV93.8|http://unitsofmeasure.org|Femtoliters
MCHC31.3|http://unitsofmeasure.org|gm/dL
MCH29.3|http://unitsofmeasure.org|pg
Lipase Lvl132|http://unitsofmeasure.org|Intl_units/L
Hgb10.8|http://unitsofmeasure.org|gm/dL
Hct34.5|http://unitsofmeasure.org|%
INRUnknown
Lactic Acid Lvl3.7|http://unitsofmeasure.org|mmol/L
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Medication NameMedication Start Date
atorvastatin (Lipitor 20 mg oral tablet)20220516202400+0000
fluticasone-salmeterol (Wixela Inhub 500 mcg-50 mcg inhalation powder)20220516202400+0000
glipiZIDE (glipiZIDE 5 mg oral tablet)20220516202200+0000
metFORMIN (metFORMIN 1000 mg oral tablet)20220516202200+0000
methotrexate (methotrexate 2.5 mg oral tablet)20220516202300+0000
sacubitril-valsartan (Entresto 24 mg-26 mg oral tablet)20220519203100+0000
spironolactone (spironolactone 25 mg oral tablet)20220519203100+0000
torsemide (torsemide 20 mg oral tablet)20220516202300+0000
traMADol (traMADol 50 mg oral tablet)20220516202100+0000
guaiFENesin-dextromethorphan (guaifenesin-dextromethorphan 100 mg-10 mg/5 mL oral liquid)20220519203000+0000
cefuroxime (Ceftin 500 mg oral tablet)20220519203100+0000
albuterol (albuterol CFC free 90 mcg/inh inhalation aerosol)20220516101600+0000
carvedilol (Coreg)20220519160000+0000
cefTRIAXone20220514163400+0000
furosemide20220517143000+0000
guaiFENesin-dextromethorphan (guaifenesin-dextromethorphan 100 mg-10 mg/5 mL oral liquid)20220516193900+0000
insulin aspart (insulin aspart NovoLog correctional scale High)20220514190000+0000
ipratropium-albuterol (DuoNeb)20220514161000+0000
lidocaine (lidocaine 1% injectable solution)20220514220700+0000
pantoprazole (Protonix 40 mg oral enteric coated tablet)20220517133000+0000
sacubitril-valsartan (Entresto 24 mg-26 mg oral tablet)20220519143700+0000
spironolactone20220517160000+0000
carvedilol (Coreg 12.5 mg oral tablet)20220516202400+0000
potassium chloride (K-Tab 10 mEq oral tablet, extended release)20220516202300+0000
haloperidol (Haldol)20220519181500+0000
Sodium Chloride 0.9% intravenous solution (NS Bolus (ADULT))20220518201300+0000
carvedilol20220517045300+0000
sacubitril-valsartan (Entresto 24 mg-26 mg oral tablet)20220518042800+0000
Sodium Chloride 0.9% intravenous solution (NS Bolus (ADULT))20220518191000+0000
azithromycin (Zithromax 250 mg oral tablet)20220517160000+0000
heparin20220514210000+0000
magnesium sulfate20220517170000+0000
dilTIAZem (Cardizem)Unknown
furosemide20220516233000+0000
atorvastatin (Lipitor 20 mg oral tablet)20220514181400+0000
fluticasone-salmeterol (Wixela Inhub 500 mcg-50 mcg inhalation powder)20220514181800+0000
torsemide20220514203600+0000
traMADol (traMADol 50 mg oral tablet)20220514181800+0000
magnesium sulfate20220516200000+0000
furosemide20220516143000+0000
Azithromycin20220514163700+0000
pantoprazole (Protonix)20220515133000+0000
furosemide20220516000000+0000
furosemide (Lasix)20220514160400+0000
magnesium sulfate20220515160000+0000
Fentanyl20220514154000+0000
Propofol20220514142500+0000
magnesium sulfate20220515130000+0000
potassium chloride20220515070000+0000
lisinopril (lisinopril 5 mg oral tablet)20220514181600+0000
magnesium oxide (magnesium oxide 400 mg (241.3 mg elemental magnesium) oral tablet)20220514181600+0000
Diltiazem20220514142600+0000
D5/NS 1,000 mL20220514182100+0000
furosemide (Lasix)20220514151600+0000
levalbuterol (Xopenex 1.25 mg/3 mL inhalation solution)20220514134000+0000
propofol20220514143500+0000
dilTIAZem20220514133900+0000
methylPREDNISolone (SOLU-Medrol)20220514134100+0000
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Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
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DateTypeDepartmentCare TeamDescription
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and who is not shedding SARS-CoV-2 virus would expect to have a
consistent with COVID-19. An individual without symptoms of COVID-19
recent exposures and the presence of clinical signs and symptoms
negative result should be considered in the context of a patient''s
When diagnostic testing is negative, the possibility of a false
sooner.
360bbb-3(b) (1), unless the authorization is terminated or revoked
of COVID-19 infection under section 564(b)(1) of the Act, 21 U.S.C.
diagnostic tests for detection of SARS-CoV-2 virus and/or diagnosis
justifying the authorization of the emergency use of in vitro
for the duration of time the declaration that circumstances exist
an Emergency Use Authorization (EUA). This test is only authorized
FDA cleared or approved. This test has been authorized by FDA under
amplification tests include RT-PCR and TMA. This test has not been
characteristics determined by LabCorp Laboratories. Nucleic acid
This nucleic acid amplification test was developed and its performance
resources and information.
Visit our website at https://www.labcorp.com/COVID19 for
with mild to moderate symptoms and for hospitalized patients.
treatment options. Treatment options are available for patients
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NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "08AD5644-5A39-11ED-815F-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "576c9b22-b1f8-fc85-539e-f688ca7add3f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Stool Pathogens, NAAT, 12 to 25 TargetsMicrobiologyRoutine11/01/2022 3:23 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/f79f7fbc-cf8a-55d2-34b4-108ebff26173"}]}, {"id": "08C99EF8-5A39-11ED-815F-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "
ProblemNoted Date
Bipolar I disorder11/19/20
Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
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"extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Stool"}, {"url": "specimen collection time", "valueDateTime": "2022-11-01T22:23:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-11-01T22:56:40Z"}]}], "subject": {"reference": "Patient/e46e30c4-9dee-410c-a899-7f0d3383e78e"}}, "request": {"method": "PUT", "url": "Observation/0d1bcf57-5d91-82e9-8b24-a045e6a445b7"}}, {"fullUrl": "urn:uuid:4474ee66-365d-c403-da4e-a4a7f1ca169c", "resource": {"resourceType": "Observation", "id": "4474ee66-365d-c403-da4e-a4a7f1ca169c", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.1.1040.1", "value": "Z41472^^72166-2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "72166-2", "display": "Tobacco smoking status NHIS", "system": "http://loinc.org"}]}, "effectiveDateTime": "2019-04-16", "valueCodeableConcept": {"coding": [{"code": "266919005", "display": "Never smoked tobacco", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/e46e30c4-9dee-410c-a899-7f0d3383e78e"}}, "request": {"method": "PUT", "url": "Observation/4474ee66-365d-c403-da4e-a4a7f1ca169c"}}, {"fullUrl": "urn:uuid:c4c7e08a-7027-806d-25f3-8c108fb5dde0", "resource": {"resourceType": "Observation", "id": "c4c7e08a-7027-806d-25f3-8c108fb5dde0", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.1.1040.8", "value": "Z41472^^713914004"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "229819007", "display": 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[{"display": "DTAP-HIB-IPV (PENTACEL)"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/7a4b0e4b-ca8a-a39b-1b44-19efe2c9ee5c"}}, {"fullUrl": "urn:uuid:b5d003f7-cfe2-56a4-6e91-07307f25aa83", "resource": {"resourceType": "Immunization", "id": "b5d003f7-cfe2-56a4-6e91-07307f25aa83", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "57643"}], "occurrenceDateTime": "2020-11-10", "note": {"text": "TDAP, (ADOL/ADULT)"}, "vaccineCode": {"coding": [{"code": "49281-400-10", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "369258741", "manufacturer": {"reference": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/e46e30c4-9dee-410c-a899-7f0d3383e78e"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/b5d003f7-cfe2-56a4-6e91-07307f25aa83"}}, {"fullUrl": "urn:uuid:b5c77b86-2764-79f9-10bf-5da5e63eb7c1", "resource": {"resourceType": "Organization", "id": "b5c77b86-2764-79f9-10bf-5da5e63eb7c1", "name": "Sanofi Pasteur", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}}, {"fullUrl": "urn:uuid:cffb2ab8-483c-a93e-56c3-5cc3d11e9168", "resource": {"resourceType": "Immunization", "id": "cffb2ab8-483c-a93e-56c3-5cc3d11e9168", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "57644"}], "occurrenceDateTime": "2011-11-11", "note": {"text": "HEP A (ADULT) 2 DOSE"}, "vaccineCode": {"coding": [{"display": "HEP A (ADULT) 2 DOSE"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/cffb2ab8-483c-a93e-56c3-5cc3d11e9168"}}, {"fullUrl": "urn:uuid:35c0d7fc-0bc0-5a24-e65e-dc30321d7e2e", "resource": {"resourceType": "Immunization", "id": "35c0d7fc-0bc0-5a24-e65e-dc30321d7e2e", 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[{"display": "HEP B (PED,ADOLESCENT) 3 DOSE"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/50fc36a0-b859-c4a4-de8f-53c149080081"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.134.3.7.8.688883.49556', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.134.3.7.8.688883.49556", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.134.3.7.8.688883.49556", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00434126-48ff-11ed-88ac-8b040cab2e6b", "assigner": {"display": "EPC"}}], "extension": [{"url": 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"0CA0A710-48FF-11ED-A9C1-8B04F0D33E31", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
diphenhydrAMINE (BENADRYL) 50 mg/ml injection 11 mgIntravenous, PRN Conditional, Starting on Tue 9/20/22 at 0907, Until Discontinued, other (enter comment), For Anaphylactic Reaction that includes CUTANEOUS SYMPTOMS (e.g. localized itching, flushing, hives, swelling) from Pegaspargase
EPINEPHrine PF (ADRENALIN) 1 mg/mL (1 mL) injection 0.11 mgIntramuscular, PRN Conditional, Starting on Tue 9/20/22 at 0907, Until Discontinued, other (enter comment), For Anaphylactic Reaction that includes RESPIRATORY SYMPTOMS (e.g. swallowing/breathing difficulty, throat tightening/closing, hoarseness) and/or CARDIOVASCULAR SYMPTOMS (e.g. hypotension/decreased blood perfusion) from Pegaspargase If both respiratory/cardiovascular systems and cutaneous symptoms of anaphylaxis present, give EPINEPHrine first, followed by BENADRYL. Repeat doses of EPINEPHrine can be given every 5-15 minutes as needed for unresolved symptoms. Please contact MD for additional EPINEPHrine orders.
famotidine (PEPCID) 10 mg/ml injection 11 mgIntravenous, PRN Conditional, Starting on Tue 9/20/22 at 0907, Until Discontinued, other (enter comment), For Anaphylactic Reaction that includes CUTANEOUS SYMPTOMS (e.g. localized itching, flushing, hives, swelling) that are UNRESOLVED following dose of BENADRYL for Pegaspargase
famotidine (PEPCID) 40 mg/5 mL oral liquid 5.52 mgOral, 2 Times a Day, First dose on Tue 9/20/22 at 0915, Until DiscontinuedGiven09/20/2022 9:15 AM PDT5.52 mg
famotidine (PEPCID) tablet 10 mgOral, 2 Times a Day, First dose on Tue 9/20/22 at 0915, Until Discontinued
methylPREDNISolone PF (SOLU-Medrol) injection 11.2 mgIntravenous, PRN Conditional, Starting on Tue 9/20/22 at 0907, Until Discontinued, other (enter comment), For Anaphylactic Reaction that includes RESPIRATORY SYMPTOMS (e.g. swallowing/breathing difficulty, throat tightening/closing, hoarseness) that are UNRESOLVED following doses of EPINEPHrine, from Pegaspargase
metoCLOPramide (REGLAN) injection 11 mgIntravenous, Every 6 Hours PRN, Starting on Thu 9/22/22 at 1510, Until Discontinued, nausea/vomiting
ondansetron (ZOFRAN) 2 mg/mL injection 1.66 mgIntravenous, Every 8 Hours PRN, Starting on Thu 9/22/22 at 0000, Until Discontinued, nausea/vomiting, To give Q8H PRN when ondansetron (zofran) Q8H order is completed. Give IV or oral ondansetron.
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
DAUNOrubicin (CERUBIDINE) 12 mg in D5W 250 mL infusionIntravenous, Once, 1 dose, On Tue 9/20/22 at 0915, Give on day 1. VESICANT; Protect from light. HAZARDOUS DRUG: Antineoplastic- Handle and dispose of properly. See Hyperlinks in MAR for PPE. , 25 mg/m2/doseNew Bag/Syringe09/20/2022 9:15 AM PDT12 mg
dexamethasone (DECADRON) tablet 2.5 mgOral, 2 Times a Day With Meals, 28 doses, First dose on Tue 9/20/22 at 0915, Last dose on Mon 10/3/22 at 1800, To be given with meals on day 1-14 (do not taper). (May give IV in the equivalent dose), 5 mg/m2/dose (round upward to the nearest 0.25 mg)Given09/20/2022 9:15 AM PDT2.5 mg
ondansetron (ZOFRAN) 1.66 mg in NS 6.6 mL injectionIntravenous, Every 8 Hours, 6 doses, First dose on Tue 9/20/22 at 0915, Last dose on Thu 9/22/22 at 0115, For nausea/vomiting. Give first dose prior to starting chemotherapy. Give IV or oral ondansetron.Given09/20/2022 9:15 AM PDT1.66 mg
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Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
CBC WITH AUTO DIFFERENTIAL, REFLEX MANUAL DIFFERENTIAL IF INDICATEDLabRoutineAcute lymphoblastic leukemia (ALL) in remission (HCC)Daily (Include Now if Desired) for 7 Days starting 9/20/22 until 9/26/22
NUTRITIONAL PANEL, COMPLETELabRoutineAcute lymphoblastic leukemia (ALL) in remission (HCC)Daily (Include Now if Desired) for 7 Days starting 9/20/22 until 9/26/22
URIC ACIDLabRoutineAcute lymphoblastic leukemia (ALL) in remission (HCC)Daily (Include Now if Desired) for 7 Days starting 9/20/22 until 9/26/22
LIPASELabSTATAcute lymphoblastic leukemia (ALL) in remission (HCC)Once - Starting Now for 1 Occurrences starting 9/20/22 until 9/20/22
TPMT AND NUDT15LabRoutineAcute lymphoblastic leukemia (ALL) in remission (HCC)Once - Starting Now for 1 Occurrences starting 9/20/22 until 9/20/22
TPMT AND NUDT15LabRoutineAcute lymphoblastic leukemia (ALL) in remission (HCC)Once - Starting Now for 1 Occurrences starting 9/20/22 until 9/20/22
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/5c994725-b0c1-14ec-c6be-618943253965"}]}, {"id": "0CC3A74C-48FF-11ED-A9C1-8B04F0D33E31", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
Alpha thalassemia9/23/21
Asthma4/3/20
ALL (acute lymphoblastic leukemia)9/19/19
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
Job Start DateOccupationIndustry
Not on fileNot on fileNot on file
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "f3b51d5d-9bf8-513b-ecd1-94a34c6656af", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
9/19/22 - 10/10/22Hospital EncounterMCH B3P1-PEDIATRICS2801 Atlantic AvenueLONG BEACH, CA 90808562-933-2000Temko, Jamie2801 Atlantic AveLong Beach, CA 90806562-933-3800 (Work)Dx: Acute lymphoblastic leukemia (ALL) in remission (HCC) (Primary Dx)
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Reportability Response Information Section
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Medication NameMedication Start Date
remdesivir20221219233000+0000
remdesivir20221215000000+0000
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Social History ObservationSocial History Observation Result
Occupation HistoryStudent
Travel HistoryGender Identification-Female (finding)
Travel HistorySexually active (finding)-Not applicable (qualifier value)
Travel HistorySexual Orientation-Not applicable (qualifier value)
Travel HistoryBreastfeeding-Not applicable (qualifier value)
Travel HistoryNausea-No (qualifier value)
Travel HistoryVomiting (disorder)-No (qualifier value)
Travel HistoryUnexplained Hemorrhage, Bleed or Bruise-No (qualifier value)
Travel HistoryDyspnea (finding)-No (qualifier value)
Travel HistoryCongestion or Runny Nose-No (qualifier value)
Travel HistoryReported Fever-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryMuscle pain (finding)-No (qualifier value)
Travel HistoryLoss of Taste or Smell-No (qualifier value)
Travel HistoryIllness With Generalized Rash-No (qualifier value)
Travel HistoryHeadache (finding)-No (qualifier value)
Travel HistoryDry Cough-No (qualifier value)
Travel HistoryDifficulty breathing (finding)-No (qualifier value)
Travel HistoryDiarrhea (finding)-No (qualifier value)
Travel HistoryChills Infectious Disease-No (qualifier value)
Travel HistoryAbnormal Bleeding-No (qualifier value)
Travel HistoryAbdominal (Stomach Pain)-No (qualifier value)
Travel HistoryPositive COVID-19 Test-No (qualifier value)
Travel HistoryDroplet, Contact Isolation Verification-Not applicable (qualifier value)
Travel HistorySymptomatic Health Care Professional/SNF-No (qualifier value)
Travel HistorySymptomatic After Exposure to Contagion-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
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Unknown History of Present Illness
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Cough and fever
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"source": "ecr"}, "code": {"coding": [{"system": "http://snomed.info/sct", "code": "420008001", "display": "Travel"}], "text": "Travel History"}, "status": "final", "component": [{"code": {"coding": [{"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "LOC", "display": "Location"}]}}], "effectiveDateTime": "2022-12-19T23:11:00Z"}, "request": {"method": "PUT", "url": "Observation/2a29e701-095c-205e-7407-e0fddfdc311d"}}, {"fullUrl": "urn:uuid:23bef302-79ba-24c5-03d1-6dc19bd163ce", "resource": {"resourceType": "Observation", "id": "23bef302-79ba-24c5-03d1-6dc19bd163ce", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/us-ph-travel-history"], "source": "ecr"}, "code": {"coding": [{"system": "http://snomed.info/sct", "code": "420008001", "display": "Travel"}], "text": "Travel History"}, "status": "final", "component": [{"code": {"coding": [{"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "LOC", "display": "Location"}]}}], "effectiveDateTime": "2022-12-19T23:11:00Z"}, "request": {"method": "PUT", "url": "Observation/23bef302-79ba-24c5-03d1-6dc19bd163ce"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.297.3.7.8.688883.518653', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.297.3.7.8.688883.518653", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.297.3.7.8.688883.518653", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": 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"display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "C1013858-1D96-11ED-B591-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "7856532d-a465-7822-6e7b-299adfd1fb0a", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Blood Gas, ArterialLabRoutine08/15/2022 1:01 PM PDT
Blood Gas, ArterialLabRoutine08/15/2022 1:10 PM PDT
Blood Gas, VenousLabRoutine08/16/2022 11:26 AM PDT
Blood Gas, Cord, VenousLabRoutine08/16/2022 11:26 AM PDT
Blood Gas, Mixed VenousLabRoutine08/16/2022 11:26 AM PDT
Blood Gas, Cord, ArterialLabRoutine08/16/2022 11:26 AM PDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
Basic Metabolic PanelLabRoutineOne Time for 1 Occurrences starting 8/9/21 until 8/9/21
CBC with DifferentialLabRoutineOne Time for 1 Occurrences starting 8/9/21 until 8/9/21
Basic Metabolic PanelLabRoutineAM Lab Morning Lab for 1 Days starting 8/10/21 until 8/10/21
CBC with DifferentialLabRoutineAM Lab Morning Lab for 1 Days starting 8/10/21 until 8/10/21
Blood Gas, ArterialLabRoutineOne Time for 1 Occurrences starting 8/15/22 until 8/15/22
Blood Gas, ArterialLabRoutineOne Time for 1 Occurrences starting 8/15/22 until 8/15/22
Blood Gas, VenousLabRoutineOne Time for 1 Occurrences starting 8/16/22 until 8/16/22
Blood Gas, Cord, VenousLabRoutineOne Time for 1 Occurrences starting 8/16/22 until 8/16/22
Blood Gas, Mixed VenousLabRoutineOne Time for 1 Occurrences starting 8/16/22 until 8/16/22
Blood Gas, Cord, ArterialLabRoutineOne Time for 1 Occurrences starting 8/16/22 until 8/16/22
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/7427301d-3a14-a606-67f5-5a5592ff776e"}]}, {"id": "C1235672-1D96-11ED-B591-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
Anemia aplastic aregenerative8/9/21
documented as of this encounter (statuses as of 08/16/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Anemia aplastic aregenerative", "reference": "Condition/d1bc5843-3121-1c2f-a2f6-6acc7fb2479e"}]}, {"id": "c658eaed-3f9a-f347-8624-e56d8d73996c", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "C1361DAC-1D96-11ED-B591-C301D81100B2", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "pH Temp Corrected, Arterial", "reference": "Observation/a2e54e91-c833-a167-7d4d-24732970f092"}, {"display": "pCO2 Temp Corrected, Arterial", "reference": "Observation/f39f8ba9-de3b-3bc2-8195-c3f4bacb2e66"}, {"display": "pO2 Temp Corrected, Arterial", "reference": "Observation/cf37f17d-44ae-2254-37d5-51b33903066d"}, {"display": "HCO3, Arterial", "reference": "Observation/5c4542a5-ea0b-849c-b64d-4682b67ead4f"}, {"display": "Base Excess, Arterial", "reference": "Observation/e2e70783-6aa4-e508-275f-af841fbc4cf3"}, {"display": "Sat O2 (calc)", "reference": "Observation/5e5be917-6dde-3ceb-c823-acd83798ec40"}, {"display": "Hemoglobin, Arterial", "reference": "Observation/b52f3d20-4d52-8868-4e8c-533c9705203d"}, {"display": "Methemoglobin, Arterial", "reference": "Observation/02866491-7cb6-a48e-45c2-8fcffa5c486e"}, {"display": "Carboxyhemoglobin, Arterial", "reference": "Observation/42669897-d384-b6c9-4f48-7a0d3c3d4048"}, {"display": "O2 Saturation, Arterial", "reference": "Observation/94ead4e1-0feb-0ae2-078b-7bff5d251b86"}, {"display": "Oxygen Content, Arterial", "reference": "Observation/3f910ee3-8f5b-3c0f-19c3-be461dc0518f"}, {"display": "Alveolar-Arterial Oxygen Difference", "reference": "Observation/dd36beec-d3a6-c1ec-1590-79f10b45f651"}, {"display": "FiO2", "reference": "Observation/8af50489-5c70-57e0-5650-6383447b6c23"}, {"display": "PATIENT TEMP", "reference": "Observation/6eb0f158-d81b-a546-d4f4-ab34918da535"}, {"display": "Lab Interpretation", "reference": "Observation/d2e961cc-5f98-1e16-2e26-c005ac3ad388"}, {"display": "End Tidal CO2", "reference": "Observation/bf7a3cf1-d8c5-c25c-2df1-ca3268b7af1d"}, {"display": "pH Temp Corrected, Arterial", "reference": "Observation/c680aacd-c818-f252-7345-874487fb4883"}, {"display": "pCO2 Temp Corrected, Arterial", "reference": "Observation/9365049e-974d-4c3a-6dc8-c802778fb238"}, {"display": "pO2 Temp Corrected, Arterial", "reference": 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{"display": "Vent Mode", "reference": "Observation/433b0f60-02b0-b454-aee9-4ad4f5b57555"}, {"display": "O2 Device", "reference": "Observation/48bc2bc7-a09d-43f0-bd54-6f5e3002b6ed"}, {"display": "FiO2", "reference": "Observation/ed456b56-3d60-abad-8e5f-29604bdd45d6"}, {"display": "PEEP", "reference": "Observation/c9eff174-45ae-544b-78b6-0d31d716076f"}, {"display": "CPAP", "reference": "Observation/4ced3ed6-a1b1-67f9-1cdc-e7210c40e93b"}, {"display": "IPAP/Pressure", "reference": "Observation/dae7c80a-ad10-9285-3a0b-1f24d13bdbcf"}, {"display": "EPAP/Pressure", "reference": "Observation/fcd5323f-97c1-aaf3-c7af-77f23e7661b8"}, {"display": "Pressure Support Vent", "reference": "Observation/a0d6929e-1095-dd84-c385-153d74611492"}, {"display": "Pressure Control Vent", "reference": "Observation/a45c2b24-6b4b-781e-c462-ec021a5c5a0a"}, {"display": "Pulse Oximetry", "reference": "Observation/9b2305e0-2636-9c14-ea05-810805b9432f"}, {"display": "Nitric Oxide", "reference": 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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "27b313dd-eef9-bbb4-d927-45a74bfe049d", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
8/9/21Hospital EncounterPROVIDENCE CEDARS SINAI TARZANA MED CTR POST PARTUM SVC18321 Clark StTarzana, CA 91356-3501818-609-2250Wardono, Ira Paula, MD18322 CLARK STTARZANA, CA 91356323-361-6265 (Work)323-361-8106 (Fax)Regala, Jayvee R, MD5525 Etiwanda Ave. #212Tarzana, CA 91356818-996-9677 (Work)818-734-3621 (Fax)Radiology, Osv Rad, MD9205 SW Barnes RdPORTLAND, OR 97225
Idiopathic aplastic anemia (HCC)
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Reportability Response Information Section
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Team Status: Active
MemberRoleStatusDates
Adam Sheradmitting physicianActive
Start: March 12th, 2022
MCUTLERattending physicianActive
Start: March 12th, 2022
DR MEDITECHprimary care physicianActive
Start: March 12th, 2022
AMANDA NOELREFERRINGActive
Start: March 12th, 2022
AMANDA PARLATOFAMILYActive
Start: March 12th, 2022
Rickey RobertsOTHERActive
Start: March 12th, 2022
Stephen NewtonCONSULTINGActive
Start: March 12th, 2022
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Assigned Birth SexMale
Gender Identityunknown
Sexual OrientationDo not know
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ImmunizationEvent DateNot Given ReasonDose NumberManufacturerLot NumberVaccine Information Statement (VIS) Detail
Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
anthraxMarch 15th, 2022 7:20am1PFIZER & OTHER CHARACTERSLOT9911Z
RIGRAPID HEART BEAT
anthraxMarch 24th, 2022 9:34am2JOHNSON AND JOHNSONLOT942X
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Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
Weight68.039 kgMarch 14th, 2022 1:48pm
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RIFA150C15 (Rifampin ) 150 MG CAPSULE150MGORALQ6HMarch 24th, 2022 9:34amMarch 24th, 2022 9:34am
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Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 24th, 2022 9:38am
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Team Status: Active
MemberRoleStatusDates
Adam Sheradmitting physicianActive
Start: March 12th, 2022
MCUTLERattending physicianActive
Start: March 12th, 2022
DR MEDITECHprimary care physicianActive
Start: March 12th, 2022
AMANDA NOELREFERRINGActive
Start: March 12th, 2022
AMANDA PARLATOFAMILYActive
Start: March 12th, 2022
Rickey RobertsOTHERActive
Start: March 12th, 2022
Stephen NewtonCONSULTINGActive
Start: March 12th, 2022
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Assigned Birth SexMale
Gender Identityunknown
Sexual OrientationDo not know
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COVID-19Active
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ImmunizationEvent DateNot Given ReasonDose NumberManufacturerLot NumberVaccine Information Statement (VIS) Detail
Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
anthraxMarch 15th, 2022 7:20am1PFIZER & OTHER CHARACTERSLOT9911Z
RIGRAPID HEART BEAT
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Vital ReadingResultReference RangeCollection Date/Time
Height65 [in_i]March 14th, 2022 1:48pm
Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
Weight68.039 kgMarch 14th, 2022 1:48pm
BMI (Body Mass Index)25.0 kg/m2March 14th, 2022 1:48pm
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ZIDO100C4 (Zidovudine ) 100 MG TABLET100MGORALQ6HMarch 12th, 2022 7:49pmMarch 12th, 2022 7:49pm
RIFA150C15 (Rifampin ) 150 MG CAPSULE150MGORALQ6HMarch 24th, 2022 9:34amMarch 24th, 2022 9:34am
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Admitted InpatientDot Facility (No ARM)March 12th, 2022 7:45pmMCUTLER
Recent DiagnosisOnset Date
Anthrax

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AnthraxActive
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Medication NameStart DateInstructions
Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 24th, 2022 9:38am
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Reportability Response Information Section
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"Organization/fb121477-4011-40b3-40fe-f884cdfecd6a"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('5da4c0ae-92d2-424c-b038-4e104e48235d', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:5da4c0ae-92d2-424c-b038-4e104e48235d", "resource": {"resourceType": "Composition", "id": "5da4c0ae-92d2-424c-b038-4e104e48235d", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "30470272|65157249"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "1"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-05-18T16:48:23Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "db5530c3-e644-7369-7cfb-f0d2183c2ada", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Vaginal bleedingActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Bleeding from vagina (finding)", "reference": "Condition/e7cc40bf-8d4e-da3e-104f-dd109944651b"}]}, {"id": "41f59314-c298-9c2f-13b6-084a3bfd9501", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
Outpatient20220517192300+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "54c47fc3-c151-3122-4416-6fef42c84841", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
Estimated Creatinine Clearance121.78|http://unitsofmeasure.org|mL/min
Symptomatic as defined by CDC?Yes
In ICU?No
Group care resident?No
Employed in healthcare?No
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRNegative
eGFR PediatricNot Reported
Flu B PCRNot Detected
Flu A PCRDetected
Calc Osmo264|http://unitsofmeasure.org|mOsmol/L
A/G Ratio0.7|http://unitsofmeasure.org|Ratio
eGFR Non-African American120.46 mL/min/1.73m2
eGFR African American139.62 mL/min/1.73m2
Sodium134|http://unitsofmeasure.org|mmol/L
Potassium3.7|http://unitsofmeasure.org|mmol/L
Baso # Auto0.01|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.1|http://unitsofmeasure.org|gm/dL
Mono # Auto0.6|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto10.8|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.1|http://unitsofmeasure.org|%
Eos % Auto0.2|http://unitsofmeasure.org|%
Lymph % Auto4.3|http://unitsofmeasure.org|%
Neut % Auto89.7|http://unitsofmeasure.org|%
Calcium9.0|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.06|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto0.5|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto5.2|http://unitsofmeasure.org|%
RDW-CV14.8|http://unitsofmeasure.org|%
Immature Grans %0.5|http://unitsofmeasure.org|%
Eos # Auto0.0|http://unitsofmeasure.org|x10e3/mcL
Chloride102|http://unitsofmeasure.org|mmol/L
BUN2|http://unitsofmeasure.org|mg/dL
Plt324|http://unitsofmeasure.org|x10e3/mcL
WBC12.1|http://unitsofmeasure.org|x10e3/mcL
TP7.5|http://unitsofmeasure.org|gm/dL
RBC4.11|http://unitsofmeasure.org|x10e6/mcL
MPV10.1|http://unitsofmeasure.org|Femtoliters
MCV83.5|http://unitsofmeasure.org|Femtoliters
MCHC33.2|http://unitsofmeasure.org|gm/dL
MCH27.7|http://unitsofmeasure.org|pg
Lactic Acid Lvl1.2|http://unitsofmeasure.org|mmol/L
Hgb11.4|http://unitsofmeasure.org|gm/dL
Hct34.3|http://unitsofmeasure.org|%
Glucose Level82|http://unitsofmeasure.org|mg/dL
CO220.5|http://unitsofmeasure.org|mmol/L
T Bili0.3|http://unitsofmeasure.org|mg/dL
AST15|http://unitsofmeasure.org|Intl_units/L
ALT17|http://unitsofmeasure.org|Intl_units/L
Alk Phos66|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio2.9|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine0.7|http://unitsofmeasure.org|mg/dL
Ur pH8.0
Ur Spec Grav1.020 mg/dL
Ur Urobilinogen0.2 EU/dL
Ur BloodTrace-intact
Ur BiliNegative
Ur Leuk EstNegative
Ur ProteinNegative mg/dL
Ur NitriteNegative
Ur KetonesNegative mg/dL
UR GlucoseNegative mg/dL
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Influenza
Febrile illness
Influenza A
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"urn:uuid:69518708-e64d-4b82-b239-55f9b4e91aa1", "resource": {"resourceType": "Composition", "id": "69518708-e64d-4b82-b239-55f9b4e91aa1", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "39453861|65101461"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "1"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-05-12T23:35:42Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "023165da-4724-8702-8ee6-39b0c623177c", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
DiverticulosisActive
Mantoux: positive (finding)Active
OsteoarthritisActive
Stasis dermatitisActive
Intermittent asthmaActive
Anemia (disorder)Active
Hypertensive disorder, systemic arterial (disorder)Active
DM2 (diabetes mellitus, type 2)Active
Allergic rhinitisActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Diverticular disease (disorder)", "reference": "Condition/6bec41e8-d5c5-2289-0a24-daa7ba4e8238"}, {"display": "Problem - Mantoux: positive (finding)", "reference": "Condition/cd74e0fb-1889-c0c5-ab5e-bb949e3f809e"}, {"display": "Problem - Osteoarthritis (disorder)", "reference": "Condition/11b8c126-474f-dd6d-f0cb-84a3e515384b"}, {"display": "Problem - Stasis dermatitis (disorder)", "reference": "Condition/841e1737-49ef-e54d-90bb-e9fcca9071dd"}, {"display": "Problem - Intermittent asthma (disorder)", "reference": "Condition/faa53623-3461-44c3-0cdb-3d44d5970930"}, {"display": "Problem - Anemia (disorder)", "reference": "Condition/67097ffd-7c62-62ad-41e2-3dcb787d9a16"}, {"display": "Problem - Hypertensive disorder, systemic arterial (disorder)", "reference": "Condition/1aaacc9f-fcf1-405f-7fe6-316215134322"}, {"display": "Problem - Diabetes mellitus type 2 (disorder)", "reference": "Condition/eb9d26af-56f3-e546-5d4f-26492f76b2fd"}, {"display": "Problem - Allergic rhinitis (disorder)", "reference": "Condition/d1f4c862-27af-88c2-3332-bc2f701cc0c0"}]}, {"id": "f43e70da-a17e-9470-879a-46086e326a1d", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
inpatient encounter20220511201400+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "699d8e14-d2e3-01a1-4983-954d5e774aad", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
POC Glucose182|http://unitsofmeasure.org|mg/dL
POC Glucose229|http://unitsofmeasure.org|mg/dL
Estimated Creatinine Clearance49.88|http://unitsofmeasure.org|mL/min
eGFR PediatricNot Reported
Calc Osmo282|http://unitsofmeasure.org|mOsmol/L
A/G Ratio0.5|http://unitsofmeasure.org|Ratio
eGFR Non-African American80.56 mL/min/1.73m2
eGFR African American93.37 mL/min/1.73m2
Sodium138|http://unitsofmeasure.org|mmol/L
Potassium4.1|http://unitsofmeasure.org|mmol/L
Ferritin Lvl1320|http://unitsofmeasure.org|ng/mL
Baso # Auto0.01|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level2.6|http://unitsofmeasure.org|gm/dL
Mono # Auto0.2|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto4.3|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.2|http://unitsofmeasure.org|%
Lymph % Auto12.8|http://unitsofmeasure.org|%
Neut % Auto82.0|http://unitsofmeasure.org|%
Calcium10.5|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.02|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto0.7|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto4.6|http://unitsofmeasure.org|%
RDW-CV15.7|http://unitsofmeasure.org|%
Immature Grans %0.4|http://unitsofmeasure.org|%
Chloride105|http://unitsofmeasure.org|mmol/L
BUN11|http://unitsofmeasure.org|mg/dL
Plt326|http://unitsofmeasure.org|x10e3/mcL
WBC5.2|http://unitsofmeasure.org|x10e3/mcL
TP7.5|http://unitsofmeasure.org|gm/dL
RBC3.27|http://unitsofmeasure.org|x10e6/mcL
PT12.3|http://unitsofmeasure.org|Seconds
MPV10.8|http://unitsofmeasure.org|Femtoliters
MCV86.5|http://unitsofmeasure.org|Femtoliters
MCHC30.4|http://unitsofmeasure.org|gm/dL
MCH26.3|http://unitsofmeasure.org|pg
Mg Lvl2.3|http://unitsofmeasure.org|mg/dL
Hgb8.6|http://unitsofmeasure.org|gm/dL
Hct28.3|http://unitsofmeasure.org|%
Glucose Level216|http://unitsofmeasure.org|mg/dL
D Dimer1.21|http://unitsofmeasure.org|mg/L
CRP16.7|http://unitsofmeasure.org|mg/dL
CO224.0|http://unitsofmeasure.org|mmol/L
T Bili0.2|http://unitsofmeasure.org|mg/dL
D Bili0.05|http://unitsofmeasure.org|mg/dL
AST23|http://unitsofmeasure.org|Intl_units/L
ALT34|http://unitsofmeasure.org|Intl_units/L
Alk Phos118|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio15.7|http://unitsofmeasure.org|Ratio
INRUnknown
Anion GapUnknown
Creatinine0.7|http://unitsofmeasure.org|mg/dL
Ferritin Lvl1280|http://unitsofmeasure.org|ng/mL
NT-ProBNP726|http://unitsofmeasure.org|pg/mL
Hgb A1c %6.6|http://unitsofmeasure.org|%
LD170|http://unitsofmeasure.org|units/L
Hgb9.0|http://unitsofmeasure.org|gm/dL
D Dimer1.48|http://unitsofmeasure.org|mg/L
CRP12.0|http://unitsofmeasure.org|mg/dL
POC Glucose144|http://unitsofmeasure.org|mg/dL
Ur pHUnknown
Ur Spec GravUnknown
Ur Urobilinogen<2.0 mg/dL
Ur BloodNegative mg/dL
Ur BiliNegative mg/dL
Ur Leuk EstNegative
Ur ColorStraw
Ur ProteinNegative mg/dL
Ur NitriteNegative
Ur KetonesNegative mg/dL
UR GlucoseNegative mg/dL
Ur ClarityClear
Estimated Creatinine Clearance34.91|http://unitsofmeasure.org|mL/min
Troponin TNIH8.9|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
Calc Osmo261|http://unitsofmeasure.org|mOsmol/L
A/G Ratio0.6|http://unitsofmeasure.org|Ratio
eGFR Non-African American55.74 mL/min/1.73m2
eGFR African American64.60 mL/min/1.73m2
Sodium129|http://unitsofmeasure.org|mmol/L
Potassium4.6|http://unitsofmeasure.org|mmol/L
Baso # Auto0.02|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.1|http://unitsofmeasure.org|gm/dL
Mono # Auto0.8|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto5.5|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.3|http://unitsofmeasure.org|%
Eos % Auto0.3|http://unitsofmeasure.org|%
Lymph % Auto15.4|http://unitsofmeasure.org|%
Neut % Auto73.1|http://unitsofmeasure.org|%
Calcium11.3|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto1.2|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto10.5|http://unitsofmeasure.org|%
TSH Ultrasensitive1.105|http://unitsofmeasure.org|mc Intl units/mL
RDW-CV15.5|http://unitsofmeasure.org|%
Immature Grans %0.4|http://unitsofmeasure.org|%
Eos # Auto0.0|http://unitsofmeasure.org|x10e3/mcL
Chloride96|http://unitsofmeasure.org|mmol/L
BUN15|http://unitsofmeasure.org|mg/dL
Plt389|http://unitsofmeasure.org|x10e3/mcL
WBC7.5|http://unitsofmeasure.org|x10e3/mcL
TP8.4|http://unitsofmeasure.org|gm/dL
RBC3.58|http://unitsofmeasure.org|x10e6/mcL
MPV10.3|http://unitsofmeasure.org|Femtoliters
MCV85.5|http://unitsofmeasure.org|Femtoliters
MCHC30.4|http://unitsofmeasure.org|gm/dL
MCH26.0|http://unitsofmeasure.org|pg
Lactic Acid Lvl1.1|http://unitsofmeasure.org|mmol/L
Hgb9.3|http://unitsofmeasure.org|gm/dL
Hct30.6|http://unitsofmeasure.org|%
Glucose Level119|http://unitsofmeasure.org|mg/dL
CO224.8|http://unitsofmeasure.org|mmol/L
T Bili0.5|http://unitsofmeasure.org|mg/dL
AST26|http://unitsofmeasure.org|Intl_units/L
Ammonia Level10|http://unitsofmeasure.org|mmol/L
ALT41|http://unitsofmeasure.org|Intl_units/L
Alk Phos140|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio15.0|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine1.0|http://unitsofmeasure.org|mg/dL
Symptomatic as defined by CDC?Yes
In ICU?No
Group care resident?No
Employed in healthcare?No
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRPositive
Flu B PCRNot Detected
Flu A PCRNot Detected
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Medication NameMedication Start Date
amLODIPine (Norvasc 5 mg oral tablet)20220511233400+0000
aspirin (aspirin 81 mg oral enteric coated tablet)20220511233900+0000
atenolol (Tenormin 25 mg oral tablet)20220511233600+0000
atorvastatin (Lipitor 10 mg oral tablet)20220511233600+0000
diclofenac topical (Voltaren 1% topical gel)20220511233700+0000
ferrous gluconate (ferrous gluconate 324 mg (38 mg elemental iron) oral tablet)20220511233400+0000
hydrocortisone topical (Proctozone HC 2.5% rectal cream with applicator)20220511233600+0000
losartan (Cozaar 50 mg oral tablet)20220511233800+0000
potassium chloride (Klor-Con 8 oral tablet, extended release)20220511233500+0000
atenolol (Tenormin)20220512160000+0000
atorvastatin (Lipitor)20220512160000+0000
losartan (Cozaar)20220512160000+0000
aspirin20220512150000+0000
enoxaparin20220512133000+0000
insulin regular (insulin regular correctional scale Low)20220512050000+0000
amLODIPine (Norvasc)20220512040000+0000
sennosides-docusate (docusate-senna 50 mg-8.6 mg oral tablet)20220512025200+0000
guaiFENesin-dextromethorphan (guaifenesin-dextromethorphan 100 mg-10 mg/5 mL oral liquid)20220512023300+0000
ondansetron20220512023200+0000
acetaminophen (Tylenol)20220512023000+0000
famotidine (Pepcid)20220512040000+0000
dexamethasone20220512030000+0000
remdesivir20220513000000+0000
remdesivir20220512030000+0000
acetaminophen (Tylenol)20220511223600+0000
Sodium Chloride 0.9% intravenous solution (Sodium Chloride 0.9% Bolus (ADULT SEPSIS))20220511203200+0000
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Social History ObservationSocial History Observation Result
Birth SexF
Travel HistoryInfluenza vaccination status (observable entity)-Received prior to admission, during current flu season
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryMRSA Sceen Dialysis or Venous Access-No (qualifier value)
Travel HistoryMRSA Screen Admit From Non-home Loc-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryPregnancy Status-Not applicable (qualifier value)
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryCOVID- 19 Testing Reason-Diagnostic
"}, "code": {"coding": [{"code": "29762-2", "display": "Social History", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/59ada9e2-5a41-aa03-8698-0914ad1799e3"}, {"reference": "Observation/9145e613-e60e-d56b-acb1-43c563213abf"}, {"reference": "Observation/abf0c35c-5087-bf1e-dd52-83fdab3cd400"}, {"reference": "Observation/8cf3943f-56a8-04ff-5668-b491fa7ac83a"}, {"reference": "Observation/8490504a-ebde-5b5c-5d51-82caacecae44"}, {"reference": "Observation/9d38b561-c558-9682-7f27-d84104502c85"}, {"reference": "Observation/f14ef68b-a77f-ade3-7a74-d5a4d7a22d70"}, {"reference": "Observation/ef594b8a-a7de-0fba-b64b-a6bfd365c8e9"}, {"reference": "Observation/cfa4d0c5-5029-41d6-dff8-862949054720"}, {"reference": "Observation/6662dc38-0f85-e6fe-24d1-b39e56010cb0"}, {"reference": "Observation/88877f6e-3137-cc19-a303-0aeae04da5c5"}, {"reference": "Observation/b7496f82-02da-d1b7-feb7-f87fe3459e2b"}, {"reference": "Observation/84abdb2c-c14d-8800-097b-67f503f6300f"}, {"reference": "Observation/35ca7616-1d14-81bd-7a64-146549ac66ab"}, {"reference": "Observation/dce72f66-7de3-7379-2b87-ebd8e4350746"}, {"reference": "Observation/eb928322-9132-d8b8-0ee7-6e19531d2c02"}, {"reference": "Observation/5ca1888a-d3a3-bdab-c20d-af21333eb6f9"}, {"reference": "Observation/f400c3f8-6884-7437-f1db-4d821bf7c62a"}, {"reference": "Observation/f8db60c8-7876-61fd-b07a-7fc5143e74e6"}]}, {"id": "7dbd51e8-1c15-8cfa-cbce-f6f4b9a1ed5d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "No Plan Of Treatment Information"}, "code": {"coding": [{"code": "18776-5", "display": "Treatment Plan", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/ec77d178-de8a-915a-311a-1f11f2838946"}]}, {"id": "e1d7061e-b93f-5a9b-7ed4-681a9d4ce55d", "title": "History of Present Illness", "text": {"status": "generated", "div": "
Narrative Text
Hypercalcemia
HTN (hypertension)
Lung nodules
Hypoxemia
COVID-19
Renal mass
DM2 (diabetes mellitus, type 2)
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text
COVID 19 RENAL MASS
"}, "code": {"coding": [{"code": "29299-5", "display": "Reason For Visit", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "COVID 19 RENAL MASS"}]}, {"id": "920927d1-47ae-f326-c7fb-1b7cea77f7f4", "title": "Reportability Response Information Section", "text": {"status": "generated", "div": "
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Tobacco Cessation:
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Alcohol UseStandard Drinks/WeekComments
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DateTypeDepartmentCare TeamDescription
12/9/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Soh, Isabelle Ying-Ying, MD8767 WILSHIRE BLVDSTE 301BEVERLY HILLS, CA 90211310-248-7077 (Work)424-314-8735 (Fax)Isabelle.Soh@cshs.org
Laboratory confirmed diagnosis of COVID-19Suspected COVID-19 virus infection (Primary Dx);
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sooner.
360bbb-3(b) (1), unless the authorization is terminated or revoked
of COVID-19 infection under section 564(b)(1) of the Act, 21 U.S.C.
diagnostic tests for detection of SARS-CoV-2 virus and/or diagnosis
justifying the authorization of the emergency use of in vitro
for the duration of time the declaration that circumstances exist
an Emergency Use Authorization (EUA). This test is only authorized
FDA cleared or approved. This test has been authorized by FDA under
amplification tests include RT-PCR and TMA. This test has not been
characteristics determined by LabCorp Laboratories. Nucleic acid
This nucleic acid amplification test was developed and its performance
resources and information.
Visit our website at https://www.labcorp.com/COVID19 for
with mild to moderate symptoms and for hospitalized patients.
treatment options. Treatment options are available for patients
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COVID-19Diagnosis interpretation (observable entity)Oct-17-2022 -
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No Information
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No Information
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Reportability Response Information Section
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine03/31/2022 11:31 AM PDT
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"Tobacco smoking status NHIS", "system": "http://loinc.org"}]}, "valueCodeableConcept": {"coding": [{"code": "266927001", "display": "Tobacco smoking consumption unknown", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/20f460b4-1f3a-4ff4-9113-4d7b39009019"}}, "request": {"method": "PUT", "url": "Observation/d1bd608c-ff77-5e30-4f2b-89ce600fbe64"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('c516ad5e-9ca2-4cb1-97d5-2dfab2962c63', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:c516ad5e-9ca2-4cb1-97d5-2dfab2962c63", "resource": {"resourceType": "Composition", "id": "c516ad5e-9ca2-4cb1-97d5-2dfab2962c63", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "39491972|65203906"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "1"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-05-23T19:01:51Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "e6617896-cfff-ef90-588d-0da9f71fd002", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Acute COVID-19Active
Acute pulmonary embolism (disorder)Active
Ineffective airway clearance (finding)Active
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Acute COVID-19", "reference": "Condition/0e346df7-8ea4-583f-5d3c-a4d15461437d"}, {"reference": "Condition/60c9e0a6-a64c-20bf-9b19-ed84b1260605"}, {"display": "Problem - Acute pulmonary embolism (disorder)", "reference": "Condition/43378e45-afc3-84b3-25a2-bc4414689967"}, {"display": "Problem - Ineffective airway clearance (finding)", "reference": "Condition/9a6bef6b-a68c-9efe-09f5-2a70b36878b2"}]}, {"id": "1a8d2a31-4447-e77f-e04c-c0d81c3afe2c", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
inpatient encounter20220522212400+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "a2b2297b-0a38-8cd3-cb66-b803d9a36233", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
Estimated Creatinine Clearance152.57|http://unitsofmeasure.org|mL/min
Art Hct43|http://unitsofmeasure.org|%
HCO3 Art25.2|http://unitsofmeasure.org|mmol/L
POC Pt Temp37.0|http://unitsofmeasure.org|DegC
POC FIO240|http://unitsofmeasure.org|%
POC Allen TestPOS
Art Base Excess1.0|http://unitsofmeasure.org|mmol/L
Art tHB14.0|http://unitsofmeasure.org|gm/dL
Art sO295|http://unitsofmeasure.org|%
Art pO273.0|http://unitsofmeasure.org|mmHg
pH ArterialUnknown
Art pCO239.1|http://unitsofmeasure.org|mmHg
eGFR PediatricNot Reported
Phosphorus3.8|http://unitsofmeasure.org|mg/dL
eGFR Non-African American121|http://unitsofmeasure.org|mL/min/1.73m2
eGFR African American140|http://unitsofmeasure.org|mL/min/1.73m2
Sodium138|http://unitsofmeasure.org|mmol/L
Potassium4.5|http://unitsofmeasure.org|mmol/L
Baso # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.5|http://unitsofmeasure.org|gm/dL
Mono # Auto0.99|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto10.23|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.3|http://unitsofmeasure.org|%
Eos % Auto0.0|http://unitsofmeasure.org|%
Lymph % Auto3.4|http://unitsofmeasure.org|%
Neut % Auto87.0|http://unitsofmeasure.org|%
Calcium8.7|http://unitsofmeasure.org|mg/dL
RDW-SD46.8|http://unitsofmeasure.org|Femtoliters
Immature Grans # Auto0.11|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto0.40|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.4|http://unitsofmeasure.org|%
RDW-CV14.6|http://unitsofmeasure.org|%
Immature Grans %0.9|http://unitsofmeasure.org|%
Eos # Auto0.00|http://unitsofmeasure.org|x10e3/mcL
Chloride107|http://unitsofmeasure.org|mmol/L
BUN8|http://unitsofmeasure.org|mg/dL
Plt264|http://unitsofmeasure.org|x10e3/mcL
WBC11.76|http://unitsofmeasure.org|x10e3/mcL
Uric Acid3.6|http://unitsofmeasure.org|mg/dL
RBC4.74|http://unitsofmeasure.org|x10e6/mcL
MPV11.8|http://unitsofmeasure.org|Femtoliters
MCV87.3|http://unitsofmeasure.org|Femtoliters
MCHC33.3|http://unitsofmeasure.org|gm/dL
MCH29.1|http://unitsofmeasure.org|pg
Mg Lvl2.0|http://unitsofmeasure.org|mg/dL
Hgb13.8|http://unitsofmeasure.org|gm/dL
Hct41.4|http://unitsofmeasure.org|%
Glucose Level134|http://unitsofmeasure.org|mg/dL
CO226|http://unitsofmeasure.org|mmol/L
BUN/Creat RatioUnknown
Anion Gap5|http://unitsofmeasure.org|mmol/L
Creatinine0.77|http://unitsofmeasure.org|mg/dL
Hgb13.8|http://unitsofmeasure.org|gm/dL
Hct42.9|http://unitsofmeasure.org|%
Procalcitonin0.04|http://unitsofmeasure.org|ng/mL
PTT28|http://unitsofmeasure.org|Seconds
PT11.6|http://unitsofmeasure.org|Seconds
Lactic Acid Lvl3.4|http://unitsofmeasure.org|mmol/L
CRP4.40|http://unitsofmeasure.org|mg/dL
INRUnknown
Troponin TNIH2.50|http://unitsofmeasure.org|ng/L
Art Hct44|http://unitsofmeasure.org|%
HCO3 Art22.3|http://unitsofmeasure.org|mmol/L
POC Pt Temp37.0|http://unitsofmeasure.org|DegC
POC Set RR14|http://unitsofmeasure.org|br/min
POC FIO260|http://unitsofmeasure.org|%
POC Allen TestPOS
Art Base Excess-2.2|http://unitsofmeasure.org|mmol/L
Art tHB14.3|http://unitsofmeasure.org|gm/dL
Art sO287|http://unitsofmeasure.org|%
Art pO256.1|http://unitsofmeasure.org|mmHg
pH ArterialUnknown
Art pCO237.5|http://unitsofmeasure.org|mmHg
Troponin TNIH2.50|http://unitsofmeasure.org|ng/L
Lactic Acid Lvl1.6|http://unitsofmeasure.org|mmol/L
Hgb13.7|http://unitsofmeasure.org|gm/dL
Hct43.8|http://unitsofmeasure.org|%
SARS-CoV-2Not Detected
Strep A PCRNot Detected
Influenza ANot Detected
Coronavirus OC43Not Detected
Coronavirus NL63Not Detected
Coronavirus HKU1Not Detected
Coronavirus 229ENot Detected
See CommentComment Charted
MRSA by PCRNot Detected
Ur pHUnknown
Ur Spec GravUnknown
Ur MethadoneNot Detected
Ur Urobilinogen<2.0 mg/dL
Ur BloodNegative
Ur BiliNegative
Ur Leuk EstNegative
Ur ColorYellow
Ur CannabinoidsNot Detected
Ur MucousOccasional /LPF
Ur Squam Epithelial1|http://unitsofmeasure.org|/HPF
Ur BarbituratesDetected
U Legionella AgNegative
Ur WBC1|http://unitsofmeasure.org|/HPF
Ur RBC1|http://unitsofmeasure.org|/HPF
Ur Protein1+
U PCPNot Detected
Ur OpiatesNot Detected
Ur NitriteNegative
Ur KetonesTrace
UR GlucoseNegative
Ur CocaineNot Detected
U Benzodiazepine ScreenNot Detected
Ur BacteriaNone Seen /HPF
Ur ClarityClear
Estimated Creatinine Clearance126.32|http://unitsofmeasure.org|mL/min
HCO3 Art24.7|http://unitsofmeasure.org|mmol/L
POC Pt Temp37.0|http://unitsofmeasure.org|DegC
POC FIO245|http://unitsofmeasure.org|%
POC Allen TestN/A
Art Base Excess0.5|http://unitsofmeasure.org|mmol/L
Art sO291|http://unitsofmeasure.org|%
Art pO262.9|http://unitsofmeasure.org|mmHg
pH ArterialUnknown
Art pCO237.4|http://unitsofmeasure.org|mmHg
Symptomatic as defined by CDC?YES
In ICU?NO
Group care resident?NO
Employed in healthcare?NO
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRNegative
Flu B PCRNegative
Flu A PCRNegative
Troponin TNIH2.50|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
A/G RatioUnknown
eGFR Non-African American109|http://unitsofmeasure.org|mL/min/1.73m2
eGFR African American126|http://unitsofmeasure.org|mL/min/1.73m2
Sodium141|http://unitsofmeasure.org|mmol/L
Potassium3.7|http://unitsofmeasure.org|mmol/L
Baso # Auto0.06|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.3|http://unitsofmeasure.org|gm/dL
Mono # Auto1.50|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto11.66|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.4|http://unitsofmeasure.org|%
Eos % Auto0.2|http://unitsofmeasure.org|%
Lymph % Auto3.4|http://unitsofmeasure.org|%
Neut % Auto84.4|http://unitsofmeasure.org|%
Calcium8.0|http://unitsofmeasure.org|mg/dL
RDW-SD47.7|http://unitsofmeasure.org|Femtoliters
Immature Grans # Auto0.09|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto0.47|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto10.9|http://unitsofmeasure.org|%
RDW-CV14.8|http://unitsofmeasure.org|%
Immature Grans %0.7|http://unitsofmeasure.org|%
Eos # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Chloride110|http://unitsofmeasure.org|mmol/L
BUN9|http://unitsofmeasure.org|mg/dL
Plt265|http://unitsofmeasure.org|x10e3/mcL
WBC13.81|http://unitsofmeasure.org|x10e3/mcL
TP5.0|http://unitsofmeasure.org|gm/dL
RBC4.86|http://unitsofmeasure.org|x10e6/mcL
MPV11.6|http://unitsofmeasure.org|Femtoliters
MCV88.3|http://unitsofmeasure.org|Femtoliters
MCHC31.7|http://unitsofmeasure.org|gm/dL
MCH28.0|http://unitsofmeasure.org|pg
Lactic Acid Lvl2.9|http://unitsofmeasure.org|mmol/L
Hgb13.6|http://unitsofmeasure.org|gm/dL
Hct42.9|http://unitsofmeasure.org|%
Glucose Level116|http://unitsofmeasure.org|mg/dL
CO225|http://unitsofmeasure.org|mmol/L
T Bili0.5|http://unitsofmeasure.org|mg/dL
AST30|http://unitsofmeasure.org|units/L
ALT23|http://unitsofmeasure.org|units/L
Alk Phos52|http://unitsofmeasure.org|units/L
BUN/Creat RatioUnknown
Anion Gap6|http://unitsofmeasure.org|mmol/L
Creatinine0.93|http://unitsofmeasure.org|mg/dL
Ionized Calcium1.14|http://unitsofmeasure.org|mmol/L
D Dimer1.77|http://unitsofmeasure.org|mcg/mL FEU
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Medication NameMedication Start Date
acetylcysteine (acetylcysteine 10% inhalation solution)20220523002700+0000
budesonide (budesonide 0.5 mg/2 mL inhalation suspension)20220523003000+0000
dabigatran (Pradaxa 150 mg oral capsule)20220523002600+0000
ipratropium (Atrovent HFA 17 mcg/inh inhalation aerosol)20220523002600+0000
guaiFENesin (Mucinex)20220523040000+0000
arformoterol20220523020000+0000
budesonide20220523020000+0000
levalbuterol (Xopenex)20220523020000+0000
acetaminophen20220522230700+0000
bisacodyl20220522230700+0000
hydrALAZINE20220522230700+0000
ipratropium-albuterol (DuoNeb)20220522230700+0000
labetalol20220522230700+0000
cefTRIAXone20220523210000+0000
azithromycin20220523220000+0000
methylPREDNISolone (SOLU-Medrol)20220523040000+0000
acetylcysteine (Mucomyst-20 (200mg/mL))20220523020000+0000
midazolam20220523182800+0000
midazolam20220523182700+0000
lidocaine20220523182400+0000
fentaNYL20220523171500+0000
midazolam20220523171500+0000
fentaNYL20220523155900+0000
fentaNYL20220523155900+0000
midazolam (midazolam PF)20220523155900+0000
midazolam (midazolam PF)20220523155900+0000
midazolam (midazolam PF)20220523155900+0000
Lactated Ringers (Lactated Ringers Bolus)20220523132100+0000
Sodium Chloride 0.9% intravenous solution (Sodium Chloride 0.9% Bolus (ADULT))20220522213200+0000
budesonide (Pulmicort Flexhaler 90 mcg/inh inhalation powder)20220523002800+0000
azithromycin20220522213200+0000
cefTRIAXone20220522213200+0000
butalbital/acetaminophen/caffeine (butalbital/acetaminophen/caffeine 50 mg-325 mg-40 mg oral tablet)20220522230000+0000
dexamethasone20220522220000+0000
Sodium Chloride 0.9% intravenous solution (Sodium Chloride 0.9% Bolus (ADULT SEPSIS))20220522213200+0000
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Social History ObservationSocial History Observation Result
Birth SexM
Travel HistoryCOVID-19 Resolved-Yes (qualifier value)
Travel HistoryCOVID-19 Test Date-
Travel HistoryCOVID-19 Previously tested-Yes, negative result
Travel HistoryInfluenza vaccination status (observable entity)-Received prior to admission, during current flu season
Travel HistoryCOVID-19 Previously tested-
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
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Drugs Of Abuse Comprehensive Screen, UrLabSTAT12/23/2022 11:13 AM PST
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
Drugs Of Abuse Comprehensive Screen, UrLabRoutineOne Time for 1 Occurrences starting 12/23/22 until 12/23/22
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MCUTLERattending physicianActive
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DR MEDITECHprimary care physicianActive
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AMANDA NOELREFERRINGActive
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Start: March 12th, 2022
Rickey RobertsOTHERActive
Start: March 12th, 2022
Stephen NewtonCONSULTINGActive
Start: March 12th, 2022
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Gender Identityunknown
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Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
anthraxMarch 15th, 2022 7:20am1PFIZER & OTHER CHARACTERSLOT9911Z
RIGRAPID HEART BEAT
anthraxMarch 24th, 2022 9:34am2JOHNSON AND JOHNSONLOT942X
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Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
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Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 24th, 2022 9:38am
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TESTPHYS AAAprimary care physicianActive
Start: March 31st, 2022
Ed Bakeradmitting physicianActive
Start: March 31st, 2022
GAIL SILVAattending physicianActive
Start: March 31st, 2022
DR DEBRA A ALEXANDER JR, PHDFAMILYActive
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Gender Identityunknown
Sexual OrientationDo not know
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Active ProblemsNoted Date
Hashimoto''s encephalopathy10/11/22
Motion sickness10/11/22
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
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DateTypeDepartmentCare TeamDescription
10/11/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Hashimoto''s encephalopathyMotion sickness, sequela; Coronavirus infection; Close exposure to COVID-19 virus (Primary Dx);
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Reportability Response Information Section
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('1.2.840.114350.1.13.202.3.7.8.688883.486', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.202.3.7.8.688883.486", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.202.3.7.8.688883.486", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "28beb5ae-3f68-11ed-8bdc-005056a7fb21", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "30"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-10-04T17:04:37-07:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": 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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
alum-mag hydroxide-simeth (MAALOX) 200-200-20 mg/5 mL oral suspension 15 mL15 mL, Oral, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 dose, Order WILL be automatically substituted with P&T Approved equivalent per protocol. SHAKE WELL prior to use.Given09/28/2022 8:37 PM PDT15 mL
aspirin tablet 325 mg325 mg, Oral, ONCE, On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT325 mg
lidocaine (XYLOCAINE) 2% viscous oral solution5 mL, Swish and Spit, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT5 mL
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/367be6b3-75f2-2053-63e4-f0a6f1d6bff1"}, {"reference": "MedicationAdministration/3d9ad81e-9518-1b14-44a8-cc86725ed68c"}, {"reference": "MedicationAdministration/b3a81224-d404-4fd4-3134-5c54815acd0f"}]}, {"id": "ca51a58e-d5d5-8f6d-28be-f526ca11481f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/5ddcb7d6-d32c-e91c-f715-cf239eb4aee6"}]}, {"id": "4D3C57C8-4441-11ED-B2C1-005056A7FB21", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
documented as of this encounter (statuses as of 10/04/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Seasonal allergies", "reference": "Condition/1c2932d2-ae86-4b76-fafa-b0a12b17a027"}, {"display": "Problem - Coronavirus infection", "reference": "Condition/1e7e7161-de05-f41e-f064-c227e43edd3e"}, {"display": "Problem - Close exposure to COVID-19 virus", "reference": "Condition/6cb5bd36-5db9-68d4-ec94-afc3f96f6392"}]}, {"id": "578e38a5-2cc7-00e0-1769-ea74746c5fe8", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "4D3F4866-4441-11ED-B2C1-005056A7FB21", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "SARS-CoV-2, RNA", "reference": "Observation/3a45daf2-6872-fd2a-6ede-606810d52bb2"}, {"display": "Lab Interpretation", "reference": "Observation/e9c8e4b3-3fec-4f29-a5c5-e45f96680a4c"}]}, {"id": "8a900c7f-2adf-c43c-4fde-16f9696944df", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "8cfa32e2-c143-2ba9-dc72-266a3ba673c6", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Close exposure to COVID-19 virusCoronavirus infection (Primary Dx);
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Reportability Response Information Section
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine04/28/2022 10:52 AM PDT
Clostridium difficile A and B EIAMicrobiologyRoutine04/28/2022 10:52 AM PDT
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NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
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Active ProblemsNoted Date
Bipolar I disorder11/19/20
Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
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Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Yes0 (1 standard drink = 0.6 oz pure alcohol)
Sex Assigned at BirthDate Recorded
Not on file
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DateTypeDepartmentCare TeamDescription
9/28/22Lab RequisitionPROVIDENCE ST JOSEPH MED CTR LABORATORY501 S Buena Vista StBurbank, CA 91505-4809818-847-6060Test, Ambhp1, MD2001 LIND AVERENTON, WA 98059
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"Tobacco use and exposure", "system": "http://snomed.info/sct"}]}, "effectiveDateTime": "2019-04-16", "valueCodeableConcept": {"coding": [{"code": "451381000124107", "display": "Smokeless tobacco non-user", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/b9b4f47c-2186-440a-9868-b61a5dafe5fc"}}, "request": {"method": "PUT", "url": "Observation/37171526-b247-7b79-30ce-cc392c4b5af1"}}, {"fullUrl": "urn:uuid:3399337e-669a-be70-29a8-f8c6ec97be6e", "resource": {"resourceType": "Observation", "id": "3399337e-669a-be70-29a8-f8c6ec97be6e", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.1.1040.12", "value": "Z41472^55374.98^160573003"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "160573003", "display": "Alcohol intake", "system": "http://snomed.info/sct"}]}, "effectiveDateTime": "2022-02-16", "valueCodeableConcept": {"coding": [{"code": "219006", "display": "Current drinker of alcohol (finding)", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/b9b4f47c-2186-440a-9868-b61a5dafe5fc"}}, "request": {"method": "PUT", "url": "Observation/3399337e-669a-be70-29a8-f8c6ec97be6e"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}, {"fullUrl": "urn:uuid:7a4b0e4b-ca8a-a39b-1b44-19efe2c9ee5c", "resource": {"resourceType": "Immunization", "id": "7a4b0e4b-ca8a-a39b-1b44-19efe2c9ee5c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "35371"}], "occurrenceDateTime": "2010-04-16", "note": {"text": "DTAP-HIB-IPV (PENTACEL)"}, "vaccineCode": {"coding": [{"display": "DTAP-HIB-IPV (PENTACEL)"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/7a4b0e4b-ca8a-a39b-1b44-19efe2c9ee5c"}}, {"fullUrl": "urn:uuid:b5d003f7-cfe2-56a4-6e91-07307f25aa83", "resource": {"resourceType": "Immunization", "id": "b5d003f7-cfe2-56a4-6e91-07307f25aa83", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "57643"}], "occurrenceDateTime": "2020-11-10", "note": {"text": "TDAP, (ADOL/ADULT)"}, "vaccineCode": {"coding": [{"code": "49281-400-10", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "369258741", "manufacturer": {"reference": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/b9b4f47c-2186-440a-9868-b61a5dafe5fc"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/b5d003f7-cfe2-56a4-6e91-07307f25aa83"}}, {"fullUrl": "urn:uuid:b5c77b86-2764-79f9-10bf-5da5e63eb7c1", "resource": {"resourceType": "Organization", "id": "b5c77b86-2764-79f9-10bf-5da5e63eb7c1", "name": "Sanofi Pasteur", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}}, {"fullUrl": "urn:uuid:cffb2ab8-483c-a93e-56c3-5cc3d11e9168", "resource": {"resourceType": "Immunization", "id": "cffb2ab8-483c-a93e-56c3-5cc3d11e9168", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "57644"}], "occurrenceDateTime": "2011-11-11", "note": {"text": "HEP A (ADULT) 2 DOSE"}, "vaccineCode": {"coding": [{"display": "HEP A (ADULT) 2 DOSE"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/cffb2ab8-483c-a93e-56c3-5cc3d11e9168"}}, {"fullUrl": "urn:uuid:35c0d7fc-0bc0-5a24-e65e-dc30321d7e2e", "resource": {"resourceType": "Immunization", "id": "35c0d7fc-0bc0-5a24-e65e-dc30321d7e2e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "58353"}], "occurrenceDateTime": "2020-11-16", "note": {"text": "MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)"}, "vaccineCode": {"coding": [{"code": "50090-1890-1", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "1", "manufacturer": {"reference": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/b9b4f47c-2186-440a-9868-b61a5dafe5fc"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/35c0d7fc-0bc0-5a24-e65e-dc30321d7e2e"}}, {"fullUrl": "urn:uuid:50fc36a0-b859-c4a4-de8f-53c149080081", "resource": {"resourceType": "Immunization", "id": "50fc36a0-b859-c4a4-de8f-53c149080081", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "58354"}], "occurrenceDateTime": "1974-03-21", "note": {"text": "HEP B (PED,ADOLESCENT) 3 DOSE"}, "vaccineCode": {"coding": [{"display": "HEP B (PED,ADOLESCENT) 3 DOSE"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/50fc36a0-b859-c4a4-de8f-53c149080081"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('a48d9602-8fad-48db-814e-b2d9d9e38272', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:a48d9602-8fad-48db-814e-b2d9d9e38272", "resource": {"resourceType": "Composition", "id": "a48d9602-8fad-48db-814e-b2d9d9e38272", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "27264711|64753207"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "2"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-04-21T04:29:46Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "b5671da1-ae0d-b076-16a0-e1b35c405d3c", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Morbid obesity (disorder)Active
Bronchitis (disorder)Active
Hypertensive disorder, systemic arterial (disorder)Active
Disease caused by 2019-nCoVActive
Sleep apnea (finding)Active
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Morbid obesity (disorder)", "reference": "Condition/fda60b87-4a6a-726f-d7c7-d47d7a2a5b3e"}, {"display": "Problem - Bronchitis (disorder)", "reference": "Condition/6c708648-e187-80e1-7637-8c8dd835bee9"}, {"display": "Problem - Hypertensive disorder, systemic arterial (disorder)", "reference": "Condition/6ce62093-29b5-1603-8f3f-ff64372f7f44"}, {"display": "Problem - Disease caused by 2019-nCoV", "reference": "Condition/dd79131b-bd57-027e-cfc7-a1a36ffbc65b"}, {"reference": "Condition/23acd9bc-d02c-f3f6-6b1c-cff9d9f00730"}, {"display": "Problem - Sleep apnea (finding)", "reference": "Condition/87f49e43-a0fa-290e-6517-9cef77143ccd"}]}, {"id": "615cf8a5-abe2-f777-800b-2bf4ce577b7c", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
Outpatient20220407123000+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "71f3ffdb-7b33-db90-492b-31b05c87dac9", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
Hct43.2|http://unitsofmeasure.org|%
U Beta hCG QlNegative
"}, "code": {"coding": [{"code": "30954-2", "display": "RESULTS", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/5ecfe192-e9c3-6eb4-038a-a1a1d6ecdf4a"}, {"reference": "Observation/6bbe2c73-a90e-c457-4518-dd4f1c29027f"}]}, {"id": "a404e444-ea7a-d8a0-9d29-624084e1d6b0", "title": "Medications Administered", "text": {"status": "generated", "div": "
Medication NameMedication Start Date
ergocalciferol (ergocalciferol 1.25 mg (50,000 intl units) oral capsule)20220414172400+0000
lisinopril (lisinopril 10 mg oral tablet)20220414172700+0000
acetaminophen (Ofirmev)20220419153100+0000
ceFAZolin (Ancef/Kefzol)20220419140000+0000
hydrocodone-acetaminophen (Norco 5 mg-325 mg oral tablet)20220419153100+0000
ondansetron (Zofran)20220419153100+0000
pantoprazole (Protonix)20220419153500+0000
prochlorperazine (Compazine)20220419153100+0000
LORazepam20220419151900+0000
ondansetron20220419151900+0000
diphenhydrAMINE20220419151900+0000
fentaNYL20220419151900+0000
fentaNYL20220419151900+0000
morphine20220419151900+0000
morphine20220419151900+0000
naloxone (Narcan)20220419151900+0000
glycopyrrolate (glycopyrrolate (ANES))20220419155600+0000
labetalol (labetalol (ANES))20220419155600+0000
neostigmine (neostigmine (ANES))20220419155600+0000
ondansetron (ondansetron (ANES))20220419155600+0000
ceFAZolin 1 g injection (ANES) 1 gm20220419145100+0000
phenylephrine (phenylephrine (ANES))20220419153300+0000
Lactated Ringers (ANES) 1000 mL20220419142700+0000
propofol20220419152300+0000
bupivacaine-epinephrine20220419151700+0000
dexamethasone (dexAMETHasone 4 mg/mL injectable solution (ANES))20220419150700+0000
esmolol (esmolol (ANES))20220419150700+0000
etomidate (etomidate (ANES))20220419150200+0000
lidocaine (Xylocaine-MPF 1% injectable solution (ANES))20220419150200+0000
propofol (Diprivan 10 mg/mL intravenous emulsion (ANES))20220419150200+0000
rocuronium (rocuronium (ANES))20220419150200+0000
midazolam (midazolam 1 mg/mL injectable solution (ANES))20220419145700+0000
morphine (morphine (ANES))20220419145700+0000
ceFAZolin20220419145000+0000
dexamethasone (dexAMETHasone)20220419145000+0000
esmolol20220419144800+0000
etomidate20220419144800+0000
rocuronium (rocuronium/isoosmotic)20220419144800+0000
lidocaine (lidocaine PF 1% (50mg/5ml))20220419143700+0000
lidocaine (lidocaine PF 2%)20220419143700+0000
morphine20220419143700+0000
propofol20220419143700+0000
midazolam20220419143600+0000
scopolamine (scopolamine 1 mg/72 hr transdermal film, extended release)20220419140000+0000
acetaminophen (Ofirmev)20220419140000+0000
enoxaparin (Lovenox)20220419140000+0000
azithromycin (azithromycin 250 mg oral tablet)20220414172800+0000
benzonatate (benzonatate 100 mg oral capsule)20220414172700+0000
predniSONE (predniSONE 5 mg oral tablet)20220414172600+0000
bupivacaine-epinephrine (bupivacaine-EPINEPHrine 0.25%)20220419133800+0000
"}, "code": {"coding": [{"code": "29549-3", "display": "Medications Administered", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/88856730-b93f-a614-6aec-4144c832c6d5"}, {"reference": "MedicationAdministration/57dc21b4-c8c7-46d3-0dd0-9b9b423d9332"}, {"reference": "MedicationAdministration/e46755c1-98a9-0b72-30bd-f04ebac9aba0"}, {"reference": "MedicationAdministration/7d7145ff-06ca-9c60-2ff3-9145587f3ff1"}, {"reference": "MedicationAdministration/a1ff7ad3-de3f-b73c-a2d7-bc8cdecf7b2f"}, {"reference": "MedicationAdministration/d1c83fc6-4671-1f69-1549-1e1fac8e5d9e"}, {"reference": "MedicationAdministration/b1447a0f-3e01-7c57-7f1a-03266ea1dac2"}, {"reference": "MedicationAdministration/d4a2541c-acf6-901c-f464-bad3e4c41174"}, {"reference": "MedicationAdministration/b2b3734c-f347-7ed0-1ca3-580a0d6e4ea8"}, {"reference": "MedicationAdministration/3e5b04d6-e634-4f80-e41e-d9c123c6a06f"}, {"reference": "MedicationAdministration/98c7abe2-51da-cbfc-afd9-5a7fb6a0dad0"}, {"reference": "MedicationAdministration/7e0f1d2f-d8fc-9cb4-6192-352d7974ae4a"}, {"reference": "MedicationAdministration/21060100-c181-7a4e-3c48-113d9ddc0fd7"}, {"reference": "MedicationAdministration/053601e4-4ce7-2b0e-c518-b8aae9a3827f"}, {"reference": "MedicationAdministration/5a91cee4-e421-b7d4-0d74-978f1ec9bd76"}, {"reference": "MedicationAdministration/4c80430b-ae0d-4dd2-0f38-3a398db3b7a0"}, {"reference": "MedicationAdministration/de67dd20-60df-14ce-4cc5-1bdd8271e2b8"}, {"reference": "MedicationAdministration/e22ddac3-9f94-f322-a68c-687e33f745be"}, {"reference": "MedicationAdministration/ac926912-e819-904e-a72f-f27b540af8cc"}, {"reference": "MedicationAdministration/f8a66894-fcf7-985a-e3d8-925da492f97c"}, {"reference": "MedicationAdministration/7aa3ec89-a135-8ea8-6cc5-d52b65eccf06"}, {"reference": "MedicationAdministration/a66f9499-6645-99b6-d6da-adf20c659957"}, {"reference": "MedicationAdministration/266e540a-3ea5-850f-df16-5ca3b0c3a6f2"}, {"reference": "MedicationAdministration/4fdc4e6c-fadf-c462-23e0-50e506887129"}, {"reference": "MedicationAdministration/41173944-0978-14f5-7553-cad40f6372e2"}, {"reference": "MedicationAdministration/72df6b60-56ff-e971-a219-8592a4344369"}, {"reference": "MedicationAdministration/a26cfdf6-ced9-83db-6ce5-31f3d390bc8d"}, {"reference": "MedicationAdministration/b763dd95-6bf7-828b-8a98-fa233033d067"}, {"reference": "MedicationAdministration/2aa3747f-a196-c147-ed69-bddd78f36984"}, {"reference": "MedicationAdministration/df8f6ed6-2058-0ff8-d827-4bebb5975887"}, {"reference": "MedicationAdministration/e4e91f40-d90c-21f7-0b29-029083b36741"}, {"reference": "MedicationAdministration/7b87defd-4fb8-8dab-b95e-573408dc115d"}, {"reference": "MedicationAdministration/e5d22d6c-3a44-0e9e-2f4d-9a04319cd7c7"}, {"reference": "MedicationAdministration/81b0f169-4da5-f5ca-7de2-2bdcdd2adc1c"}, {"reference": "MedicationAdministration/3d7ad965-4930-e58b-6bf7-298156a1e1aa"}, {"reference": "MedicationAdministration/439c4331-cd8a-3124-3400-155facc55dcb"}, {"reference": "MedicationAdministration/f4d8e77d-9810-3df4-b451-b6bc12a87953"}, {"reference": "MedicationAdministration/7bed0d98-863a-b32b-1164-69714faee9eb"}, {"reference": "MedicationAdministration/92f82a4a-c46b-7834-f12a-48d35024b470"}, {"reference": "MedicationAdministration/fa3f4e40-47c6-0b93-87ef-f1f64b02069d"}, {"reference": "MedicationAdministration/14860d65-890e-9358-6edd-88426e558b03"}, {"reference": "MedicationAdministration/ca07bb39-087f-85d8-072b-8eda556c85e6"}, {"reference": "MedicationAdministration/e483836a-5251-f3cd-64d4-da5daebb503d"}, {"reference": "MedicationAdministration/a352b05f-40d1-24e3-10de-490dedcaddac"}, {"reference": "MedicationAdministration/a94981d5-8d5e-8aed-073b-36930ffb10a7"}, {"reference": "MedicationAdministration/07563404-1df2-d4b5-ece5-4b1b2e3750aa"}, {"reference": "MedicationAdministration/6219212c-4c49-b527-02c0-79408747798f"}, {"reference": "MedicationAdministration/c8b8bd8c-37a2-8a84-2afe-90b69c5981bf"}, {"reference": "MedicationAdministration/35b33ac9-dfa5-3f0b-95c1-cad308395785"}, {"reference": "MedicationAdministration/69347529-a65f-8bd4-676f-d8faa47437c8"}]}, {"id": "b356bfdf-bb47-ba14-e6ef-063a174b2b4a", "title": "IMMUNIZATIONS", "text": {"status": "generated", "div": "
Vaccine NameVaccination Date
SARS-COV-2 (COVID-19 MODERNA) mRNA-1273Tue Mar 15 00:00:00 GMT 2022
SARS-COV-2 (COVID-19 MODERNA) mRNA-1273Tue Apr 27 00:00:00 GMT 2021
SARS-COV-2 (COVID-19 MODERNA) mRNA-1273Tue Mar 30 00:00:00 GMT 2021
"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "a68223e8-6948-25cc-882f-5eeca2c79f98", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Birth SexF
Travel HistoryCOVID-19 Test Date-
Travel HistoryCOVID-19 Previously tested-Yes, negative result
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryPregnancy Status-Negative HCG result
Travel HistoryCOVID-19 Test Date-
Travel HistoryCOVID-19 Previously tested-Yes, result pending
Travel HistoryExposure to severe acute respiratory syndrome coronavirus 2 (event)-Yes (qualifier value)
Travel HistoryMERS-CoV Travel History-Yes (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMERS-CoV Symptoms-Cough (finding)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryMRSA Sceen Dialysis or Venous Access-No (qualifier value)
Travel HistoryMRSA Screen Admit From Non-home Loc-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-Mexico (geographic location)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-Mexico (geographic location)
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CORONAVIRUS (COVID-19), PCRLabRoutineCoronavirus infectionClose exposure to COVID-19 virusOrdered: 9/28/22
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Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
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Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
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DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
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Active ProblemsNoted Date
Hashimoto''s encephalopathy10/11/22
Motion sickness10/11/22
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
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DateTypeDepartmentCare TeamDescription
10/11/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
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Team Status: Active
MemberRoleStatusDates
Kevin Lanzilloattending physicianActive
Start: March 17th, 2022
MRS. PUMSEN R SOR SRprimary care physicianActive
Start: March 17th, 2022
Sandra E Hoytadmitting physicianActive
Start: March 17th, 2022
DR. LARDIEREFAMILYActive
Start: March 17th, 2022
Brian Leary , MDREFERRINGActive
Start: March 17th, 2022
DR. DAVID CONNOROTHERActive
Start: March 17th, 2022
MCUTLERCONSULTINGActive
Start: March 17th, 2022
Samuel HoytNext of KinActive
Start: March 17th, 2022
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Never smoker (Never Smoked)March 17th, 2022 2:54pm
StatusDate of Observation
Not pregnantMarch 17th, 2022
Assigned Birth SexFemale
Gender Identityunknown
Sexual OrientationDo not know
Date of TravelLocation
January 18th, 2018 - February 18th, 2018
my family.Traveled to Singapore, Malaysia and Bali with
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COVID-19March 14th, 2022Active
HeadacheActive
Heart abnormalityActive
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RIFA150C15 (Rifampin ) 150 MG CAPSULE150MGORALBIDMarch 18th, 2022 3:30pmMarch 18th, 2022 3:30pm
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EncounterLocation(s)Arrival/Admit DateDischarge/Depart DateProvider(s)
Admitted InpatientDot Facility (No ARM)March 17th, 2022 2:45pmKevin Lanzillo
Recent DiagnosisOnset Date
COVID-19March 14th, 2022

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DiagnosisOnset DateResolutionStatus
COVID-19March 14th, 2022Active
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Author
CANTON MEDICAL CENTER OF MASSACHUSETTS-North Canton FacilitSandra Hoyt
AuthoredMarch 22nd, 2022 11:23am
Follow-up with PSOR referral and PCP.
Test NameOrdered DateScheduled Date
WHITE BLOOD COUNT
HEMOGLOBIN
HEMATOCRIT
MEAN CELL VOLUME
MEAN CORPUSCULAR HEMOGLOBIN
PLATELET COUNT
COVID19 OTHER VENDOR 94500-6March 18th, 2022 2:48pmMarch 18th, 2022
COVID-19 OV 94500-6March 17th, 2022 5:06pmMarch 31st, 2022
HIV Test: LOINC 10351-5March 22nd, 2022 11:26amMarch 28th, 2022
Reason for ReferralReferral Start DateProviderProvider Contact InformationProvider Address
Cardiac abnormalityPUMSEN''S PROVIDER GROUPWork Phone: +1(508)789-7891
BROCKTON MA 02301SUITE 1010110 MAIN ST
Medication NameStart DateInstructions
Atorvastatin Calcium Tablet Dispense (LIPITOR - WITH DISPENSE) 40 MG TABMarch 17th, 2022 3:48pm
Benazepril HCl (Benazepril) 40 MG TABLETMarch 22nd, 2022 8:32am
Cyclobenzaprine (CYCL10T) 10 MG TABMarch 21st, 2022 4:19pm
Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 21st, 2022 3:59pm
Rifampin - RXCUI C198201 (RIFAMPIN150 MG) 150 MG CAPMarch 17th, 2022 3:48pm
Severe Acute Respiratory Syndrome (SARS)

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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Drugs Of Abuse Comprehensive Screen, UrLabSTAT12/23/2022 11:13 AM PST
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
Drugs Of Abuse Comprehensive Screen, UrLabRoutineOne Time for 1 Occurrences starting 12/23/22 until 12/23/22
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Unconfirmed screening results must not be used for non-medical purposes (e.g., employment testing).
Only positive maternal and neonatal screening results reflex for confirmation and are reported separately.
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{"fullUrl": "urn:uuid:b02f3743-5484-7dd8-8cc5-947a1f8ab685", "resource": {"resourceType": "CarePlan", "id": "b02f3743-5484-7dd8-8cc5-947a1f8ab685", "status": "unknown", "intent": "proposal", "subject": {"reference": "Patient/a7809075-9bc6-4890-993d-6d216bd1d6c6"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "CarePlan/b02f3743-5484-7dd8-8cc5-947a1f8ab685"}}, {"fullUrl": "urn:uuid:d389129e-8fce-0deb-b717-5a23bd4cb6df", "resource": {"resourceType": "Condition", "id": "d389129e-8fce-0deb-b717-5a23bd4cb6df", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "96719"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "C72.0", "display": "Malignant teratoma of spinal cord", "system": 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["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "15182482|110500680"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "19"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-11-28T17:23:40Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "3d3f48d8-1a54-cebb-4b1c-2c667ca60ebc", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Disease caused by 2019-nCoVActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Disease caused by 2019-nCoV", "reference": "Condition/298b03c4-a2cf-efdd-180a-ed000f4d630e"}, {"reference": "Condition/6d3200fa-8bce-062e-9960-6d2def58a7dc"}]}, {"id": "04320d3a-d09e-e3d9-6c01-0bd2973bb99f", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
inpatient encounter20220919145900+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "89a11f4e-e55c-8929-7fcf-0bad9e264925", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
SARS-CoV-2 BioFireNot Detected
Coronavirus HKU1Not Detected
Coronavirus NL63Not Detected
Coronavirus OC43Not Detected
Coronavirus 229ENot Detected
SARS-CoV-2 Xpert Xpress ResultsDetected
RSV PCRNot Detected
Influenza B, PCRNot Detected
Influenza A, PCRNot Detected
"}, "code": {"coding": [{"code": "30954-2", "display": "RESULTS", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/be844c85-b9f4-9392-e0df-9d9944be7751"}, {"reference": "Observation/b6d380ff-572b-4a79-9407-b2644db163ef"}, {"reference": "Observation/55c38733-4eb8-4a6a-7e23-44bff90a4fb0"}, {"reference": "Observation/f61f7d29-28a2-6a8c-ec17-2334d968a2bd"}, {"reference": "Observation/9fd36dae-6b24-b218-f901-dd19c3a7201e"}, {"reference": "Observation/d0f632a3-b0d2-08dc-1db4-25d6044592f1"}, {"reference": "Observation/521fbc78-9973-b07e-c493-3518fc548037"}, {"reference": "Observation/c312e4fe-6a56-ccc2-c2e0-840ee5ff893f"}, {"reference": "Observation/f503ba7e-9f4b-f5aa-47c6-0f84cf02bd15"}]}, {"id": "39cff3c8-745d-0f71-9d44-92f3642a93d1", "title": "Medications Administered", "text": {"status": "generated", "div": "
Medication NameMedication Start Date
remdesivir20221123010000+0000
remdesivirUnknown
remdesivirUnknown
"}, "code": {"coding": [{"code": "29549-3", "display": "Medications Administered", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/9f3374d3-b2e5-8017-72d2-a06945f1e713"}, {"reference": "MedicationAdministration/3ea5fee2-5758-dfe9-20a7-45ee4ec9e44f"}, {"reference": "MedicationAdministration/e1659ab8-c4fe-9c44-d546-07f36f2920f3"}]}, {"id": "b178572b-d77b-71cc-2862-ccca48ab961d", "title": "IMMUNIZATIONS", "text": {"status": "generated", "div": "
Vaccine NameVaccination Date
influenza virus vaccine, liveWed Nov 10 00:00:00 GMT 2021
"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "98e57790-a2fc-cd4f-3f5f-3336ee2240fb", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Occupation HistoryStudent
Travel HistoryCovid Test Result-Negative (qualifier value)
Travel HistoryCovid Test Result-Negative (qualifier value)
Travel HistoryCongestion or Runny Nose-No (qualifier value)
Travel HistoryNausea-No (qualifier value)
Travel HistoryPositive COVID-19 Test-No (qualifier value)
Travel HistoryLoss of Taste or Smell-No (qualifier value)
Travel HistoryReported Fever-No (qualifier value)
Travel HistoryDry Cough-No (qualifier value)
Travel HistorySymptomatic Health Care Professional/SNF-No (qualifier value)
Travel HistorySymptomatic After Exposure to Contagion-No (qualifier value)
Travel HistoryDroplet, Contact Isolation Verification-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryUnexplained Hemorrhage, Bleed or Bruise-No (qualifier value)
Travel HistoryAbnormal Bleeding-No (qualifier value)
Travel HistoryAbdominal (Stomach Pain)-No (qualifier value)
Travel HistoryDifficulty breathing (finding)-No (qualifier value)
Travel HistoryChills Infectious Disease-No (qualifier value)
Travel HistoryBreastfeeding-Not applicable (qualifier value)
Travel HistoryDiarrhea (finding)-No (qualifier value)
Travel HistoryVomiting (disorder)-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryDyspnea (finding)-No (qualifier value)
Travel HistoryIllness With Generalized Rash-No (qualifier value)
Travel HistoryMuscle pain (finding)-No (qualifier value)
Travel HistoryHeadache (finding)-No (qualifier value)
Travel HistorySexual Orientation-Not applicable (qualifier value)
Travel HistorySexually active (finding)-Not applicable (qualifier value)
Travel HistoryCongestion or Runny Nose-No (qualifier value)
Travel HistoryNausea-No (qualifier value)
Travel HistoryPositive COVID-19 Test-No (qualifier value)
Travel HistoryLoss of Taste or Smell-No (qualifier value)
Travel HistoryReported Fever-No (qualifier value)
Travel HistoryDry Cough-No (qualifier value)
Travel HistorySymptomatic Health Care Professional/SNF-No (qualifier value)
Travel HistorySymptomatic After Exposure to Contagion-No (qualifier value)
Travel HistoryDroplet, Contact Isolation Verification-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryUnexplained Hemorrhage, Bleed or Bruise-No (qualifier value)
Travel HistoryAbnormal Bleeding-No (qualifier value)
Travel HistoryAbdominal (Stomach Pain)-No (qualifier value)
Travel HistoryDifficulty breathing (finding)-No (qualifier value)
Travel HistoryChills Infectious Disease-No (qualifier value)
Travel HistoryDiarrhea (finding)-No (qualifier value)
Travel HistoryVomiting (disorder)-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryDyspnea (finding)-No (qualifier value)
Travel HistoryIllness With Generalized Rash-No (qualifier value)
Travel HistoryMuscle pain (finding)-No (qualifier value)
Travel HistoryHeadache (finding)-No (qualifier value)
Travel HistoryInfectious Diseases Health History-None (qualifier value)
Travel HistorySexual Orientation-Not applicable (qualifier value)
Travel HistorySexually active (finding)-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
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This panel is not to be used for legal drug cases. The presence of other compounds in the patient''s specimen may cause a false positive. Correlate the results with clinical evaluation and other diagnostic testing procedures.

.....DRUG...... \u00a0 \u00a0 \u00a0 \u00a0 THRESHOLD DETECTION LIMIT
AMPH/METHAMPHET \u00a0 \u00a0 \u00a0 \u00a0 >1000 ng/mL
BARBITUATES \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 200 ng/mL
BENZODIAZEPINES \u00a0 \u00a0 \u00a0 \u00a0 > 200 ng/mL
COCAINE \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 300 ng/mL
OPIATES \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 300 ng/mL
PCP \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a025 ng/mL
THC \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a050 ng/mL
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Team Status: Active
MemberRoleStatusDates
Adam Sheradmitting physicianActive
Start: March 12th, 2022
MCUTLERattending physicianActive
Start: March 12th, 2022
DR MEDITECHprimary care physicianActive
Start: March 12th, 2022
AMANDA NOELREFERRINGActive
Start: March 12th, 2022
AMANDA PARLATOFAMILYActive
Start: March 12th, 2022
Rickey RobertsOTHERActive
Start: March 12th, 2022
Stephen NewtonCONSULTINGActive
Start: March 12th, 2022
"}, "code": {"coding": [{"code": "85847-2", "display": "Care team", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CareTeam/0069e221-fc22-ddae-cb7c-7f606d26463e"}]}, {"id": "ebee278c-baeb-2ac4-3399-7355f2cabeb5", "title": "Reason for Visit", "text": {"status": "generated", "div": "No reason for visit information available"}, "code": {"coding": [{"code": "29299-5", "display": "Reason for Visit", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "No reason for visit information available"}]}, {"id": "7b1d6abb-cea5-12c2-6f6b-83e0c1c01b06", "title": "History of Present Illness", "text": {"status": "generated", "div": "No history of present illness information available"}, "code": {"coding": [{"code": "10164-2", "display": "History Of Present Illness", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "dd887cb6-cf65-8ee4-ba47-3d24b023e1c8", "title": "Social History", "text": {"status": "generated", "div": "Smoking Status Unknown if ever smoked Additional Data
Assigned Birth SexMale
Gender Identityunknown
Sexual OrientationDo not know
"}, "code": {"coding": [{"code": "29762-2", "display": "Social History", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/3d950365-4c94-05a3-0f30-ae741089137b"}]}, {"id": "be17251e-cbc0-688c-6388-eebd0f5fc0e7", "title": "Problems", "text": {"status": "generated", "div": "Active Problems
Medical ProblemOnset DateStatus
AnthraxActive
COVID-19Active
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Anthrax", "reference": "Condition/c172d574-fdc1-89f7-3278-005764c4e297"}, {"display": "Problem - Infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)", "reference": "Condition/f3f66c7c-b9ae-57ac-18e4-f6ff681f0e06"}]}, {"id": "d8361422-5b78-3451-1ceb-044df5fa4cbd", "title": "Immunizations", "text": {"status": "generated", "div": "
ImmunizationEvent DateNot Given ReasonDose NumberManufacturerLot NumberVaccine Information Statement (VIS) Detail
Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
anthraxMarch 15th, 2022 7:20am1PFIZER & OTHER CHARACTERSLOT9911Z
RIGRAPID HEART BEAT
anthraxMarch 24th, 2022 9:34am2JOHNSON AND JOHNSONLOT942X
"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "b4dca430-0937-826b-5105-4c74964d84fe", "title": "Procedures", "text": {"status": "generated", "div": "No procedure information available"}, "code": {"coding": [{"code": "47519-4", "display": "PROCEDURES", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "cb100e34-732f-7121-cf3b-57d896f73289", "title": "Relevant Diagnostic Tests and/or Laboratory Data", "text": {"status": "generated", "div": "No known relevant diagnostic tests and/or laboratory data."}, "code": {"coding": [{"code": "30954-2", "display": "RELEVANT DIAGNOSTIC TESTS AND/OR LABORATORY DATA", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "a5de6418-79c0-dbd1-6376-420c06bab76a", "title": "Vital Signs", "text": {"status": "generated", "div": "
Vital ReadingResultReference RangeCollection Date/Time
Height65 [in_i]March 14th, 2022 1:48pm
Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
Weight68.039 kgMarch 14th, 2022 1:48pm
BMI (Body Mass Index)25.0 kg/m2March 14th, 2022 1:48pm
"}, "code": {"coding": [{"code": "8716-3", "display": "VITAL SIGNS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "7faf7c0d-9dae-d4e2-3411-2df68cb30d4a", "title": "Administered Medications", "text": {"status": "generated", "div": "
MedicationDoseUnitsRouteDirectionsQtyDaysStart DateEnd DateInstructions
ZIDO100C4 (Zidovudine ) 100 MG TABLET100MGORALQ6HMarch 12th, 2022 7:49pmMarch 12th, 2022 7:49pm
RIFA150C15 (Rifampin ) 150 MG CAPSULE150MGORALQ6HMarch 24th, 2022 9:34amMarch 24th, 2022 9:34am
"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/b0b53e46-0fff-1fae-1534-8ebf6656fd81"}, {"reference": "MedicationAdministration/8a31f9a3-0802-e1c6-761b-b9bec4911950"}]}, {"id": "2f42b738-9c3b-d2d5-2937-056dfd15cb20", "title": "Encounters", "text": {"status": "generated", "div": "
EncounterLocation(s)Arrival/Admit DateDischarge/Depart DateProvider(s)
Admitted InpatientDot Facility (No ARM)March 12th, 2022 7:45pmMCUTLER
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MemberRoleStatusDates
Kevin Lanzilloattending physicianActive
Start: March 17th, 2022
MRS. PUMSEN R SOR SRprimary care physicianActive
Start: March 17th, 2022
Sandra E Hoytadmitting physicianActive
Start: March 17th, 2022
DR. LARDIEREFAMILYActive
Start: March 17th, 2022
Brian Leary , MDREFERRINGActive
Start: March 17th, 2022
DR. DAVID CONNOROTHERActive
Start: March 17th, 2022
MCUTLERCONSULTINGActive
Start: March 17th, 2022
Samuel HoytNext of KinActive
Start: March 17th, 2022
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Never smoker (Never Smoked)March 17th, 2022 2:54pm
StatusDate of Observation
Not pregnantMarch 17th, 2022
Assigned Birth SexFemale
Gender Identityunknown
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January 18th, 2018 - February 18th, 2018
my family.Traveled to Singapore, Malaysia and Bali with
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HeadacheActive
Heart abnormalityActive
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RIFA150C15 (Rifampin ) 150 MG CAPSULE150MGORALBIDMarch 18th, 2022 3:30pmMarch 18th, 2022 3:30pm
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Admitted InpatientDot Facility (No ARM)March 17th, 2022 2:45pmKevin Lanzillo
Recent DiagnosisOnset Date
COVID-19March 14th, 2022
Manual Initiation ReasonDate
NMI Testing UtilityMarch 23rd, 2022 4:51pm

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Author
CANTON MEDICAL CENTER OF MASSACHUSETTS-North Canton FacilitSandra Hoyt
AuthoredMarch 22nd, 2022 11:23am
Follow-up with PSOR referral and PCP.
Test NameOrdered DateScheduled Date
WHITE BLOOD COUNT
HEMOGLOBIN
HEMATOCRIT
MEAN CELL VOLUME
MEAN CORPUSCULAR HEMOGLOBIN
PLATELET COUNT
COVID-19 OV 94500-6March 17th, 2022 5:06pmMarch 31st, 2022
HIV Test: LOINC 10351-5March 22nd, 2022 11:26amMarch 28th, 2022
Reason for ReferralReferral Start DateProviderProvider Contact InformationProvider Address
Cardiac abnormalityPUMSEN''S PROVIDER GROUPWork Phone: +1(508)789-7891
BROCKTON MA 02301SUITE 1010110 MAIN ST
Medication NameStart DateInstructions
Atorvastatin Calcium Tablet Dispense (LIPITOR - WITH DISPENSE) 40 MG TABMarch 17th, 2022 3:48pm
Benazepril HCl (Benazepril) 40 MG TABLETMarch 22nd, 2022 8:32am
Cyclobenzaprine (CYCL10T) 10 MG TABMarch 21st, 2022 4:19pm
Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 21st, 2022 3:59pm
Rifampin - RXCUI C198201 (RIFAMPIN150 MG) 150 MG CAPMarch 17th, 2022 3:48pm
Severe Acute Respiratory Syndrome (SARS)

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DTaP, 5 pertussis antigens vaccine (DAPTACEL)06/15/2021
Hep B, adult vaccine (Engerix/Recombivax)09/08/2020
SARS-COV-2 (COVID-19) Spikevax Vaccine, Moderna01/22/2021
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
PCR SARS-CoV-2 and Influenza A/BLabRoutine07/27/2022 3:49 PM CDT
PCR SARS-CoV-2 and Influenza A/BLabRoutine07/27/2022 3:49 PM CDT
PCR SARS-CoV-2 and Influenza A/BLabRoutine07/27/2022 3:49 PM CDT
PCR SARS-CoV-2 and Influenza A/BLabRoutine07/27/2022 3:49 PM CDT
PCR SARS-CoV-2 and Influenza A/BLabRoutine07/27/2022 3:49 PM CDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
PCR Hepatitis C Virus QtLabRoutineOrdered: 5/12/22
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Active ProblemsNoted Date
COVID toes7/13/22
Chest pain on breathing5/26/22
Type 1 diabetes2/28/22
Overview:Formatting of this note might be different from the original.
08/30/21 28.69 kg/m\u00b2BMI Readings from Last 1 Encounters:
Plague pneumonia6/16/21
Absence of menstruation6/12/18
Foot callus8/11/17
Overview:Formatting of this note might be different from the original.
Ouch.
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Sex Assigned at BirthDate Recorded
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2/18/22Transcribe OrdersVanderbilt University Adult Hospital1211 Medical Center DrNashville, TN 37232615-322-5000Tech, Lab, MLT
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"methodCode originalText", "valueString": "MIC"}]}], "subject": {"reference": "Patient/e2822458-d9a9-4a97-84c9-58418643d14e"}}, "request": {"method": "PUT", "url": "Observation/b6543a6e-0953-3e8f-1ffe-913573b6d8ab"}}, {"fullUrl": "urn:uuid:6146a6d6-1b2c-26e8-82db-dab711b57aeb", "resource": {"resourceType": "DiagnosticReport", "id": "6146a6d6-1b2c-26e8-82db-dab711b57aeb", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.798268", "value": "2061338"}], "status": "final", "code": {"coding": [{"code": "118332", "display": "FISH ALL Pnl", "system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.696580"}]}, "effectivePeriod": {"start": "2022-03-11T19:05:00Z", "end": "2022-03-11T19:05:00Z"}, "subject": {"reference": "Patient/e2822458-d9a9-4a97-84c9-58418643d14e"}, "performer": [{"reference": "Organization/22c6cdd0-bde1-e220-9ba4-2c2802f795ad"}], "result": [{"reference": "Observation/0c7d57dc-a961-8ffe-4593-540dba80b4b0"}, {"reference": "Observation/d3a8b35b-4563-2594-abd7-7d433ff0f7e8"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/6146a6d6-1b2c-26e8-82db-dab711b57aeb"}}, {"fullUrl": "urn:uuid:0c7d57dc-a961-8ffe-4593-540dba80b4b0", "resource": {"resourceType": "Observation", "id": "0c7d57dc-a961-8ffe-4593-540dba80b4b0", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.7.798268.1000", "value": "2061338"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2022-03-11T19:27:37Z", "valueString": "FISH REPORT

Request#:CG-22-0000003
Service date:3/11/2022 13:05


FISH IMPRESSION:

Abnormal for homozygous deletion of CDKN2A locus at 9p21 in __% of cells.

FISH KARYOTYPE:



nuc ish (DXZ1x1,DYZ3x1,D18Z1x2)[200]

\u00a0
\u00a0
\u00a0



COMMENTS:



Results of the FISH studies with the 21 DNA probes described above were analyzed in at least 200 cells per probe and no abnormal signal patterns were detected for the target regions of chromosomes 1, 4, 7, 9, 10, 11, 12, 14, 17, 19, 21, and 22.

Normal cut off values for probes:

1.0% for t(1;19) PBX1/TCF3
1.0% for t(9;22) BCR/ABL1
1.0% for KMT2A (11q23)
1.0% for t(12;21) ETV6/RUNX1
1.0% for IKZF1/CEP7
3.0% for CEP 4
2.0% for CEP 10
2.0% for CEP 17
1.0% for CDKN2A/CEP9 (9p21)
1.0% for IGH breakapart
1.0% for ABL2 breakapart
1.0% for ABL1 breakapart

These probes were developed by Vysis and their performance characteristics determined by VUMC as required by the CLIA ''88 regulations. \u00a0These probes have not been cleared or approved by the U.S. Food and Drug administration.


Ferrin Courtney Wheeler, PhD, FACMG
reviewed and approved

Electronically signed out by:
Mavrak, Geoffrey A

on 03/11/2022

Clinical History: \u00a0ALL
Specimen List: Blood
Date In Lab: 3/11/2022 13:09
Date Collected: 3/11/2022 13:05

Testing performed at Vanderbilt Cytogenetics One Hundred Oaks Laboratory, Suite 21100, 719 Thompson Ln,
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A detected result is positive and indicates the presence of the virus in the sample. A not detected result indicates that the test did not detect the virus in the sample."}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Nares"}, {"url": "specimen collection time", "valueDateTime": "2022-03-11T19:05:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-03-11T19:46:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.478.3.7.2.798268.2061339.Comp1"}]}, {"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "840539006", "system": "http://snomed.info/sct"}]}], "subject": {"reference": "Patient/e2822458-d9a9-4a97-84c9-58418643d14e"}, "performer": [{"display": "VUMC CERNER LAB", "reference": "Organization/e3ece69c-0968-59c9-47dd-f16db731621a"}]}, "request": {"method": "PUT", "url": "Observation/b1ba1ccd-e2cd-3261-7460-be0abb6508cb"}}, {"fullUrl": "urn:uuid:b4965bf2-9a65-df39-676b-acc5151db64b", "resource": {"resourceType": "Observation", "id": "b4965bf2-9a65-df39-676b-acc5151db64b", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.6.798268.2000", "value": "2061339.2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "16535", "display": "SARS-CoV-2 Nucleic Acid Method (Comment)", "system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.768282"}]}, "effectiveDateTime": "2022-03-11T19:49:19Z", "valueString": "Nares
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Request #: MD-22-0000041

Service Date: 3/31/2022 17:36

Reason for Request: Genotyping for Determination of Drug Efficacy, Dosage and Safety

Type of Specimen: DNA

Date Received: 3/31/2022 17:44

Date Reported: 3/31/2022 17:51

Interpretation:
Results from this assay may indicate dosage adjustments or medication alternatives that should be considered for this patient. Additional information regarding the implications of these results is available at www.mydruggenome.org.

For VUMC patients, clinical decision support regarding the management of this patient with respect to specific drugs based upon the patient''s genotype as listed below is available in the patient''s electronic medical record under Genomic Indicators. Clinical decision support may also be provided for some drugs through order entry and medication prescribing tools utilized within the VUMC system.



Comments:

Results:

CYP2C19 - \u00a0Cancelled

CYP2C9 - \u00a0 Cancelled

CYP2D6 - \u00a0 Cancelled \u00a0

CYP3A5 - \u00a0 Cancelled

CYP4F2 - \u00a0 Cancelled

DPYD - \u00a0 \u00a0 Cancelled

NUDT15 - \u00a0 Cancelled

SLCO1B1 - \u00a0Cancelled \u00a0 \u00a0 \u00a0

TPMT - \u00a0 \u00a0 Cancelled

VKORC1 - \u00a0 Cancelled \u00a0 \u00a0
\u00a0
These results should be correlated with other laboratory and clinical findings and additional testing should be considered if clinically indicated.
\u00a0 \u00a0

Methodology:

DNA was extracted from this specimen and screened for 37 variants in 10 genes that are associated with drug absorption, distribution, metabolism, excretion or response. The reported genotypes were determined using PCR amplification and oligonucleotide primers specific for each interrogated region of the genes listed within this panel. Fluorophore labeled probes were used to identify each variant.

Variants analyzed in this assay include: CYP2C19 *2, *3, *4, *6, *8, *17; CYP2C9 *2, *3, *6, *8; CYP3A5 *3, *6, *7; CYP4F2 *3; DPYD *2A, *13, c.557A>G, c.1236G>A (HapB3), c.2846A>T; \u00a0NUDT15 *2 or *3; SLCO1B1 *5; TPMT *2, *3B, *3C, *4; VKORC1 promoter variant c.-1639G>A; and CYP2D6 copy number and variants *2, *2A, *3, *4, *6, *7, *9, *10, *17, *29 and *41. A *1 allele is considered the reference (normal) sequence and is reported if none of the variants analyzed for a particular gene is detected. This assay is specific for the variants listed above and cannot exclude the presence of other variants within these genes that may affect the pharmacologic function of the protein product encoded by these genes. In most cases, variants for a particular gene exist on separate alleles; however, for individuals in which multiple variants in the same gene are detected, this assay cannot determine if the variants are on the same allele or on different alleles. Further, due to the highly polymorphic
nature of these regions, rare variants may exist that could affect the sensitivity or specificity of this assay and lead to a false-negative or a false-positive result.


Electronically signed out by:
Barba, Elizabeth

on 03/31/2022

This assay has not been cleared or approved by the US Food and Drug Administration. The performance of this assay was tested and validated prior to use for patient testing. This test is used for clinical purposes and should not be regarded as investigational or research. This laboratory is regulated by the Clinical Laboratory Improvement Act of 1988.", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "DNA"}, {"url": "specimen collection time", "valueDateTime": "2022-03-31T22:36:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-03-31T22:44:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.478.3.7.2.798268.2061345.Narrative"}]}], "subject": {"reference": "Patient/e2822458-d9a9-4a97-84c9-58418643d14e"}, "performer": [{"display": "VUMC CERNER LAB", "reference": "Organization/e3ece69c-0968-59c9-47dd-f16db731621a"}]}, "request": {"method": "PUT", "url": "Observation/2e9477e8-412b-905c-270f-16ca12bff791"}}, {"fullUrl": "urn:uuid:ed66ccf7-584a-1142-b9a4-8fe01b6f21fb", "resource": {"resourceType": "Observation", "id": "ed66ccf7-584a-1142-b9a4-8fe01b6f21fb", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.798268", "value": "2061345"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2022-03-31T22:51:17Z", "valueCodeableConcept": {"coding": [{"code": "16", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "DNA"}, {"url": "specimen collection time", "valueDateTime": "2022-03-31T22:36:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-03-31T22:44:00Z"}]}], "subject": {"reference": "Patient/e2822458-d9a9-4a97-84c9-58418643d14e"}}, "request": {"method": "PUT", "url": "Observation/ed66ccf7-584a-1142-b9a4-8fe01b6f21fb"}}, {"fullUrl": "urn:uuid:b0f590a6-4bf5-7add-9716-2bd3ba6defb2", "resource": {"resourceType": "DiagnosticReport", "id": "b0f590a6-4bf5-7add-9716-2bd3ba6defb2", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.798268", "value": "2061347"}], "status": "final", "code": {"coding": [{"code": "118330", "display": "Cytogenomic SNP microarray", "system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.696580"}]}, "effectivePeriod": {"start": "2022-04-04T16:55:00Z", "end": "2022-04-04T16:55:00Z"}, "subject": {"reference": "Patient/e2822458-d9a9-4a97-84c9-58418643d14e"}, "performer": [{"reference": "Organization/22c6cdd0-bde1-e220-9ba4-2c2802f795ad"}], "result": [{"reference": "Observation/2a4f8fb5-f957-3c30-1353-a30aa441a12b"}, {"reference": "Observation/2e70be1d-fa6c-0256-cf67-f695f5bba1ac"}, {"reference": "Observation/97b316f7-bb96-051f-adba-72ddc4ae5825"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/b0f590a6-4bf5-7add-9716-2bd3ba6defb2"}}, {"fullUrl": "urn:uuid:2a4f8fb5-f957-3c30-1353-a30aa441a12b", "resource": {"resourceType": "Observation", "id": "2a4f8fb5-f957-3c30-1353-a30aa441a12b", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.7.798268.1000", "value": "2061347"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2022-04-18T19:57:02Z", "valueString": "MICROARRAY REPORT- Corrected

Request#: CG-22-0000006
Service date: 4/4/2022 11:55

Microarray Result:
Normal female

Microarray Interpretation:
SNP chromosomal microarray analysis (CMA) of a blood sample from this patient demonstrated no copy number changes of known clinical significance. No large regions of homozygosity (ROH) were detected. The ISCN nomenclature describing this result is: arr(X,1-22)x2.
Electronically signed out by:
Benfield, Luis A

on 04/18/2022
___________________________________________________________________

Clinical indication:
Specimen List: Blood
Date in Lab: 4/18/2022 14:46
Date Collected: 4/4/2022 11:55
___________________________________________________________________

Disclaimer:

Copy number gains less than 400 kb in size and copy number losses less than 200 kb in size will not be reported unless they represent a known or suspected clinically relevant imbalance. The reporting of copy number variants less than 100 kb in size is at the discretion of the laboratory and some clinically relevant copy number changes under 50 kb may not be reported due to limitations in probe coverage in certain genomic regions. Copy number changes of any size with no apparent clinical significance (likely benign or benign) have not been discussed in this report but may be available upon request. Regions of homozygosity (ROH) less than 10 Mb in size will not be reported unless the ROH is clinically relevant for potential uniparental disomy. Genome-wide ROH under 2% will not be reported. Copy number variants less than 200 kb associated with a carrier status for autosomal recessive conditions will not be reported unless specifically indicated in the reason for referral.

This microarray was designed and manufactured by Affymetrix for the sole purpose of identifying DNA copy number gains and losses associated with chromosomal imbalances and regions of homozygosity (ROH) associated with uniparental isodisomy (isoUPD).This microarray will detect aneuploidy, deletions and duplications of loci represented on the microarray. \u00a0It will not detect balanced alterations including: reciprocal translocations, inversions and balanced insertions. It will not detect point mutations and imbalances less than 10 kb. \u00a0Failure to detect an alteration at any locus does not exclude the diagnosis of any of the disorders represented on the microarray. This assay is not designed to detect mosaic gains and losses and its performance in detecting mosaicism has not been established. This test was developed and its performance characteristics determined by Affymetrix as required by CLIA \u00c2\u201988 regulations. This test is used for clinical purposes and the accuracy and precision has
been established and verified by this laboratory. This test has not been cleared or approved by the U.S. Food and Drug Administration.

Interpretation of copy number variants is performed using VUMC-laboratory maintained databases as well as the following resources:
Database of Genomic Variants (http://dgv.tcag.ca/dgv/app/home)
Online Mendelian Inheritance in Man (http://www.omim.org/)
UCSC Genome Bioinformatics (http://genome.ucsc.edu/cgi-bin/hgGateway)
ClinGen Clinical Genome Resource (http://www.ncbi.nlm.nih.gov/projects/dbvar/clingen)
DECIPHER Database (https://decipher.sanger.ac.uk/browser)
PubMed-NCBI (http://www.ncbi.nlm.nih.gov/pubmed)
Technical standards for the interpretation and reporting of constitutional copy-number variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics (ACMG) and the Clinical Genome Resource (ClinGen). PMID: 31690835

Method:
Microarray platform: ThermoFisher Scientific CytoScanTM HD Cytogenetics Solution
Version: 1.1 (Based on UCSC hg19 assembly)
Number of loci analyzed: 2,696,550
Mean probe spacing: <700 bp






Testing performed at Vanderbilt Cytogenetics One Hundred Oaks Laboratory, Suite 21100, 719 Thompson Ln,
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Problem or DiagnosisProblem Status
UnknownActive
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Encounter ReasonDate of Encounter
Emergency20220426031700+0000
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Lab Test NameLab Test Result ValueLab Test Result Date
Estimated Creatinine Clearance98.48|http://unitsofmeasure.org|mL/min
Troponin TNIH7.9|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
Calc Osmo266|http://unitsofmeasure.org|mOsmol/L
ABO+Rh IO POS
A/G Ratio1.1|http://unitsofmeasure.org|Ratio
eGFR Non-African American119.74 mL/min/1.73m2
eGFR African American138.78 mL/min/1.73m2
Sodium135|http://unitsofmeasure.org|mmol/L
Potassium3.7|http://unitsofmeasure.org|mmol/L
HCG QT29556|http://unitsofmeasure.org|milli intl units/mL
Baso # Auto0.05|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level4.2|http://unitsofmeasure.org|gm/dL
Mono # Auto0.8|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto8.2|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.5|http://unitsofmeasure.org|%
Eos % Auto0.8|http://unitsofmeasure.org|%
Lymph % Auto5.4|http://unitsofmeasure.org|%
Neut % Auto84.0|http://unitsofmeasure.org|%
Calcium9.0|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.07|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto0.5|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.6|http://unitsofmeasure.org|%
RDW-CV12.3|http://unitsofmeasure.org|%
Immature Grans %0.7|http://unitsofmeasure.org|%
Eos # Auto0.1|http://unitsofmeasure.org|x10e3/mcL
Chloride104|http://unitsofmeasure.org|mmol/L
BUN3|http://unitsofmeasure.org|mg/dL
Plt326|http://unitsofmeasure.org|x10e3/mcL
WBC9.7|http://unitsofmeasure.org|x10e3/mcL
TP8.0|http://unitsofmeasure.org|gm/dL
RBC4.70|http://unitsofmeasure.org|x10e6/mcL
MPV8.6|http://unitsofmeasure.org|Femtoliters
MCV91.7|http://unitsofmeasure.org|Femtoliters
MCHC35.0|http://unitsofmeasure.org|gm/dL
MCH32.1|http://unitsofmeasure.org|pg
Lipase Lvl94|http://unitsofmeasure.org|Intl_units/L
Hgb15.1|http://unitsofmeasure.org|gm/dL
Hct43.1|http://unitsofmeasure.org|%
Glucose Level95|http://unitsofmeasure.org|mg/dL
CO2TNP mmol/L
T Bili0.6|http://unitsofmeasure.org|mg/dL
AST10|http://unitsofmeasure.org|Intl_units/L
ALT21|http://unitsofmeasure.org|Intl_units/L
Alk Phos78|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio5.0|http://unitsofmeasure.org|Ratio
Creatinine0.6|http://unitsofmeasure.org|mg/dL
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Medication NameMedication Start Date
acetaminophen (Tylenol)20220426042600+0000
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Social History ObservationSocial History Observation Result
Birth SexF
Pregnancy ConditionPatient currently pregnant (finding)
Travel HistoryCOVID-19 Previously tested-Yes, positive result
Travel HistoryTB Risk Score-
Travel HistoryRisk Factors of TB-No risk factors identified
Travel HistorySymptoms of TB-
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryLast Menstrual Period-
Travel HistoryPregnancy Status-Confirmed positive
"}, "code": {"coding": [{"code": "29762-2", "display": "Social History", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/2b17f55d-bf9e-6fde-ce5f-deb519ec5eb7"}, {"reference": "Observation/b0c46db8-026e-942d-0aee-429acda37236"}, {"reference": "Observation/1d6ce605-8e6a-32b8-6039-b01dff4d41b7"}, {"reference": "Observation/37cd93a4-feea-78ec-e8ce-e32636284983"}, {"reference": "Observation/3f2df707-125d-bd5d-ae9a-000889695c8e"}, {"reference": "Observation/ce542281-8050-4d9a-58d6-752fed1816cc"}, {"reference": "Observation/219df162-1713-3cf7-a3bb-2e7a14365289"}, {"reference": "Observation/fd52fbad-6919-3aa7-f090-45e94ce90709"}, {"reference": "Observation/9c734782-f965-009c-5ba8-729f49eb1697"}, {"reference": "Observation/a336b749-aec3-d407-2cd1-f06d83bcc7ad"}]}, {"id": "7dbd51e8-1c15-8cfa-cbce-f6f4b9a1ed5d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "No Plan Of Treatment Information"}, "code": {"coding": [{"code": "18776-5", "display": "Treatment Plan", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/ec77d178-de8a-915a-311a-1f11f2838946"}]}, {"id": "07a28c1e-8321-7fa4-e654-66ae50374bc4", "title": "History of Present Illness", "text": {"status": "generated", "div": "
Narrative Text
COVID-19
Cough
Abdominal pain
Subchorionic hemorrhage
Encounter for medical screening examination
"}, "code": {"coding": [{"code": "10164-2", "display": "History of Present Illness", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "bc9bdaa4-198d-21a8-0f57-2071633fe649", "title": "Reason For Visit", "text": {"status": "generated", "div": "
text
COVID POS CP 5 WKS PREG
"}, "code": {"coding": [{"code": "29299-5", "display": "Reason For Visit", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "COVID POS CP 5 WKS PREG"}]}, {"id": "de7515e8-2c1a-1585-b19d-a8bee87913a0", "title": "Reportability Response Information Section", "text": {"status": "generated", "div": "
Reportability Response Information Section
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MemberRoleStatusDates
Adam Sheradmitting physicianActive
Start: March 12th, 2022
MCUTLERattending physicianActive
Start: March 12th, 2022
DR MEDITECHprimary care physicianActive
Start: March 12th, 2022
AMANDA NOELREFERRINGActive
Start: March 12th, 2022
AMANDA PARLATOFAMILYActive
Start: March 12th, 2022
Rickey RobertsOTHERActive
Start: March 12th, 2022
Stephen NewtonCONSULTINGActive
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Gender Identityunknown
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Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
anthraxMarch 15th, 2022 7:20am1PFIZER & OTHER CHARACTERSLOT9911Z
RIGRAPID HEART BEAT
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Height65 [in_i]March 14th, 2022 1:48pm
Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
Weight68.039 kgMarch 14th, 2022 1:48pm
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Admitted InpatientDot Facility (No ARM)March 12th, 2022 7:45pmMCUTLER
Recent DiagnosisOnset Date
Anthrax

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Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 24th, 2022 9:38am
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This panel is not to be used for legal drug cases. The presence of other compounds in the patient''s specimen may cause a false positive. Correlate the results with clinical evaluation and other diagnostic testing procedures.

.....DRUG...... \u00a0 \u00a0 \u00a0 \u00a0 THRESHOLD DETECTION LIMIT
AMPH/METHAMPHET \u00a0 \u00a0 \u00a0 \u00a0 >1000 ng/mL
BARBITUATES \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 200 ng/mL
BENZODIAZEPINES \u00a0 \u00a0 \u00a0 \u00a0 > 200 ng/mL
COCAINE \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 300 ng/mL
OPIATES \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 300 ng/mL
PCP \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a025 ng/mL
THC \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a050 ng/mL
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"section": [{"id": "b7a7ed08-af88-4a31-cc4e-8dddd58b7fc8", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "19964E02-5A39-11ED-87E1-C301D81100B2", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "199CE1A4-5A39-11ED-87E1-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "576c9b22-b1f8-fc85-539e-f688ca7add3f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Stool Pathogens, NAAT, 12 to 25 TargetsMicrobiologyRoutine11/01/2022 3:23 PM PDT
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ProblemNoted Date
Bipolar I disorder11/19/20
Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
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ProblemNoted Date
Malignant neoplasm of lower-inner quadrant of left breast in female, estrogen receptor positive12/14/22
Headache8/19/22
Backache8/19/22
Malignant neoplasm of urinary bladder neck11/5/21
Malignant neoplasm of overlapping sites of pancreas9/18/17
Cancer Staging:Stage IIB Stage III
(pT1, pN2, cM0) - Signed by Ocmd Phsbeacon, MD on 9/30/2022Pathologic: (cT1, cN1, cM0) - Signed by Ocmd Phsbeacon, MD on 1/13/2022Clinical stage from 1/13/2022:
Bilateral malignant neoplasm of lower outer quadrant of breast in female2/27/17
Cancer Staging:Stage IIA Stage IV
(rpT2, pN1a(f), pM1, G3, ER: Negative, PR: Negative, HER2: Negative) - Signed by Ocmd Phsbeacon, MD on 1/10/2018Pathologic stage from 12/10/2017: (T1, N1, M0) - Signed by Ocmd Phsbeacon, MD on 2/27/2017Clinical stage from 2/27/2017:
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MRS. PUMSEN R SOR SRprimary care physicianActive
Start: March 17th, 2022
Sandra E Hoytadmitting physicianActive
Start: March 17th, 2022
DR. LARDIEREFAMILYActive
Start: March 17th, 2022
Brian Leary , MDREFERRINGActive
Start: March 17th, 2022
DR. DAVID CONNOROTHERActive
Start: March 17th, 2022
MCUTLERCONSULTINGActive
Start: March 17th, 2022
Samuel HoytNext of KinActive
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Not pregnantMarch 17th, 2022
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Recent DiagnosisOnset Date
COVID-19March 14th, 2022

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Author
CANTON MEDICAL CENTER OF MASSACHUSETTS-North Canton FacilitSandra Hoyt
AuthoredMarch 22nd, 2022 11:23am
Follow-up with PSOR referral and PCP.
Test NameOrdered DateScheduled Date
WHITE BLOOD COUNT
HEMOGLOBIN
HEMATOCRIT
MEAN CELL VOLUME
MEAN CORPUSCULAR HEMOGLOBIN
PLATELET COUNT
COVID19 OTHER VENDOR 94500-6March 18th, 2022 2:48pmMarch 18th, 2022
COVID-19 OV 94500-6March 17th, 2022 5:06pmMarch 31st, 2022
HIV Test: LOINC 10351-5March 22nd, 2022 11:26amMarch 28th, 2022
Reason for ReferralReferral Start DateProviderProvider Contact InformationProvider Address
Cardiac abnormalityPUMSEN''S PROVIDER GROUPWork Phone: +1(508)789-7891
BROCKTON MA 02301SUITE 1010110 MAIN ST
Medication NameStart DateInstructions
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Benazepril HCl (Benazepril) 40 MG TABLETMarch 22nd, 2022 8:32am
Cyclobenzaprine (CYCL10T) 10 MG TABMarch 21st, 2022 4:19pm
Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 21st, 2022 3:59pm
Rifampin - RXCUI C198201 (RIFAMPIN150 MG) 150 MG CAPMarch 17th, 2022 3:48pm
Severe Acute Respiratory Syndrome (SARS)

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(ecr_id, data) VALUES ('5ff34904-1cdd-45a9-bdae-69023b840c22', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:5ff34904-1cdd-45a9-bdae-69023b840c22", "resource": {"resourceType": "Composition", "id": "5ff34904-1cdd-45a9-bdae-69023b840c22", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "34682681|64851396"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "1"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-04-13T12:23:12Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "86eb9053-07e9-9b48-4906-a8b07a056d18", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Neoplasm of pituitary gland (disorder)Active
Strain of neckActive
HTN (hypertension)Active
Chronic male pelvic painActive
Motor vehicle crash, injuryActive
Closed injury of head (disorder)Active
Cerebrovascular accident (disorder)Active
Disease caused by 2019-nCoVActive
Low back strainActive
Cervicogenic headacheActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Neoplasm of pituitary gland (disorder)", "reference": "Condition/063ada0c-960f-8557-e828-76ea3ed99aba"}, {"display": "Problem - Strain of neck muscle (disorder)", "reference": "Condition/2c4295cc-bde8-63b2-7f48-081683140235"}, {"display": "Problem - Hypertensive disorder, systemic arterial (disorder)", "reference": "Condition/07559a5f-52d6-186f-25fd-123dd7950656"}, {"display": "Problem - Chronic pain in male pelvis (finding)", "reference": "Condition/65565a5f-5d97-9656-fc4f-c3fac1b55e3d"}, {"display": "Problem - Motor vehicle injury (disorder)", "reference": "Condition/8fabb65c-a7bc-d78a-ee66-87bc0f6f8f23"}, {"display": "Problem - Closed injury of head (disorder)", "reference": "Condition/47c4eafe-d230-03e3-a449-f3d4e8a570bb"}, {"display": "Problem - Cerebrovascular accident (disorder)", "reference": "Condition/2b0e32d9-1c75-b38e-c628-165e8fb18782"}, {"display": "Problem - Disease caused by 2019-nCoV", "reference": "Condition/7bcd701e-5d28-f178-a33f-64aa74239d54"}, {"reference": "Condition/bc63883a-ebd9-370f-0d9f-ad35c8fe7f52"}, {"display": "Problem - Low back strain (disorder)", "reference": "Condition/eef12569-0e57-b962-463d-8c74f3f211eb"}, {"display": "Problem - Cervicogenic headache (finding)", "reference": "Condition/6e0fec6b-8384-ad29-0f00-a6c9e11d0a29"}]}, {"id": "aeeada66-8e79-8d88-540c-1c05ea027505", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
observation encounter20220413083600+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "4e998068-85bd-8c62-8e2c-fd91a9254c46", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
Estimated Creatinine Clearance104.42|http://unitsofmeasure.org|mL/min
eGFR PediatricNot Reported
Calc Osmo277|http://unitsofmeasure.org|mOsmol/kg
A/G RatioUnknown
eGFR Non-African American88|http://unitsofmeasure.org|mL/min/1.73m2
eGFR African American102|http://unitsofmeasure.org|mL/min/1.73m2
NRBC #0.02|http://unitsofmeasure.org|x10e3/mcL
Sodium137|http://unitsofmeasure.org|mmol/L
Potassium4.1|http://unitsofmeasure.org|mmol/L
Baso # Auto0.05|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.6|http://unitsofmeasure.org|gm/dL
Mono # Auto1.15|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto7.67|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.4|http://unitsofmeasure.org|%
Eos % Auto0.8|http://unitsofmeasure.org|%
Lymph % Auto34.1|http://unitsofmeasure.org|%
Neut % Auto56.1|http://unitsofmeasure.org|%
Calcium9.6|http://unitsofmeasure.org|mg/dL
RDW-SD45.6|http://unitsofmeasure.org|Femtoliters
Immature Grans # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto4.67|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.4|http://unitsofmeasure.org|%
RDW-CV17.5|http://unitsofmeasure.org|%
Immature Grans %0.2|http://unitsofmeasure.org|%
Eos # Auto0.11|http://unitsofmeasure.org|x10e3/mcL
Chloride105|http://unitsofmeasure.org|mmol/L
BUN23|http://unitsofmeasure.org|mg/dL
Plt315|http://unitsofmeasure.org|x10e3/mcL
WBC13.68|http://unitsofmeasure.org|x10e3/mcL
TP7.5|http://unitsofmeasure.org|gm/dL
RBC5.41|http://unitsofmeasure.org|x10e6/mcL
PTT30|http://unitsofmeasure.org|Seconds
PT10.8|http://unitsofmeasure.org|Seconds
MPV8.3|http://unitsofmeasure.org|Femtoliters
MCV72.3|http://unitsofmeasure.org|Femtoliters
MCHC30.4|http://unitsofmeasure.org|gm/dL
MCH22.0|http://unitsofmeasure.org|pg
Hgb11.9|http://unitsofmeasure.org|gm/dL
Hct39.1|http://unitsofmeasure.org|%
Glucose Level95|http://unitsofmeasure.org|mg/dL
CO229|http://unitsofmeasure.org|mmol/L
T Bili0.2|http://unitsofmeasure.org|mg/dL
AST20|http://unitsofmeasure.org|units/L
ALT26|http://unitsofmeasure.org|units/L
Alk Phos74|http://unitsofmeasure.org|units/L
NRBC %0.1|http://unitsofmeasure.org|/100 WBC
BUN/Creat RatioUnknown
INRUnknown
Anion Gap3|http://unitsofmeasure.org|mmol/L
Creatinine1.010|http://unitsofmeasure.org|mg/dL
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Medication NameMedication Start Date
famotidine (Pepcid)20220413170000+0000
heparin20220413130000+0000
meclizine20220413113800+0000
Sodium Chloride 0.9% intravenous solution 1,000 mL20220413110600+0000
acetaminophen (Tylenol)20220413110600+0000
ondansetron (Zofran)20220413110600+0000
morphine20220413113700+0000
morphine20220413105900+0000
prochlorperazine (Compazine)20220413120000+0000
diphenhydrAMINE (Benadryl)20220413105900+0000
ketorolac (Toradol)20220413105900+0000
"}, "code": {"coding": [{"code": "29549-3", "display": "Medications Administered", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/063f42b9-ec2a-c337-abc2-79465353a684"}, {"reference": "MedicationAdministration/1202713c-e31b-375a-feb0-c1825ef426ad"}, {"reference": "MedicationAdministration/6c3e2499-c536-d1dd-714a-7df34ebae992"}, {"reference": "MedicationAdministration/1c38d993-ef4b-0843-c004-f034c053743b"}, {"reference": "MedicationAdministration/6bd89508-7ee5-920b-0378-58b2b5688fca"}, {"reference": "MedicationAdministration/45bea8f0-6879-f811-f156-c7492e0f5963"}, {"reference": "MedicationAdministration/b1f87437-e50e-bdc1-cf1e-917e57e88521"}, {"reference": "MedicationAdministration/7ef50974-3a01-14c4-c8bd-fcd0a6984abb"}, {"reference": "MedicationAdministration/25c13c20-f35f-b9a6-772c-0f25ae50e215"}, {"reference": "MedicationAdministration/43150611-0371-84f8-e6c3-b5a906dbf9e3"}, {"reference": "MedicationAdministration/9297be23-425e-ccd9-46f8-045150362589"}]}, {"id": "dd08df91-869b-46df-dd36-c5c0f2ad2eae", "title": "IMMUNIZATIONS", "text": {"status": "generated", "div": "No ImmunizationInformation"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "3f42c9a8-e7bc-8936-142e-d6ae7f1deaa7", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Birth SexM
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryPregnancy Status-Not applicable (qualifier value)
"}, "code": {"coding": [{"code": "29762-2", "display": "Social History", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/ac6ec079-b9e5-db04-1c67-ed69fbd14259"}, {"reference": "Observation/3b397daa-2acc-953f-9923-4ae3b5d5f2e8"}, {"reference": "Observation/66b6e1d0-8edb-f178-0e4a-1bc395effcdf"}, {"reference": "Observation/5d2ded7e-915e-9dd9-1d0f-a882b114182b"}, {"reference": "Observation/1dd0d0fe-398f-dfe4-fd99-e3948de0e56e"}, {"reference": "Observation/d3091bc7-a3dd-dd22-3a40-75780c26ce74"}, {"reference": "Observation/2c089c54-a4a1-520a-92e1-68e173b94780"}, {"reference": "Observation/100fae56-4b59-87dc-0297-0a543f57a011"}]}, {"id": "7dbd51e8-1c15-8cfa-cbce-f6f4b9a1ed5d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "No Plan Of Treatment Information"}, "code": {"coding": [{"code": "18776-5", "display": "Treatment Plan", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/ec77d178-de8a-915a-311a-1f11f2838946"}]}, {"id": "3bf22954-7e60-35a6-45d5-322ce2bae993", "title": "History of Present Illness", "text": {"status": "generated", "div": "
Narrative Text
Headache
Brain tumor
Headache
"}, "code": {"coding": [{"code": "10164-2", "display": "History of Present Illness", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "9f06fac1-cf69-4b39-ac51-fcf1e80aedf2", "title": "Reason For Visit", "text": {"status": "generated", "div": "
text
HEADACHE BRAIN TUMOR
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Problem or DiagnosisProblem Status
Closed injury of head (disorder)Active
COVID-19Active
Hypertensive disorder, systemic arterial (disorder)Active
Neoplasm of pituitary gland (disorder)Active
Cerebrovascular accident (disorder)Active
Low back strainActive
Motor vehicle crash, injuryActive
Chronic male pelvic painActive
Strain of neckActive
Cervicogenic headacheActive
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Encounter ReasonDate of Encounter
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Lab Test NameLab Test Result ValueLab Test Result Date
Chol/HDL RiskUnknown
Phosphorus4.1|http://unitsofmeasure.org|mg/dL
VLDL Chol Calc34.00|http://unitsofmeasure.org|mg/dL
LDL Direct81|http://unitsofmeasure.org|mg/dL
Trig168|http://unitsofmeasure.org|mg/dL
PTT31|http://unitsofmeasure.org|Seconds
PT10.6|http://unitsofmeasure.org|Seconds
Mg Lvl1.9|http://unitsofmeasure.org|mg/dL
HDL36|http://unitsofmeasure.org|mg/dL
Cholesterol129|http://unitsofmeasure.org|mg/dL
INRUnknown
Estimated Creatinine Clearance104.42|http://unitsofmeasure.org|mL/min
eGFR PediatricNot Reported
Calc Osmo277|http://unitsofmeasure.org|mOsmol/kg
A/G RatioUnknown
eGFR Non-African American88|http://unitsofmeasure.org|mL/min/1.73m2
eGFR African American102|http://unitsofmeasure.org|mL/min/1.73m2
NRBC #0.02|http://unitsofmeasure.org|x10e3/mcL
Sodium137|http://unitsofmeasure.org|mmol/L
Potassium4.1|http://unitsofmeasure.org|mmol/L
Baso # Auto0.05|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.6|http://unitsofmeasure.org|gm/dL
Mono # Auto1.15|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto7.67|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.4|http://unitsofmeasure.org|%
Eos % Auto0.8|http://unitsofmeasure.org|%
Lymph % Auto34.1|http://unitsofmeasure.org|%
Neut % Auto56.1|http://unitsofmeasure.org|%
Calcium9.6|http://unitsofmeasure.org|mg/dL
RDW-SD45.6|http://unitsofmeasure.org|Femtoliters
Immature Grans # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto4.67|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.4|http://unitsofmeasure.org|%
RDW-CV17.5|http://unitsofmeasure.org|%
Immature Grans %0.2|http://unitsofmeasure.org|%
Eos # Auto0.11|http://unitsofmeasure.org|x10e3/mcL
Chloride105|http://unitsofmeasure.org|mmol/L
BUN23|http://unitsofmeasure.org|mg/dL
Plt315|http://unitsofmeasure.org|x10e3/mcL
WBC13.68|http://unitsofmeasure.org|x10e3/mcL
TP7.5|http://unitsofmeasure.org|gm/dL
RBC5.41|http://unitsofmeasure.org|x10e6/mcL
PTT30|http://unitsofmeasure.org|Seconds
PT10.8|http://unitsofmeasure.org|Seconds
MPV8.3|http://unitsofmeasure.org|Femtoliters
MCV72.3|http://unitsofmeasure.org|Femtoliters
MCHC30.4|http://unitsofmeasure.org|gm/dL
MCH22.0|http://unitsofmeasure.org|pg
Hgb11.9|http://unitsofmeasure.org|gm/dL
Hct39.1|http://unitsofmeasure.org|%
Glucose Level95|http://unitsofmeasure.org|mg/dL
CO229|http://unitsofmeasure.org|mmol/L
T Bili0.2|http://unitsofmeasure.org|mg/dL
AST20|http://unitsofmeasure.org|units/L
ALT26|http://unitsofmeasure.org|units/L
Alk Phos74|http://unitsofmeasure.org|units/L
NRBC %0.1|http://unitsofmeasure.org|/100 WBC
BUN/Creat RatioUnknown
INRUnknown
Anion Gap3|http://unitsofmeasure.org|mmol/L
Creatinine1.010|http://unitsofmeasure.org|mg/dL
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acetaminophen (Tylenol)20220413132200+0000
hydrocodone-acetaminophen (Norco 5 mg-325 mg oral tablet)20220413132200+0000
ipratropium-albuterol (DuoNeb)20220413132200+0000
hydrALAZINE20220413132200+0000
labetalol20220413132200+0000
levETIRAcetam (Keppra)Unknown
meclizine20220413113800+0000
melatonin (melatonin 3 mg oral tablet)20220413132200+0000
morphine20220413132200+0000
ondansetron (Zofran)20220413132200+0000
simethicone (Mylicon)20220413132200+0000
heparin20220413170000+0000
famotidine (Pepcid)Unknown
Sodium Chloride 0.9% intravenous solution 1,000 mL20220413110600+0000
acetaminophen (Tylenol)20220413110600+0000
heparin20220413130000+0000
morphine20220413113700+0000
ondansetron (Zofran)20220413110600+0000
morphine20220413105900+0000
prochlorperazine (Compazine)20220413120000+0000
diphenhydrAMINE (Benadryl)20220413105900+0000
ketorolac (Toradol)20220413105900+0000
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Social History ObservationSocial History Observation Result
Birth SexM
Travel HistoryPregnancy Status-Not applicable (qualifier value)
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryPregnancy Status-Not applicable (qualifier value)
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Narrative Text
Headache
Brain tumor
Headache
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text
HEADACHE BRAIN TUMOR
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Reportability Response Information Section
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https://www.testmenu.com/Intermountain/Tests/1035258 See Syphilis Interpretative Guide in Laboratory Test DirectoryResult Comment: (NOTE)2 Result Comment: Nontreponemal antibodies detected. Treponema-specific testing to follow.
NameDate
RPR Titer (RPR TITER)8/16/22
Syphilis RPR: Only for Pregnant, Pediatric or Post-Treatment patients (SYPHILIS (RPR) PEDIATRIC, PREGNANCY OR POST TREATMENT)8/16/22
Treponema pallidum Ab by TP-PA (ARUP) (T.PALLIDUM AB BY TPPA)8/16/22
Most recent to oldest [Reference Range]:1
RPR Titer
(8/16/22 9:00 AM) 1:32
Syphilis Interpretation1
(8/16/22 9:00 AM) See Comments
RPR [Nonreactive]2
(8/16/22 9:00 AM) *ABN*Reactive
T.pallidum Ab by TP-PA (ARUP)
(8/16/22 9:00 AM) Reactive
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"request": {"method": "PUT", "url": "Patient/6cc7e9c7-2ae0-4733-9605-e34328f3eaf6"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "CareTeam", "subject": {"reference": "Patient/6cc7e9c7-2ae0-4733-9605-e34328f3eaf6"}, "meta": {"source": "ecr"}}}, {"fullUrl": "urn:uuid:8c67b78f-aea8-f718-c388-a54a10c9fdee", "resource": {"resourceType": "CarePlan", "id": "8c67b78f-aea8-f718-c388-a54a10c9fdee", "status": "unknown", "intent": "proposal", "subject": {"reference": "Patient/6cc7e9c7-2ae0-4733-9605-e34328f3eaf6"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "CarePlan/8c67b78f-aea8-f718-c388-a54a10c9fdee"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}, {"fullUrl": "urn:uuid:2710dc8e-b004-fc60-8db2-5a6160eee50b", "resource": {"resourceType": "Immunization", "id": "2710dc8e-b004-fc60-8db2-5a6160eee50b", "identifier": [{"system": "urn:ietf:rfc:3986", "value": "urn:uuid:B1D1DA7E-B6D0-4648-884D-20B0A7A0E0C9"}], "note": {"text": "No data available for this section"}, "vaccineCode": {"coding": [{"display": "No data available for this section"}]}, "lotNumber": "NI", "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/2710dc8e-b004-fc60-8db2-5a6160eee50b"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.297.3.7.8.688883.550864', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.297.3.7.8.688883.550864", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.297.3.7.8.688883.550864", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "d6e533de-5a38-11ed-815f-c301d81100b2", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "43"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-11-01T16:01:06-07:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "b7a7ed08-af88-4a31-cc4e-8dddd58b7fc8", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "11124330-5A39-11ED-815F-C301D81100B2", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "11194946-5A39-11ED-815F-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "576c9b22-b1f8-fc85-539e-f688ca7add3f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Stool Pathogens, NAAT, 12 to 25 TargetsMicrobiologyRoutine11/01/2022 3:23 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/f79f7fbc-cf8a-55d2-34b4-108ebff26173"}]}, {"id": "1136072A-5A39-11ED-815F-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "
ProblemNoted Date
Bipolar I disorder11/19/20
Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
documented as of this encounter (statuses as of 11/01/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Sprain of calcaneofibular ligament of right ankle", "reference": "Condition/a46e803b-6d39-52e0-e8aa-4b7d9d10eacd"}, {"display": "Problem - Knee pain", "reference": "Condition/8baa9408-41a9-2931-3ec6-1a7e3daa7ee5"}, {"display": "Problem - Anxiety", "reference": "Condition/16da93aa-9058-ba7e-c13c-2e108c70f650"}, {"display": "Problem - Asthma", "reference": "Condition/c588ca4a-e665-08c7-f082-c15e8933eb19"}, {"display": "Problem - Rheumatoid arthritis with negative rheumatoid factor", "reference": "Condition/9c9eefa7-eaf3-b0a6-94a8-8fd343eac989"}, {"display": "Problem - Arthralgia of both ankles", "reference": "Condition/99cf508c-8c63-e17f-8413-46d61302f241"}, {"display": "Problem - Bipolar I disorder", "reference": "Condition/e7d7079d-d22b-cca2-38d4-d92694600eb8"}, {"display": "Problem - Reactive depression", "reference": "Condition/d5278cd7-cdda-a05b-5615-66814cac6b3d"}]}, {"id": "c658eaed-3f9a-f347-8624-e56d8d73996c", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "116A34B4-5A39-11ED-815F-C301D81100B2", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Campylobacter, NAAT", "reference": "Observation/4079de8f-4a5f-1074-83d4-b5a529fd4027"}, {"display": "C. 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Problem or DiagnosisProblem Status
Ineffective airway clearance (finding)Active
Chest pain (finding)Resolved
Pneumonia, unspecified organismResolved
HypertensionActive
Sleep apnea (finding)Active
Sleep apnea (finding)Active
Sleep apnea (finding)Active
At risk for injury due to fall (finding)Active
Bowel dysfunction (disorder)Active
Pneumonia due to COVID-19 virusResolved
At risk for falls (finding)Active
Vancomycin Resistant Enterococcus (organism)Resolved
Alcoholism /alcohol abuseActive
History of placement of stent for coronary artery disease (situation)Active
Chronic obstructive lung disease (disorder)Active
Other chest painResolved
Seizure disorderActive
Acute chest painResolved
Methicillin resistant Staphylococcus aureus (organism)Active
Methicillin resistant Staphylococcus aureus (organism)Resolved
Abdominal pain in maleResolved
DM (diabetes mellitus)Active
2019-nCoVResolved
Oxygen dependentActive
2019-nCoV acute respiratory diseaseActive
Acute pain (finding)Active
Myocardial infarction (disorder)Active
Anxiety (finding)Active
HomelessActive
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BUN/Creat RatioUnknown
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NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "1D6BC7D2-5A39-11ED-87E1-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "576c9b22-b1f8-fc85-539e-f688ca7add3f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Stool Pathogens, NAAT, 12 to 25 TargetsMicrobiologyRoutine11/01/2022 3:23 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/f79f7fbc-cf8a-55d2-34b4-108ebff26173"}]}, {"id": "1D882724-5A39-11ED-87E1-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "
ProblemNoted Date
Bipolar I disorder11/19/20
Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
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Smokes tobacco daily (finding)March 25th, 2021 4:57pm
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Hives due to cold and heat exposureActive
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Full body hivesResolved
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DTaPJanuary 31st, 2019232323232
DTaPJanuary 31st, 2019+56+65464
Hepatitis B, Recombinant- EngerixFebruary 8th, 20196
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Measles, Mumps, and Rubella Virus VaccineFebruary 8th, 2019354654
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Pneumococcal Conjugate Vaccine, 13 valentJanuary 31st, 2019
Pneumococcal Conjugate Vaccine, 13 valentJanuary 31st, 20194564654
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PentacelFebruary 8th, 201935454364
Prevnar 13February 8th, 201964654654
RotaTeqFebruary 8th, 201953465464
Varicella Virus VaccineFebruary 6th, 20196545646564
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Height67.00 [in_i]January 29th, 2019 1:14pm
Weight160.00 [lb_av]January 29th, 2019 1:14pm
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EncounterLocation(s)Arrival/Admit DateDischarge/Depart DateProvider(s)
Departed ClinicalMEDITECH General Hospital-Day Hospital - MTGHJanuary 29th, 2019 1:09pmJanuary 29th, 2019 1:10pmAnthony Brown
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Arterial Blood GlucoseJanuary 25th, 2021 9:39amMarch 14th, 2021 5:08pm
AmmoniaJanuary 25th, 2021 9:39amJanuary 25th, 2021 9:38am
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Emergency20220513072500+0000
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Ur MucousNONE /LPF
Ur Squam Epithelial1|http://unitsofmeasure.org|/HPF
Ur WBC1|http://unitsofmeasure.org|/HPF
Ur RBC2|http://unitsofmeasure.org|/HPF
Ur BacteriaNone Seen /HPF
Symptomatic as defined by CDC?No
In ICU?No
Group care resident?No
First test?UNK
Employed in healthcare?No
Date of onset?UNK
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRNegative
Flu B PCRNot Detected
Flu A PCRNot Detected
Ur pH6.0
Ur Spec Grav1.020 mg/dL
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Ur BloodTrace-lysed
Ur BiliNegative
Ur Leuk EstNegative
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Ur NitriteNegative
Ur KetonesNegative mg/dL
UR GlucoseNegative mg/dL
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ibuprofen (ibuprofen 100 mg/5 mL oral suspension)20220513094400+0000
azithromycin (azithromycin 200 mg/5 mL oral liquid)20220513094200+0000
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Birth SexM
Travel HistoryCOVID- 19 Testing Reason-Screening
Travel HistoryPregnancy Status-Not applicable (qualifier value)
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Narrative Text
Fever
Cough
Encounter for medical screening examination
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FEVER
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Reportability Response Information Section
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DateTypeSpecialtyCare TeamDescription
7/21/22Office VisitInternal MedicineHoq, Lalima A, MD8501 WILSHIRE BLVD SUITE 100BEVERLY HILLS, CA 90211310-385-3307 (Work)310-385-3397 (Fax)COVID-19 (Primary Dx)
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Depression, recurrent7/21/22
PregnantComments
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Smoking Tobacco: Every DayCigarettes0.30.5
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Yes0 (1 standard drink = 0.6 oz pure alcohol)
Sex Assigned at BirthDate Recorded
Female07/21/2022 4:09 PM PDT
Job Start DateOccupationIndustry
1/1/10Not on fileNot on file
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NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
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"urn:uuid:b5c77b86-2764-79f9-10bf-5da5e63eb7c1", "resource": {"resourceType": "Organization", "id": "b5c77b86-2764-79f9-10bf-5da5e63eb7c1", "name": "Sanofi Pasteur", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}}, {"fullUrl": "urn:uuid:cffb2ab8-483c-a93e-56c3-5cc3d11e9168", "resource": {"resourceType": "Immunization", "id": "cffb2ab8-483c-a93e-56c3-5cc3d11e9168", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "57644"}], "occurrenceDateTime": "2011-11-11", "note": {"text": "HEP A (ADULT) 2 DOSE"}, "vaccineCode": {"coding": [{"display": "HEP A (ADULT) 2 DOSE"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/cffb2ab8-483c-a93e-56c3-5cc3d11e9168"}}, {"fullUrl": "urn:uuid:35c0d7fc-0bc0-5a24-e65e-dc30321d7e2e", "resource": {"resourceType": "Immunization", "id": "35c0d7fc-0bc0-5a24-e65e-dc30321d7e2e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "58353"}], "occurrenceDateTime": "2020-11-16", "note": {"text": "MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)"}, "vaccineCode": {"coding": [{"code": "50090-1890-1", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "1", "manufacturer": {"reference": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/e7e7e025-45de-4fd4-861b-8c74ff14f456"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/35c0d7fc-0bc0-5a24-e65e-dc30321d7e2e"}}, {"fullUrl": "urn:uuid:50fc36a0-b859-c4a4-de8f-53c149080081", "resource": {"resourceType": "Immunization", "id": "50fc36a0-b859-c4a4-de8f-53c149080081", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "58354"}], "occurrenceDateTime": "1974-03-21", "note": {"text": "HEP B (PED,ADOLESCENT) 3 DOSE"}, "vaccineCode": {"coding": [{"display": "HEP B (PED,ADOLESCENT) 3 DOSE"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/50fc36a0-b859-c4a4-de8f-53c149080081"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.478.3.7.8.688883.252732', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.478.3.7.8.688883.252732", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.478.3.7.8.688883.252732", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "5e539dbe-8abe-11ed-847f-0050561597b4", "assigner": {"display": "EPC"}}], "extension": [{"url": 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NameAdministration DatesNext Due
DTaP, 5 pertussis antigens vaccine (DAPTACEL)06/15/2021
Hep B, adult vaccine (Engerix/Recombivax)09/08/2020
SARS-COV-2 (COVID-19) RED CAP +BLUE LABEL VACCINE, MODERNA 12+YO01/22/2021
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
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Active ProblemsNoted Date
COVID toes7/13/22
Chest pain on breathing5/26/22
Type 1 diabetes2/28/22
Overview:Formatting of this note might be different from the original.
08/30/21 28.69 kg/m\u00b2BMI Readings from Last 1 Encounters:
Plague pneumonia6/16/21
Absence of menstruation6/12/18
Foot callus8/11/17
Overview:Formatting of this note might be different from the original.
Ouch.
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
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DateTypeDepartmentCare TeamDescription
10/27/21Orders OnlyVanderbilt University Adult Hospital1211 Medical Center Dr6 Critical Care TowerNashville, TN 37232615-322-5000Inpatient, Nurse, RN
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Reportability Response Information Section
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Formatting of this note might be different from the original.

Ouch."}], "subject": {"reference": "Patient/1c4c24d7-269b-4219-a2d1-474a9bacd425"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/74e3244b-afcc-1fd0-4cbb-864d85303dbc"}}, {"fullUrl": "urn:uuid:85d00c53-2448-939b-80ea-c251042ef350", "resource": {"resourceType": "Condition", "id": "85d00c53-2448-939b-80ea-c251042ef350", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.768076", "value": "66245"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N91.2", "display": "Absence of menstruation", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2018-06-12", "subject": {"reference": "Patient/1c4c24d7-269b-4219-a2d1-474a9bacd425"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/85d00c53-2448-939b-80ea-c251042ef350"}}, {"fullUrl": "urn:uuid:c6bc07dc-6be8-ff50-ac51-e096139f444d", "resource": {"resourceType": "Condition", "id": "c6bc07dc-6be8-ff50-ac51-e096139f444d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.768076", "value": "90498"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "A20.2", "display": "Plague pneumonia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-06-16", "subject": {"reference": "Patient/1c4c24d7-269b-4219-a2d1-474a9bacd425"}, "meta": {"source": "ecr"}, "extension": [{"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "58750007", "system": "http://snomed.info/sct"}]}]}, "request": {"method": "PUT", "url": "Condition/c6bc07dc-6be8-ff50-ac51-e096139f444d"}}, {"fullUrl": "urn:uuid:e47bddd9-8edd-ab04-1bc8-188ae3662beb", "resource": {"resourceType": "Condition", "id": "e47bddd9-8edd-ab04-1bc8-188ae3662beb", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.768076", "value": "95631"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.9", "display": "Type 1 diabetes", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-28", "note": [{"text": "Overview:
Formatting of this note might be different from the original.

BMI Readings from Last 1 Encounters:
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"display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "15182482|110500680"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "23"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-12-06T17:42:15Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "c9401c25-8529-73a2-3cd6-f917bb4da82c", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Disease caused by 2019-nCoVActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Disease caused by 2019-nCoV", "reference": "Condition/298b03c4-a2cf-efdd-180a-ed000f4d630e"}, {"reference": "Condition/6d3200fa-8bce-062e-9960-6d2def58a7dc"}]}, {"id": "68f4ee02-1da0-3f83-bc12-9c376a7bf14e", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
inpatient encounter20220919145900+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "837f2f7c-ae50-4c56-a2ba-cb9518715887", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
SARS-CoV-2 BioFireNot Detected
Coronavirus HKU1Not Detected
Coronavirus NL63Not Detected
Coronavirus OC43Not Detected
Coronavirus 229ENot Detected
SARS-CoV-2 Xpert Xpress ResultsDetected
RSV PCRNot Detected
Influenza B, PCRNot Detected
Influenza A, PCRNot Detected
"}, "code": {"coding": [{"code": "30954-2", "display": "RESULTS", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/be844c85-b9f4-9392-e0df-9d9944be7751"}, {"reference": "Observation/b6d380ff-572b-4a79-9407-b2644db163ef"}, {"reference": "Observation/55c38733-4eb8-4a6a-7e23-44bff90a4fb0"}, {"reference": "Observation/f61f7d29-28a2-6a8c-ec17-2334d968a2bd"}, {"reference": "Observation/9fd36dae-6b24-b218-f901-dd19c3a7201e"}, {"reference": "Observation/d0f632a3-b0d2-08dc-1db4-25d6044592f1"}, {"reference": "Observation/521fbc78-9973-b07e-c493-3518fc548037"}, {"reference": "Observation/c312e4fe-6a56-ccc2-c2e0-840ee5ff893f"}, {"reference": "Observation/f503ba7e-9f4b-f5aa-47c6-0f84cf02bd15"}]}, {"id": "bb131d02-bf3c-d6bf-05ef-d55c8b1e9da9", "title": "Medications Administered", "text": {"status": "generated", "div": "
Medication NameMedication Start Date
remdesivir20221123010000+0000
remdesivirUnknown
remdesivirUnknown
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Vaccine NameVaccination Date
influenza virus vaccine, liveWed Nov 10 00:00:00 GMT 2021
"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "d69703e2-5f33-f5f2-cba1-93d7574e262d", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Occupation HistoryStudent
Travel HistoryCovid Test Result-Negative (qualifier value)
Travel HistoryCovid Test Result-Negative (qualifier value)
Travel HistoryCongestion or Runny Nose-No (qualifier value)
Travel HistoryNausea-No (qualifier value)
Travel HistoryPositive COVID-19 Test-No (qualifier value)
Travel HistoryLoss of Taste or Smell-No (qualifier value)
Travel HistoryReported Fever-No (qualifier value)
Travel HistoryDry Cough-No (qualifier value)
Travel HistorySymptomatic Health Care Professional/SNF-No (qualifier value)
Travel HistorySymptomatic After Exposure to Contagion-No (qualifier value)
Travel HistoryDroplet, Contact Isolation Verification-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryUnexplained Hemorrhage, Bleed or Bruise-No (qualifier value)
Travel HistoryAbnormal Bleeding-No (qualifier value)
Travel HistoryAbdominal (Stomach Pain)-No (qualifier value)
Travel HistoryDifficulty breathing (finding)-No (qualifier value)
Travel HistoryChills Infectious Disease-No (qualifier value)
Travel HistoryBreastfeeding-Not applicable (qualifier value)
Travel HistoryDiarrhea (finding)-No (qualifier value)
Travel HistoryVomiting (disorder)-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryDyspnea (finding)-No (qualifier value)
Travel HistoryIllness With Generalized Rash-No (qualifier value)
Travel HistoryMuscle pain (finding)-No (qualifier value)
Travel HistoryHeadache (finding)-No (qualifier value)
Travel HistorySexual Orientation-Not applicable (qualifier value)
Travel HistorySexually active (finding)-Not applicable (qualifier value)
Travel HistoryCongestion or Runny Nose-No (qualifier value)
Travel HistoryNausea-No (qualifier value)
Travel HistoryPositive COVID-19 Test-No (qualifier value)
Travel HistoryLoss of Taste or Smell-No (qualifier value)
Travel HistoryReported Fever-No (qualifier value)
Travel HistoryDry Cough-No (qualifier value)
Travel HistorySymptomatic Health Care Professional/SNF-No (qualifier value)
Travel HistorySymptomatic After Exposure to Contagion-No (qualifier value)
Travel HistoryDroplet, Contact Isolation Verification-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryUnexplained Hemorrhage, Bleed or Bruise-No (qualifier value)
Travel HistoryAbnormal Bleeding-No (qualifier value)
Travel HistoryAbdominal (Stomach Pain)-No (qualifier value)
Travel HistoryDifficulty breathing (finding)-No (qualifier value)
Travel HistoryChills Infectious Disease-No (qualifier value)
Travel HistoryDiarrhea (finding)-No (qualifier value)
Travel HistoryVomiting (disorder)-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryDyspnea (finding)-No (qualifier value)
Travel HistoryIllness With Generalized Rash-No (qualifier value)
Travel HistoryMuscle pain (finding)-No (qualifier value)
Travel HistoryHeadache (finding)-No (qualifier value)
Travel HistoryInfectious Diseases Health History-None (qualifier value)
Travel HistorySexual Orientation-Not applicable (qualifier value)
Travel HistorySexually active (finding)-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
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[{"code": "266927001", "display": "Tobacco smoking consumption unknown", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/49daf9aa-c554-4b7c-abd4-2f68075b4f7f"}}, "request": {"method": "PUT", "url": "Observation/0a214427-33ea-1188-0c16-2469051371ee"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('6100896d-b520-497c-b2fe-1c111c679274', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:6100896d-b520-497c-b2fe-1c111c679274", "resource": {"resourceType": "Composition", "id": "6100896d-b520-497c-b2fe-1c111c679274", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "38381210|64871322"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "1"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-04-17T04:17:21Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "8387d52d-4149-8faf-9cf0-55a1d72748d5", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
TTP (thrombotic thrombocytopenic purpura)Active
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Thrombotic thrombocytopenic purpura (disorder)", "reference": "Condition/3907477b-3eba-59c4-6622-d3c3a81a39f4"}]}, {"id": "58ebd6f7-9c63-dac4-1f3f-c4a55907bb39", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
observation encounter20220415161500+0000
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Lab Test NameLab Test Result ValueLab Test Result Date
Troponin TNIH8.2|http://unitsofmeasure.org|ng/L
Troponin TNIH8.1|http://unitsofmeasure.org|ng/L
Troponin TNIH9.5|http://unitsofmeasure.org|ng/L
NT-ProBNP84|http://unitsofmeasure.org|pg/mL
Estimated Creatinine Clearance52.76|http://unitsofmeasure.org|mL/min
Symptomatic as defined by CDC?Yes
In ICU?No
Group care resident?No
Employed in healthcare?No
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRNegative
eGFR PediatricNot Reported
Flu B PCRNot Detected
Flu A PCRNot Detected
Calc Osmo270|http://unitsofmeasure.org|mOsmol/kg
A/G RatioUnknown
eGFR Non-African American70|http://unitsofmeasure.org|mL/min/1.73m2
eGFR African American81|http://unitsofmeasure.org|mL/min/1.73m2
Sodium135|http://unitsofmeasure.org|mmol/L
Potassium4.0|http://unitsofmeasure.org|mmol/L
Baso # Auto0.02|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.6|http://unitsofmeasure.org|gm/dL
Mono # Auto0.60|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto4.73|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.3|http://unitsofmeasure.org|%
Eos % Auto0.7|http://unitsofmeasure.org|%
Lymph % Auto21.3|http://unitsofmeasure.org|%
Neut % Auto68.9|http://unitsofmeasure.org|%
Calcium9.1|http://unitsofmeasure.org|mg/dL
RDW-SD49.7|http://unitsofmeasure.org|Femtoliters
Immature Grans # Auto0.01|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto1.46|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.7|http://unitsofmeasure.org|%
RDW-CV14.9|http://unitsofmeasure.org|%
Immature Grans %0.1|http://unitsofmeasure.org|%
Eos # Auto0.05|http://unitsofmeasure.org|x10e3/mcL
Chloride101|http://unitsofmeasure.org|mmol/L
BUN9|http://unitsofmeasure.org|mg/dL
Plt195|http://unitsofmeasure.org|x10e3/mcL
WBC6.87|http://unitsofmeasure.org|x10e3/mcL
TP8.9|http://unitsofmeasure.org|gm/dL
RBC4.92|http://unitsofmeasure.org|x10e6/mcL
MPV11.6|http://unitsofmeasure.org|Femtoliters
MCV90.7|http://unitsofmeasure.org|Femtoliters
MCHC33.0|http://unitsofmeasure.org|gm/dL
MCH29.9|http://unitsofmeasure.org|pg
Hgb14.7|http://unitsofmeasure.org|gm/dL
Hct44.6|http://unitsofmeasure.org|%
Glucose Level115|http://unitsofmeasure.org|mg/dL
D Dimer0.34|http://unitsofmeasure.org|mcg/mL FEU
CO228|http://unitsofmeasure.org|mmol/L
T Bili0.8|http://unitsofmeasure.org|mg/dL
AST25|http://unitsofmeasure.org|units/L
ALT19|http://unitsofmeasure.org|units/L
Alk Phos67|http://unitsofmeasure.org|units/L
BUN/Creat RatioUnknown
Anion Gap6|http://unitsofmeasure.org|mmol/L
Creatinine0.856|http://unitsofmeasure.org|mg/dL
"}, "code": {"coding": [{"code": "30954-2", "display": "RESULTS", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/94f5feb0-b01a-e1ee-e418-052f9efb84c7"}, {"reference": "Observation/78facf8f-f08a-26f9-5527-4bafe534a4f9"}, {"reference": "Observation/e5294ace-dc90-71ab-1183-0ecce3cdbb57"}, {"reference": "Observation/a5487fa0-7b9c-4b9e-d5fd-78aaf89a3bd3"}, {"reference": "Observation/a3c3b47a-bf65-775e-7f5c-2c215cdd613c"}, {"reference": "Observation/30bf6f23-8624-eaa9-fb82-678901f75c5e"}, {"reference": "Observation/c3029932-4c25-a515-b4c6-e35e5764b464"}, {"reference": "Observation/f50c588e-778b-2fb8-95ca-b2895c85dcdd"}, {"reference": "Observation/1cec98b6-3381-dd8d-360c-21d5ed818f62"}, {"reference": "Observation/7f07e455-5574-a648-1543-cba70270a4e4"}, {"reference": "Observation/562aaa4c-b024-2655-efe5-1155eab8aabc"}, {"reference": "Observation/fc5517ad-dbab-6e81-d88a-c7589f32a820"}, {"reference": "Observation/986e51be-bcb9-0e85-26de-ee93f55b9652"}, {"reference": "Observation/6a6a5554-9b68-a91a-76d9-f32c051dfa62"}, {"reference": "Observation/30b4c04b-9788-b94d-bd4b-eb849b2d9102"}, {"reference": "Observation/9082dd79-88a9-1f15-c4fd-93d955d16ecd"}, {"reference": "Observation/09b3ec87-393a-9b52-1609-db67d66cf21c"}, {"reference": "Observation/8170fe97-63af-51c4-3454-20966f4a2c7b"}, {"reference": "Observation/036a8d7b-df19-cbfa-37a7-21e9583ce4c1"}, {"reference": "Observation/e32e94e6-7415-be5d-3292-0966edd22333"}, {"reference": "Observation/b1127a40-3939-691b-d336-236f6546d029"}, {"reference": "Observation/ec7b419f-634e-4271-dc91-ba2effb97b76"}, {"reference": "Observation/f03f3593-6156-f89f-14bd-86a34685d4bc"}, {"reference": "Observation/2dd4f4d5-0f5e-ebf1-3604-fec9d6bffbd0"}, {"reference": "Observation/f2523ccf-f211-d164-ff88-33d8c6468983"}, {"reference": "Observation/1f283bd6-2d5c-1710-7d06-ec698c99493a"}, {"reference": "Observation/a9249110-9884-0b13-e66c-1c010f5e65fa"}, {"reference": "Observation/131665fd-57c3-71bd-684e-923b6f757c06"}, {"reference": "Observation/396356a0-a50c-b781-9f28-f298804e4d92"}, {"reference": "Observation/56129862-0f40-6d26-9b6a-b4ad52d28a19"}, {"reference": "Observation/98f99e5f-cc42-1a10-9513-fa6de9461791"}, {"reference": "Observation/e9649c89-9768-2ccc-02a1-21c5ba61cf90"}, {"reference": "Observation/7a12de1d-a25c-57ec-2f76-9cc36e6cc6ab"}, {"reference": "Observation/12e99bf8-7870-70c1-aeb2-3b6776d820c9"}, {"reference": "Observation/2ad0896c-fe55-1df4-7698-862223348f49"}, {"reference": "Observation/68dd9edb-14d7-3cdd-e3df-a1084fd65e71"}, {"reference": "Observation/24c9897d-8045-2680-9a81-2bed3a0bf8c1"}, {"reference": "Observation/1f783aae-998b-170b-0fe3-85c1fd49d571"}, {"reference": "Observation/dba50ebc-cd5f-f7d8-63a2-1f3dfadc9faa"}, {"reference": "Observation/ee31ebe3-89af-f9c1-5c9d-77a3d1dae142"}, {"reference": "Observation/123b523e-91bd-4ac5-ea2b-fa30625adba8"}, {"reference": "Observation/8ac33820-131e-b29f-eea9-4dca7aca7bb1"}, {"reference": "Observation/3e6d19ba-99ec-b040-a03a-ea96d6abcac1"}, {"reference": "Observation/eeb82005-0020-b4c9-48db-8b2de294e54e"}, {"reference": "Observation/a5a632d6-4369-0a9a-8907-91c8b997e869"}, {"reference": "Observation/2815bda1-1dc3-e1cc-1dd8-ebb9ee9b1717"}, {"reference": "Observation/d64acb60-f1d0-3fbd-2225-71c1eea6a741"}, {"reference": "Observation/db9c6727-aa8d-bbfa-e559-e33ba98ede46"}, {"reference": "Observation/5e514b8a-4779-67dd-4d03-b94d7d711f9b"}, {"reference": "Observation/e3325ed8-7e9b-6119-a3bd-0e210444b3ce"}, {"reference": "Observation/1f829d47-da43-84cd-31cf-86d37c899e95"}, {"reference": "Observation/2bfdc249-8248-7487-6dc7-d712929fa0bc"}, {"reference": "Observation/d01b3806-be84-5331-b6e8-30b4d70d584e"}, {"reference": "Observation/4522f2ed-ad93-341b-b5ff-ada74da2ab25"}, {"reference": "Observation/8a3e4fe5-a269-3cb1-49ff-4ef054b8fa30"}, {"reference": "Observation/54f875a6-2f8a-b093-d4c2-afa62467df93"}, {"reference": "Observation/0d5219a6-ab87-16b9-ba0f-79240342f308"}, {"reference": "Observation/d62fc0a5-46a4-7dbe-dadf-4adba4d008b8"}]}, {"id": "c000a97e-4421-7caa-ffa7-481aadaa031b", "title": "Medications Administered", "text": {"status": "generated", "div": "
Medication NameMedication Start Date
albuterol (Ventolin HFA 90 mcg/inh inhalation aerosol)20220416050100+0000
doxycycline (doxycycline hyclate 100 mg oral tablet)20220416050100+0000
predniSONE (predniSONE 50 mg oral tablet)20220416050100+0000
Sodium Chloride 0.9% intravenous solution (NS Bolus (ADULT))20220415164100+0000
dexamethasone20220415164300+0000
ipratropium-albuterol (DuoNeb)20220415164300+0000
"}, "code": {"coding": [{"code": "29549-3", "display": "Medications Administered", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/cf9718b1-e622-e7af-3f57-7ccc11f47168"}, {"reference": "MedicationAdministration/660a34cf-6bb4-a0a0-70c1-2556ec6323f3"}, {"reference": "MedicationAdministration/4f0c772a-f2ae-e341-cf1a-7f2c778d8a53"}, {"reference": "MedicationAdministration/13d4231b-70e9-c943-f0e7-d149fdd14973"}, {"reference": "MedicationAdministration/7860e902-7286-abce-b085-f1ddf30bc76f"}, {"reference": "MedicationAdministration/c45ce1df-b3f0-999b-90a8-aa39fec61fa1"}]}, {"id": "dd08df91-869b-46df-dd36-c5c0f2ad2eae", "title": "IMMUNIZATIONS", "text": {"status": "generated", "div": "No ImmunizationInformation"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "1ee0e176-222f-864a-5b05-9a38d5189d31", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Birth SexF
Travel HistoryCOVID- 19 Testing Reason-Screening
Travel HistoryCOVID- 19 Testing Reason-Screening
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryExposure to severe acute respiratory syndrome coronavirus 2 (event)-No (qualifier value)
Travel HistoryMERS-CoV Travel History-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMERS-CoV Symptoms-
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
"}, "code": {"coding": [{"code": "29762-2", "display": "Social History", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/9389af18-d1a2-58ab-ee16-0681acd78c6f"}, {"reference": "Observation/51746276-2451-9932-9e58-4f21971c62ac"}, {"reference": "Observation/e3794f31-0b96-7d3f-69d5-7b944494e540"}, {"reference": "Observation/f21fadab-af58-b443-50c0-2201075d0c25"}, {"reference": "Observation/88ab5385-5cb5-0308-a58e-bc67b2f3b725"}, {"reference": "Observation/dbe310c6-9580-0fe6-11c8-4b8caa33a9fb"}, {"reference": "Observation/f4ed88e3-7742-2dea-1a58-8505caead382"}, {"reference": "Observation/68f1da74-94b9-7976-76f3-b5354cc0f35f"}, {"reference": "Observation/994278a6-ca17-8619-c789-19b8b6bf6f9c"}, {"reference": "Observation/1e6de63d-ea70-84d6-52d2-46429d031b57"}, {"reference": "Observation/3ca15288-a6ed-8ad3-77c9-eee0ba9275be"}, {"reference": "Observation/eedc882c-0f16-276c-3bd8-b677a1a6c600"}]}, {"id": "7dbd51e8-1c15-8cfa-cbce-f6f4b9a1ed5d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "No Plan Of Treatment Information"}, "code": {"coding": [{"code": "18776-5", "display": "Treatment Plan", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/ec77d178-de8a-915a-311a-1f11f2838946"}]}, {"id": "d9d29cc3-a276-3cb1-dfbf-e1c4ce391ff6", "title": "History of Present Illness", "text": {"status": "generated", "div": "
Narrative Text
Wheezing
Acute URI
Cough
Tachycardia
"}, "code": {"coding": [{"code": "10164-2", "display": "History of Present Illness", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "65225627-ffb0-e051-e796-fbbd26035fbc", "title": "Reason For Visit", "text": {"status": "generated", "div": "
text
ACUTE URI
"}, "code": {"coding": [{"code": "29299-5", "display": "Reason For Visit", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "ACUTE URI"}]}, {"id": "fe5ea6af-6ec5-edfd-fe9b-c6b07748e2dd", "title": "Reportability Response Information Section", "text": {"status": "generated", "div": "
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"2022-10-04T16:10:34-07:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "c80f67bb-6876-6ad5-ea57-46aea1afa973", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "BFEB06A0-4439-11ED-9D28-005056A7FB21", "title": "Immunizations", "text": {"status": "generated", "div": "Not on file documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "BFF008C6-4439-11ED-9D28-005056A7FB21", "title": "Administered Medications", "text": {"status": "generated", "div": "
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
alum-mag hydroxide-simeth (MAALOX) 200-200-20 mg/5 mL oral suspension 15 mL15 mL, Oral, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 dose, Order WILL be automatically substituted with P&T Approved equivalent per protocol. SHAKE WELL prior to use.Given09/28/2022 8:37 PM PDT15 mL
aspirin tablet 325 mg325 mg, Oral, ONCE, On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT325 mg
lidocaine (XYLOCAINE) 2% viscous oral solution5 mL, Swish and Spit, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT5 mL
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/6dd25719-9ba8-9164-79fe-005e349bcb21"}, {"reference": "MedicationAdministration/3d9ad81e-9518-1b14-44a8-cc86725ed68c"}, {"reference": "MedicationAdministration/b3a81224-d404-4fd4-3134-5c54815acd0f"}]}, {"id": "ca51a58e-d5d5-8f6d-28be-f526ca11481f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/5ddcb7d6-d32c-e91c-f715-cf239eb4aee6"}]}, {"id": "BFF3AE86-4439-11ED-9D28-005056A7FB21", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
documented as of this encounter (statuses as of 10/04/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Seasonal allergies", "reference": "Condition/5c1d48d8-1b16-c482-65b0-874cdffb0325"}, {"display": "Problem - Coronavirus infection", "reference": "Condition/1e7e7161-de05-f41e-f064-c227e43edd3e"}, {"display": "Problem - Close exposure to COVID-19 virus", "reference": "Condition/6cb5bd36-5db9-68d4-ec94-afc3f96f6392"}]}, {"id": "578e38a5-2cc7-00e0-1769-ea74746c5fe8", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "BFF6E3A8-4439-11ED-9D28-005056A7FB21", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "SARS-CoV-2, RNA", "reference": "Observation/3a45daf2-6872-fd2a-6ede-606810d52bb2"}, {"display": "Lab Interpretation", "reference": "Observation/e9c8e4b3-3fec-4f29-a5c5-e45f96680a4c"}]}, {"id": "8a900c7f-2adf-c43c-4fde-16f9696944df", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "8cfa32e2-c143-2ba9-dc72-266a3ba673c6", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Close exposure to COVID-19 virusCoronavirus infection (Primary Dx);
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COVID-19Diagnosis interpretation (observable entity)Mar-11-2022 -
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Panel Description: SARS-like coronavirus N gene [Presence] in Unspecified specimen by NAA with probe detectionUnknown
Antigen of severe acute respiratory syndrome coronavirus 2 (substance)840536004^Reactive^SCT^REA^Reactive^LAUnknownPerformed by:LabCorp Burlington Testing (800)762-4344 (34D0655059)1447 York CourtBurlington, NC 272153361
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{"id": "E70C8DE6-4441-11ED-91C1-005056A7FB21", "title": "Administered Medications", "text": {"status": "generated", "div": "
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
alum-mag hydroxide-simeth (MAALOX) 200-200-20 mg/5 mL oral suspension 15 mL15 mL, Oral, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 dose, Order WILL be automatically substituted with P&T Approved equivalent per protocol. SHAKE WELL prior to use.Given09/28/2022 8:37 PM PDT15 mL
aspirin tablet 325 mg325 mg, Oral, ONCE, On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT325 mg
lidocaine (XYLOCAINE) 2% viscous oral solution5 mL, Swish and Spit, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT5 mL
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Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
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DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Close exposure to COVID-19 virusCoronavirus infection (Primary Dx);
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Reportability Response Information Section
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Problem or DiagnosisProblem Status
Disease caused by 2019-nCoVActive
Abdominal pain (finding)Active
Abdominal pain (finding)Active
Patient encounter status (finding)Active
Patient encounter status (finding)Active
Lupus erythematosus (disorder)Active
Abdominal painActive
Lupus erythematosusActive
Malaise (finding)Active
Low back painActive
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Encounter ReasonDate of Encounter
Emergency20220428011000+0000
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Lab Test NameLab Test Result ValueLab Test Result Date
Ur pHUnknown
Ur Spec GravUnknown
Ur Urobilinogen<2.0 mg/dL
Ur Blood1+ mg/dL
Ur BiliNegative mg/dL
Ur Leuk Est1+
Ur ColorYellow
Ur MucousRare /LPF
Ur Squam Epithelial5|http://unitsofmeasure.org|/HPF
Ur WBC18|http://unitsofmeasure.org|/HPF
Ur RBC2|http://unitsofmeasure.org|/HPF
Ur ProteinNegative mg/dL
Ur NitriteNegative
Ur KetonesNegative mg/dL
UR GlucoseNegative mg/dL
Ur BacteriaNone Seen /HPF
Ur ClarityClear
U Beta hCG QlNegative
Ur pH5.5
Ur Spec Grav1.020 mg/dL
Ur Urobilinogen0.2 EU/dL
Ur BloodTrace-lysed
Ur BiliNegative
Ur Leuk EstTrace
Ur ProteinNegative mg/dL
Ur NitriteNegative
Ur KetonesNegative mg/dL
UR GlucoseNegative mg/dL
Estimated Creatinine Clearance55.01|http://unitsofmeasure.org|mL/min
Troponin TNIH4.2|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
Calc Osmo284|http://unitsofmeasure.org|mOsmol/L
A/G Ratio1.1|http://unitsofmeasure.org|Ratio
eGFR Non-African American64.68 mL/min/1.73m2
eGFR African American74.97 mL/min/1.73m2
Sodium141|http://unitsofmeasure.org|mmol/L
Potassium3.6|http://unitsofmeasure.org|mmol/L
NT-ProBNP44|http://unitsofmeasure.org|pg/mL
Baso # Auto0.05|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level4.1|http://unitsofmeasure.org|gm/dL
Mono # Auto0.6|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto3.3|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.8|http://unitsofmeasure.org|%
Eos % Auto1.9|http://unitsofmeasure.org|%
Lymph % Auto32.3|http://unitsofmeasure.org|%
Neut % Auto55.5|http://unitsofmeasure.org|%
Calcium8.8|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.01|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto1.9|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto9.3|http://unitsofmeasure.org|%
RDW-CV13.9|http://unitsofmeasure.org|%
Immature Grans %0.2|http://unitsofmeasure.org|%
Eos # Auto0.1|http://unitsofmeasure.org|x10e3/mcL
Chloride106|http://unitsofmeasure.org|mmol/L
BUN20|http://unitsofmeasure.org|mg/dL
Plt231|http://unitsofmeasure.org|x10e3/mcL
WBC5.9|http://unitsofmeasure.org|x10e3/mcL
TP7.8|http://unitsofmeasure.org|gm/dL
RBC4.01|http://unitsofmeasure.org|x10e6/mcL
PT11.3|http://unitsofmeasure.org|Seconds
MPV11.7|http://unitsofmeasure.org|Femtoliters
MCV93.8|http://unitsofmeasure.org|Femtoliters
MCHC31.9|http://unitsofmeasure.org|gm/dL
MCH29.9|http://unitsofmeasure.org|pg
Hgb12.0|http://unitsofmeasure.org|gm/dL
Hct37.6|http://unitsofmeasure.org|%
Glucose Level97|http://unitsofmeasure.org|mg/dL
CO224.8|http://unitsofmeasure.org|mmol/L
T BiliTNP see comment mg/dL
AST22|http://unitsofmeasure.org|Intl_units/L
ALT27|http://unitsofmeasure.org|Intl_units/L
Alk Phos72|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio20.0|http://unitsofmeasure.org|Ratio
INRUnknown
Anion GapUnknown
HCG Bld QLNegative
Creatinine1.0|http://unitsofmeasure.org|mg/dL
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NameAdministration DatesNext Due
COVID-19, mRNA, Moderna, Preservative Free06/12/202111/12/2022
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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
albuterol (VENTOLIN) 2.5 mg /3 mL (0.083 %) nebulizer solution 2.5 mg2.5 mg, Nebulization, ONCE (IN CLINIC), On Tue 8/2/22 at 1200, For 1 dose, Order MAY be automatically substituted with P&T Approved equivalent per protocol. Dilute before use with normal saline if needed. , Delivery Mode: HHNGiven08/02/2022 11:39 AM PDT2.5 mg
aspirin tablet 650 mg650 mg, Oral, ONCE (IN CLINIC), On Tue 8/2/22 at 1200, For 1 doseGiven08/02/2022 11:40 AM PDT650 mg
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Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
CREATININE, SERUMLabRoutineCOVID-19 virus detectedPregnancy test positiveOrdered: 8/2/22
THYROID-STIMULATING HORMONE (TSH)LabRoutineCOVID-19 virus detectedPregnancy test positiveOrdered: 8/2/22
THYROXINE (T4), FREELabRoutineCOVID-19 virus detectedPregnancy test positiveOrdered: 8/2/22
GLUCOSE, BLOODLabRoutineCOVID-19 virus detectedPregnancy test positiveOrdered: 8/2/22
HELICOBACTER PYLORI ANTIBODY, IGALabRoutineCOVID-19 virus detectedPregnancy test positiveOrdered: 8/2/22
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Active ProblemsNoted Date
2019 novel coronavirus disease (COVID-19)8/2/22
Generalized abdominal pain8/2/22
Eclampsia, antepartum8/2/22
Pregnancy related exhaustion and fatigue, antepartum8/2/22
Pregnancy test positive8/2/22
Pain, upper back7/22/22
Mild to moderate pre-eclampsia7/21/22
Depression, recurrent7/21/22
PregnantComments
Yes
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Every DayCigarettes330
Smokeless Tobacco: Never
Tobacco Cessation:
Ready to Quit: No; Counseling Given: Yes
Alcohol UseStandard Drinks/WeekComments
Yes0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Doctorate07/25/2022
Sex Assigned at BirthDate Recorded
Female07/21/2022 4:09 PM PDT
Job Start DateOccupationIndustry
1/1/14Not on fileNot on file
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DateTypeDepartmentCare TeamDescription
8/2/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031So, Naomi
Pregnancy test positiveCOVID-19 virus detected (Primary Dx);
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NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "A643FC02-3F70-11ED-9549-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "af896ab0-09ae-234e-c3ec-12823ba33230", "title": "Plan of Treatment", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/bc17dacd-4cfa-7ecf-f264-423f87ef2461"}]}, {"id": "A654AFCA-3F70-11ED-9549-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
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Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture bloodMicrobiologyRoutineRoutine general medical examination at a health care facility06/16/2022 4:12 PM EDT
Blood culture pathogens molecular studyMicrobiologyRoutineRoutine general medical examination at a health care facility06/16/2022 4:12 PM EDT
Culture bloodMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 2:19 PM EDT
Blood culture pathogens molecular studyMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 2:19 PM EDT
Culture body fluid with gram stainMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 2:27 PM EDT
Legionella antigen urine, EIALabRoutineRoutine general medical examination at a health care facility06/17/2022 2:48 PM EDT
Culture throatMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 2:58 PM EDT
Culture throatMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 3:37 PM EDT
Culture woundMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 3:49 PM EDT
Occult blood screen, guaiacLabRoutineRoutine general medical examination at a health care facility06/17/2022 4:05 PM EDT
Rapid influenza A and B, molecularMicrobiologyRoutineRoutine general medical examination at a health care facility06/20/2022 7:58 AM EDT
SARS-COV2-RNA, qualitative RT-PCR, internal labMicrobiologyRoutineRoutine general medical examination at a health care facility06/20/2022 7:58 AM EDT
SARS-COV2-RNA, RSV, Influenza A and B qualitative RT-PCRMicrobiologyRoutineRoutine general medical examination at a health care facility06/20/2022 7:58 AM EDT
MRSA molecular studyMicrobiologyRoutineRoutine general medical examination at a health care facility06/20/2022 8:11 AM EDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
SARS-COV2-RNA, qualitative RT-PCRMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Culture bloodMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Culture body fluid with gram stainMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Legionella antigen urine, EIALabRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Culture throatMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Culture throatMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Culture woundMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Occult blood screen, guaiacLabRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Rapid influenza A and B, molecularMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/20/22 until 6/20/23
SARS-COV2-RNA, qualitative RT-PCR, internal labMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/20/22 until 6/20/23
SARS-COV2-RNA, RSV, Influenza A and B qualitative RT-PCRMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/20/22 until 6/20/23
Rapid influenza A and B, molecularMicrobiologyRoutineRoutine general medical examination at a health care facilityOnce for 1 Occurrences starting 6/20/22 until 6/20/22
SARS-COV2-RNA, qualitative RT-PCR, internal labMicrobiologyRoutineRoutine general medical examination at a health care facilityOnce for 1 Occurrences starting 6/20/22 until 6/20/22
SARS-COV2-RNA, RSV, Influenza A and B qualitative RT-PCRMicrobiologyRoutineRoutine general medical examination at a health care facilityOnce for 1 Occurrences starting 6/20/22 until 6/20/22
MRSA molecular studyMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/20/22 until 6/20/23
MRSA molecular studyMicrobiologyRoutineRoutine general medical examination at a health care facilityOnce for 1 Occurrences starting 6/20/22 until 6/20/22, 1 completed
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Tobacco UseTypesPacks/DayYears UsedDate
Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
Job Start DateOccupationIndustry
Not on fileNot on fileNot on file
COVID-19 ExposureResponseDate Recorded
In the last 10 days, have you been in contact with someone who was confirmed or suspected to have Coronavirus/COVID-19?No / Unsure6/13/2022 10:25 AM EDT
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DateTypeDepartmentCare TeamDescription
6/16/22Hospital EncounterTrinity Health Lab - Muskegon Hospital1500 E Sherman BlvdMuskegon, MI 49444-1849231-672-6259
Routine general medical examination at a health care facilityInfertility male (Primary Dx);
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Diagnosis
Infertility male - PrimaryUnspecified male infertility
Routine general medical examination at a health care facility
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Procedure NamePriorityDate/TimeAssociated DiagnosisComments
SARS-COV2-RNA, RSV, FLU A AND B QUALITATIVE RT-PCR, INTERNAL LABRoutine06/20/2022 7:58 AM EDTRoutine general medical examination at a health care facilityresults section .Results for this procedure are in the
LEGIONELLA ANTIGEN URINE, EIARoutine06/16/2022 4:22 PM EDTRoutine general medical examination at a health care facilityresults section .Results for this procedure are in the
CULTURE BLOODRoutine06/16/2022 4:12 PM EDTRoutine general medical examination at a health care facility
SEMEN ANALYSIS, POST VASECTOMYRoutine06/16/2022 3:18 PM EDTInfertility maleresults section .Results for this procedure are in the
MONONUCLEOSIS SCREENRoutine06/16/2022 1:53 PM EDTRoutine general medical examination at a health care facilityresults section .Results for this procedure are in the
THROMBOELASTOGRAPH 6 GLOBAL HEMOSTASIS PANELRoutine06/16/2022 1:44 PM EDTRoutine general medical examination at a health care facilityresults section .Results for this procedure are in the
THROMBOELASTOGRAPH WITH PLATELET MAPPING ADPRoutine06/16/2022 1:31 PM EDTRoutine general medical examination at a health care facilityresults section .Results for this procedure are in the
SEMEN ANALYSISRoutine06/16/2022 12:48 PM EDTInfertility maleresults section .Results for this procedure are in the
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InfectionOnset DateLast IndicatedResolved Time
COVID-1906/13/202206/13/2022
Respiratory Rule-Out06/20/202206/20/202206/20/2022 8:22 AM EDT
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Reportability Response Information Section
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('1.2.840.114350.1.13.202.3.7.8.688883.487', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.202.3.7.8.688883.487", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.202.3.7.8.688883.487", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "28beb5ae-3f68-11ed-8bdc-005056a7fb21", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "31"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-10-04T17:05:47-07:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": 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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
alum-mag hydroxide-simeth (MAALOX) 200-200-20 mg/5 mL oral suspension 15 mL15 mL, Oral, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 dose, Order WILL be automatically substituted with P&T Approved equivalent per protocol. SHAKE WELL prior to use.Given09/28/2022 8:37 PM PDT15 mL
aspirin tablet 325 mg325 mg, Oral, ONCE, On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT325 mg
lidocaine (XYLOCAINE) 2% viscous oral solution5 mL, Swish and Spit, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT5 mL
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/6dd25719-9ba8-9164-79fe-005e349bcb21"}, {"reference": "MedicationAdministration/3d9ad81e-9518-1b14-44a8-cc86725ed68c"}, {"reference": "MedicationAdministration/b3a81224-d404-4fd4-3134-5c54815acd0f"}]}, {"id": "ca51a58e-d5d5-8f6d-28be-f526ca11481f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/5ddcb7d6-d32c-e91c-f715-cf239eb4aee6"}]}, {"id": "76F9D87E-4441-11ED-91C1-005056A7FB21", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
documented as of this encounter (statuses as of 10/04/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Seasonal allergies", "reference": "Condition/5c1d48d8-1b16-c482-65b0-874cdffb0325"}, {"display": "Problem - Coronavirus infection", "reference": "Condition/1e7e7161-de05-f41e-f064-c227e43edd3e"}, {"display": "Problem - Close exposure to COVID-19 virus", "reference": "Condition/6cb5bd36-5db9-68d4-ec94-afc3f96f6392"}]}, {"id": "578e38a5-2cc7-00e0-1769-ea74746c5fe8", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "76FCD222-4441-11ED-91C1-005056A7FB21", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "SARS-CoV-2, RNA", "reference": "Observation/3a45daf2-6872-fd2a-6ede-606810d52bb2"}, {"display": "Lab Interpretation", "reference": "Observation/e9c8e4b3-3fec-4f29-a5c5-e45f96680a4c"}]}, {"id": "8a900c7f-2adf-c43c-4fde-16f9696944df", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "8cfa32e2-c143-2ba9-dc72-266a3ba673c6", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Close exposure to COVID-19 virusCoronavirus infection (Primary Dx);
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Reportability Response Information Section
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Public Health Case Report", "confidentiality": "N", "section": [{"id": "1f359338-80e3-5e83-4aa1-5168ab4c153a", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
UnknownActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Condition/0a66854a-5643-4338-2b22-4564d9958ed8"}]}, {"id": "119142ea-0976-3fbf-8f73-0f955476c21d", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
Emergency20220515223400+0000
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Lab Test NameLab Test Result ValueLab Test Result Date
Symptomatic as defined by CDC?Yes
In ICU?No
Group care resident?No
Employed in healthcare?No
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRNegative
Flu B PCRNot Detected
Flu A PCRNot Detected
Troponin TNIH46.4|http://unitsofmeasure.org|ng/L
Estimated Creatinine Clearance108.17|http://unitsofmeasure.org|mL/min
Troponin TNIH54.2|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
Calc Osmo271|http://unitsofmeasure.org|mOsmol/L
A/G Ratio0.9|http://unitsofmeasure.org|Ratio
eGFR Non-African American108.66 mL/min/1.73m2
eGFR African American125.94 mL/min/1.73m2
Sodium136|http://unitsofmeasure.org|mmol/L
Potassium4.1|http://unitsofmeasure.org|mmol/L
NT-ProBNP25|http://unitsofmeasure.org|pg/mL
Baso # Auto0.06|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level4.0|http://unitsofmeasure.org|gm/dL
Mono # Auto0.9|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto13.1|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.4|http://unitsofmeasure.org|%
Eos % Auto2.9|http://unitsofmeasure.org|%
Lymph % Auto13.7|http://unitsofmeasure.org|%
Neut % Auto77.1|http://unitsofmeasure.org|%
Calcium10.0|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.08|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto2.3|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto5.4|http://unitsofmeasure.org|%
RDW-CV13.2|http://unitsofmeasure.org|%
Immature Grans %0.5|http://unitsofmeasure.org|%
Eos # Auto0.5|http://unitsofmeasure.org|x10e3/mcL
Chloride105|http://unitsofmeasure.org|mmol/L
BUN8|http://unitsofmeasure.org|mg/dL
Plt326|http://unitsofmeasure.org|x10e3/mcL
WBC17.0|http://unitsofmeasure.org|x10e3/mcL
TP8.4|http://unitsofmeasure.org|gm/dL
RBC5.10|http://unitsofmeasure.org|x10e6/mcL
PT10.7|http://unitsofmeasure.org|Seconds
MPV9.3|http://unitsofmeasure.org|Femtoliters
MCV86.7|http://unitsofmeasure.org|Femtoliters
MCHC34.2|http://unitsofmeasure.org|gm/dL
MCH29.6|http://unitsofmeasure.org|pg
Mg Lvl2.2|http://unitsofmeasure.org|mg/dL
Hgb15.1|http://unitsofmeasure.org|gm/dL
Hct44.2|http://unitsofmeasure.org|%
Glucose Level110|http://unitsofmeasure.org|mg/dL
D Dimer0.58|http://unitsofmeasure.org|mg/L
CO221.2|http://unitsofmeasure.org|mmol/L
T Bili0.5|http://unitsofmeasure.org|mg/dL
AST18|http://unitsofmeasure.org|Intl_units/L
ALT31|http://unitsofmeasure.org|Intl_units/L
Alk Phos88|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio10.0|http://unitsofmeasure.org|Ratio
INRUnknown
Anion GapUnknown
HCG Bld QLNegative
Creatinine0.8|http://unitsofmeasure.org|mg/dL
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Travel HistoryCOVID- 19 Testing Reason-Diagnostic
Travel HistoryCOVID- 19 Testing Reason-Diagnostic
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
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Pneumonia due to COVID-19 virus
Encounter for medical screening examination
Shortness of breath
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Drugs Of Abuse Comprehensive Screen, UrLabSTAT12/23/2022 11:13 AM PST
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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
alum-mag hydroxide-simeth (MAALOX) 200-200-20 mg/5 mL oral suspension 15 mL15 mL, Oral, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 dose, Order WILL be automatically substituted with P&T Approved equivalent per protocol. SHAKE WELL prior to use.Given09/28/2022 8:37 PM PDT15 mL
aspirin tablet 325 mg325 mg, Oral, ONCE, On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT325 mg
lidocaine (XYLOCAINE) 2% viscous oral solution5 mL, Swish and Spit, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT5 mL
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Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
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DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Close exposure to COVID-19 virusCoronavirus infection (Primary Dx);
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Reportability Response Information Section
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(ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.297.3.7.8.688883.518869', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.297.3.7.8.688883.518869", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.297.3.7.8.688883.518869", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "54482604-1a8a-11ed-b217-c301d81100b2", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "4"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-08-16T16:25:06-07:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "85fc8a49-7528-b342-07a4-d7fbf380bd2f", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "A9BB042A-1DBA-11ED-AEA0-C301D81100B2", "title": "Immunizations", "text": {"status": "generated", "div": "Not on file documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "A9F62348-1DBA-11ED-AEA0-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
albuterol 90 mcg/puff inhaler 2 puff2 puff, Inhalation, ONCE PRN, Bronchospasm or hypoxemia, Starting on Fri 8/12/22 at 1503, Shake well. May repeat x 1. Shake well.Given08/12/2022 3:12 PM PDT2 puffs
diphenhydrAMINE (BENADRYL) injection 25 mg25 mg, Intravenous, EVERY 15 MIN PRN, infusion reaction, may repeat x1, Starting on Fri 8/12/22 at 1503, For 2 dosesGiven08/12/2022 3:11 PM PDT25 mg
EPINEPHrine 1 mg/mL injection 0.3 mg0.3 mg, Intramuscular, EVERY 5 MIN PRN, Anaphylaxis, Starting on Fri 8/12/22 at 1503, For 3 doses, Administer in the anterior lateral thigh using 1 - 1.5 inch needle for airway obstruction symptoms and/or hypotension.Given08/12/2022 3:10 PM PDT0.3 mgDeltoid-Left
famotidine (PF) (PEPCID) injection 20 mg20 mg, Intravenous, ONCE PRN, Moderate reaction or anaphylaxis., Starting on Fri 8/12/22 at 1503, Dilute 2 mL of famotidine with 8 mL of normal saline to a final concentration of 2 mg/mL. Administer ordered dose over a period of at least 2 minutes.Given08/12/2022 3:12 PM PDT20 mg
heparin 100 units/mL flush injection 500 Units500 Units (5 mL), Intracatheter, PRN, Line Care, Starting on Fri 8/12/22 at 1503Given08/12/2022 3:10 PM PDT500 Units
methylPREDNISolone sodium succinate (solu-MEDROL) 62.5 mg/mL injection 125 mg125 mg, Intravenous, ONCE PRN, Infusion reaction, Starting on Fri 8/12/22 at 1503, For 1 dose, Mix with 2 mL provided diluent to make 62.5 mg/mL.Given08/12/2022 3:11 PM PDT125 mg
sodium chloride 0.9% (NS) bolus 250 mL250 mL, Intravenous, PRN, Flush before and after IV medication(s) and as needed with NS, Starting on Fri 8/12/22 at 1503New Bag08/12/2022 3:09 PM PDT250 mLs250 mL/hr
sodium chloride 0.9% (NS) infusion 500 mLat 500 mL/hr, Intravenous, PRN, Moderate reacton or anaphylaxis., Starting on Fri 8/12/22 at 1503, Run wide open to gravity.New Bag08/12/2022 3:10 PM PDT500 mLs500 mL/hr
sodium chloride 0.9% flush 10 mL10 mL, Intracatheter, PRN, Line Care, Starting on Fri 8/12/22 at 1503Given08/12/2022 3:10 PM PDT10 mLs
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/c2b754b8-f67e-2f12-b52d-6cbf7b1f8aee"}, {"reference": "MedicationAdministration/70cb3e2b-13ba-e755-31a2-e7cb7e4597e8"}, {"reference": "MedicationAdministration/f68ce018-403c-b976-6cc3-26dd1b4fd625"}, {"reference": "MedicationAdministration/771d3d37-8fa2-7bfa-ab4f-72b60aae4bab"}, {"reference": "MedicationAdministration/aa3a6323-e4c1-0b26-93f9-0389c7c32227"}, {"reference": "MedicationAdministration/76883e63-529a-e134-729b-63fccbd9db76"}, {"reference": "MedicationAdministration/401566d8-f50f-7a24-b9c9-da94040c32d3"}, {"reference": "MedicationAdministration/43e8ffea-cba6-c5ba-1c3c-2465c016e048"}, {"reference": "MedicationAdministration/c2b901e1-13c0-57e3-8dc6-4508ac1fc4c2"}]}, {"id": "eb66d618-8ad1-0a61-7aef-29738cbad56d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/dbb4df9f-6c1f-ea78-b404-09d9474816ca"}]}, {"id": "AA0C8F20-1DBA-11ED-AEA0-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
Malignant neoplasm of overlapping sites of left lung8/12/22
Osteoporosis5/9/22
documented as of this encounter (statuses as of 08/16/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Osteoporosis", "reference": "Condition/479cd37d-8c87-dd4d-995c-0b7ff72f1a99"}, {"display": "Problem - Malignant neoplasm of overlapping sites of left lung", "reference": "Condition/10f40634-09ec-4c1b-a05d-800a074127d6"}]}, {"id": "42d11352-ddb6-5b9f-bcd6-f5767cc11565", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "AA0F192A-1DBA-11ED-AEA0-C301D81100B2", "title": "Results", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "88b750bb-7bd3-1293-bc9e-c518eb1dd9c0", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "c981e93a-29e9-58d8-8650-9aa5042d1f25", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
8/11/22Office VisitPROVIDENCE RESEARCH CLINIC AT CROSSON CANCER INSTITUTE NORTH PLAZA2151 North Harbor BlvdFullerton, CA 92835-3824714-446-5177Valle, Natalie Perdomo, NPMalignant neoplasm of overlapping sites of left lung (HCC) (Primary Dx)
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Hospitalizations+Outpatient visits Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "24deca5f-cd50-65c3-fa31-386ff890638f", "title": "Reportability Response Information Section", "text": {"status": "generated", "div": "
Reportability Response Information Section
"}, "extension": [{"url": "http://hl7.org/fhir/us/ecr/StructureDefinition/rr-composition", "valueIdentifier": {"use": "official", "type": {"coding": [{"code": "88085-6", "display": "Reportability response report Document Public health", "system": "http://loinc.org"}]}, "value": "1fb3d498-c3cb-4115-afd5-b8bfbc5fa2f9"}}, {"url": "http://hl7.org/fhir/us/ecr/StructureDefinition/rr-eicr-processing-status-extension", "valueCodeableConcept": {"coding": [{"code": "RRVS19", "display": "eICR processed", "system": "urn:oid:2.16.840.1.114222.4.5.274"}]}}], "code": {"coding": [{"code": "88085-6", "display": "Reportability response report Document Public health", "system": "http://loinc.org"}]}, "entry": [{"display": "Relevant Reportable Condition Observation - Malignant neoplastic disease (disorder)", "reference": "Observation/81921be7-9dfe-4a10-a360-47bee2c2490b"}]}], "subject": {"reference": "Patient/7667e154-a859-46ec-8f6d-30624d526cde"}, "relatesTo": [{"code": "replaces", "targetReference": 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"url": "Practitioner/3f9a8f0e-6eda-2c06-6caf-280ec5f58845"}}, {"resource": {"resourceType": "PractitionerRole", "id": "fc583f8f-7555-8eb8-aed6-174c592c10a8", "practitioner": {"reference": "Practitioner/3f9a8f0e-6eda-2c06-6caf-280ec5f58845"}, "organization": {"reference": "Organization/1dde1de0-65fa-bed4-6e56-e6bf9a47315a"}, "meta": {"source": "ecr"}}}, {"fullUrl": "urn:uuid:1dde1de0-65fa-bed4-6e56-e6bf9a47315a", "resource": {"resourceType": "Organization", "id": "1dde1de0-65fa-bed4-6e56-e6bf9a47315a", "name": "Providence California", "address": [{"use": "work", "line": ["4733 TORRANCE BLVD #4400"], "city": "TORRANCE", "state": "CA", "country": "USA", "postalCode": "90503", "district": "LOS ANGELES"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/1dde1de0-65fa-bed4-6e56-e6bf9a47315a"}}, {"fullUrl": "urn:uuid:f87de327-7272-42ac-012d-58904caf7ef1", "resource": {"resourceType": "Organization", "id": "f87de327-7272-42ac-012d-58904caf7ef1", "meta": 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MemberRoleStatusDates
Kevin Lanzilloattending physicianActive
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MRS. PUMSEN R SOR SRprimary care physicianActive
Start: March 17th, 2022
Sandra E Hoytadmitting physicianActive
Start: March 17th, 2022
DR. LARDIEREFAMILYActive
Start: March 17th, 2022
Brian Leary , MDREFERRINGActive
Start: March 17th, 2022
DR. DAVID CONNOROTHERActive
Start: March 17th, 2022
MCUTLERCONSULTINGActive
Start: March 17th, 2022
Samuel HoytNext of KinActive
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Never smoker (Never Smoked)March 17th, 2022 2:54pm
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Not pregnantMarch 17th, 2022
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Gender Identityunknown
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HeadacheActive
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RIFA150C15 (Rifampin ) 150 MG CAPSULE150MGORALBIDMarch 18th, 2022 3:30pmMarch 18th, 2022 3:30pm
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Author
CANTON MEDICAL CENTER OF MASSACHUSETTS-North Canton FacilitSandra Hoyt
AuthoredMarch 22nd, 2022 11:23am
Follow-up with PSOR referral and PCP.
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WHITE BLOOD COUNT
HEMOGLOBIN
HEMATOCRIT
MEAN CELL VOLUME
MEAN CORPUSCULAR HEMOGLOBIN
PLATELET COUNT
COVID19 OTHER VENDOR 94500-6March 18th, 2022 2:48pmMarch 18th, 2022
COVID-19 OV 94500-6March 17th, 2022 5:06pmMarch 31st, 2022
HIV Test: LOINC 10351-5March 22nd, 2022 11:26amMarch 28th, 2022
Reason for ReferralReferral Start DateProviderProvider Contact InformationProvider Address
Cardiac abnormalityPUMSEN''S PROVIDER GROUPWork Phone: +1(508)789-7891
BROCKTON MA 02301SUITE 1010110 MAIN ST
Medication NameStart DateInstructions
Atorvastatin Calcium Tablet Dispense (LIPITOR - WITH DISPENSE) 40 MG TABMarch 17th, 2022 3:48pm
Benazepril HCl (Benazepril) 40 MG TABLETMarch 22nd, 2022 8:32am
Cyclobenzaprine (CYCL10T) 10 MG TABMarch 21st, 2022 4:19pm
Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 21st, 2022 3:59pm
Rifampin - RXCUI C198201 (RIFAMPIN150 MG) 150 MG CAPMarch 17th, 2022 3:48pm
Severe Acute Respiratory Syndrome (SARS)

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Providers-Please access the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV and the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV plus FDA FACT Sheet at the following web \u00a0address: www.providence.org/covidtesting
Patients-Please access the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV and the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSVplus FDA FACT sheet at the following \u00a0address: www.providence.org/covidtesting
Testing performed using the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV or the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSVplus, PCR Testing
\u00a0
This laboratory is certified under the Clinical Laboratory Improvement Amendments (CLIA) Act, to perform, at minimum, Waived Testing.\u00a0 This test''s performance characteristics have been verified. These results are not intended to be used as the sole means for clinical diagnosis or patient management decisions.
\u00a0
This test has not been FDA cleared or approved. This test has been authorized by the FDA under an EUA for use by authorized laboratories. This test is only authorized for the duration of time the declaration that circumstances exist justifying the authorization of the emergency use of in vitro diagnostic tests for detection of SARS-CoV-2 virus and/or diagnosis of COVID-19 infection under section 564(b)(1) of the Act, 21 U.S.C. 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
If only one viral target is positive but coinfection with multiple targets is suspected, the sample should be re-tested with another FDA cleared, approved, or authorized test, if coinfection would change clinical management.
Positive (Detected) results are indicative of the presence of SARS-CoV-2 RNA, clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses.
\u00a0
This is a PCR performed test.
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NameAdministration DatesNext Due
Hepatitis B Pediatric/Adolescent07/27/2024 Deferred: Patient Refused ) (
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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
erythromycin (ROMYCIN) 5 mg/gram (0.5 %) eye ointment 1 Application1 Application, Both Eyes, Once, On Thu 7/25/24 at 1245, 1 dose, Administer within one hour of birth.Given07/25/2024 8:09 PM CDT1 Application
phytonadione-vitamin K (AQUA-MEPHYTON) injection 0.5-1 mg0.5-1 mg, Intramuscular, Once, On Thu 7/25/24 at 1245, 1 dose, Give 0.5 mg for newborns with birthweight less than 1000 g; give 1 mg for newborns with birthweight over 1000 g. Administer within one hour of birth.Given07/25/2024 8:09 PM CDT1 mgLeft Anterior Thigh
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ProblemNoted DateDiagnosed Date
Term newborn delivered vaginally, current hospitalization07/26/2024
Term birth of newborn female07/25/2024
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Smoking Tobacco: Never Assessed
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
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DateTypeDepartmentCare Team (Latest Contact Info)Description
07/25/2024 8:08 PM CDT - 07/27/2024 3:52 PM CDTHospital EncounterWOM NURSERY6225 Humphreys BlvdMemphis, TN 38120901-227-9000Sevier, Georgette Rochelle, MD5366 Mendenhall MallMemphis, TN 38115901-842-3163 (Work)901-842-2368 (Fax)Discharge Disposition: Home
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Reportability Response Information Section
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1701 Century Center Cove Memphis, TN 38134
American Esoteric Laboratories
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NameAdministration DatesNext Due
Anthrax07/01/2007 06/17/2007 06/02/2007 , ,
FLU VACCINE (IIV4) EQUAL TO 6MONTHS-35MONTHS OLD WITH PRESERVATIVE (VFC)10/19/2021 11/04/2019 ,
Flu vaccine (IIV4) 6months and older, preservative free11/03/2023 12/07/2022 12/09/2020 10/17/2018 11/03/2017 , , , ,
Flu vaccine, quadrivalent, intranasal 2years-49 years (VFC)10/15/2013
Hep A / Hep B09/01/2005 06/23/2004 05/25/2004 05/23/2004 , , ,
Hep A, Adult09/01/2005
IPV11/15/2004 05/25/2004 ,
Influenza, Split (incl. purified surface antigen)11/30/2010 02/25/2009 11/30/2007 10/27/2006 11/09/2005 05/25/2004 , , , , ,
Influenza, Unspecified10/24/2017
Influenza, injectable, MDCK, quadrivalent10/24/2017
Influenza, live, intranasal10/09/2012 10/19/2011 11/19/2010 09/22/2009 , , ,
Influenza, seasonal, injectable, preservative free03/07/2017 10/05/2015 09/29/2014 , ,
MMR10/26/2017 05/25/2004 ,
Meningococcal MPSV405/25/2004
Novel influenza-H1N1-0902/11/2010
OPV01/10/2006
PPD Test09/22/2008
Pneumococcal Polysaccharide PPV2309/01/2021
TD (adult), 2 Lf tetanus toxoid, preservative free, adsorbed06/23/2004 05/25/2004 ,
Tdap05/12/2023 08/17/2012 ,
Tetanus toxoid, adsorbed06/12/2006
Typhoid, ViCPs08/17/2012 12/06/2006 11/16/2006 11/15/2004 , , ,
Yellow Fever06/23/2004
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-010B-6AE5-8B6D-9DF4AB7CEB82", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "2f9a48f2-d7fe-2c68-f260-152a5836c902", "title": "Plan of Treatment", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/b2c66834-765a-abc7-50d7-b70310498762"}]}, {"id": "00000000-010B-6AE6-8B6D-9DF4AB7CEB82", "title": "Problems", "text": {"status": "generated", "div": "
ProblemNoted DateDiagnosed Date
BMI 29.0-29.9,adult11/03/2023
Type 2 diabetes mellitus with hyperosmolarity without coma, without long-term current use of insulin06/23/2023
Hyperlipidemia06/23/2023
Hypertension06/23/2023
Assessment & Plan (06/23/2023 12:39 PM CDT):Formatting of this note might be different from the original.
stable
Viral infection, unspecified06/23/2023
Edema06/08/2023
COVID-1901/21/2022
Plantar fasciitis06/22/2019
Assessment & Plan (06/23/2023 12:40 PM CDT):Formatting of this note might be different from the original.
Uses inserts--podiatry referral
Baker''s cyst of knee, right06/05/2019
Carpal tunnel syndrome06/22/2018
Cubital tunnel syndrome of both upper extremities06/22/2018
Type 2 diabetes mellitus06/01/2017
Fusion of spine, cervical region06/01/2016
Arthritis06/01/2015
Diverticulitis02/01/2009
documented as of this encounter (statuses as of 07/29/2024)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Type 2 diabetes mellitus with hyperosmolarity without coma, without long-term current use of insulin", "reference": "Condition/cbf5ec25-b066-bb06-63e8-02f62976aa22"}, {"display": "Problem - Arthritis", "reference": "Condition/7ac38eec-073d-2cd9-32c7-8e93bab99ef7"}, {"display": "Problem - Plantar fasciitis", "reference": "Condition/30c861ed-e2fd-1b14-4819-6855a869305f"}, {"display": "Problem - Baker''s cyst of knee, right", "reference": "Condition/61b4aa09-f43a-07b3-b617-cb64c3ecb239"}, {"display": "Problem - Carpal tunnel syndrome", "reference": "Condition/805abf56-1314-73bc-811f-90f0aaf23665"}, {"display": "Problem - Cubital tunnel syndrome of both upper extremities", "reference": "Condition/7b01cd67-b162-a52d-fe2f-e7f49dd8aa08"}, {"display": "Problem - Diverticulitis", "reference": "Condition/a35f515c-1028-e41e-0b7e-4c167fc0b1c5"}, {"display": "Problem - Edema", "reference": "Condition/a92758d4-41d9-885a-6381-7386899815d4"}, {"display": "Problem - Fusion of spine, cervical region", "reference": "Condition/56c0d3f1-b56f-249a-7e07-5967929c1e2a"}, {"display": "Problem - Hyperlipidemia", "reference": "Condition/6d046942-f33a-04f5-4f02-cfcdca81e30d"}, {"display": "Problem - Hypertension", "reference": "Condition/86857c4a-e988-a30b-1710-381aa1144609"}, {"display": "Problem - Viral infection, unspecified", "reference": "Condition/21645922-1ee9-d207-7dd0-1ec82067acd2"}, {"display": "Problem - COVID-19", "reference": "Condition/8d73a4bc-ca56-33c7-c91d-e025b35405d6"}, {"display": "Problem - Type 2 diabetes mellitus", "reference": "Condition/3bf53746-727c-758a-2f13-0dfe10105a7e"}, {"display": "Problem - BMI 29.0-29.9,adult", "reference": "Condition/7a4e0659-8e44-f40d-b316-8063ad426f02"}]}, {"id": "f40a22d7-23dc-cf63-8c19-c55a1ed03d2b", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "00000000-010B-6AE7-8B6D-9DF4AB7CEB82", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "POCT Covid Rapid Test - PCR", "reference": "Observation/21458942-e225-89eb-59fc-1c257862d745"}, {"display": "Lab Interpretation", "reference": "Observation/cee4c18f-a5a5-8322-ad9a-ad81e3ac7ee0"}]}, {"id": "1af939c5-d9ab-8ed4-d28c-78b3fc9e3ef1", "title": "Social History", "text": {"status": "generated", "div": "
Smoking Status as of 07/12/2024
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Every DayCigarettes0.515
Smokeless Tobacco: Never
Tobacco Cessation:
Ready to Quit: Not Asked; Counseling Given: Not Answered
Smoking Status as of 10/02/2023
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Every DayCigarettes0.515
Smokeless Tobacco: Never
Alcohol Use as of 07/12/2024
Alcohol UseStandard Drinks/WeekComments
Yes2 (1 standard drink = 0.6 oz pure alcohol)OCCASIONAL
Humiliation, Afraid, Rape, and Kick questionnaireAnswerDate Recorded
Within the last year, have you been afraid of your partner or ex-partner?No06/22/2023
Within the last year, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?Patient declined06/22/2023
Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?No06/22/2023
Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?No06/22/2023
Social Connection and Isolation Panel [NHANES]AnswerDate Recorded
In a typical week, how many times do you talk on the phone with family, friends, or neighbors?More than three times a week06/22/2023
How often do you get together with friends or relatives?Three times a week06/22/2023
How often do you attend church or religious services?1 to 4 times per year06/22/2023
Do you belong to any clubs or organizations such as church groups, unions, fraternal or athletic groups, or school groups?Yes06/22/2023
How often do you attend meetings of the clubs or organizations you belong to?1 to 4 times per year06/22/2023
Are you married, widowed, divorced, separated, never married, or living with a partner?Married06/22/2023
AUDIT-CAnswerDate Recorded
Q1: How often do you have a drink containing alcohol?2-4 times a month06/22/2023
Q2: How many drinks containing alcohol do you have on a typical day when you are drinking?1 or 206/22/2023
Q3: How often do you have six or more drinks on one occasion?Never06/22/2023
Overall Financial Resource Strain (CARDIA)AnswerDate Recorded
How hard is it for you to pay for the very basics like food, housing, medical care, and heating?Not hard at all06/22/2023
PHQ-2AnswerDate Recorded
Patient Health Questionnaire-2 Score404/25/2024
Finnish Institute of Occupational Health - Occupational Stress QuestionnaireAnswerDate Recorded
Do you feel stress - tense, restless, nervous, or anxious, or unable to sleep at night because your mind is troubled all the time - these days?Rather much06/22/2023
Exercise Vital SignAnswerDate Recorded
On average, how many days per week do you engage in moderate to strenuous exercise (like a brisk walk)?2 days06/22/2023
On average, how many minutes do you engage in exercise at this level?30 min06/22/2023
Hunger Vital SignAnswerDate Recorded
Within the past 12 months, you worried that your food would run out before you got the money to buy more.Never true06/22/2023
Within the past 12 months, the food you bought just didn''t last and you didn''t have money to get more.Never true06/22/2023
PRAPARE - TransportationAnswerDate Recorded
In the past 12 months, has lack of transportation kept you from medical appointments or from getting medications?No06/22/2023
In the past 12 months, has lack of transportation kept you from meetings, work, or from getting things needed for daily living?No06/22/2023
Housing StabilityAnswerDate Recorded
In the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?No06/22/2023
In the last 12 months, how many places have you lived?306/22/2023
In the last 12 months, was there a time when you did not have a steady place to sleep or slept in a shelter (including now)?No06/22/2023
Health LiteracyAnswerDate Recorded
Do you ever need help reading medical materials?206/22/2023
Child CareAnswerDate Recorded
Child Care: Difficult to Study or WorkNot on file07/08/2024
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthMale06/22/2023 12:50 PM CDT
Gender IdentityMale06/22/2023 12:50 PM CDT
Sexual OrientationStraight06/22/2023 12:50 PM CDT
Job Start DateOccupationIndustry
Not on fileNot on fileNot on file
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DateTypeDepartmentCare Team (Latest Contact Info)Description
07/29/2024 12:30 PM CDTOffice VisitWest TN Medical Group Primary Care Thomsen Farms1270 Union University DrJACKSON, TN 38305-3855731-664-0103Rasnic, Allison Leigh, NP1270 Union University DriveOFF1Jackson, TN 38305731-664-0103 (Work)731-512-3548 (Fax)Fever, unspecified fever cause (Primary Dx)
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Reportability Response Information Section
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{"coding": [{"code": "02", "display": "OPV", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "UNKNOWN", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/d52f7a35-167a-6655-af9b-9be956abe602"}}, {"fullUrl": "urn:uuid:d471fff1-2abf-d774-a9bb-d32c90316b25", "resource": {"resourceType": "Immunization", "id": "d471fff1-2abf-d774-a9bb-d32c90316b25", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460489"}], "occurrenceDateTime": "2004-05-25", "note": {"text": "TD (adult), 2 Lf tetanus toxoid, preservative free, adsorbed"}, "vaccineCode": {"coding": [{"code": "09", "display": "TD (adult), 2 Lf tetanus toxoid, preservative free, adsorbed", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "U1021AA", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/d471fff1-2abf-d774-a9bb-d32c90316b25"}}, {"fullUrl": "urn:uuid:29828f28-e013-a2c4-56fc-d1df5ba7c91e", "resource": {"resourceType": "Immunization", "id": "29828f28-e013-a2c4-56fc-d1df5ba7c91e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460490"}], "occurrenceDateTime": "2004-06-23", "note": {"text": "TD (adult), 2 Lf tetanus toxoid, preservative free, adsorbed"}, "vaccineCode": {"coding": [{"code": "09", "display": "TD (adult), 2 Lf tetanus toxoid, preservative free, adsorbed", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "UNKNOWN", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/29828f28-e013-a2c4-56fc-d1df5ba7c91e"}}, {"fullUrl": "urn:uuid:7bc8421b-ed36-603a-ca86-bd84e3484d4e", "resource": {"resourceType": "Immunization", "id": "7bc8421b-ed36-603a-ca86-bd84e3484d4e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460491"}], "occurrenceDateTime": "2006-06-12", "note": {"text": "Tetanus toxoid, adsorbed"}, "vaccineCode": {"coding": [{"code": "35", "display": "Tetanus toxoid, adsorbed", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "UNKNOWN", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/7bc8421b-ed36-603a-ca86-bd84e3484d4e"}}, {"fullUrl": "urn:uuid:eb0eed28-1116-fc4b-62af-be2b0967b527", "resource": {"resourceType": "Immunization", "id": "eb0eed28-1116-fc4b-62af-be2b0967b527", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460492"}], "occurrenceDateTime": "2012-08-17", "note": {"text": "Tdap"}, "vaccineCode": {"coding": [{"code": "115", "display": "Tdap", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "C419AA", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/eb0eed28-1116-fc4b-62af-be2b0967b527"}}, {"fullUrl": "urn:uuid:6dccd213-5796-7aa6-43e1-43a33287407a", "resource": {"resourceType": "Immunization", "id": "6dccd213-5796-7aa6-43e1-43a33287407a", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460493"}], "occurrenceDateTime": "2023-05-12", "note": {"text": "Tdap"}, "vaccineCode": {"coding": [{"code": "115", "display": "Tdap", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "2755D", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/6dccd213-5796-7aa6-43e1-43a33287407a"}}, {"fullUrl": "urn:uuid:7879c465-7969-7238-fb88-fa89e709a4e2", "resource": {"resourceType": "Immunization", "id": "7879c465-7969-7238-fb88-fa89e709a4e2", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460494"}], "occurrenceDateTime": "2008-09-22", "note": {"text": "PPD Test"}, "vaccineCode": {"coding": [{"code": "96", "display": "PPD Test", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "TRANSCRIBED", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/7879c465-7969-7238-fb88-fa89e709a4e2"}}, {"fullUrl": "urn:uuid:35293781-d68e-59e5-8dcb-395f0174693f", "resource": {"resourceType": "Immunization", "id": "35293781-d68e-59e5-8dcb-395f0174693f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460495"}], "occurrenceDateTime": "2012-08-17", "note": {"text": "Typhoid, ViCPs"}, "vaccineCode": {"coding": [{"code": "101", "display": "Typhoid, ViCPs", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "G1541-1", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/35293781-d68e-59e5-8dcb-395f0174693f"}}, {"fullUrl": "urn:uuid:a564e91e-1697-a13d-9da0-89191ec294fd", "resource": {"resourceType": "Immunization", "id": "a564e91e-1697-a13d-9da0-89191ec294fd", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460496"}], "occurrenceDateTime": "2006-11-16", "note": {"text": "Typhoid, ViCPs"}, "vaccineCode": {"coding": [{"code": "101", "display": "Typhoid, ViCPs", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "UNK", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/a564e91e-1697-a13d-9da0-89191ec294fd"}}, {"fullUrl": "urn:uuid:63a8e21d-48e2-4523-3fd8-e6dcd11d5799", "resource": {"resourceType": "Immunization", "id": "63a8e21d-48e2-4523-3fd8-e6dcd11d5799", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460497"}], "occurrenceDateTime": "2006-12-06", "note": {"text": "Typhoid, ViCPs"}, "vaccineCode": {"coding": [{"code": "101", "display": "Typhoid, ViCPs", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "Z0663", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/63a8e21d-48e2-4523-3fd8-e6dcd11d5799"}}, {"fullUrl": "urn:uuid:accebbab-2bca-b7a4-6c62-c8434fb06677", "resource": {"resourceType": "Immunization", "id": "accebbab-2bca-b7a4-6c62-c8434fb06677", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460498"}], "occurrenceDateTime": "2004-11-15", "note": {"text": "Typhoid, ViCPs"}, "vaccineCode": {"coding": [{"code": "101", "display": "Typhoid, ViCPs", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "UNKNOWN", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/accebbab-2bca-b7a4-6c62-c8434fb06677"}}, {"fullUrl": "urn:uuid:77e08339-011e-600e-1ff9-8d79e8a4abfb", "resource": {"resourceType": "Immunization", "id": "77e08339-011e-600e-1ff9-8d79e8a4abfb", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460499"}], "occurrenceDateTime": "2004-06-23", "note": {"text": "Yellow Fever"}, "vaccineCode": {"coding": [{"code": "37", "display": "Yellow Fever", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "UE014AA", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/77e08339-011e-600e-1ff9-8d79e8a4abfb"}}, {"fullUrl": "urn:uuid:286a4b61-e56e-1996-3461-01f290ac9729", "resource": {"resourceType": "Immunization", "id": "286a4b61-e56e-1996-3461-01f290ac9729", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3610956"}], "occurrenceDateTime": "2023-11-03", "note": {"text": "Flu vaccine (IIV4) 6months and older, preservative free"}, "vaccineCode": {"coding": [{"code": "58160-909-41", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "FJ4X5", "manufacturer": {"reference": "Organization/a1439865-b6cb-7b35-67e3-cc00011c9f1c"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/286a4b61-e56e-1996-3461-01f290ac9729"}}, {"fullUrl": "urn:uuid:a1439865-b6cb-7b35-67e3-cc00011c9f1c", "resource": {"resourceType": "Organization", "id": "a1439865-b6cb-7b35-67e3-cc00011c9f1c", "name": "GlaxoSmithKline", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/a1439865-b6cb-7b35-67e3-cc00011c9f1c"}}, {"fullUrl": "urn:uuid:fcf0aad4-b6f1-f11c-c9fb-3e5095310810", "resource": {"resourceType": "Immunization", "id": "fcf0aad4-b6f1-f11c-c9fb-3e5095310810", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "4361173"}], "occurrenceDateTime": "2017-10-24", "note": {"text": "Influenza, Unspecified"}, "vaccineCode": {"coding": [{"code": "88", "display": "Influenza, Unspecified", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "L95248", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d336b2d5-59ec-4c05-a00c-ada2bca2c34b"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/fcf0aad4-b6f1-f11c-c9fb-3e5095310810"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.66.2.7.8.688883.2728380843', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.66.2.7.8.688883.2728380843", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.66.2.7.8.688883.2728380843", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-247f-f505-e118-3adff9b59515", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "10"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-07-29T05:28:19-07:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "abf8106a-2b40-0578-d253-08a75fbbdf9d", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-0B5E-F190-C213-F6543E4A3F7B", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
DTP08/19/1986 06/25/1982 07/15/1981 04/08/1981 12/12/1980 , , , ,
Flu, Preservative Free11/08/2022 10/04/2021 09/16/2020 , ,
HEP A-HEP B04/09/2018 09/26/2016 08/26/2016 , ,
HIB, HISTORICAL08/19/1982
Hib (HbOC)08/19/1986
MMR (MMR II/Priorix)03/19/1982
Moderna COVID-19 Vaccine, red cap blue label, 12+ Primary Series08/31/2021 01/29/2021 12/29/2020 , ,
OPV, Trivalent08/19/1986 06/25/1982 07/15/1981 04/08/1981 12/12/1980 , , , ,
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-0B5E-F191-C213-F6543E4A3F7B", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "93d6a0b5-34fa-8d23-19f5-729b79cb0d33", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
07/30/2024 10:00 AM PDTTelemedicine VisitCempa Community Care Clinic1000 East Third St Suite 300Chattanooga, TN 37403-2153423-265-2273Campbell, Zachary, NP-C1000 EAST THIRD STSUITE 300CHATTANOOGA, TN 37403423-265-2273 (Work)423-648-9935 (Fax)
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/20ba7b1c-caa5-5e98-ecfc-93e28bb0cfd8"}]}, {"id": "00000000-0B5E-F192-C213-F6543E4A3F7B", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
Acute left flank pain08/03/2023
Overview:Formatting of this note might be different from the original.
Pt c/o mild left sided back/flank pain w/o the presence of hematuria or dysuria. Pt states he has been exercising and working out more and believes this coincides with his new exercise routine. No CVA tenderness, site is not tender or acutely painful. Discomfort improves when not slouching, likely muscle strain. Recommended ice and heat therapy and if site pain does not improve in 4 weeks to call clinic for additional support.
Need for vaccination11/08/2022
Erectile dysfunction11/08/2022
Overview:Formatting of this note might be different from the original.
Pt states sildenafil works well and has had no adrs or se related to medication administration. Requires refill today.
Anxiety disorder09/30/2020
Obesity09/30/2020
Human immunodeficiency virus (HIV) disease (HCC-CMS)01/01/2014
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Long-term well-controlled HIV. His primary health concerns are primary care in naturePt denies barriers to care or medication administration at this time. Denies ADRs and s/e to medication administration and denies any missed doses. Formatting of this note might be different from the original.
Follow up in clinic in 6 months for lab results with labs drawn one week before.Encouraged overall health behavior modifications to improve health including diet and exercise.Encouraged ongoing adherence to this regimen and discussed side effects, risks and benefits of antiretroviral therapy.Continue current HAART.
Blood chemistry abnormal
Controlled type 2 diabetes mellitus without complication, without long-term current use of insulin (HCC-CMS)
Overview:Formatting of this note might be different from the original.
Pt has only been taking Synjardy d/t being out of his Trulicity and unable to find time to refill medication. Pt''s A1C has only shown a mild increase of 4/10 of a point. Educated pt on the importance of medication administration but his A1C is still well controlled at this time. Pt voiced understanding. Denies any ADRs to medication admin.
Mixed hyperlipidemia
Insomnia disorder related to another mental disorder
Benign essential hypertension
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Pt''s BP is mildly elevated today but he states he was rushed to get to Hub location, didn''t know which office was ours and mildly irritated by experience. Feels fine now and denies HA. Has no barriers to taking his antihypertensives at this time. Will continue to refill and recheck at next visit. Formatting of this note might be different from the original.
Discussed sodium restriction, maintaining ideal body weight and regular exercise program as physiologic means to achieve blood pressure control. The patient will strive towards this. Meanwhile, it is appropriate to lower BP with medications, while observing for therapeutic effect and if appropriate later, can discontinue medications if physiologic methods appear to be effective. The patient indicates understanding of these issues and agrees to the plan. The various types of antihypertensives are discussed fully. See medication orders in EpicCare. Side effects explained in detail. Continue home readings and see me for follow-up as scheduled.
Impotence of organic origin
Obese class II
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Yes2 (1 standard drink = 0.6 oz pure alcohol)1-2 DRINKS 2 TO 4 TIMES A MONTH
Social ConnectionsAnswerDate Recorded
Social Connections and Isolation009/02/2022
Financial Resource StrainAnswerDate Recorded
Financial Resource Strain009/02/2022
StressAnswerDate Recorded
Stress009/02/2022
Physical ActivityAnswerDate Recorded
Physical Activity009/02/2022
Food InsecurityAnswerDate Recorded
Food009/02/2022
Transportation NeedsAnswerDate Recorded
Transportation009/02/2022
Housing StabilityAnswerDate Recorded
Housing009/02/2022
Safety and EnvironmentAnswerDate Recorded
Safety009/02/2022
UtilitiesAnswerDate Recorded
Utilities009/02/2022
EmploymentAnswerDate Recorded
Employment009/02/2022
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthMale11/08/2022 11:08 AM PST
Gender IdentityMale09/12/2022 7:42 PM PDT
Sexual OrientationLesbian or Gay09/12/2022 7:42 PM PDT
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DateTypeDepartmentCare Team (Latest Contact Info)Description
07/24/2024 8:30 AM PDTErroneous EncounterCempa Community Care Clinic1000 East Third St Suite 300Chattanooga, TN 37403-2153423-265-2273Campbell, Zachary, NP-C1000 EAST THIRD STSUITE 300CHATTANOOGA, TN 37403423-265-2273 (Work)423-648-9935 (Fax)
ERRONEOUS ENCOUNTER--DISREGARDAnxiety disorder, unspecified type; Blood chemistry abnormal; Other problems related to lifestyle; Encounter for screening for infections with predominantly sexual mode of transmission; Other long term (current) drug therapy; Human immunodeficiency virus (HIV) disease (HCC-CMS) (Primary Dx);
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Reportability Response Information Section
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"urn:ietf:bcp:47"}]}}]}, "request": {"method": "PUT", "url": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "CareTeam", "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}}, {"fullUrl": "urn:uuid:20ba7b1c-caa5-5e98-ecfc-93e28bb0cfd8", "resource": {"resourceType": "CarePlan", "id": "20ba7b1c-caa5-5e98-ecfc-93e28bb0cfd8", "status": "unknown", "intent": "proposal", "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "CarePlan/20ba7b1c-caa5-5e98-ecfc-93e28bb0cfd8"}}, {"fullUrl": "urn:uuid:fafbd077-661e-b35b-ea24-dd63a8462b1b", "resource": {"resourceType": "Condition", "id": "fafbd077-661e-b35b-ea24-dd63a8462b1b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687221"}], "clinicalStatus": {"coding": [{"code": "246455001", "display": "Recurrence", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "B20", "display": "Human immunodeficiency virus (HIV) disease (HCC-CMS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2014-01-01", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote34
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System.Collections.Generic.List`1[System.Object]
problemNote35
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System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}, "extension": [{"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "86406008", "system": "http://snomed.info/sct"}]}]}, "request": {"method": "PUT", "url": "Condition/fafbd077-661e-b35b-ea24-dd63a8462b1b"}}, {"fullUrl": "urn:uuid:2d171402-d536-5802-8c2e-9a26718e377c", "resource": {"resourceType": "Condition", "id": "2d171402-d536-5802-8c2e-9a26718e377c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687224"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R79.9", "display": "Abnormal blood chemistry level", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-09-07T10:37:26-07:00", "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/2d171402-d536-5802-8c2e-9a26718e377c"}}, {"fullUrl": "urn:uuid:169ad249-aac7-e6a7-aa55-5e17876e5d91", "resource": {"resourceType": "Condition", "id": "169ad249-aac7-e6a7-aa55-5e17876e5d91", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687226"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "F41.9", "display": "Anxiety disorder", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2020-09-30", "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/169ad249-aac7-e6a7-aa55-5e17876e5d91"}}, {"fullUrl": "urn:uuid:759aac4d-1e78-cda4-e581-51ffa5628b38", "resource": {"resourceType": "Condition", "id": "759aac4d-1e78-cda4-e581-51ffa5628b38", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687229"}], "clinicalStatus": {"coding": [{"code": "246455001", "display": "Recurrence", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.9", "display": "Controlled type 2 diabetes mellitus without complication, without long-term current use of insulin (HCC-CMS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-08-03T15:11:31-07:00", "note": [{"text": "Overview:
problemNote40
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Pt has only been taking Synjardy d/t being out of his Trulicity and unable to find time to refill medication. Pt''s A1C has only shown a mild increase of 4/10 of a point. Educated pt on the importance of medication administration but his A1C is still well controlled at this time. Pt voiced understanding. Denies any ADRs to medication admin. "}], "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/759aac4d-1e78-cda4-e581-51ffa5628b38"}}, {"fullUrl": "urn:uuid:b9c369fb-95cc-02ab-d326-5957784ef703", "resource": {"resourceType": "Condition", "id": "b9c369fb-95cc-02ab-d326-5957784ef703", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687231"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E78.2", "display": "Mixed hyperlipidemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-09-07T10:37:26-07:00", "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/b9c369fb-95cc-02ab-d326-5957784ef703"}}, {"fullUrl": "urn:uuid:6476b8da-a197-94a5-99a5-298b2df82320", "resource": {"resourceType": "Condition", "id": "6476b8da-a197-94a5-99a5-298b2df82320", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687234"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E66.9", "display": "Obesity", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2020-09-30", "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/6476b8da-a197-94a5-99a5-298b2df82320"}}, {"fullUrl": "urn:uuid:d54bb5b7-c31a-0cc9-3f83-7c4300565059", "resource": {"resourceType": "Condition", "id": "d54bb5b7-c31a-0cc9-3f83-7c4300565059", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687237"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "F51.05", "display": "Insomnia related to another mental disorder", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-09-07T10:37:26-07:00", "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/d54bb5b7-c31a-0cc9-3f83-7c4300565059"}}, {"fullUrl": "urn:uuid:ae076694-18bc-1321-3f6b-ff56f881ff3e", "resource": {"resourceType": "Condition", "id": "ae076694-18bc-1321-3f6b-ff56f881ff3e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687240"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I10", "display": "Benign essential hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-08-03T15:12:38-07:00", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote45
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Pt''s BP is mildly elevated today but he states he was rushed to get to Hub location, didn''t know which office was ours and mildly irritated by experience. Feels fine now and denies HA. Has no barriers to taking his antihypertensives at this time. Will continue to refill and recheck at next visit.
problemNote46
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Discussed sodium restriction, maintaining ideal body weight and regular exercise program as physiologic means to achieve blood pressure control. The patient will strive towards this. Meanwhile, it is appropriate to lower BP with medications, while observing for therapeutic effect and if appropriate later, can discontinue medications if physiologic methods appear to be effective. The patient indicates understanding of these issues and agrees to the plan. The various types of antihypertensives are discussed fully. See medication orders in EpicCare. Side effects explained in detail. Continue home readings and see me for follow-up as scheduled."}], "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ae076694-18bc-1321-3f6b-ff56f881ff3e"}}, {"fullUrl": "urn:uuid:5bd75093-1f4b-df91-1a3c-a34449937280", "resource": {"resourceType": "Condition", "id": "5bd75093-1f4b-df91-1a3c-a34449937280", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687242"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N52.9", "display": "Impotence of organic origin", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-09-07T10:37:26-07:00", "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5bd75093-1f4b-df91-1a3c-a34449937280"}}, {"fullUrl": "urn:uuid:75a3275b-0cf8-5865-2489-f106add93964", "resource": {"resourceType": "Condition", "id": "75a3275b-0cf8-5865-2489-f106add93964", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687245"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z68.39", "display": "Body mass index (BMI) 39.0-39.9, adult", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-09-07T10:37:26-07:00", "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/75a3275b-0cf8-5865-2489-f106add93964"}}, {"fullUrl": "urn:uuid:28002d98-3a28-b579-9deb-530e0ad889e5", "resource": {"resourceType": "Condition", "id": "28002d98-3a28-b579-9deb-530e0ad889e5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "169262051"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z23", "display": "Need for vaccination", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-11-08", "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/28002d98-3a28-b579-9deb-530e0ad889e5"}}, {"fullUrl": "urn:uuid:f29ecf9e-1bd7-0364-3881-ecd275509c6e", "resource": {"resourceType": "Condition", "id": "f29ecf9e-1bd7-0364-3881-ecd275509c6e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "169287254"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N52.9", "display": "Erectile dysfunction", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-11-08", "note": [{"text": "Overview:
problemNote51
Formatting of this note might be different from the original.

Pt states sildenafil works well and has had no adrs or se related to medication administration. Requires refill today. "}], "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/f29ecf9e-1bd7-0364-3881-ecd275509c6e"}}, {"fullUrl": "urn:uuid:e9ae6a11-aea2-0afc-d08e-7f0edc3eff83", "resource": {"resourceType": "Condition", "id": "e9ae6a11-aea2-0afc-d08e-7f0edc3eff83", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "193635834"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R10.9", "display": "Acute left flank pain", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-08-03", "note": [{"text": "Overview:
problemNote53
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Pt c/o mild left sided back/flank pain w/o the presence of hematuria or dysuria. Pt states he has been exercising and working out more and believes this coincides with his new exercise routine. No CVA tenderness, site is not tender or acutely painful. Discomfort improves when not slouching, likely muscle strain. Recommended ice and heat therapy and if site pain does not improve in 4 weeks to call clinic for additional support. 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Laboratory Director: Jonathan R. Genzen, MD, PhD
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500 Chipeta Way
Performed By: ARUP Laboratories
clinical purposes.
performed in a CLIA certified laboratory and is intended for
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determined by ARUP Laboratories. It has not been cleared or
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antiviral therapy and to monitor the efficacy of treatment. The
establish decision points for initiating P. jirovecii prophylaxis,
infection. The measurement of CD4 T-cell levels has been used to
clinical conditions by CDC''s classification system for HIV
T-cells levels are a criterion for categorizing HIV-related
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The CD4 cells are Helper T-cells expressing both CD3 and CD4. CD4
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1010 Airpark Center Dr., Suite C, Nashville, TN 37217
Benton R. Middleman, MD, Laboratory Director
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"request": {"method": "PUT", "url": "Observation/88a6052c-2067-5730-1766-351423cb9312"}}, {"fullUrl": "urn:uuid:4743a33c-da23-d66e-307a-095a16b29fd9", "resource": {"resourceType": "Observation", "id": "4743a33c-da23-d66e-307a-095a16b29fd9", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.6.798268.2000", "value": "780417444.6"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "13457-7", "display": "LDL Cholesterol (Calculation)", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-26T22:01:00Z", "valueQuantity": {"value": 60, "unit": "mg/dL"}, "referenceRange": [{"text": "<130", "high": {"value": 130, "unit": "mg/dL"}}], "note": [{"text": "* Categories as recommended by the 2004 ATPIII guidelines
\u00a0
\u00a0190 mg/dL and above \u00a0 \u00a0 Very High
\u00a0160 to 189 mg/dL \u00a0 \u00a0 \u00a0 \u00a0High
\u00a0130 to 159 mg/dL \u00a0 \u00a0 \u00a0 \u00a0Borderline High
\u00a0100 to 129 mg/dL \u00a0 \u00a0 \u00a0 \u00a0Near Optimal/ Above Optimal
\u00a0Less than 100 mg/dL \u00a0 \u00a0 Optimal
\u00a0LDL Cholesterol Levels*"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T11:27:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T20:53:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780417444.Comp6"}]}], "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/4743a33c-da23-d66e-307a-095a16b29fd9"}}, {"fullUrl": "urn:uuid:caccd32c-c9c5-5aa4-d1a0-4e0165b717d9", "resource": {"resourceType": "Observation", "id": "caccd32c-c9c5-5aa4-d1a0-4e0165b717d9", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.6.798268.2000", "value": "780417444.7"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "11054-4", "display": "LDL/HDL Ratio", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-26T22:01:00Z", "valueQuantity": {"value": 1.6}, "referenceRange": [{"text": "<3.3 Ratio", "high": {"value": "3.3", "unit": "Ratio"}}], "note": [{"text": "_________________________________________________________________________
% Change: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0-20%
Units: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 mg/dL
LDL Results: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 60
Test Date: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 07/24/2024
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% Change: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0+33%
Units: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 mg/dL
LDL Results: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 75
Test Date: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 01/24/2024
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% Change: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0-18%
Units: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 mg/dL
LDL Results: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 56
Test Date: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 07/21/2023
_________________________________________________________________________
LDL Cholesterol Patient History
_________________________________________________________________________"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T11:27:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T20:53:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780417444.Comp7"}]}], "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/caccd32c-c9c5-5aa4-d1a0-4e0165b717d9"}}, {"fullUrl": "urn:uuid:e88ff567-64c7-d714-7847-6ddddc5bbbdd", "resource": {"resourceType": "Observation", "id": "e88ff567-64c7-d714-7847-6ddddc5bbbdd", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.7.798268.1000", "value": "780417444"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-07-26T22:01:00Z", "valueString": "Test performed by PathGroup Labs, LLC
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\u00a0 \u00a0 \u00a0 \u00a0> 100 ng/mL - Super-therapeutic- toxicity may occur above this level.
\u00a0 \u00a0 30 - 100 ng/mL - Sufficiency
\u00a0 \u00a0 \u00a020 - 29 ng/mL - Insufficiency
\u00a0 \u00a0 \u00a0 \u00a0 < 20 ng/mL - Deficiency
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Benton R. Middleman, MD, Laboratory Director
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{"fullUrl": "urn:uuid:7fc7ce1f-074d-515e-2a8e-b6fc9e9f6462", "resource": {"resourceType": "DiagnosticReport", "id": "7fc7ce1f-074d-515e-2a8e-b6fc9e9f6462", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.798268", "value": "780419471"}], "status": "final", "code": {"coding": [{"code": "246184", "display": "HEMOGLOBIN A1C", "system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-07-24T11:27:00Z", "end": "2024-07-24T11:27:00Z"}, "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "performer": [{"reference": "Organization/8b4c0a0f-8c6a-6c97-70dd-334db61a6064"}], "result": [{"reference": "Observation/215e16f8-1244-dce9-3026-d832d5f7bb7a"}, {"reference": "Observation/bc6a3b90-6ca4-86da-8ed0-4aa9507436f6"}, {"reference": "Observation/7737ec18-c0e7-d9ad-dfaf-a10eceb79113"}, {"reference": "Observation/e0d66010-3fcd-ef77-7955-3cf2259c80ff"}, {"reference": "Observation/10cfc175-e8c4-1bf5-0541-5cade1854a9c"}], "meta": 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\u00a0 \u00a0 5.7% - 6.4% \u00a0 \u00a0 \u00a0 \u00a0 Pre-Diabetic
\u00a0 \u00a0 \u00a0 >=6.5% \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Diabetic
\u00a0 \u00a0 \u00a0 \u00a0HA1c \u00a0 \u00a0 \u00a0 \u00a0 Suggested Diagnosis
\u00a0(ADA) may be used as an aid in the diagnosis of diabetes mellitus.
\u00a0The following HbA1c ranges recommended by the American Diabetes Association"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T11:27:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T20:53:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780419471.Comp1"}]}], "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/215e16f8-1244-dce9-3026-d832d5f7bb7a"}}, {"fullUrl": "urn:uuid:bc6a3b90-6ca4-86da-8ed0-4aa9507436f6", "resource": {"resourceType": "Observation", "id": "bc6a3b90-6ca4-86da-8ed0-4aa9507436f6", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.6.798268.2000", "value": "780419471.2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "27353-2", "display": "ESTIMATED AVERAGE GLUCOSE", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-26T22:01:00Z", "valueQuantity": {"value": 123, "unit": "mg/dL"}, "note": [{"text": "based on the guidelines established by the ADA.
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1010 Airpark Center Dr., Suite C, Nashville, TN 37217
Benton R. Middleman, MD, Laboratory Director
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or sampling error. Test performed by Associated Pathologists, LLC
does not preclude a possible infection due to a specimen inadequacy
prevalence populations may require re-evaluation. A negative result
positive and negative results may occur. Positive results in low
clinical presentation. This assay is highly accurate, but rare false
Results should be interpreted in conjunction with patient history and
DNA testing performed by Transcription Mediated Amplification (TMA)."}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Urine"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T12:36:49Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T05:00:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780424744.Comp1"}]}], "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/1a5a946f-3485-5955-81e9-de8878ef3b48"}}, {"fullUrl": "urn:uuid:271443bb-810e-5f55-cc4e-a9a9e8603508", "resource": {"resourceType": "Observation", "id": "271443bb-810e-5f55-cc4e-a9a9e8603508", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.6.798268.2000", "value": "780424744.2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "43403-5", "display": "Neisseria gonorrhoeae", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-25T12:09:00Z", "valueString": "NOT DETECTED", "note": [{"text": "37217, Pranil K. Chandra, DO, Laboratory Director, CLIA# 44D2062928
d/b/a PathGroup, 1010 Airpark Center Dr., Suite M, Nashville, TN
or sampling error. Test performed by Associated Pathologists, LLC
does not preclude a possible infection due to a specimen inadequacy
prevalence populations may require re-evaluation. A negative result
positive and negative results may occur. Positive results in low
clinical presentation. This assay is highly accurate, but rare false
Results should be interpreted in conjunction with patient history and
DNA testing performed by Transcription Mediated Amplification (TMA)."}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Urine"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T12:36:49Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T05:00:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780424744.Comp2"}]}], "subject": {"reference": "Patient/14d4ed77-8e4a-4ce3-ad84-1d7030d6f285"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/271443bb-810e-5f55-cc4e-a9a9e8603508"}}, {"fullUrl": "urn:uuid:103e4385-7bcd-ce33-5ed7-6c401105ad01", "resource": {"resourceType": "Observation", "id": "103e4385-7bcd-ce33-5ed7-6c401105ad01", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.6.798268.2000", "value": "780424744.3"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "43404-3", "display": "Chlamydia trachomatis", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-25T12:09:00Z", "valueString": "NOT DETECTED", "note": [{"text": "37217, Pranil K. Chandra, DO, Laboratory Director, CLIA# 44D2062928
d/b/a PathGroup, 1010 Airpark Center Dr., Suite M, Nashville, TN
or sampling error. Test performed by Associated Pathologists, LLC
does not preclude a possible infection due to a specimen inadequacy
prevalence populations may require re-evaluation. A negative result
positive and negative results may occur. Positive results in low
clinical presentation. This assay is highly accurate, but rare false
Results should be interpreted in conjunction with patient history and
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"status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-07-27T00:07:13-04:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "b803948f-e4dc-37a4-0a7c-190a535ac9e7", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-547F-4477-1796-144FC31D1926", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
DTaP01/22/2020
DTaP / Hep B / IPV02/14/2019 12/03/2018 08/30/2018 , ,
DTaP / IPV08/09/2022
Hep A, 2 Dose Pediatric01/22/2020 07/03/2019 ,
Hep B, Adolescent or Pediatric06/22/2018
Hib (PRP-OMP)01/22/2020 12/03/2018 08/30/2018 , ,
Influenza, Quadrivalent, Ped Pres Free IM10/09/2019 04/18/2019 02/14/2019 , ,
Influenza, Quadrivalent, Pres Free (FLUARIX,FLULAVEL,FLUZONE)02/08/2021
Influenza, Quadrivalent, Pres Free (FLUCELVAX)09/20/2023
MMR07/03/2019
MMRV08/09/2022
Pneumococcal Conjugate 13-Valent01/22/2020 02/14/2019 12/03/2018 08/30/2018 , , ,
Rotavirus Pentavalent02/14/2019 12/03/2018 08/30/2018 , ,
Varicella07/03/2019
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-547F-448D-1796-144FC31D1926", "title": "Administered Medications", "text": {"status": "generated", "div": "
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
sodium chloride 0.9 % bolus 356 mL356 mL (20 mL/kg \u00d7 17.8 kg), intravenous, at 356 mL/hr, Administer over 1 Hours, Once, On Fri 7/26/24 at 2226, For 1 doseNew Bag07/26/2024 10:33 PM EDT356 mL356 mL/hr
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "49c8af06-d6a1-6bd0-44fa-92482bedd01e", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
11/11/2024 1:10 PM ESTOffice VisitEMG CHE General Pediatrics900 East Third Street2nd floorCHATTANOOGA, TN 37403423-778-5437Cox, Victoria S, DO910 Blackford StreetDepartment of PediatricsChattanooga, TN 37403423-778-5437 (Work)423-778-6958 (Fax)
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
POCT Occult Blood Stool, SinglePoint of Care TestingSTAT07/26/2024 9:20 PM EDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
Urinalysis Reflex To CultureLabSTATSTAT for 1 Occurrences starting 7/26/24 until 7/26/24
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ProblemNoted DateDiagnosed Date
Dental caries12/04/2023
Failed vision screen10/03/2022
Overview:Formatting of this note might be different from the original.
Anisometropia, myopia, astimatism and amblyopia. Seen on 8/11/22 and rx for glasses updated
Myopia07/08/2021
Overview:Formatting of this note might be different from the original.
Wears glasses
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Hunger Vital SignAnswerDate Recorded
Within the past 12 months, you worried that your food would run out before you got the money to buy more.Never true02/08/2021
Within the past 12 months, the food you bought just didn''t last and you didn''t have money to get more.Never true02/08/2021
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
Job Start DateOccupationIndustry
Not on fileNot on fileNot on file
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DateTypeDepartmentCare Team (Latest Contact Info)Description
07/26/2024 8:34 PM EDT - PresentEmergencyCH Emergency Room910 Blackford StreetChattanooga, TN 37403-2147423-778-6101Bruns, Thomas, MD975 EAST THIRD STREETCHATTANOOGA, TN 37403423-778-6060 (Work)423-778-3240 (Fax)
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Reportability Response Information Section
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"identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "8706612"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "H52.10", "display": "Myopia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-07-08", "note": [{"text": "Overview:
problemNote42
Formatting of this note might be different from the original.

Wears glasses"}], "subject": {"reference": "Patient/99869983-d02d-49b7-9927-ea5b1b0c1d20"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4d4c1cb7-7b26-51c3-b709-086eacfd35a8"}}, {"fullUrl": "urn:uuid:1ae9b4d2-1e00-722f-0752-05dedb50f785", "resource": {"resourceType": "Condition", "id": "1ae9b4d2-1e00-722f-0752-05dedb50f785", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "11155452"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z01.01", "display": "Failed vision screen", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-03", "note": [{"text": "Overview:
problemNote44
Formatting of this note might be different from the original.

Anisometropia, myopia, astimatism and amblyopia. Seen on 8/11/22 and rx for glasses updated "}], "subject": {"reference": "Patient/99869983-d02d-49b7-9927-ea5b1b0c1d20"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1ae9b4d2-1e00-722f-0752-05dedb50f785"}}, {"fullUrl": "urn:uuid:2bcc3936-af37-e8d9-1353-7ff7572eecb1", "resource": {"resourceType": "Condition", "id": "2bcc3936-af37-e8d9-1353-7ff7572eecb1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "13270335"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K02.9", "display": "Dental caries", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-12-04", "subject": {"reference": "Patient/99869983-d02d-49b7-9927-ea5b1b0c1d20"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/2bcc3936-af37-e8d9-1353-7ff7572eecb1"}}, {"fullUrl": "urn:uuid:e8c6f57a-ada7-212f-41af-dce167731172", "resource": {"resourceType": "DiagnosticReport", "id": "e8c6f57a-ada7-212f-41af-dce167731172", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.798268", "value": "197645960"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.461.2.798268.2.197645960.1"}], "status": "final", "code": {"coding": [{"code": "33720", "display": "X-ray abdomen 2 views AP supine and erect", "system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-07-27T02:46:39Z", "end": "2024-07-27T02:46:39Z"}, "subject": {"reference": "Patient/99869983-d02d-49b7-9927-ea5b1b0c1d20"}, "performer": [{"reference": "Organization/1388e08a-fcdc-4f35-d1c5-633c7fce2dae"}], "result": [{"reference": "Observation/3b15800b-8e8c-c49a-67c6-3fd1dbf02a3f"}, {"reference": "Observation/1d07b454-774a-b40b-dd20-222505bbd8c7"}, {"reference": "Observation/923fff36-b661-527a-b14a-6e9b66244a28"}, {"reference": "Observation/22d8b48a-0863-e629-232c-56b2c14905ae"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/e8c6f57a-ada7-212f-41af-dce167731172"}}, {"fullUrl": "urn:uuid:1388e08a-fcdc-4f35-d1c5-633c7fce2dae", "resource": {"resourceType": "Organization", "id": "1388e08a-fcdc-4f35-d1c5-633c7fce2dae", "name": "CARESTREAM PACS/PS360", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/1388e08a-fcdc-4f35-d1c5-633c7fce2dae"}}, {"fullUrl": "urn:uuid:3b15800b-8e8c-c49a-67c6-3fd1dbf02a3f", "resource": {"resourceType": "Observation", "id": "3b15800b-8e8c-c49a-67c6-3fd1dbf02a3f", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.3.696580.52175", "value": "33720"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-07-27T01:33:19Z", "end": "2024-07-27T01:37:38Z"}, "bodySite": {"coding": [{"code": "123", "display": "Body", "system": "urn:oid:1.2.840.114350.1.13.461.2.7.10.696580.52010"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-07-27T02:46:39Z"}]}], "subject": {"reference": "Patient/99869983-d02d-49b7-9927-ea5b1b0c1d20"}}, "request": {"method": "PUT", "url": "Observation/3b15800b-8e8c-c49a-67c6-3fd1dbf02a3f"}}, {"fullUrl": "urn:uuid:1d07b454-774a-b40b-dd20-222505bbd8c7", "resource": {"resourceType": "Observation", "id": "1d07b454-774a-b40b-dd20-222505bbd8c7", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.7.798268.1000", "value": "197645960"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-07-27T02:48:19Z", "valueString": "XR ABDOMEN SUPINE ERECT

HISTORY: abdominal pain, rectal bleeding

TECHNIQUE: Two views of the abdomen.

COMPARISON: None

FINDINGS/IMPRESSION:
There is a paucity of bowel gas at the right abdomen including the right lower quadrant which is nonspecific but could raise concern for intussusception in the appropriate clinical setting. If there is clinical concern, consider an abdominal ultrasound for further evaluation.

Mildly distended colon projects over the left abdomen. No definite dilated air filled loops of small bowel.

No suspicious calcifications.

Osseous structures appear normal.

The imaged lung bases appear clear






Dictated By: \u00a0 \u00a0- 7/26/2024 10:46 PM EDT

Electronically Signed By: \u00a0Kevin Crawford, MD - 7/26/2024 10:48 PM EDT

", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-07-27T02:46:39Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.461.2.7.2.798268.197645960.Narrative"}]}], "subject": {"reference": "Patient/99869983-d02d-49b7-9927-ea5b1b0c1d20"}, "performer": [{"display": "CARESTREAM PACS/PS360", "reference": "Organization/0b5c71c1-fdf4-2661-6d26-6c10fab9d415"}]}, "request": {"method": "PUT", "url": "Observation/1d07b454-774a-b40b-dd20-222505bbd8c7"}}, {"fullUrl": "urn:uuid:0b5c71c1-fdf4-2661-6d26-6c10fab9d415", "resource": {"resourceType": "Organization", "id": "0b5c71c1-fdf4-2661-6d26-6c10fab9d415", "name": "CARESTREAM PACS/PS360", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/0b5c71c1-fdf4-2661-6d26-6c10fab9d415"}}, {"fullUrl": "urn:uuid:923fff36-b661-527a-b14a-6e9b66244a28", "resource": {"resourceType": "Observation", "id": "923fff36-b661-527a-b14a-6e9b66244a28", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.727879", "value": "670766436"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-07-27T02:48:19Z", "valueString": "

Electronically Signed By: Kevin Crawford, MD - 7/26/2024 10:48 PM EDT

Dictated By: - 7/26/2024 10:46 PM EDT






The imaged lung bases appear clear

Osseous structures appear normal.

No suspicious calcifications.

air filled loops of small bowel.
Mildly distended colon projects over the left abdomen. No definite dilated

concern, consider an abdominal ultrasound for further evaluation.
intussusception in the appropriate clinical setting. If there is clinical
lower quadrant which is nonspecific but could raise concern for
There is a paucity of bowel gas at the right abdomen including the right
FINDINGS/IMPRESSION:

COMPARISON: None

TECHNIQUE: Two views of the abdomen.

HISTORY: abdominal pain, rectal bleeding

XR ABDOMEN SUPINE ERECT
Formatting of this note might be different from the original.
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Dictated By: \u00a0 \u00a0- 7/26/2024 11:41 PM EDT

Electronically Signed By: \u00a0Justin Buchanan, MD - 7/26/2024 11:41 PM EDT

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HISTORY: bloody diarrhea

COMPARISON: None

TECHNIQUE:
Multiplanar gray-scale and color Doppler images of the abdomen were obtained.

FINDINGS:
No evidence of target sign or pseudokidney sign or other findings to suggest ileocolic intussusception. No other significant incidental findings are identified.
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Electronically Signed By: Justin Buchanan, MD - 7/26/2024 11:41 PM EDT

Dictated By: - 7/26/2024 11:41 PM EDT

persistent pain, close follow-up ultrasound is recommended.
No sonographic evidence of ileocolic intussusception. If clinically
IMPRESSION:

findings are identified.
suggest ileocolic intussusception. No other significant incidental
No evidence of target sign or pseudokidney sign or other findings to
FINDINGS:

obtained.
Multiplanar gray-scale and color Doppler images of the abdomen were
TECHNIQUE:

COMPARISON: None

HISTORY: bloody diarrhea

EXAMINATION: US ABDOMEN FOR INTUSSUSCEPTION
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"lotNumber": "UT7011MA", "manufacturer": {"reference": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/99869983-d02d-49b7-9927-ea5b1b0c1d20"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/c23d64ce-b902-3ddf-9cde-925e88511b41"}}, {"fullUrl": "urn:uuid:f8a155a3-86be-0d98-6597-4b455c3fe1ec", "resource": {"resourceType": "Immunization", "id": "f8a155a3-86be-0d98-6597-4b455c3fe1ec", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "10869088"}], "occurrenceDateTime": "2022-08-09", "note": {"text": "DTaP / IPV"}, "vaccineCode": {"coding": [{"code": "58160-812-52", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "E2L54", "manufacturer": {"reference": "Organization/a1439865-b6cb-7b35-67e3-cc00011c9f1c"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/99869983-d02d-49b7-9927-ea5b1b0c1d20"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/f8a155a3-86be-0d98-6597-4b455c3fe1ec"}}, {"fullUrl": "urn:uuid:05444f7a-c69a-cf27-f3d8-27b2aece95c8", "resource": {"resourceType": "Immunization", "id": "05444f7a-c69a-cf27-f3d8-27b2aece95c8", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "10869089"}], "occurrenceDateTime": "2022-08-09", "note": {"text": "MMRV"}, "vaccineCode": {"coding": [{"code": "0006-4171-01", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "W006587", "manufacturer": {"reference": "Organization/6cf87e59-f4c2-a044-88fa-94a2bff77460"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/99869983-d02d-49b7-9927-ea5b1b0c1d20"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/05444f7a-c69a-cf27-f3d8-27b2aece95c8"}}, {"fullUrl": "urn:uuid:91782aeb-e3d4-24c8-6a1a-96e6a6804d85", "resource": {"resourceType": "Immunization", "id": 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DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.363.2.7.8.688883.859361050', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.363.2.7.8.688883.859361050", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.363.2.7.8.688883.859361050", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-17eb-cab7-0c68-e9e7bf945115", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "2"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-07-26T22:00:06-05:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "b7a7ed08-af88-4a31-cc4e-8dddd58b7fc8", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-1C06-B153-0C68-E9E7BF945115", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
Hepatitis A04/28/2022 07/26/2021 ,
Influenza (Historical)10/01/2020
Influenza Inj. Cell Derived Quadrivalent 4 years+ (PF)12/03/2018
Influenza Inj. QIV (PF)09/29/2023 11/29/2022 Deferred: Other - pt recived bfore admission ) ( 11/09/2022 11/05/2022 Deferred: Other ) ( 11/01/2021 10/07/2021 09/16/2020 , , , , , ,
Influenza Nasal (Historical)09/29/2023
Influenza TIV (IM)09/18/2013 11/05/2012 03/03/2012 , ,
Pfizer-BioNTech COVID-19 Vaccine11/29/2021 03/29/2021 03/04/2021 , ,
Pfizer-BioNTech COVID-19 Vaccine 12Y+ Bivalent11/14/2022
Pneumo Polysaccharide 23-valent01/19/2022 10/26/2020 03/11/2012 , ,
Pneumococcal Conjugate 13-Valent04/01/2021
Tdap07/02/2021
Zoster Vaccine Recombinant02/23/2024 09/29/2023 ,
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-1C06-B165-0C68-E9E7BF945115", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "8adbae3c-970d-4aba-3e93-c981803eb02d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
08/01/2024 1:15 PM CDTPost-Op VisitUT Podiatry1068 Cresthaven RdSuite 110MEMPHIS, TN 38119901-767-5620Moinester, David M, DPM6575 Stage RDMemphis, TN 38134-3809901-382-0393 (Work)901-381-1177 (Fax)
08/08/2024 1:15 PM CDTPost-Op VisitUT Podiatry1068 Cresthaven RdSuite 110MEMPHIS, TN 38119901-767-5620Moinester, David M, DPM6575 Stage RDMemphis, TN 38134-3809901-382-0393 (Work)901-381-1177 (Fax)
08/21/2024 9:00 AM CDTLabBaptist Memorial Hospital - Memphis6019 Walnut Grove Rd.Memphis, TN 38120901-226-5000Discharge Disposition: Home
08/21/2024 9:30 AM CDTOffice VisitMemphis Transplant Clinic6025 WALNUT GROVE, STE 111MEMPHIS, TN 38120901-226-2000Discharge Disposition: Home
08/21/2024 10:00 AM CDTAppointmentBaptist Memorial Hospital - Memphis6019 Walnut Grove Rd.Memphis, TN 38120901-226-5000Discharge Disposition: Home
08/21/2024 10:15 AM CDTAppointmentBaptist Memorial Hospital - Memphis6029 Walnut Grove RdMemphis, TN 38120901-226-5000Discharge Disposition: Home
11/12/2024 9:30 AM CSTOffice VisitBMG Family Physicians Group Winchester7685 Winchester RoadMemphis, TN 38125901-752-6963Venegas, Julian Lucas, DO400 Market BLVDSTE 101Collierville, TN 38017901-752-6963 (Work)901-737-3640 (Fax)
06/03/2025 10:15 AM CDTOffice VisitBMG The Endocrine Clinic5659 South Rex RdMEMPHIS, TN 38119-3821901-763-3636Cohen, Alan Jay, MD5659 S Rex RDMemphis, TN 38119901-763-3636 (Work)901-763-3694 (Fax)
Scheduled Procedures
NamePriorityAssociated DiagnosesDate/Time
COLONOSCOPYEncounter for screening colonoscopyIschemic cardiomyopathy
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/7fd3552e-5b1b-9616-5ae2-d6dab71f509c"}]}, {"id": "00000000-1C06-B1BE-0C68-E9E7BF945115", "title": "Problems", "text": {"status": "generated", "div": "
ProblemNoted DateDiagnosed Date
History of heart transplant05/31/2024
History of arterial ischemic stroke05/31/2024
Dilated cardiomyopathy04/18/2024
Overview (04/18/2024):Formatting of this note might be different from the original.
Noted by THRELKELD STEPHEN C MD last documented on 20230106
Chronic viral hepatitis B without delta-agent10/17/2023
Overview (10/17/2023):Formatting of this note might be different from the original.
Noted by CENSEO HEALTH LLC last documented on 20230629
Chronic kidney disease, stage 3a09/05/2023
Overview (09/05/2023):Formatting of this note might be different from the original.
Noted by SWEAT BONNIE J NP last documented on 20230316
Portal hypertension09/05/2023
Overview (09/05/2023):Formatting of this note might be different from the original.
Noted by BAPTIST MEMORIAL HOSPITAL last documented on 20220428
Uncontrolled type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin09/05/2023
Overview (09/05/2023):Formatting of this note might be different from the original.
Noted by VENEGAS JULIAN L DO last documented on 20230606
Localization-related epilepsy08/28/2023
Chronic hepatitis, unspecified08/28/2023
Paroxysmal atrial fibrillation08/28/2023
Encounter for aftercare following heart transplant04/28/2023
Blood pressure check04/28/2023
Hypomagnesemia04/28/2023
Steroid-induced hyperglycemia04/28/2023
Seizure-like activity03/27/2023
Decreased diffusion capacity of lung03/21/2023
Encounter for therapeutic drug level monitoring02/22/2023
Hepatitis B core antibody positive02/22/2023
Hypertensive cardiovascular-renal disease, stage 1-4 or unspecified chronic kidney disease, without heart failure02/22/2023
Heart transplanted01/28/2023
Stroke01/17/2023
Donor, organ: CMV D (+) / R (+) ; EBV D (+) / R (+); Toxo D (-) / R (-) Hep B core D (+) / Hep B core (+) R12/28/2022
CKD (chronic kidney disease)04/29/2022
Ulcerative colitis03/24/2022
Hyperlipidemia03/24/2022
Mixed restrictive and obstructive lung disease03/24/2022
Pulmonary emphysema03/24/2022
Mixed hyperlipidemia03/11/2021
PAH (pulmonary arterial hypertension) with portal hypertension12/09/2020
Stage 1 mild COPD by GOLD classification08/03/2020
documented as of this encounter (statuses as of 07/26/2024)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Stage 1 mild COPD by GOLD classification", "reference": "Condition/9373a0f7-c7e8-5542-7d78-397bea62f10e"}, {"display": "Problem - PAH (pulmonary arterial hypertension) with portal hypertension", "reference": "Condition/faae7256-730b-b13c-00d4-058022a75778"}, {"display": "Problem - Mixed hyperlipidemia", "reference": "Condition/21604e63-8df5-a386-ce32-6d01933a7a7c"}, {"display": "Problem - Ulcerative colitis", "reference": "Condition/c5e64b1b-a7d0-c50a-7917-89f8b18aff2a"}, {"display": "Problem - Hyperlipidemia", "reference": "Condition/8e9a0e84-86f9-fddb-8370-4feda03632c2"}, {"display": "Problem - Mixed restrictive and obstructive lung disease", "reference": "Condition/2b7519c3-f7bb-9f23-4ed1-d9e78d50f706"}, {"display": "Problem - Pulmonary emphysema", "reference": "Condition/c109107c-22ea-f4ec-6546-bc2a15421502"}, {"display": "Problem - CKD (chronic kidney disease)", "reference": "Condition/8caceaba-d6a7-f33e-3855-0bcbb64b1715"}, {"display": "Problem - Donor, organ", "reference": "Condition/f707ddcf-34dd-f756-b148-e07a8c99fba6"}, {"display": "Problem - Stroke", "reference": "Condition/4a5b532a-6bc8-cd73-7d92-0fb56dbbbb86"}, {"display": "Problem - Heart transplanted", "reference": "Condition/34a075ed-c48b-3078-3c8b-a56f399a6dfe"}, {"display": "Problem - Encounter for therapeutic drug level monitoring", "reference": "Condition/eadafe80-54bb-c64e-9139-2542f44790ff"}, {"display": "Problem - Hepatitis B core antibody positive", "reference": "Condition/9a588f18-07de-85e6-2721-48a950c496dc"}, {"display": "Problem - Hypertensive cardiovascular-renal disease, stage 1-4 or unspecified chronic kidney disease, without heart failure", "reference": "Condition/461c5d1f-1632-91a9-deaa-9b66ec29f286"}, {"display": "Problem - Decreased diffusion 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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: FormerCigarettes147.801/01/1973 - 10/08/2020
Smokeless Tobacco: Never
Comments:
pt states he stopped 2 weeks ago
Alcohol UseStandard Drinks/WeekComments
Not Currently0 (1 standard drink = 0.6 oz pure alcohol)
PHQ-2AnswerDate Recorded
PHQ-2 Score005/03/2024
BOC Food InsecurityAnswerDate Recorded
Food Insecurity103/24/2024
BOC Transportation NeedsAnswerDate Recorded
Transportation Needs103/24/2024
BOC Housing Stability SourceAnswerDate Recorded
Housing Insecurity103/24/2024
BOC Utility Needs SourceAnswerDate Recorded
Utility Needs102/28/2024
BOC Financial Resource NeedsAnswerDate Recorded
Financial Resource Strain103/24/2024
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthMale01/23/2021 7:27 AM CST
Gender IdentityMale01/23/2021 7:27 AM CST
Sexual OrientationStraight01/23/2021 7:27 AM CST
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DateTypeDepartmentCare Team (Latest Contact Info)Description
07/24/2024 10:00 AM CDTLabBaptist Memorial Hospital - Memphis6019 Walnut Grove Rd.Memphis, TN 38120901-226-5000
Shortness of breathMixed hyperlipidemia; Magnesium deficiency; Steroid-induced diabetes mellitus (HCC); Screening PSA (prostate specific antigen); Thyroid disorder screening; Vitamin D deficiency; Immunosuppression due to chronic steroid use (HCC); Current chronic use of systemic steroids; Steroid-induced osteopenia; Encounter for therapeutic drug level monitoring; Hypomagnesemia; Immunosuppressed status (HCC); Encounter for aftercare following heart transplant (HCC); Immunosuppression (HCC); Immunocompromised (HCC); At high risk for infection; S/P orthotopic heart transplant (HCC);
Discharge Disposition: Home
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Pierce, M.D.
\u00a01701 Century Center Cove, Memphis, TN 38134-8975
MEM - American Esoteric Laboratories - Memphis CLIA# 44D0889744
for blood or blood products.
This CMV assay is not intended for use as a screening tool
can be used to assess viral response to treatment.
receiving anti-CMV therapy, serial DNA measurements
hematopoietic stem cell transplant patients. \u00a0In patients
of CMV in solid organ transplant patients and in
This test is intended for use as an aid in the management
Reference Range: \u00a0None Detected
Comment for CMV VIRAL LOAD"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T16:35:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T17:52:19Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.363.2.7.2.798268.658526038.Comp2"}]}], "subject": {"reference": "Patient/48a774e3-cfbf-46af-bc38-59552fb13cff"}, "performer": [{"display": "AEL", "reference": "Organization/baf1a81f-fd90-674d-c1ed-40d724c1d83b"}]}, "request": {"method": "PUT", "url": "Observation/6df750e5-c83a-34d0-e4bf-d06b902d9732"}}, {"fullUrl": "urn:uuid:8694917f-a83a-e42e-1f4c-6d96fd5cd305", "resource": {"resourceType": "Observation", "id": "8694917f-a83a-e42e-1f4c-6d96fd5cd305", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.798268", "value": "658526038"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "56850-1", "display": "Lab Interpretation", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-27T02:59:00Z", "valueString": "Abnormal", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T16:35:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T17:52:19Z"}]}], "subject": {"reference": "Patient/48a774e3-cfbf-46af-bc38-59552fb13cff"}}, "request": {"method": "PUT", "url": "Observation/8694917f-a83a-e42e-1f4c-6d96fd5cd305"}}, {"fullUrl": "urn:uuid:c242f6aa-7965-d92f-d7cc-e3f096eba2dd", "resource": {"resourceType": "Observation", "id": "c242f6aa-7965-d92f-d7cc-e3f096eba2dd", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.798268", "value": "658526038"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2024-07-27T02:59:00Z", "valueCodeableConcept": {"coding": [{"code": "17", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T16:35:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T17:52:19Z"}]}], "subject": {"reference": "Patient/48a774e3-cfbf-46af-bc38-59552fb13cff"}}, "request": {"method": "PUT", "url": "Observation/c242f6aa-7965-d92f-d7cc-e3f096eba2dd"}}, {"fullUrl": "urn:uuid:c1a7e37a-78ba-8647-dece-58e62b24293b", "resource": {"resourceType": "DiagnosticReport", "id": "c1a7e37a-78ba-8647-dece-58e62b24293b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.798268", "value": "658526039"}], "status": "final", "code": {"coding": [{"code": "211539", "display": "ImmuKnow", "system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-07-24T16:35:00Z", "end": "2024-07-24T16:35:00Z"}, "subject": {"reference": "Patient/48a774e3-cfbf-46af-bc38-59552fb13cff"}, "performer": [{"reference": "Organization/5183447d-912b-edd3-271d-c6e9d2a1425d"}], "result": [{"reference": "Observation/ae5b6e82-f4e9-4080-b4a9-5a33f516b2f0"}, {"reference": "Observation/b6d1c1b7-e26b-2405-ffd2-a324cdc2f0b5"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/c1a7e37a-78ba-8647-dece-58e62b24293b"}}, {"fullUrl": "urn:uuid:ae5b6e82-f4e9-4080-b4a9-5a33f516b2f0", "resource": {"resourceType": "Observation", "id": "ae5b6e82-f4e9-4080-b4a9-5a33f516b2f0", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.6.798268.2000", "value": "658526039.1"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "53939-5", "display": "ImmuKnow", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-26T12:12:00Z", "valueQuantity": {"value": 163}, "referenceRange": [{"text": "ATP ng/mL"}], "note": [{"text": "Laboratory Director: Holly H. Pierce, M.D. CLIA# 44D0889744
1701 Century Center Cove Memphis, TN 38134
American Esoteric Laboratories
Unless otherwise indicated, all testing performed at:
FLAG Interpretation: A = Abnormal, H = High, L = Low
CLIA # 26D-0983643
Lab Director: Brock Neil, PhD BCLD (ABB)
Lenexa, KS 66219
18000 W. 99th Street, Suite 10
Eurofins Viracor, LLC
Testing Performed At:
____________________________________________________________
Administration. ImmuKnow (R) is a registered trademark.
cleared or approved for diagnostic use by the U.S. Food and Drug
establishing the immune status of a patient. This test has been
presentation, medical history, and other clinical indicators when
These results should be used in conjunction with clinical
directly quantify the level of immunosuppression.
NOTE: This is a qualitative assay. Therefore the result does not
Strong Immune Cell Response >=525 ATP Level ng/mL
Moderate Immune Cell Response 226 - 524 ATP Level ng/mL
Low Immune Cell Response <=225 ATP Level ng/mL
Assay Range:"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T16:35:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T16:48:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.363.2.7.2.798268.658526039.Comp1"}]}], "subject": {"reference": "Patient/48a774e3-cfbf-46af-bc38-59552fb13cff"}, "performer": [{"display": "AEL", "reference": "Organization/baf1a81f-fd90-674d-c1ed-40d724c1d83b"}]}, "request": {"method": "PUT", "url": "Observation/ae5b6e82-f4e9-4080-b4a9-5a33f516b2f0"}}, {"fullUrl": "urn:uuid:b6d1c1b7-e26b-2405-ffd2-a324cdc2f0b5", "resource": {"resourceType": "Observation", "id": "b6d1c1b7-e26b-2405-ffd2-a324cdc2f0b5", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": 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QIV (PF)"}, "vaccineCode": {"coding": [{"code": "19515-814-41", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "MC355", "manufacturer": {"reference": "Organization/d71f8943-b3e0-07cf-5ccb-7cba5505cd15"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/48a774e3-cfbf-46af-bc38-59552fb13cff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/9339316b-caf7-a61c-d016-2be792a9755f"}}, {"fullUrl": "urn:uuid:e7bf36d6-9f77-0f38-f70c-d50a626299bc", "resource": {"resourceType": "Immunization", "id": "e7bf36d6-9f77-0f38-f70c-d50a626299bc", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.768076", "value": "35779715"}], "occurrenceDateTime": "2023-09-29", "note": {"text": "Zoster Vaccine Recombinant"}, "vaccineCode": {"coding": [{"code": "58160-823-11", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "manufacturer": {"reference": "Organization/a1439865-b6cb-7b35-67e3-cc00011c9f1c"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/48a774e3-cfbf-46af-bc38-59552fb13cff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/e7bf36d6-9f77-0f38-f70c-d50a626299bc"}}, {"fullUrl": "urn:uuid:68013aab-1b76-44de-4a08-a34b325289e2", "resource": {"resourceType": "Immunization", "id": "68013aab-1b76-44de-4a08-a34b325289e2", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.768076", "value": "36375026"}], "occurrenceDateTime": "2023-09-29", "note": {"text": "Influenza Nasal (Historical)"}, "vaccineCode": {"coding": [{"code": "151", "display": "Influenza Nasal (Historical)", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/48a774e3-cfbf-46af-bc38-59552fb13cff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/68013aab-1b76-44de-4a08-a34b325289e2"}}, {"fullUrl": "urn:uuid:65438b2f-7f06-9786-d148-b094e18fd563", "resource": {"resourceType": "Immunization", "id": "65438b2f-7f06-9786-d148-b094e18fd563", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.768076", "value": "37597645"}], "occurrenceDateTime": "2024-02-23", "note": {"text": "Zoster Vaccine Recombinant"}, "vaccineCode": {"coding": [{"code": "58160-828-03", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "47LF3", "manufacturer": {"reference": "Organization/a1439865-b6cb-7b35-67e3-cc00011c9f1c"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/48a774e3-cfbf-46af-bc38-59552fb13cff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/65438b2f-7f06-9786-d148-b094e18fd563"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('0a094680-9a5d-45b5-bdda-197f79df2d03', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:0a094680-9a5d-45b5-bdda-197f79df2d03", "resource": {"resourceType": "Composition", "id": "0a094680-9a5d-45b5-bdda-197f79df2d03", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "1013-156287716|298594141"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "3"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-07-28T11:56:45-04:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "1c6b60d4-0f98-67b9-6078-ccbc8cee7ce5", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "No Problem Information"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "bdea0a78-bfa2-fe93-ab37-ab7bb9b3fe19", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter CodeDate of Encounter
inpatient encounter07/23/24 11:27 EDT
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "214592e7-735b-ea93-528d-ae3b0a059003", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueCollection DateResult DateLab Result InterpretationLab Result Reference RangeLab Result Note
Glucose:MCnc:Pt:Ser/Plas:Qn:124.007/23/24 12:10 EDT07/23/24 13:01 EDTHigh40-114None
Erythrocyte mean corpuscular hemoglobin concentration:MCnc:Pt:RBC:Qn:36.1 g/dL07/23/24 12:10 EDT07/23/24 13:44 EDTHigh32-36None
Erythrocyte mean corpuscular hemoglobin:EntMass:Pt:RBC:Qn:34.9 pg07/23/24 12:10 EDT07/23/24 13:44 EDTHigh25-34None
Platelets:PrThr:Pt:Bld:Ord:Microscopy.lightADEQUATE07/23/24 12:10 EDT07/23/24 13:44 EDTUnknownUnknownNone
Platelets:NCnc:Pt:Bld:Qn:193.0 k/uL07/23/24 12:10 EDT07/23/24 13:44 EDTNormal145-483None
Platelet morphology finding:Prid:Pt:Bld:Nom:NORMAL07/23/24 12:10 EDT07/23/24 13:44 EDTUnknownUnknownNone
Erythrocyte mean corpuscular volume:EntVol:Pt:RBC:Qn:96.8 fl07/23/24 12:10 EDT07/23/24 13:44 EDTNormal96.2-131.8None
Sodium:SCnc:Pt:Ser/Plas:Qn:140.0 mmo/L07/23/24 12:10 EDT07/23/24 13:01 EDTNormal131-143None
Creatinine:MCnc:Pt:Ser/Plas:Qn:0.32 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTLow0.90-1.30None
Potassium:SCnc:Pt:Ser/Plas:Qn:5.1 mmol/L07/23/24 12:10 EDT07/23/24 13:01 EDTNormal3.9-5.9None
Chloride:SCnc:Pt:Ser/Plas:Qn:109.0 mmol/L07/23/24 12:10 EDT07/23/24 13:01 EDTHigh98-107None
Carbon dioxide:SCnc:Pt:Ser/Plas:Qn:22.0 mmol/l07/23/24 12:10 EDT07/23/24 13:01 EDTNormal16-28None
Bilirubin:MCnc:Pt:Ser/Plas:Qn:18.1 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTHigh0.1-11.7CALLED TO AND RESULTS VERBALLY REPEATED BACK BY MALIA VARNER; BY SM.LB.LF 07/23/241157;
Leukocytes:NCnc:Pt:Bld:Qn:10.4 k/ul07/23/24 12:10 EDT07/23/24 13:44 EDTNormal9.0-30.0None
Hematocrit:VFr:Pt:Bld:Qn:52.1 %07/23/24 12:10 EDT07/23/24 13:44 EDTNormal42.4-71.6None
C reactive protein:MCnc:Pt:Ser/Plas:Qn:< 0.29 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTNormal0.0-0.29None
Bilirubin.glucuronidated+Bilirubin.albumin bound:MCnc:Pt:Ser/Plas:Qn:0.3 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTHigh0.0-0.2None
Urea nitrogen:MCnc:Pt:Ser/Plas:Qn:9.0 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTNormal6-20None
Hemoglobin:MCnc:Pt:Bld:Qn:18.8 g/dL07/23/24 12:10 EDT07/23/24 13:44 EDTNormal15.4-19.8None
Glucose:MCnc:Pt:Bld:Qn:71.0 mg/dL07/23/24 12:03 EDT07/23/24 12:03 EDTNormal33-144None
Anion gap:SCnc:Pt:Ser/Plas:Qn:9.0 mmol/L07/23/24 12:10 EDT07/23/24 13:01 EDTNormal4-14None
Calcium:MCnc:Pt:Ser/Plas:Qn:9.3 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTNormal8.6-10.0None
Eosinophils/100 leukocytes:NFr:Pt:Bld:Qn:Automated count1.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTNormal0-4None
Lymphocytes/100 leukocytes:NFr:Pt:Bld:Qn:50.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTHigh20-40None
Erythrocytes:NCnc:Pt:Bld:Qn:5.38 m/uL07/23/24 12:10 EDT07/23/24 13:44 EDTNormal4.17-5.77None
Neutrophils.segmented/100 leukocytes:NFr:Pt:Bld:Qn:25.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTLow53-61None
Monocytes/100 leukocytes:NFr:Pt:Bld:Qn:12.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTHigh0-8None
Granulocytes.immature/100 leukocytes:NFr:Pt:Bld:Qn:0.5 %07/23/24 12:10 EDT07/23/24 13:44 EDTNormal0-0.5None
Erythrocytes.nucleated:NCnc:Pt:Bld:Qn:0.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTNormal0-1None
Erythrocytes.nucleated:NCnc:Pt:Bld:Qn:0.0 k/uL07/23/24 12:10 EDT07/23/24 13:44 EDTUnknownUnknownNone
Lymphocytes.variant/100 leukocytes:NFr:Pt:Bld:Qn:12.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTUnknownUnknownNone
Glucose:MCnc:Pt:Ser/Plas:Qn:84.007/24/24 03:43 EDT07/24/24 04:52 EDTNormal40-114None
Erythrocyte mean corpuscular hemoglobin concentration:MCnc:Pt:RBC:Qn:36.4 g/dL07/24/24 03:43 EDT07/24/24 04:47 EDTHigh32-36None
Erythrocyte mean corpuscular hemoglobin:EntMass:Pt:RBC:Qn:35.1 pg07/24/24 03:43 EDT07/24/24 04:47 EDTHigh25-34None
Platelets:PrThr:Pt:Bld:Ord:Microscopy.lightADEQUATE07/24/24 03:43 EDT07/24/24 04:47 EDTUnknownUnknownNone
Platelets:NCnc:Pt:Bld:Qn:147.0 k/uL07/24/24 03:43 EDT07/24/24 04:47 EDTNormal145-483None
Platelet morphology finding:Prid:Pt:Bld:Nom:NORMAL07/24/24 03:43 EDT07/24/24 04:47 EDTUnknownUnknownfew plts clumps seen . plts count may not be accurate`;
Erythrocyte mean corpuscular volume:EntVol:Pt:RBC:Qn:96.4 fl07/24/24 03:43 EDT07/24/24 04:47 EDTNormal96.2-131.8None
Sodium:SCnc:Pt:Ser/Plas:Qn:138.0 mmo/L07/24/24 03:43 EDT07/24/24 04:52 EDTNormal131-143None
Creatinine:MCnc:Pt:Ser/Plas:Qn:0.32 mg/dL07/24/24 03:43 EDT07/24/24 04:52 EDTLow0.90-1.30None
Potassium:SCnc:Pt:Ser/Plas:Qn:5.7 mmol/L07/24/24 03:43 EDT07/24/24 04:52 EDTNormal3.9-5.9None
Chloride:SCnc:Pt:Ser/Plas:Qn:106.0 mmol/L07/24/24 03:43 EDT07/24/24 04:52 EDTNormal98-107None
Carbon dioxide:SCnc:Pt:Ser/Plas:Qn:24.0 mmol/l07/24/24 03:43 EDT07/24/24 04:52 EDTNormal16-28None
Bilirubin:MCnc:Pt:Ser/Plas:Qn:16.2 mg/dL07/24/24 03:43 EDT07/24/24 04:52 EDTHigh0.1-11.7None
Leukocytes:NCnc:Pt:Bld:Qn:11.9 k/ul07/24/24 03:43 EDT07/24/24 04:47 EDTNormal9.0-30.0None
Hematocrit:VFr:Pt:Bld:Qn:51.1 %07/24/24 03:43 EDT07/24/24 04:47 EDTNormal42.4-71.6None
Neutrophils.band form/100 leukocytes:NFr:Pt:Bld:Qn:0.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTNormal0-5None
C reactive protein:MCnc:Pt:Ser/Plas:Qn:< 0.29 mg/dL07/24/24 03:43 EDT07/24/24 04:52 EDTNormal0.0-0.29None
C reactive protein:MCnc:Pt:Ser/Plas:Qn:C-REACTIVE PROTEIN Ordered07/24/24 07:00 EDT07/24/24 01:02 EDTUnknownUnknownNone
Glucose:MCnc:Pt:CSF:Qn:68.007/23/24 16:19 EDT07/23/24 17:34 EDTNormal40-70None
Protein:MCnc:Pt:CSF:Qn:55.0 MG/DL07/23/24 16:19 EDT07/23/24 17:34 EDTHigh15-45None
Leukocytes:NCnc:Pt:CSF:Qn:Manual count1.0 /cmm07/23/24 16:19 EDT07/23/24 17:34 EDTNormal0-5None
Urea nitrogen:MCnc:Pt:Ser/Plas:Qn:<6 mg/dL07/24/24 03:43 EDT07/24/24 04:52 EDTLow6-20None
Hemoglobin:MCnc:Pt:Bld:Qn:18.6 g/dL07/24/24 03:43 EDT07/24/24 04:47 EDTNormal15.4-19.8None
Glucose:MCnc:Pt:Bld:Qn:110.0 mg/dL07/23/24 15:58 EDT07/23/24 16:17 EDTNormal33-144None
Glucose:MCnc:Pt:Bld:Qn:101.0 mg/dL07/23/24 23:05 EDT07/23/24 23:07 EDTNormal33-144None
Glucose:MCnc:Pt:Bld:Qn:99.0 mg/dL07/24/24 03:48 EDT07/24/24 03:53 EDTNormal33-144None
Anion gap:SCnc:Pt:Ser/Plas:Qn:8.0 mmol/L07/24/24 03:43 EDT07/24/24 04:52 EDTNormal4-14None
Calcium:MCnc:Pt:Ser/Plas:Qn:9.7 mg/dL07/24/24 03:43 EDT07/24/24 04:52 EDTNormal8.6-10.0None
Glomerular filtration rate/1.73 sq M.predicted:ArVRat:Pt:Ser/Plas:Qn:Creatinine-based formula (MDRD)GFR not calculated if age <18 yrs.07/24/24 03:43 EDT07/24/24 04:52 EDTUnknownUnknownThe Glomerular Filtration Rate is a calculated parameter; based on serum Creatinine levels, patient age, and sex. GFR; values less than 60 mL/min/1.73 square meters are indicative; of Chronic Kidney Disease. Values less than 15 mL/min/1.73; square meters indicate Kidney failure.; The calculation for GFR is based on the CKD-EPI(2021); calculation. This formula is race indifferent and is the; recommended formula for GFR by the National Kidney; Foundation for adults.; The GFR will not calculate if the sex is Unknown or if the; patient''s age is <18 years.;
Eosinophils/100 leukocytes:NFr:Pt:Bld:Qn:Automated count2.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTNormal0-4None
Lymphocytes/100 leukocytes:NFr:Pt:Bld:Qn:25.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTNormal20-40None
Erythrocytes:NCnc:Pt:Bld:Qn:5.3 m/uL07/24/24 03:43 EDT07/24/24 04:47 EDTNormal4.17-5.77None
Neutrophils.segmented/100 leukocytes:NFr:Pt:Bld:Qn:21.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTLow53-61None
Monocytes/100 leukocytes:NFr:Pt:Bld:Qn:9.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTHigh0-8None
Color:Type:Pt:CSF:Nom:YELLOW07/23/24 16:19 EDT07/23/24 17:34 EDTAbnormalCOLORLESSNone
Appearance:Aper:Pt:CSF:Nom:CLEAR07/23/24 16:19 EDT07/23/24 17:34 EDTUnknownCLEARNone
Erythrocytes:NCnc:Pt:CSF:Qn:33.0 /cmm07/23/24 16:19 EDT07/23/24 17:34 EDTHigh0-0None
Granulocytes.immature/100 leukocytes:NFr:Pt:Bld:Qn:0.7 %07/24/24 03:43 EDT07/24/24 04:47 EDTHigh0-0.5None
Erythrocytes.nucleated:NCnc:Pt:Bld:Qn:0.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTNormal0-1None
Erythrocytes.nucleated:NCnc:Pt:Bld:Qn:0.0 k/uL07/24/24 03:43 EDT07/24/24 04:47 EDTUnknownUnknownNone
Lymphocytes.variant/100 leukocytes:NFr:Pt:Bld:Qn:43.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTUnknownUnknownNone
Glucose:MCnc:Pt:Bld:Qn:95.0 mg/dL07/24/24 12:45 EDT07/24/24 12:46 EDTNormal33-144None
Glucose:MCnc:Pt:Bld:Qn:84.0 mg/dL07/24/24 18:37 EDT07/24/24 19:00 EDTNormal33-144None
Staphylococcus aureus.methicillin resistant isolate:PrThr:Pt:XXX:Ord:Organism specific cultureMethicillin resistant Staphylococcus aureus07/23/24 12:10 EDT07/24/24 15:15 EDTAbnormalUnknownNone
Bacteria identified:Prid:Pt:Bld:Nom:CultureStaphylococcus epidermidis07/23/24 12:10 EDT07/26/24 12:34 EDTAbnormalUnknownNone
Bacteria identified:Prid:Pt:Bld:Nom:CultureNeisseria flavescens07/23/24 12:10 EDT07/26/24 12:34 EDTAbnormalUnknownNone
Bacteria identified:Prid:Pt:Bld:Nom:CultureStreptococcus parasanguinis07/23/24 12:10 EDT07/26/24 12:34 EDTAbnormalUnknownNone
Microscopic observation:Prid:Pt:CSF:Nom:Gram stainNo WBC(s) Present07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Bacteria identified:Prid:Pt:CSF:Nom:CultureNO GROWTH AFTER 4 DAYS INCUBATION07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Streptococcus agalactiae DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Streptococcus pneumoniae DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Cytomegalovirus DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Enterovirus RNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Herpes simplex virus 1 DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Herpes simplex virus 2 DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Herpes virus 6 DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Parechovirus RNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Varicella zoster virus DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Cryptococcus neoformans rRNA:PrThr:Pt:XXX:Ord:ProbeNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Microscopic observation:Prid:Pt:CSF:Nom:Gram stainNo Organism Seen07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Escherichia coli K1 Ag:PrThr:Pt:Ser:Ord:NOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Haemophilus influenzae DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarHaemophilus influenzae07/23/24 16:19 EDT07/27/24 16:30 EDTAbnormalUnknownNone
Listeria monocytogenes DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Neisseria meningitidis rRNA:PrThr:Pt:XXX:Ord:ProbeNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Bacteria identified:Prid:Pt:Bld:Nom:CultureNo growth in 3 days07/24/24 12:59 EDT07/27/24 13:46 EDTNormalUnknownNone
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Narrative Text
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ILLNESS, UNSPECIFIED
HYPOTHERMIA OF NEWBORN, UNSPECIFIED
BACTERIAL SEPSIS OF NEWBORN, UNSPECIFIED
MENINGITIS, UNSPECIFIED
UNSPECIFIED APNEA OF NEWBORN
OTHER SPECIFIED INFECTIONS SPECIFIC TO THE PERINAT
OTHER RESPIRATORY DISTRESS OF NEWBORN
NEONATAL JAUNDICE, UNSPECIFIED
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[{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "600-7", "display": "Bacteria identified:Prid:Pt:Bld:Nom:Culture (LOINC concept)", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-24T11:59:00-05:00", "valueString": "No growth in 3 days", "interpretation": [{"coding": [{"code": "N", "display": "Normal", "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"}]}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-07-24T11:59:00-05:00"}]}], "subject": {"reference": "Patient/c05dab2f-599b-466e-b608-a292c1645b76"}}, "request": {"method": "PUT", "url": "Observation/4118565f-039a-f65d-3187-458c89c07848"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.478.2.7.8.688883.331587038', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.478.2.7.8.688883.331587038", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.478.2.7.8.688883.331587038", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-0447-49a7-0ad9-73e39bea24fa", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "4"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-07-28T22:46:32-05:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "eef4643d-e3df-2ca5-780a-9e6dad610595", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-04DD-D9E9-32B4-FF9C6A46DBA2", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
Rho (D) Immune Globulin05/23/2024
Tdap vaccine (Adacel/Boostrix)05/23/2024
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-04DD-D9EA-32B4-FF9C6A46DBA2", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (TYLENOL) tablet 650 mg650 mg, oral, Every 6 hours PRN, headaches, PRN headache/ pain score 1-4, or if pt declines opioids, Starting on Sat 7/27/24 at 2312, Postpartum, Do not exceed 4000mg acetaminophen in 24hrs.Given07/28/2024 8:34 PM CDT650 mg
benzocaine-menthoL (DERMOPLAST) 20-0.5 % topical sprayPostpartumGiven07/27/2024 11:17 PM CDT
ibuprofen (ADVIL,MOTRIN) tablet 600 mg600 mg, oral, Every 6 hours scheduled, First dose on Sat 7/27/24 at 2315, Postpartum, Don''t give within 6 hours of patient receiving ketorolac (TORADOL) Tier One pain medicationGiven07/28/2024 5:46 PM CDT600 mg
Given07/28/2024 12:21 PM CDT600 mg
Given07/28/2024 5:56 AM CDT600 mg
LR infusion125 mL/hr, intraVENOUS, Continuous, Starting on Fri 7/26/24 at 1330New Bag07/27/2024 6:46 PM CDT125 mL/hr125 mL/hr
Rate/Dose Verify07/27/2024 2:56 PM CDT125 mL/hr125 mL/hr
New Bag07/27/2024 12:45 PM CDT125 mL/hr125 mL/hr
ondansetron (ZOFRAN) injection 4 mg4 mg, intraVENOUS, Every 6 hours PRN, nausea, vomiting, 1st line treatment for patients with IV access, Starting on Sat 7/27/24 at 2312, For 48 hours, Postpartum, Doses up to 4 mg may be administered undiluted. Inject over at least 30 seconds, but preferably over 2-5 minutes.
ondansetron (ZOFRAN) tablet 4 mg4 mg, oral, Every 6 hours PRN, nausea, vomiting, 1st line treatment for patients without IV access, Starting on Sat 7/27/24 at 2312, For 48 hours, Postpartum
Prenatal multivitamin tablet 1 tablet1 tablet, oral, Daily, First dose on Sun 7/28/24 at 1000, PostpartumGiven07/28/2024 10:47 AM CDT1 tablet
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
ampicillin (OMNIPEN) 2,000 mg in NS 100 mL IVPB (ADD-Vantage)2,000 mg, intraVENOUS, at 200 mL/hr, Administer over 30 Minutes, Once, On Fri 7/26/24 at 1630, For 1 dose, Scheduling/ADT, Indication: Prophylaxis, Pharmacist may adjust the dose according to the patient\u2019s renal function per the Pharmacist Antimicrobial Renal Dose Adjustment Protocol: YesGiven07/27/2024 7:15 PM CDT2,000 mg200 mL/hr
fentaNYL 2 mcg/mL-bupivacaine 0.0625 % in NS 250 mL OB epiduralInitial Prep Volume: 250 mL, epidural, Continuous, Starting on Fri 7/26/24 at 2345, L&D Pre-Delivery, Priming volume = 3 mL CONTROLLED SUBSTANCE - MUST ALWAYS BE SECURED - DO NOT TUBE, OB Epidural PCEA : See Anesthesia Record for dosing detailsAnesthesia - IntraOp Start Epidural Infusion07/27/2024 5:48 PM CDT
Rate/Dose Verify07/27/2024 1:10 PM CDT
Rate/Dose Verify07/27/2024 4:18 AM CDT
lactated Ringer''s bolus 500 mL500 mL, intraVENOUS, at 1,000 mL/hr, Administer over 30 Minutes, Once, On Fri 7/26/24 at 2345, For 1 dose, L&D Pre-Delivery, Administer immediately prior to epidural placement.New Bag07/26/2024 11:38 PM CDT500 mL1000 mL/hr
miSOPROStol (CYTOTEC) tablet (for vaginal or buccal use) 50 mcg50 mcg, buccal, Every 4 hours, First dose on Fri 7/26/24 at 1900, For 2 doses, L&D Pre-Delivery, FOR USE IN OB/GYN PROCEDURES ONLYGiven07/26/2024 7:03 PM CDT50 mcg
nalbuphine (NUBAIN) 10 mg/mL 2.5 mg injection 0.25 mL2.5 mg, intraVENOUS, Every 3 hours PRN, pruritus, Starting on Fri 7/26/24 at 2339, For 2 doses, L&D Pre-Delivery, 1st line therapy for pruritusGiven07/27/2024 4:06 AM CDT2.5 mg
nicotine (NICODERM CQ) 7 mg/24 hr 1 patch1 patch, transdermal, Administer over 24 Hours, Daily, First dose on Fri 7/26/24 at 1545, L&D Pre-Delivery, EPA WASTE CATEGORY *P* Apply to hairless, clean, dry skin on the upper body or upper outer arm.Medication Applied07/27/2024 12:07 PM CDT1 patchLeft Upper Back
Medication Applied07/26/2024 5:26 PM CDT1 patchLeft Upper Arm
ondansetron (ZOFRAN) injection 4 mg4 mg, intraVENOUS, Every 8 hours PRN, nausea, vomiting, Starting on Fri 7/26/24 at 1323, L&D Pre-Delivery, Slow IV Push Doses up to 4 mg may be administered undiluted. Inject over at least 30 seconds, but preferably over 2-5 minutes.Self Administered Via Pump07/27/2024 1:17 PM CDT4 mg
oxytocin (PITOCIN) 30 unit/500 mL (0.06 units/mL) in NS infusion2-20 milli-units/min (2-20 mL/hr), intraVENOUS, Titrated, Starting on Fri 7/26/24 at 1330, L&D Pre-Delivery, Start at 2 milli-units/min and increase by 2 milli-units/min every 30 minutes until adequate labor, (uterine contractions are 2-3 minutes apart and are of moderate quality by palpation, or 50-60 mmHg above baseline with IUPC. \u00a0Labor progress may be 0.5 to 1 cm of cervical dilation per hour during induction, particularly for nulliparous women). Max dose 20 milli-units/min. Notify house officer if more than 20 milli-units/min required. Refer to SOP for Care of the Patient Admitted with Intended Labor and Vaginal Birth.Rate/Dose Verify07/27/2024 6:30 PM CDT18 milli-units/min18 mL/hr
Rate/Dose Change07/27/2024 2:27 PM CDT18 milli-units/min18 mL/hr
Rate/Dose Change07/27/2024 1:12 PM CDT16 milli-units/min16 mL/hr
oxytocin (PITOCIN) 30 unit/500 mL (0.06 units/mL) in NS infusion0.5-20 milli-units/min (0.5-20 mL/hr), intraVENOUS, Titrated, Starting on Fri 7/26/24 at 1615, L&D Pre-Delivery, Begin infusion at 2 milli-units/min; increase infusion by 2 milli-units every 30 minutes until adequate uterine activity is established (3 contractions at least 40 seconds duration within a continuous 10 minute window). Max rate 20 milli-units/min. NHO if adequate uterine activity is not established. Limit to one 500 mL bag.Rate/Dose Change07/26/2024 6:08 PM CDT4 milli-units/min4 mL/hr
New Bag07/26/2024 5:38 PM CDT2 milli-units/min2 mL/hr
penicillin G potassium 5 million units in 100 mL NS IVPB5 Million Units, intraVENOUS, Administer over 30 Minutes, Once, On Fri 7/26/24 at 1330, For 1 dose, L&D Pre-Delivery, Over 30 minutes Infiltration/Extravasation Risk = Yellow (Irritant), Indication: ProphylaxisNew Bag07/26/2024 9:27 PM CDT5 Million Units
penicillin G potassium IVPB 2.5 million units in NS 100 mL2.5 Million Units (2,500,000 Units), intraVENOUS, Administer over 30 Minutes, Every 4 hours, First dose on Fri 7/26/24 at 1730, L&D Pre-Delivery, For GBS prophylaxis, discontinue after baby is born. Infiltration/Extravasation Risk = Yellow (Irritant), Indication: ProphylaxisNew Bag07/27/2024 4:54 PM CDT2,500,000 Units
New Bag07/27/2024 1:11 PM CDT2,500,000 Units
New Bag07/27/2024 9:00 AM CDT2,500,000 Units
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Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
08/08/2024 9:00 AM CDTClinical SupportVanderbilt Center for Women''s Health719 Thompson LnSuite 27100Nashville, TN 37204615-343-5700
08/08/2024 9:30 AM CDTRoutine PrenatalVanderbilt Center for Women''s Health719 Thompson LnSuite 27100Nashville, TN 37204Eshelman, Anne Ward, APRN719 THOMPSON LANESUITE 27100NASHVILLE, TN 37204615-875-0425 (Work)615-936-1106 (Fax)
08/08/2024 10:00 AM CDTOffice VisitVanderbilt Center for Women''s Health719 Thompson LnSuite 27100Nashville, TN 37204Generic, Attending
08/15/2024 9:00 AM CDTClinical SupportVanderbilt Center for Women''s Health719 Thompson LnSuite 27100Nashville, TN 37204615-343-5700
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
PCR Hepatitis C Virus QtLabSTAT07/26/2024 2:18 PM CDT
RPR TiterLabRoutine07/26/2024 1:43 PM CDT
UR Drug Scrn 9 Pnl w/Rfx Conf-ARUPLabSTAT07/28/2024 3:41 PM CDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
PCR Hepatitis C Virus QtLabSTATOnce for 1 Occurrences starting 7/26/24 until 7/26/24
RPR TiterLabRoutineOnce for 1 Occurrences starting 7/26/24 until 7/26/24
UR Drug Scrn 9 Pnl w/Rfx Conf-ARUPLabSTATSTAT for 1 Occurrences starting 7/28/24 until 7/28/24
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/d600f29a-aa2e-3b97-4d6c-1328ac6e073e"}]}, {"id": "00000000-04DD-D9EC-32B4-FF9C6A46DBA2", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
Postpartum state07/28/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
BCM: TBD.F/U 3 and 6 wks Eshelman/ OHO.B neg/ RI/ Tdap UTD. (No need for Rhogam/ baby B neg).Plans D/C tomorrow. EPDS pending.Pumping.Baby in NICU transitioning w/ poss TTN. VSS.Minimal rubra. No clots this am. No dizziness. EBL300.Now PPD #1 after SVD. Intact. EBL 300.- GBS positive - First child in foster care - Nicotine use -Hx of septic PE - Rh negative - received rhogam 5/23/2024 -Chronic hepatitis C - Polysubstance use- reports last used methamphetamines 2/2024; hx heroine use, + for MDMA in pregnancy - Syphilis, treated in 6/2024 - cHTN, no meds -FGR, EFW 7%tile; AC 17%tilePregnancy c/b: 26 y.o G2P2002 at 37.2 admitted for IOL iso FGR
Encounter for induction of labor07/26/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
- 10/100/+1, pt starting to push- Amp completed before delivery as prophylaxis for hx of septic PE in last delivery- Close BP surveillance. - Nsy aware of HCV/ latent Syphilis- Continuous fetal surveillance. - Labs Q 12 hrs to trend LFTs. - RN to continue to titrate pit.- Plan: recheck in 4hrs or as clinically indicated.- SVE 7/C/0 AROM''d w/pt agreement for clear non odorous fluid.- GBS + on PCN.- Epidural in situ and comfortable.- UCS: 2-3/10 lasting 40 seconds. Pit at 18- Cat 1 FHR tracing -Elevated LFTs upon admit. Labs Q 12. Downtrending. #BMI 45/ # cHTN no meds/ # HCV VL pending/ # poly substance abuse UDS pending/ Hx of Septic - PE (Needs amp before delivery).Latent Syphilis treated in June.IOL in setting of FGR / elevated UADs. Neg OCT upon admit.
Nicotine use07/26/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Nicotine patch ordered 6 cigarettes day
Custody issue07/26/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Social work PP 1st child in foster care
Septic pulmonary embolism07/26/2024
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Hx of septic PE in 2017 and 2020 Formatting of this note might be different from the original.
See MFM note PCN to be admin within 1 hr of delivery Echocardiogram ordered
Encounter for triage in pregnant patient07/24/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
- Discharged to home with scheduled IOL tomorrow 7/25 @ 2200- Discharged to home with strict return precautions- NST appropriate for GA
Positive GBS test07/22/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
PCN for GBS prophylaxis
Fetal growth restriction antepartum07/18/2024
Overview:Formatting of this note might be different from the original.
TWT. Repeat growth at 38 weeks.Dx at 36 weeks
Pregnancy03/22/2024
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
NIPT low risk female EDD 8/15/24 by LMP Formatting of this note might be different from the original.
GBS next visit Start weekly visits next week Discussed IOL at 39-40wks, will continue to discuss Precautions reviewed
Polysubstance use disorder03/22/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Utox collected on admission 7/25 Presumptive + MDMA
Chronic hypertension affecting pregnancy03/22/2024
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Multiple mild range BPs in outside records Formatting of this note might be different from the original.
HELLP labs collected Denies S&S of pre-e Normotensive
Short interval between pregnancies affecting pregnancy, antepartum03/22/2024
Syphilis03/19/2024
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Reports treatment in 2022 Formatting of this note might be different from the original.
Titers ordered Retreated in June 2024
Chronic hepatitis C virus infection03/19/2024
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
AST/ALT mildly elevated on NOB labs Formatting of this note might be different from the original.
Viral load and HIV collected
Rh negative state in antepartum period03/19/2024
PregnantComments
Yes
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Every DayCigarettes0.56.1Started: 01/01/2018; Last attempted to quit: 02/24/2024
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Not Currently0 (1 standard drink = 0.6 oz pure alcohol)
PHQ-2AnswerDate Recorded
PHQ-9 Score003/18/2024
PregnantComments
Yes
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityFemale02/12/2024 10:53 AM CST
Sexual OrientationNot on file
COVID-19 ExposureResponseDate Recorded
In the last 10 days, have you been in contact with someone who was confirmed or suspected to have Coronavirus/COVID-19?No / Unsure7/26/2024 2:10 PM CDT
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DateTypeDepartmentCare Team (Latest Contact Info)Description
07/26/2024 12:59 PM CDT - PresentHospital EncounterVanderbilt University Adult Hospital1211 Medical Center Dr4E Post PartumNashville, TN 37232615-322-5000Detzel, Patricia, CNM, APRN719 THOMPSON LANESUITE 27100NASHVILLE, TN 37204615-343-5700 (Work)615-936-1106 (Fax)Stec, Melissa Ann, CNM719 THOMPSON LANESUITE 27100NASHVILLE, TN 37204615-875-0425 (Work)615-936-1106 (Fax)Perry, Amanda Paige, CNM719 THOMPSON LANESUITE 27100NASHVILLE, TN 37204615-875-0425 (Work)615-936-1106 (Fax)
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Last Assessment & Plan:
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Last Assessment & Plan:
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System.Collections.Generic.Dictionary`2[System.String,System.Object]

AST/ALT mildly elevated on NOB labs
problemNote97
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Viral load and HIV collected "}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}, "extension": [{"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "50711007", "system": "http://snomed.info/sct"}]}]}, "request": {"method": "PUT", "url": "Condition/6a7ae801-4e63-52f2-a79c-dbbd952050e7"}}, {"fullUrl": "urn:uuid:1ee8afed-b25d-8fc0-745d-222375799527", "resource": {"resourceType": "Condition", "id": "1ee8afed-b25d-8fc0-745d-222375799527", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "47035953"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "O26.899", "display": "Rh negative state in antepartum period", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-03-19", "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1ee8afed-b25d-8fc0-745d-222375799527"}}, {"fullUrl": "urn:uuid:26594aa5-1a38-415d-21f3-f8b6606ebdc1", "resource": {"resourceType": "Condition", "id": "26594aa5-1a38-415d-21f3-f8b6606ebdc1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "47108535"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z34.90", "display": "Pregnancy", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-03-22", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote100
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote101
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/26594aa5-1a38-415d-21f3-f8b6606ebdc1"}}, {"fullUrl": "urn:uuid:46e23328-ecd5-9889-b3cc-e31c6f54b7c6", "resource": {"resourceType": "Condition", "id": "46e23328-ecd5-9889-b3cc-e31c6f54b7c6", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "47108540"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "F19.90", "display": "Polysubstance use disorder", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-03-22", "note": [{"text": "Last Assessment & Plan:
problemNote104
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7/25 Presumptive + MDMA
Utox collected on admission "}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/46e23328-ecd5-9889-b3cc-e31c6f54b7c6"}}, {"fullUrl": "urn:uuid:f7c6d0fe-d098-184d-1fa1-04a56a02a0b3", "resource": {"resourceType": "Condition", "id": "f7c6d0fe-d098-184d-1fa1-04a56a02a0b3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "47108942"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "O10.919", "display": "Chronic hypertension affecting pregnancy", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-03-22", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote108
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Multiple mild range BPs in outside records
problemNote109
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/f7c6d0fe-d098-184d-1fa1-04a56a02a0b3"}}, {"fullUrl": "urn:uuid:0d9ed265-b00b-6690-fa6a-8db14e762a39", "resource": {"resourceType": "Condition", "id": "0d9ed265-b00b-6690-fa6a-8db14e762a39", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "47108946"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "O09.899", "display": "Short interval between pregnancies affecting pregnancy, antepartum", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-03-22", "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/0d9ed265-b00b-6690-fa6a-8db14e762a39"}}, {"fullUrl": "urn:uuid:726334d9-50fd-7b33-2e35-b09df09a9a8b", "resource": {"resourceType": "Condition", "id": "726334d9-50fd-7b33-2e35-b09df09a9a8b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49247360"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "O36.5990", "display": "Fetal growth restriction antepartum", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-18", "note": [{"text": "Overview:
problemNote114
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Dx at 36 weeks
TWT. Repeat growth at 38 weeks."}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/726334d9-50fd-7b33-2e35-b09df09a9a8b"}}, {"fullUrl": "urn:uuid:42fe7b21-cd3c-5048-912b-3d0585001876", "resource": {"resourceType": "Condition", "id": "42fe7b21-cd3c-5048-912b-3d0585001876", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49298327"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "B95.1", "display": "Positive GBS test", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-22", "note": [{"text": "Last Assessment & Plan:
problemNote116
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PCN for GBS prophylaxis "}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/42fe7b21-cd3c-5048-912b-3d0585001876"}}, {"fullUrl": "urn:uuid:cd842186-f62f-a72c-ae0f-bfcd516651dd", "resource": {"resourceType": "Condition", "id": "cd842186-f62f-a72c-ae0f-bfcd516651dd", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49372393"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z36.89", "display": "Encounter for triage in pregnant patient", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-24", "note": [{"text": "Last Assessment & Plan:
problemNote119
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- NST appropriate for GA
- Discharged to home with strict return precautions
- Discharged to home with scheduled IOL tomorrow 7/25 @ 2200"}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/cd842186-f62f-a72c-ae0f-bfcd516651dd"}}, {"fullUrl": "urn:uuid:27791555-4fa0-6f54-5371-489443b6fcf6", "resource": {"resourceType": "Condition", "id": "27791555-4fa0-6f54-5371-489443b6fcf6", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49410838"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z34.90", "display": "Encounter for induction of labor", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-26", "note": [{"text": "Last Assessment & Plan:
problemNote121
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IOL in setting of FGR / elevated UADs. Neg OCT upon admit.
#BMI 45/ # cHTN no meds/ # HCV VL pending/ # poly substance abuse UDS pending/ Hx of Septic - PE (Needs amp before delivery).Latent Syphilis treated in June.
-Elevated LFTs upon admit. Labs Q 12. Downtrending.
- Cat 1 FHR tracing
- UCS: 2-3/10 lasting 40 seconds. Pit at 18
- Epidural in situ and comfortable.
- GBS + on PCN.
- SVE 7/C/0 AROM''d w/pt agreement for clear non odorous fluid.
- Plan: recheck in 4hrs or as clinically indicated.
- RN to continue to titrate pit.
- Labs Q 12 hrs to trend LFTs.
- Continuous fetal surveillance.
- Nsy aware of HCV/ latent Syphilis
- Close BP surveillance.
- Amp completed before delivery as prophylaxis for hx of septic PE in last delivery
- 10/100/+1, pt starting to push"}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/27791555-4fa0-6f54-5371-489443b6fcf6"}}, {"fullUrl": "urn:uuid:6522dfd1-cd59-b5db-a38e-c9dc05331d25", "resource": {"resourceType": "Condition", "id": "6522dfd1-cd59-b5db-a38e-c9dc05331d25", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49415018"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z72.0", "display": "Nicotine use", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-26", "note": [{"text": "Last Assessment & Plan:
problemNote127
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6 cigarettes day
Nicotine patch ordered "}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/6522dfd1-cd59-b5db-a38e-c9dc05331d25"}}, {"fullUrl": "urn:uuid:eff42d34-a063-4259-624c-8342c8e10043", "resource": {"resourceType": "Condition", "id": "eff42d34-a063-4259-624c-8342c8e10043", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49415114"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z65.3", "display": "Custody issue", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-26", "note": [{"text": "Last Assessment & Plan:
problemNote129
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1st child in foster care
Social work PP "}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/eff42d34-a063-4259-624c-8342c8e10043"}}, {"fullUrl": "urn:uuid:f2450258-e9c2-654b-7fec-e9555ec96542", "resource": {"resourceType": "Condition", "id": "f2450258-e9c2-654b-7fec-e9555ec96542", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49415658"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I26.90", "display": "Septic pulmonary embolism", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-26", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote131
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Hx of septic PE in 2017 and 2020
problemNote132
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/f2450258-e9c2-654b-7fec-e9555ec96542"}}, {"fullUrl": "urn:uuid:25680984-f769-6d2c-999d-3b476c528e66", "resource": {"resourceType": "Condition", "id": "25680984-f769-6d2c-999d-3b476c528e66", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49423379"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z39.2", "display": "Postpartum state", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-28", "note": [{"text": "Last Assessment & Plan:
problemNote134
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26 y.o G2P2002 at 37.2 admitted for IOL iso FGR
Pregnancy c/b:
-FGR, EFW 7%tile; AC 17%tile
- cHTN, no meds
- Syphilis, treated in 6/2024
- Polysubstance use- reports last used methamphetamines 2/2024; hx heroine use, + for MDMA in pregnancy
-Chronic hepatitis C
- Rh negative - received rhogam 5/23/2024
-Hx of septic PE
- Nicotine use
- First child in foster care
- GBS positive
Now PPD #1 after SVD. Intact. EBL 300.
Minimal rubra. No clots this am. No dizziness. EBL300.
VSS.
Baby in NICU transitioning w/ poss TTN.
Pumping.
Plans D/C tomorrow. EPDS pending.
B neg/ RI/ Tdap UTD. (No need for Rhogam/ baby B neg).
F/U 3 and 6 wks Eshelman/ OHO.
BCM: TBD."}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/25680984-f769-6d2c-999d-3b476c528e66"}}, {"fullUrl": "urn:uuid:f59af6da-6dec-e72c-74a5-d912730df734", "resource": {"resourceType": "DiagnosticReport", "id": "f59af6da-6dec-e72c-74a5-d912730df734", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.798268", "value": "462386203"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.478.2.798268.2.462386203.1"}], "status": "final", "code": {"coding": [{"code": "104443", "display": "Transthoracic echo (TTE) complete with or without contrast per protocol", "system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.696580"}]}, "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "performer": [{"reference": "Organization/d61d56a8-7cff-d6de-4938-7162d5353ea6"}], "result": [{"reference": "Observation/7ff54a1a-0407-7c16-0708-a6dd6bbed56e"}, {"reference": "Observation/18af0182-67bc-47c2-e9b3-89acd792afc5"}, {"reference": "Observation/1f639d21-ac21-0eac-ff77-809a7d11ce48"}, {"reference": "Observation/ca539092-a60d-cdaa-94da-b59920d6d061"}, {"reference": "Observation/c22d45e5-8d6b-9549-d4c8-01c4b38a581a"}, {"reference": "Observation/e8bace46-0fb7-d0a0-6bd5-e96baeb32667"}, {"reference": "Observation/00ec2adb-3089-d510-6092-0423573b3805"}, {"reference": "Observation/145fd351-2b25-631b-0847-13ea0ce3d49e"}, {"reference": "Observation/75fb5f7e-7ed6-7f68-7617-c42eacf34e55"}, {"reference": "Observation/e487019f-d253-983c-51fa-ba2513d99ca9"}, {"reference": "Observation/58be3cdc-d302-88fd-e9af-c3edb5df4aa8"}, {"reference": "Observation/5b5b7074-348f-f56e-7311-d1cf852e510b"}, {"reference": "Observation/ed0d3494-370e-55f5-8e23-bffcd97fd089"}, {"reference": "Observation/6e4b08b9-1edc-ba27-9b6e-2b65323aecd6"}, {"reference": "Observation/34a3352d-aad1-ec72-e00e-b11110bf3955"}, 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"Observation/19b5a50b-8032-14a8-d9a8-add4f4bd6687"}}, {"fullUrl": "urn:uuid:3c5780b2-f18e-177c-97ff-03078bb87b58", "resource": {"resourceType": "Observation", "id": "3c5780b2-f18e-177c-97ff-03078bb87b58", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.7.798268.1000", "value": "462386203"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-07-26T22:09:31Z", "valueString": "\u2022 \u00a0Left\u00a0Ventricle: The left ventricle is normal in size. (LVIDd 4.40 cm)
Left ventricular ejection fraction is normal. The visually estimated
ejection fraction is 55-65%.
\u2022 \u00a0Right\u00a0Ventricle: RV systolic function is normal. The TAPSE is 1.84 cm.
\u2022 \u00a0Tricuspid\u00a0Valve: The right ventricular systolic pressure is normal. \u00a0
RVSP ~ 20 mmHg
\u2022 \u00a0IVC/SVC: The inferior vena cava demonstrates a diameter of <=21 mm and
collapses >50%; therefore, the right atrial pressure is estimated at 0-5
mmHg.
\u2022 \u00a0Pericardium: There is a very small pericardial effusion. There is no
echocardiographic evidence of tamponade. The pericardium is thickened.
\u2022 \u00a0No significant valvular lesions
\u2022 \u00a0No prior echocardiogram here

Left Ventricle
The left ventricle is normal in size. (LVIDd 4.40 cm) Left ventricular wall thickness is normal. Left ventricular ejection fraction is normal. The visually estimated ejection fraction is 55-65%. Left ventricular wall motion is normal. Left ventricular diastolic function appears normal.
Right Ventricle
Right ventricular size normal. RV systolic function is normal. The TAPSE is 1.84 cm. RV wall thickness is normal.
Left Atrium
Left atrium size is normal.
Right Atrium
Right atrium is normal.
IVC/SVC
The inferior vena cava demonstrates a diameter of <=21 mm and collapses >50%; therefore, the right atrial pressure is estimated at 0-5 mmHg.
Mitral Valve
Mitral valve structure is normal. There is no regurgitation or stenosis.
Tricuspid Valve
Tricuspid valve structure is normal. There is trace regurgitation. The right ventricular systolic pressure is normal. RVSP ~ 20 mmHg
Aortic Valve
The aortic valve was not well visualized. There is no regurgitation or stenosis.
Pulmonic Valve
Pulmonic valve structure is normal. There is no regurgitation.
Ascending Aorta
The aorta appears normal in size.
Pericardium
There is a very small pericardial effusion. There is no echocardiographic evidence of tamponade. The pericardium is thickened.
Study Details
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Laboratory Director: Jonathan R. Genzen, MD, PhD
Salt Lake City, UT 84108
500 Chipeta Way
Performed By: ARUP Laboratories
For medical purposes only; not valid for forensic use.
can be ordered. Refer to aruplab.com for test information.
includes these opioids is available or individual opioid testing
meperidine, tramadol, and tapentadol. A comprehensive panel that
opioids are not detected in this test: fentanyl, buprenorphine,
results are reported with the amphetamines results. The following
Oxycodone results are reported with the opiates results. MDMA
to the laboratory.
be reported as positive. Interpretive questions should be directed
concentration value must be greater than or equal to the cutoff to
second, more specific technology (GC/MS and/or LC-MS/MS). The
or drug classes are detected by the screen are reflexed to a
metabolite varies within a drug class. Specimens for which drugs
concentration at which the screening test can detect a drug or
diluted/adulterated urine, or limitations of testing. The
collection relative to drug administration, poor drug absorption,
indicate non-compliance, inappropriate timing of specimen
The absence of expected drug(s) and/or drug metabolite(s) may
INTERPRETIVE INFORMATION: Drug Panel 9, Urn, Scrn w/Rflx to Conf"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Urine"}, {"url": "specimen collection time", "valueDateTime": "2024-07-26T20:23:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-27T00:50:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.478.2.7.2.798268.462385362.Comp11"}]}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "performer": [{"display": "VUMC CERNER LAB", "reference": "Organization/e3ece69c-0968-59c9-47dd-f16db731621a"}]}, "request": {"method": "PUT", "url": "Observation/73be09cd-bca8-ac47-cda5-e26e830cd448"}}, {"fullUrl": "urn:uuid:8c1be472-0a45-0669-926c-cd40e26ab27b", "resource": {"resourceType": "Observation", "id": "8c1be472-0a45-0669-926c-cd40e26ab27b", "meta": {"profile": 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*In the absence of evidence of kidney damage, neither GFR category G1 nor G2 fulfill the criteria for CKD (Kidney Int Suppl 2013;3:1-150)
G5 14 or less \u00a0 \u00a0Kidney failure
G4 15-29 \u00a0 \u00a0Severe decrease
G3b 30-44 \u00a0 \u00a0Moderate to severe decrease
G3a 45-59 \u00a0 \u00a0Mild to moderate decrease
G2 60-89 \u00a0 \u00a0Mild decrease*
G1 90 or greater \u00a0 \u00a0Normal or high*
GFR GFR (mL/min/1.73 Category: square meters) Interpretation:
GFR Categories in Chronic Kidney Disease (CKD)
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American Journal of Kidney Diseases (2021)"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-27T17:21:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-27T18:12:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.478.2.7.2.798268.462499688.Comp1"}]}], "subject": {"reference": "Patient/ad32a8b0-a080-4a89-b853-d13725e0ebde"}, "performer": [{"display": "VUMC CERNER LAB", "reference": "Organization/e3ece69c-0968-59c9-47dd-f16db731621a"}]}, "request": {"method": "PUT", "url": "Observation/27d80412-5b55-ace8-85bf-bcd91d06bc6a"}}, {"fullUrl": "urn:uuid:fccf7df0-ff04-02de-bc2d-969599d858d1", "resource": {"resourceType": "Observation", "id": "fccf7df0-ff04-02de-bc2d-969599d858d1", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": 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"identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-484b-2a8d-3ed3-d4617497f7f5", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "2"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-08-05T12:45:31-04:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "6015a440-5fd2-0c40-3ac4-f019b96880b3", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E7-DD0F-D69B-FFA4C7D55C45", "title": "Immunizations", "text": {"status": "generated", "div": "Not on file documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E7-DD16-D69B-FFA4C7D55C45", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (TYLENOL) 32 mg/ml oral suspension (80 mg syringe) 23.04 mg23.04 mg (rounded from 22.97 mg = 10 mg/kg \u00d7 2.297 kg), Oral, Every 6 hours PRN, Moderate Pain (4-6), NPASS >3, Starting on Sun 8/4/24 at 0305, Maximum neonatal dose: GA 28-32 weeks: 40 mg/kg/day; 33-37 weeks or term neonates < 10 days: 60 mg/kg/day; term neonates >/= 10 days: 75 mg/kg/day from all sources in 24 hoursGiven08/04/2024 4:14 AM EDT23.04 mg
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
ampicillin 100 mg/mL IV Push (Omnipen) 115 mg115 mg (rounded from 114.85 mg = 50 mg/kg \u00d7 2.297 kg), Intravenous, Every 12 hours, First dose on Sat 8/3/24 at 1930, For 2 doses, First dose given at CMMC prior to transfer Dilute 500 milligram vial of ampicillin with 5 mL of Sterile Water for injection for a final concentration of 100mg/ml. Do not exceed 100 mg/min.Given08/04/2024 6:40 AM EDT115 mg
Given08/03/2024 7:08 PM EDT115 mg
dextrose 10% infusion7.7 mL/hr, Intravenous, Continuous, Starting on Sat 8/3/24 at 1445Rate/Dose Verify08/04/2024 5:00 PM EDT1.1 mL/hr1.1 mL/hr
Rate/Dose Verify08/04/2024 4:00 PM EDT1.1 mL/hr1.1 mL/hr
Rate/Dose Verify08/04/2024 3:00 PM EDT1.1 mL/hr1.1 mL/hr
morphine (neonatal) injection 0.116 mg0.116 mg (rounded from 0.1153 mg = 0.05 mg/kg \u00d7 2.305 kg Dosing weight), Intravenous, Once, On Sat 8/3/24 at 1100, For 1 dose, NICU/CCN: Do not dilute. Otherwise for IV Administration: Add to 1 ml 0.9% sodium chloride and administer over 5 minutesGiven08/03/2024 10:57 AM EDT0.116 mg
morphine (neonatal) injection 0.116 mg0.116 mg (rounded from 0.1153 mg = 0.05 mg/kg \u00d7 2.305 kg Dosing weight), Intravenous, Once, On Sat 8/3/24 at 1215, For 1 dose, NICU/CCN: Do not dilute. Otherwise for IV Administration: Add to 1 ml 0.9% sodium chloride and administer over 5 minutesGiven08/03/2024 12:12 PM EDT0.116 mg
poractant alfa suspension 5.8 mL5.8 mL (rounded from 5.7625 mL = 2.5 mL/kg \u00d7 2.305 kg Dosing weight), Tracheal Tube, Once, On Sat 8/3/24 at 1130, For 1 doseGiven08/03/2024 3:08 PM EDT5.8 mL
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/bc04c4f9-e389-8d47-3d6e-e36f49703b26"}, {"reference": "MedicationAdministration/7158c313-04a8-144f-c203-4574b061bac3"}, {"reference": "MedicationAdministration/03920702-56bd-a866-ea79-c3a02d610d6e"}, {"reference": "MedicationAdministration/aab10817-4d22-17ce-f9b9-35a2e516e79d"}, {"reference": "MedicationAdministration/575aa120-ae09-93b1-37d3-6e2743a65675"}, {"reference": "MedicationAdministration/95d294ee-8fcd-0067-97d4-67c88b301517"}]}, {"id": "30323353-e3c7-29f3-2936-2440a0adcb06", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
NICU Monitoring Continuous Pulse OxRespiratory CareRoutineUntil Discontinued until discontinued starting 8/3/24
POC Bedside Glucose TestPoint of Care TestingRoutineAs Needed until discontinued starting 8/3/24
NICU Oxygen ProtocolRespiratory CareRoutineUntil Discontinued until discontinued starting 8/3/24
Glucose RandomLabTimedprn until discontinued starting 8/3/24, 3 completed
NICU BUBBLE/CPAPRespiratory CareRoutineContinuous until discontinued starting 8/4/24
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/631e40a0-b38e-8414-b9a3-51b8ba1d9b8d"}]}, {"id": "00000000-25E7-DD19-D69B-FFA4C7D55C45", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
High risk social situation08/04/2024
Overview:Formatting of this note might be different from the original.
Prenatal lab results from CMMC recorded in admission problem. Trep to be done of the babyParents will be giving guardianship to Jeff and Dottie Bernier. Jeff should be notified of problems and ay make medical decisions.Mom Sabrina and Dad John. Sabrina had no prenatal care and delivered at CMMC at an estimated 34 weeks. DHHS open case, Case worker Candace Gomez 740-7143
Respiratory distress08/03/2024
Overview:Formatting of this note might be different from the original.
-Obtain CXR and/or blood gas prn-Consider extubation to CPAP if remains stable-Titrate FiO2 to maintain oxygen saturations within target for age-Continue SIMV-VG with TV 12 ml (5.2 ml/kg), Rate 25, PEEP 7, PS 8Plan:SVD at CMMC, developed respiratory distress at ~3 minutes of age and placed on CPAP 6. Subsequently required increase to CPAP 7 cm with FiO2 60-100% at CMMC nursery. MMC transport team arrived to find infant on CPAP 7/FiO2 60%. Infant tachypneic with moderate retractions and intermittent grunting. Infant intubated at CMMC with curosurf administered (8/3). Transferred back to MMC NICU intubated on conventional vent. Chest film on arrival shows ~9 ribs expanded with few ground glass opacities consistent with RDS. CBG on arrival 7.38/39/23/-2.
Healthcare maintenance08/03/2024
Overview:Formatting of this note is different from the original.
PCP: No primary care provider on file. % Difference between R hand and foot: Post-ductal (Right Food): Pre-ductal (Right Hand): Congenital Heart Screening Prior to discharge [] Completed [] Results: Car Seat Angle Tolerance Test Prior to discharge [x] Completed [] Results: Hearing Screen Prior to discharge [x] Completed [] Results: 8/3/24 Hepatitis B vaccine Date Given: 2 wks age [] 24-72 hours 8/5/24 [x] State Metabolic Screen Date Ordered Completed Notes Vitamin K Date Given: 8/3/24 Notes: Erythromycin Ointment Date Given: 8/3/24 Notes: Health Maintenance: >32 wks GA Male
FEN08/03/2024
Overview:Formatting of this note might be different from the original.
- - Follow for feeding toleranceMark was started on Similac Sensitive 20 cal and has been advancing without any issues so far. Blood sugars have been appropriate as IV fluids wean. BMP appropriateAssessment/plan:NPO. Started on 80 mL/kg/day of D10W at CMMC. Mother has consented to formula.
r/o sepsis08/03/2024
Overview:Formatting of this note might be different from the original.
- If antibiotics continued beyond 36 hours, will obtain gentamicin levels and order pharmacokinetics consult. - Will consider continuing antibiotics beyond 36 hours for positive blood culture or clinical concerns for infection. - Continue ampicillin and gentamicin for an anticipated 36 hour sepsis evaluation (ampicillin X 3 doses and the gentamicin X 1 dose). - Follow-up on blood culture drawn at CMMCAssessment/plan: Infant delivered at CMMC and developed respiratory distress at ~6 minutes of life. Maternal GBS unknown with no PNC. Rupture of membranes for 2 hours prior to delivery. Blood culture obtained at CMMC on 8/3/24. Antibiotics of ampicillin and gentamicin started at CMMC for r/o sepsis pending laboratory and culture results.
Preterm infant estimated 34 weeks gestation08/03/2024
Overview:Formatting of this note might be different from the original.
PCP: No primary care provider on file.Sabrina resides in Buckfield, ME. She has 2 older child that live with MGM who has custody.Social History Mark was born estimated 34 weeks gestation with a birth weight of 2305g delivered by SVD following placental abruption. His mother is Sabrina who is a 28yo G3P3 with a pregnancy complicated by no prenatal care and polysubstance use during pregnancy. Prenatal labs, Blood type/Rh A- antibody screen unknown, GBS unknown, HIV negative, Hep C positive, Hep B negative. Rubella unknown Maternal medications included, unknown. Delivery was complicated by abruption. The APGAR score was & at 1 and 5 minutes, respectively.
Newborn affected by maternal use of other drugs of addiction (CMS-HCC V28)08/03/2024
Overview:Formatting of this note might be different from the original.
-Consider bolus and/or maintenance morphine if indicated for withdrawal symptoms-Follow-up with CMMC regarding cord toxicology results-Monitor for signs/symptoms of withdrawalPlan:Mark is irritable and jittery on exam. Very tachypnic at times but he also has respiratory distress. He received a dose of tylenol over night as he has significant facial brusing Maternal urine tox +fentanyl and cocaine, methamphetamines Cord toxicology sent at CMMC with results pending. Infant given IV morphine (0.05 mg/kg) x2 by transport team prior to arrival at MMC NICU.
Incomplete foreskin with concern for hypospadias08/03/2024
Overview:Formatting of this note might be different from the original.
-Consider Urology consult week of 8/5Plan:Infant with incomplete foreskin and apparent hypospadias.
At risk for hyperbilirubinemia08/03/2024
Overview:Formatting of this note might be different from the original.
-Trend bilirubin at 24 hours of agePlan:Infant with significant facial bruising following delivery. Bilirubin 5.1 mg/dL at ~12 hours of age.
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"30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Radiology Study observation (narrative)", "reference": "Observation/ed91d633-c896-74fe-3697-7bcf7f584f30"}, {"display": "PH, POINT OF CARE", "reference": "Observation/374cf02c-694c-1ec8-ed2a-efddf6dcf037"}, {"display": "PCO2, POINT OF CARE", "reference": "Observation/9a4ecd0b-4417-f901-1f0d-44522d285235"}, {"display": "HCO3, POINT OF CARE", "reference": "Observation/7ef78790-8263-2f6d-7ea1-149be852e254"}, {"display": "PO2, POINT OF CARE", "reference": "Observation/89d2bc54-387b-6c45-329b-e7021ae3671b"}, {"display": "SODIUM, POINT OF CARE", "reference": "Observation/cc28280c-caf1-9d4b-dfd4-737c646d1e31"}, {"display": "POTASSIUM, POINT OF CARE", "reference": "Observation/4f0271f5-be72-be65-cb88-e8aebcccf1f9"}, {"display": "CHLORIDE, POINT OF CARE", "reference": "Observation/cedd3d3b-390a-0999-5557-5c0ed37bfcd3"}, {"display": "GLUCOSE, POINT OF CARE", "reference": "Observation/f0323d04-d722-f19d-e528-11ccce4b18bb"}, {"display": "IONIZED CALCIUM, POINT OF CARE", "reference": "Observation/e681abfe-7358-6bd3-be7c-0b56d6d98acf"}, {"display": "POC METHEMOGLOBIN", "reference": "Observation/5cace15e-3a5a-81a4-f7c6-6b1282c90c45"}, {"display": "Allen Test", "reference": "Observation/652b5620-906e-a72d-5eac-1a0c8bbb39a3"}, {"display": "Lab Interpretation", "reference": "Observation/a8c4a76d-60e4-b341-16ed-e4c6e97a537b"}, {"display": "Bilirubin Direct", "reference": "Observation/3b2d4a1d-81be-a375-b0ec-407827a9b2fd"}, {"display": "Bilirubin", "reference": "Observation/0a151aaa-a32b-9f08-38ad-d4d8b1c9ccd0"}, {"display": "Glucose", "reference": "Observation/e2797f0b-8253-e804-1325-52aa875e5902"}, {"display": "Lab Interpretation", "reference": "Observation/28535aaf-267c-be75-e7d3-901ac8317a70"}, {"display": "Sodium", "reference": "Observation/08955c11-6f62-5136-d5be-e467ac9dfcd5"}, {"display": "Potassium", "reference": 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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
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DateTypeDepartmentCare Team (Latest Contact Info)Description
08/03/2024 1:31 PM EDT - PresentHospital EncounterMaineHealth Maine Medical Center Portland Barbara Bush Childrens Hospital Neonatal Intensive Care Unit 122 Bramhall StPortland, ME 04102-3134207-662-2246Frehm, Eric J, MD22 Bramhall St, 4th Flr, Ste 4809Portland, ME 04102207-662-2553 (Work)207-662-6063 (Fax)
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Reportability Response Information Section
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"PUT", "url": "Medication/a4281d20-2071-c4b7-fc3a-ff8d46c585af"}}, {"fullUrl": "urn:uuid:575aa120-ae09-93b1-37d3-6e2743a65675", "resource": {"resourceType": "MedicationAdministration", "id": "575aa120-ae09-93b1-37d3-6e2743a65675", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355077725"}], "status": "completed", "effectivePeriod": {"start": "2024-08-03T23:30:00Z", "end": "2024-08-04T10:40:00Z"}, "dosage": {"route": {"coding": [{"code": "C38276", "display": "Intravenous", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 50, "unit": "mg/kg"}}, "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "medicationReference": {"reference": "Medication/bd03efdf-85f0-e6c6-991b-3431d5f41af7"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/575aa120-ae09-93b1-37d3-6e2743a65675"}}, {"fullUrl": "urn:uuid:bd03efdf-85f0-e6c6-991b-3431d5f41af7", "resource": {"resourceType": "Medication", "id": "bd03efdf-85f0-e6c6-991b-3431d5f41af7", "code": {"coding": [{"code": "0781-3407-95", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/bd03efdf-85f0-e6c6-991b-3431d5f41af7"}}, {"fullUrl": "urn:uuid:95d294ee-8fcd-0067-97d4-67c88b301517", "resource": {"resourceType": "MedicationAdministration", "id": "95d294ee-8fcd-0067-97d4-67c88b301517", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355077542"}], "status": "stopped", "effectivePeriod": {"start": "2024-08-03T18:45:00Z", "end": "2024-08-05T02:10:04Z"}, "dosage": {"route": {"coding": [{"code": "C38276", "display": "Intravenous", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 7.7, "unit": "mL/h"}}, "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "medicationReference": {"reference": "Medication/37f1eac0-a30b-a71b-c82c-6789f339ba73"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/95d294ee-8fcd-0067-97d4-67c88b301517"}}, {"fullUrl": "urn:uuid:37f1eac0-a30b-a71b-c82c-6789f339ba73", "resource": {"resourceType": "Medication", "id": "37f1eac0-a30b-a71b-c82c-6789f339ba73", "code": {"coding": [{"code": "0264-7520-00", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/37f1eac0-a30b-a71b-c82c-6789f339ba73"}}, {"fullUrl": "urn:uuid:ed4f86fd-7c05-1439-ba50-577e24fad0b9", "resource": {"resourceType": "RelatedPerson", "id": "ed4f86fd-7c05-1439-ba50-577e24fad0b9", "relationship": [{"coding": [{"display": "Mother"}]}], "telecom": [{"system": "phone", "value": "+1-207-500-6905", "use": "mobile"}], "patient": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "RelatedPerson/ed4f86fd-7c05-1439-ba50-577e24fad0b9"}}, {"fullUrl": "urn:uuid:1559feda-2408-5aaf-6a69-59aa691fc4ba", "resource": {"resourceType": "Condition", "id": "1559feda-2408-5aaf-6a69-59aa691fc4ba", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924242"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R06.03", "display": "Respiratory distress", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote46
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SVD at CMMC, developed respiratory distress at ~3 minutes of age and placed on CPAP 6. Subsequently required increase to CPAP 7 cm with FiO2 60-100% at CMMC nursery. MMC transport team arrived to find infant on CPAP 7/FiO2 60%. Infant tachypneic with moderate retractions and intermittent grunting. Infant intubated at CMMC with curosurf administered (8/3). Transferred back to MMC NICU intubated on conventional vent. Chest film on arrival shows ~9 ribs expanded with few ground glass opacities consistent with RDS. CBG on arrival 7.38/39/23/-2.
Plan:
-Continue SIMV-VG with TV 12 ml (5.2 ml/kg), Rate 25, PEEP 7, PS 8
-Titrate FiO2 to maintain oxygen saturations within target for age
-Consider extubation to CPAP if remains stable
-Obtain CXR and/or blood gas prn"}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1559feda-2408-5aaf-6a69-59aa691fc4ba"}}, {"fullUrl": "urn:uuid:f776a8a1-c412-9e8d-90d4-57337564b4f1", "resource": {"resourceType": "Condition", "id": "f776a8a1-c412-9e8d-90d4-57337564b4f1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924267"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z00.00", "display": "Healthcare maintenance", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote48
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Health Maintenance: >32 wks GA Male
Erythromycin Ointment Date Given: 8/3/24 Notes:
Vitamin K Date Given: 8/3/24 Notes:
State Metabolic Screen Date Ordered Completed Notes
24-72 hours 8/5/24 [x]
2 wks age []
Hepatitis B vaccine Date Given:
8/3/24
Hearing Screen Prior to discharge [x] Completed [] Results:
Car Seat Angle Tolerance Test Prior to discharge [x] Completed [] Results:
Congenital Heart Screening Prior to discharge [] Completed [] Results:
Pre-ductal (Right Hand):
Post-ductal (Right Food):
% Difference between R hand and foot:
PCP: No primary care provider on file. "}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/f776a8a1-c412-9e8d-90d4-57337564b4f1"}}, {"fullUrl": "urn:uuid:44f8a7bc-be67-4fec-b099-e5be487a799b", "resource": {"resourceType": "Condition", "id": "44f8a7bc-be67-4fec-b099-e5be487a799b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924268"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "P92.8", "display": "Other feeding problems of newborn", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote50
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NPO. Started on 80 mL/kg/day of D10W at CMMC. Mother has consented to formula.
Assessment/plan:
Mark was started on Similac Sensitive 20 cal and has been advancing without any issues so far. Blood sugars have been appropriate as IV fluids wean. BMP appropriate
- Follow for feeding tolerance
- "}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/44f8a7bc-be67-4fec-b099-e5be487a799b"}}, {"fullUrl": "urn:uuid:d55a3694-a729-fb27-aaf5-a23b3c52f3c1", "resource": {"resourceType": "Condition", "id": "d55a3694-a729-fb27-aaf5-a23b3c52f3c1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924269"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z05.1", "display": "Observation and evaluation of newborn for suspected infectious condition", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote52
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Infant delivered at CMMC and developed respiratory distress at ~6 minutes of life. Maternal GBS unknown with no PNC. Rupture of membranes for 2 hours prior to delivery. Blood culture obtained at CMMC on 8/3/24. Antibiotics of ampicillin and gentamicin started at CMMC for r/o sepsis pending laboratory and culture results.
Assessment/plan:
- Follow-up on blood culture drawn at CMMC
- Continue ampicillin and gentamicin for an anticipated 36 hour sepsis evaluation (ampicillin X 3 doses and the gentamicin X 1 dose).
- Will consider continuing antibiotics beyond 36 hours for positive blood culture or clinical concerns for infection.
- If antibiotics continued beyond 36 hours, will obtain gentamicin levels and order pharmacokinetics consult. "}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/d55a3694-a729-fb27-aaf5-a23b3c52f3c1"}}, {"fullUrl": "urn:uuid:9d306df9-cb19-7fc5-26c1-7c35ae66ffc3", "resource": {"resourceType": "Condition", "id": "9d306df9-cb19-7fc5-26c1-7c35ae66ffc3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924273"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "P07.30", "display": "Preterm newborn of unknown gestational age", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote54
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Mark was born estimated 34 weeks gestation with a birth weight of 2305g delivered by SVD following placental abruption. His mother is Sabrina who is a 28yo G3P3 with a pregnancy complicated by no prenatal care and polysubstance use during pregnancy. Prenatal labs, Blood type/Rh A- antibody screen unknown, GBS unknown, HIV negative, Hep C positive, Hep B negative. Rubella unknown Maternal medications included, unknown. Delivery was complicated by abruption. The APGAR score was & at 1 and 5 minutes, respectively.
Social History
Sabrina resides in Buckfield, ME. She has 2 older child that live with MGM who has custody.
PCP: No primary care provider on file."}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/9d306df9-cb19-7fc5-26c1-7c35ae66ffc3"}}, {"fullUrl": "urn:uuid:fc64c211-6e43-5ae1-699e-a88179f3627c", "resource": {"resourceType": "Condition", "id": "fc64c211-6e43-5ae1-699e-a88179f3627c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924279"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "P04.49", "display": "Newborn affected by maternal use of other drugs of addiction (CMS-HCC V28)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote56
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Maternal urine tox +fentanyl and cocaine, methamphetamines Cord toxicology sent at CMMC with results pending. Infant given IV morphine (0.05 mg/kg) x2 by transport team prior to arrival at MMC NICU.
Mark is irritable and jittery on exam. Very tachypnic at times but he also has respiratory distress. He received a dose of tylenol over night as he has significant facial brusing
Plan:
-Monitor for signs/symptoms of withdrawal
-Follow-up with CMMC regarding cord toxicology results
-Consider bolus and/or maintenance morphine if indicated for withdrawal symptoms"}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/fc64c211-6e43-5ae1-699e-a88179f3627c"}}, {"fullUrl": "urn:uuid:fa6a2c0a-fd3f-f537-4230-ebd6371913e7", "resource": {"resourceType": "Condition", "id": "fa6a2c0a-fd3f-f537-4230-ebd6371913e7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924419"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R89.9", "display": "Abnormal findings on examination of genitourinary organs", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote58
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Infant with incomplete foreskin and apparent hypospadias.
Plan:
-Consider Urology consult week of 8/5"}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/fa6a2c0a-fd3f-f537-4230-ebd6371913e7"}}, {"fullUrl": "urn:uuid:e767a5cf-9518-1a72-3ad6-56209f931427", "resource": {"resourceType": "Condition", "id": "e767a5cf-9518-1a72-3ad6-56209f931427", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924437"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z91.89", "display": "At risk for hyperbilirubinemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote60
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Infant with significant facial bruising following delivery. Bilirubin 5.1 mg/dL at ~12 hours of age.
Plan:
-Trend bilirubin at 24 hours of age"}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e767a5cf-9518-1a72-3ad6-56209f931427"}}, {"fullUrl": "urn:uuid:64b7c99f-e106-2380-70c7-e6781d42e2dd", "resource": {"resourceType": "Condition", "id": "64b7c99f-e106-2380-70c7-e6781d42e2dd", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50927093"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z60.9", "display": "High risk social situation", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-04", "note": [{"text": "Overview:
problemNote62
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Mom Sabrina and Dad John. Sabrina had no prenatal care and delivered at CMMC at an estimated 34 weeks. DHHS open case, Case worker Candace Gomez 740-7143
Parents will be giving guardianship to Jeff and Dottie Bernier. Jeff should be notified of problems and ay make medical decisions.
Prenatal lab results from CMMC recorded in admission problem. Trep to be done of the baby"}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/64b7c99f-e106-2380-70c7-e6781d42e2dd"}}, {"fullUrl": "urn:uuid:0e026883-717c-3079-413e-b1659b9936f6", "resource": {"resourceType": "DiagnosticReport", "id": "0e026883-717c-3079-413e-b1659b9936f6", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355077723"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.206.2.798268.2.355077723.1"}], "status": "final", "code": {"coding": [{"code": "61611", "display": "XR Chest Portable", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-08-03T17:55:00Z", "end": "2024-08-03T17:55:00Z"}, "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "performer": [{"reference": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}], "result": [{"reference": "Observation/ed91d633-c896-74fe-3697-7bcf7f584f30"}, {"reference": "Observation/0d6b822e-0aac-ef44-f1a9-22f57369544e"}, {"reference": "Observation/9c7c0fea-1cc3-b69c-103b-3b9f44c83832"}, {"reference": "Observation/ff754c1d-9f3d-933a-cda3-33b3a71140b0"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/0e026883-717c-3079-413e-b1659b9936f6"}}, {"fullUrl": "urn:uuid:6785067f-cee7-c612-c204-069a2bb67949", "resource": {"resourceType": "Organization", "id": "6785067f-cee7-c612-c204-069a2bb67949", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}}, {"fullUrl": "urn:uuid:ed91d633-c896-74fe-3697-7bcf7f584f30", "resource": {"resourceType": "Observation", "id": "ed91d633-c896-74fe-3697-7bcf7f584f30", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.3.696580.52175", "value": "61611"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-08-03T17:53:53Z", "end": "2024-08-03T18:06:38Z"}, "bodySite": {"coding": [{"code": "101", "display": "Chest", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.10.696580.52010"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T17:55:00Z"}]}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}}, "request": {"method": "PUT", "url": "Observation/ed91d633-c896-74fe-3697-7bcf7f584f30"}}, {"fullUrl": "urn:uuid:0d6b822e-0aac-ef44-f1a9-22f57369544e", "resource": {"resourceType": "Observation", "id": "0d6b822e-0aac-ef44-f1a9-22f57369544e", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.7.798268.1000", "value": "355077723"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-03T19:14:36Z", "valueString": "EXAM: XR CHEST PORTABLE 1VW
INDICATION: \u00a0respiratory distress
COMPARISON: None.
TECHNIQUE: Single portable view of the chest was obtained.
FINDINGS:
Lungs/Pleura: No infiltrate or pleural fluid .
Cardiac Silhouette: Within normal limits.
Hila/Mediastinum: The endotracheal tube and nasogastric tube are in satisfactory position.
Bones: Unremarkable.
Soft Tissues: Unremarkable.
IMPRESSION: No acute process is identified. The endotracheal tube and nasogastric tube are in satisfactory position.
WORKSTATION: MILES-MG-DS1
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/3/2024 3:12 PM \u00a0Charles Mullen, MD", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T17:55:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355077723.Narrative"}]}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/0d6b822e-0aac-ef44-f1a9-22f57369544e"}}, {"fullUrl": "urn:uuid:cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "resource": {"resourceType": "Organization", "id": "cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}}, {"fullUrl": "urn:uuid:9c7c0fea-1cc3-b69c-103b-3b9f44c83832", "resource": {"resourceType": "Observation", "id": "9c7c0fea-1cc3-b69c-103b-3b9f44c83832", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051864226"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-03T19:14:36Z", "valueString": "RECOGNITION * * 8/3/2024 3:12 PM Charles Mullen, MD
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: MILES-MG-DS1
nasogastric tube are in satisfactory position.
IMPRESSION: No acute process is identified. The endotracheal tube and
Soft Tissues: Unremarkable.
Bones: Unremarkable.
satisfactory position.
Hila/Mediastinum: The endotracheal tube and nasogastric tube are in
Cardiac Silhouette: Within normal limits.
Lungs/Pleura: No infiltrate or pleural fluid .
FINDINGS:
TECHNIQUE: Single portable view of the chest was obtained.
COMPARISON: None.
INDICATION: respiratory distress
EXAM: XR CHEST PORTABLE 1VW
Formatting of this note might be different from the original.
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MH IP INTUBATION
Date/Time: 8/3/2024 11:05 AM
Performed by: Cotton, Katherine A, NP
Authorized by: Cotton, Katherine A, NP \u00a0
Consent:
\u00a0Consent obtained: \u00a0Verbal
\u00a0Consent given by: \u00a0Parent
\u00a0Risks, benefits, and alternatives were discussed: yes \u00a0
\u00a0Risks discussed: \u00a0Laryngeal injury, hypoxia and bleeding
\u00a0Alternatives discussed: \u00a0No treatment
Universal protocol:
\u00a0Procedure explained and questions answered to patient or proxy''s
satisfaction: yes \u00a0
\u00a0Imaging studies available: yes \u00a0
\u00a0Immediately prior to procedure, a time out was called: yes \u00a0
\u00a0Patient identity confirmed: \u00a0Arm band and provided demographic data
Pre-procedure details:
\u00a0Indication: failure to ventilate and predicted clinical deterioration \u00a0
\u00a0Patient status: \u00a0Awake
\u00a0Look externally: no concerns \u00a0
\u00a0Obstruction: none \u00a0
\u00a0Neck mobility: normal \u00a0
\u00a0Pharmacologic strategy comment: \u00a0Given morphine (0.05 mg/kg) x1
pre-procedure
\u00a0Preatreatment Medications: \u00a0None
\u00a0Sedation: morphine (0.05 mg/kg) x1 pre-procedure.
\u00a0Paralytics: \u00a0None
Procedure details:
\u00a0Preoxygenation: CPAP prongs.
\u00a0CPR in progress: no \u00a0
\u00a0Intubation method: \u00a0Oral
\u00a0Intubation technique: direct \u00a0
\u00a0Laryngoscope blade: \u00a0Miller 0
\u00a0Bougie used: no \u00a0
\u00a0Tube size (mm): \u00a03.0
\u00a0Tube type: \u00a0Uncuffed
\u00a0Number of attempts: \u00a03 or more
\u00a0Ventilation between attempts comment: \u00a0Yes, CPAP prongs
\u00a0Tube visualized through cords: yes \u00a0
Placement assessment:
\u00a0ETT at teeth/gumline (cm): \u00a08.5
\u00a0Tube secured with: \u00a0Adhesive tape
\u00a0Breath sounds: \u00a0Equal
\u00a0Placement verification: CXR verification, direct visualization, equal
breath sounds, ETCO2 detector and tube exhalation \u00a0
\u00a0CXR findings: \u00a0Appropriate position
Post-procedure details:
\u00a0Procedure completion: \u00a0Tolerated
Comments:
\u00a0 Timeout performed. CMMC MD (Dr. Wood) attempted intubation x1 but
unsuccessful. Moderate bloody secretions observed to oral mucosa following
attempt. NNP inserts #3.0 ETT to 8.5 cm at gum with copious bloody
secretions coming up ETT following insertion (?r/t trauma vs. Early
pulmonary hemorrhage). Placement confirmed by mist in tube, equal breath
sounds, and color change on ETCO2 detector. Infant transitioned to
conventional vent via transporter and PEEP increased to 7 with improvement
of bloody drainage. Discussed with Dr. Frehm. CXR confirms ETT in
appropriate placement with tip terminating at ~T3 above carina. Curosurf
administered via ETT in 1 aliquot. Hematocrit (post-intubation) stable at
54.1%. Infant tolerated procedure fairly well with no immediate
complications. ", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen receive time", "valueDateTime": "2024-08-05T07:07:53Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355077734.Narrative"}]}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}, "performer": [{"display": ".MANUAL ENTRY (EXTERNAL LAB)", "reference": "Organization/5f797041-fb55-9a9d-4c39-674033c3def6"}]}, "request": {"method": "PUT", "url": "Observation/cccdf2e4-b04e-544f-32f5-410cdad2efd4"}}, {"fullUrl": "urn:uuid:5f797041-fb55-9a9d-4c39-674033c3def6", "resource": {"resourceType": "Organization", "id": "5f797041-fb55-9a9d-4c39-674033c3def6", "name": ".MANUAL ENTRY (EXTERNAL LAB)", "address": [{"line": ["Please Refer to Scanned Lab Report"]}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/5f797041-fb55-9a9d-4c39-674033c3def6"}}, {"fullUrl": "urn:uuid:2c99386b-ba1b-fc79-743c-87ca477ca67f", "resource": {"resourceType": "Observation", "id": "2c99386b-ba1b-fc79-743c-87ca477ca67f", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355077734"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2024-08-03T15:05:00Z", "valueCodeableConcept": {"coding": [{"code": "12", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen receive time", "valueDateTime": "2024-08-05T07:07:53Z"}]}], "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}}, "request": {"method": "PUT", "url": "Observation/2c99386b-ba1b-fc79-743c-87ca477ca67f"}}, {"fullUrl": "urn:uuid:e05b992d-e4eb-db01-5861-b126cd2b18a3", "resource": {"resourceType": "Observation", "id": "e05b992d-e4eb-db01-5861-b126cd2b18a3", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.1.1040.1", "value": "Z4402796^^72166-2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "72166-2", "display": "Tobacco smoking status NHIS", "system": "http://loinc.org"}]}, "valueCodeableConcept": {"coding": [{"code": "266927001", "display": "Tobacco smoking consumption unknown", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/c3f221f8-22c0-4017-8e86-4ec7cd274d1a"}}, "request": {"method": "PUT", "url": "Observation/e05b992d-e4eb-db01-5861-b126cd2b18a3"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.206.2.7.8.688883.470000397', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.206.2.7.8.688883.470000397", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.206.2.7.8.688883.470000397", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-4848-224b-3ed3-d4617497f7f5", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "6"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-08-05T12:33:11-04:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "6330ab6c-b294-e349-de60-412f496fe94a", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E7-74A9-D69B-FFA4C7D55C45", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
Hepatitis B Vaccine09/24/2011 04/06/2011 ,
Influenza A H1N1 200912/01/2009
Influenza Vaccine10/10/2023 10/13/2010 10/21/2008 , ,
Influenza Vaccine 0.5mL IM High Dose Age 65+ (IMM90)10/10/2018
Influenza Vaccine 0.7mL IM High Dose Age 65+ (IMM10220)10/06/2021
Influenza Vaccine Age 3+ PF10/12/2011
MMR Vaccine04/27/2011
Moderna Red Cap(12+)Covid-19,Monovalent,mrna,lnp-s,pf,.5mL (IMM10222)08/24/2021 01/26/2021 12/28/2020 , ,
PREVNAR 20,(PCV-20),Pneumococcal Conjugate Vaccine (IMM21058)11/09/2023
Pfizer Bivalent (12+)Gray Cap,Tris-Sucrose,Covid-19,PF,30mcg/0.3mL(IMM10252)09/26/2022
Pfizer Comirnaty (12+)covid-19,mrna,lnp-s,pf,tris-sucrose,30mcg/0.3mL(IMM10263)10/20/2023
Tdap Vaccine Age 7+11/09/2023 04/06/2011 ,
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E7-74B5-D69B-FFA4C7D55C45", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (Tylenol) tablet 650 mg650 mg, Oral, Every 8 hours PRN, Mild Pain (1-3), Fever, Starting on Sun 8/4/24 at 0645, Maximum dose of acetaminophen is 4000 mg from all sources in 24 hours. Possible side effects: upset stomach, rash
amLODIPine (Norvasc) tablet 10 mg10 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900, Possible side effects: leg swelling, fatigue, flushingGiven08/05/2024 8:24 AM EDT10 mg
Given08/04/2024 9:28 AM EDT10 mg
aspirin chewable tablet 81 mg81 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900, Possible side effects: easy bruising and bleeding, heartburn, ulcerGiven08/05/2024 8:24 AM EDT81 mg
Given08/04/2024 9:25 AM EDT81 mg
atorvastatin (Lipitor) tablet 40 mg40 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900, Possible side effects: muscle pain and weakness, diarrhea, nauseaGiven08/05/2024 8:24 AM EDT40 mg
Given08/04/2024 9:25 AM EDT40 mg
azaTHIOprine (Imuran) tablet 100 mg100 mg, Oral, Daily, First dose on Sat 8/3/24 at 1530, **Hazardous Drug - Moderate Risk - Handle with double ASTM6978 rated gloves. For liquids or suspensions: wear non-permeable gown and face/eye protection if risk for spills or splashes.**Given08/05/2024 8:26 AM EDT100 mg
Given08/04/2024 9:25 AM EDT100 mg
Given08/03/2024 8:18 PM EDT100 mg
azithromycin (Zithromax) 500 mg in 0.9% NaCl 250 mL500 mg, Intravenous, at 250 mL/hr, Every 24 hours, First dose on Sun 8/4/24 at 1645, Possible side effects: nausea/vomiting, diarrhea, rashRestarted08/04/2024 9:29 PM EDT250 mL/hr
New Bag08/04/2024 4:28 PM EDT500 mg250 mL/hr
bisacodyl (Dulcolax) rectal suppository 10 mg10 mg, Rectal, Daily PRN, Constipation, Starting on Mon 8/5/24 at 0000, 2nd line therapy (Adult Bowel Management - No Risk Factors): Only initiate if no BM by 48 hours after using 1st line therapy per Bowel Management orders. Notify Provider/Team if no response to 2nd line agents (no BM) in 3 days.
carvedilol (Coreg) tablet 25 mg25 mg, Oral, 2 times daily, First dose on Sun 8/4/24 at 0900, take with food to slow absorption and reduce orthostatic effects. Possible side effects: tiredness, weakness, dizzinessGiven08/05/2024 8:25 AM EDT25 mg
Given08/04/2024 9:30 PM EDT25 mg
Given08/04/2024 9:24 AM EDT25 mg
ceFAZolin (Ancef) syringe infusion 1 gm1 gm, Intravenous, Daily, First dose on Sun 8/4/24 at 1045, Possible side effects: Nausea, diarrhea, rash Administer after dialysis on dialysis days Reconstitute\u00a01 gm vial of cefazolin in 20 mL of SWFI or 0.9% NaCl. For locations with access to Plum360 pump: Connect syringe to Plum360 Pump and infuse over 5 minutes (4 mL/min). Upon completion of infusion, flush with 20 mL at the same rate to ensure all antibiotic in tubing has been administered. In locations where Plum360 pump is unavailable: push syringe over 2 minutes. Upon completion of IV push, flush with 20 mL of NS or maintenance fluid to ensure all antibiotic in tubing has been administered.Given08/04/2024 10:53 AM EDT1 gm
cholecalciferol (VITAMIN D3) tablet 1,000 Units1,000 Units, Oral, Daily, First dose on Sun 8/4/24 at 0900, Possible side effects: nausea/vomiting, constipationGiven08/05/2024 8:24 AM EDT1,000 Units
Given08/04/2024 9:35 AM EDT1,000 Units
darbepoetin alfa 40mcg/0.4mL (Aranesp) injection 40 mcg40 mcg, Subcutaneous, Every 7 days scheduled, First dose on Sat 8/3/24 at 1800, If Hgb greater than 11, hold darbepoetin and check Hgb daily. When Hgb < 11, restart dosing as follows: decrease to next lower dose. Do not shake., Indications: Anemia assoc. with ESRD (End Stage Renal Disease)Given08/04/2024 6:40 AM EDT40 mcgLeft Lower Abdomen
famotidine (Pepcid) tablet 10 mg10 mg, Oral, Daily, First dose (after last reorder) on Sun 8/4/24 at 0900, Possible side effects: headache, dizzinessGiven08/05/2024 8:25 AM EDT10 mg
Given08/04/2024 9:25 AM EDT10 mg
gabapentin (Neurontin) capsule 100 mg100 mg, Oral, Daily with breakfast, First dose (after last modification) on Tue 8/6/24 at 0800, Possible side effects: drowsiness, dizziness, swelling in hands or feet
losartan (Cozaar) tablet 100 mg100 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900Given08/05/2024 8:24 AM EDT100 mg
Given08/04/2024 9:25 AM EDT100 mg
niacin (VITAMIN B3) tablet 50 mg50 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900, Immediate release tabletGiven08/05/2024 10:48 AM EDT50 mg
ondansetron (Zofran) injection 4 mg4 mg, Intravenous, Every 6 hours PRN, Nausea, Vomiting, Starting on Sat 8/3/24 at 1309, For doses 8mg or less, may administer undiluted IV push over 2 minutes. Otherwise, dilute in 0.9% NS (sterile water not recommended) and infuse via infusion pump. Possible side effects: headache, fatigue, constipation
polyethylene glycol (Miralax) packet 17 gm17 gm, Oral, Daily PRN, Constipation, Starting on Sat 8/3/24 at 1624, 1st line therapy (Adult Bowel Management - No Risk Factors): If no BM in 24 hours, administer one of 1st line therapy options per patient preference, switch to 2nd line therapy if no BM by 48 hours after using 1st line therapy. For 8.5g: Mix with 2 oz (60mL) non-carbonated liquid. For 17g: Mix with 4oz (120mL) non-carbonated liquid. For 119g: Mix with 32oz (~1 liter) non-carbonated, clear liquid (not blue, red, or purple). For 238g: Mix with 64oz (~2 liters) non-carbonated, clear liquid(not blue, red, or purple). Possible side effects: diarrhea, bloating, cramps
polyethylene glycol (Miralax) packet 34 gm34 gm, Oral, Daily PRN, Constipation, Starting on Mon 8/5/24 at 0000, 2nd line therapy (Adult Bowel Management - No Risk Factors): Only initiate if no BM by 48 hours after using 1st line therapy per Bowel Management orders. Do NOT administer if 1st line polyethylene glycol powder (17 gm dose) has already been administered today. Notify Provider/Team if no response to 2nd line agents (no BM) in 3 days. For 8.5g: Mix with 2 oz (60mL) non-carbonated liquid. For 17g: Mix with 4oz (120mL) non-carbonated liquid. For 119g: Mix with 32oz (~1 liter) non-carbonated, clear liquid (not blue, red, or purple). For 238g: Mix with 64oz (~2 liters) non-carbonated, clear liquid(not blue, red, or purple). Possible side effects: diarrhea, bloating, cramps
predniSONE (Deltasone) tablet 5 mg5 mg, Oral, Daily with breakfast, First dose on Sun 8/4/24 at 0800, Possible side effects: high blood sugar, change in mood, fluid retentionGiven08/05/2024 8:24 AM EDT5 mg
Given08/04/2024 9:24 AM EDT5 mg
renal multivitamin capsule 1 Capsule1 Capsule, Oral, Daily, First dose on Sun 8/4/24 at 0900Given08/05/2024 8:24 AM EDT1 Capsule
Given08/04/2024 9:23 AM EDT1 Capsule
senna (Senokot) tablet 2 Tablet2 Tablet, Oral, Daily PRN, Constipation, Starting on Sat 8/3/24 at 1624, 1st line therapy (Adult Bowel Management - No Risk Factors): If no BM in 24 hours, administer one of 1st line therapy options per patient preference, switch to 2nd line therapy if no BM by 48 hours after using 1st line therapy.
sevelamer (Renvela) tablet 1,600 mg1,600 mg, Oral, 3 times daily with meals, First dose on Sat 8/3/24 at 1730, Possible side effects: nausea/vomiting, indigestion, diarrhea. Do not crush, chew, or break. Broken/crushed tablets rapidly expand in water/saliva and may be a choking hazardGiven08/05/2024 8:23 AM EDT1,600 mg
Given08/04/2024 6:34 PM EDT1,600 mg
Given08/04/2024 2:10 PM EDT1,600 mg
sodium bicarbonate tablet 1,300 mg1,300 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900Given08/05/2024 8:23 AM EDT1,300 mg
Given08/04/2024 9:25 AM EDT1,300 mg
sodium chloride (NS) 0.9 % flush 5 mL5 mL, Intravenous, As needed, Line Care, Starting on Sat 8/3/24 at 1227
tacrolimus (Prograf) capsule 1 mg1 mg, Oral, Over 24 hours, First dose on Sat 8/3/24 at 1800, If ordered sublingually, open cap and place contents under patient''s tongue. Possible side effects: headache, insomnia, tremor **Hazardous Drug - Low Risk - Handle with single gloves. For liquids or suspensions: wear non-permeable gown and face/eye protection if risk for spills or splashes.**Given08/04/2024 6:34 PM EDT1 mg
Given08/03/2024 8:10 PM EDT1 mg
tacrolimus (Prograf) capsule 2 mg2 mg, Oral, Over 24 hours, First dose on Sun 8/4/24 at 0600, If ordered sublingually, open cap and place contents under patient''s tongue. Possible side effects: headache, insomnia, tremor **Hazardous Drug - Low Risk - Handle with single gloves. For liquids or suspensions: wear non-permeable gown and face/eye protection if risk for spills or splashes.**Given08/05/2024 5:28 AM EDT2 mg
Given08/04/2024 6:39 AM EDT2 mg
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (Tylenol) tablet 1,000 mg1,000 mg, Oral, Once, On Sun 8/4/24 at 0245, For 1 dose, Maximum dose of acetaminophen is 4000 mg from all sources in 24 hours. Possible side effects: upset stomach, rashGiven08/04/2024 2:07 AM EDT1,000 mg
azithromycin (Zithromax) 500 mg in 0.9% NaCl 250 mL500 mg, Intravenous, at 250 mL/hr, Every 24 hours, First dose on Sat 8/3/24 at 1315, Possible side effects: nausea/vomiting, diarrhea, rashNew Bag08/03/2024 2:05 PM EDT500 mg250 mL/hr
ceFEPIme 2 gm in 0.9% NaCl 50 mL2 gm, Intravenous, at 100 mL/hr, Once, On Sat 8/3/24 at 1230, For 1 dose, Possible side effects: Nausea, diarrhea, rashNew Bag08/03/2024 1:13 PM EDT2 gm100 mL/hr
gabapentin (Neurontin) capsule 100 mg100 mg, Oral, 3 times daily, First dose on Sat 8/3/24 at 1645, Possible side effects: drowsiness, dizziness, swelling in hands or feetGiven08/05/2024 8:26 AM EDT100 mg
Given08/04/2024 9:30 PM EDT100 mg
Given08/04/2024 4:37 PM EDT100 mg
lactated ringers infusion bolus 1,000 mL1,000 mL, Intravenous, Administer over 1 Hours, Every hour, First dose on Sat 8/3/24 at 1300, For 1 dose, Alternate fluids volume ordered due to: Concern for fluid overloadNew Bag08/03/2024 1:18 PM EDT1,000 mL1000 mL/hr
vancomycin 1,500 mg in 0.9% NaCl 500 mL1,500 mg, Intravenous, at 333.3 mL/hr, Once, On Sat 8/3/24 at 1245, For 1 dose, Possible side effects: rash, redness & itching. Caution: bag may contain overfill. Please ensure entire volume is infused.New Bag08/03/2024 1:18 PM EDT1,500 mg333.3 mL/hr
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/be450b99-9e2c-143d-662b-fb4c2b10293b"}, {"reference": "MedicationAdministration/ba844e59-104f-414d-e483-6ba507dd2045"}, {"reference": "MedicationAdministration/ebe7a5fd-4eb4-593a-90b4-8136915ff716"}, {"reference": "MedicationAdministration/c8016c8d-d69e-22b1-16c8-f321d5d75b83"}, {"reference": "MedicationAdministration/a2fba765-d382-6ed0-09a0-46e528d8111c"}, {"reference": "MedicationAdministration/74ad6d11-c904-f665-1ebe-d3fbf054002f"}, {"reference": "MedicationAdministration/9d535c5d-4554-4abb-2252-9edc5d81b24e"}, {"reference": "MedicationAdministration/16fba715-48c7-2d76-7a53-f6742acdfb1e"}, {"reference": "MedicationAdministration/33878db5-f630-702b-c13d-3fa4e9fea203"}, {"reference": "MedicationAdministration/7eb6f133-fa81-ff96-7bda-a978ef480149"}, {"reference": "MedicationAdministration/4fafd277-54eb-e1b6-8d69-487a4a5b6eaf"}, {"reference": "MedicationAdministration/4f6fb180-3f97-33ff-d9cb-e2f591006ac9"}, {"reference": "MedicationAdministration/f014a5a9-e659-8bec-dc05-a0037a06c428"}, {"reference": "MedicationAdministration/ed16acbe-6efe-a907-5b6d-c97201457fe9"}, {"reference": "MedicationAdministration/620ca199-3d7c-cf89-2a43-fbbb474bbb47"}, {"reference": "MedicationAdministration/d7231e5a-a031-4831-d2c3-7b6e911957f5"}, {"reference": "MedicationAdministration/ef0dae54-0017-5210-f07d-cc611750f888"}, {"reference": "MedicationAdministration/be27c90b-c58d-e67b-b2b3-35e40eed0895"}, {"reference": "MedicationAdministration/2bc53212-7db8-77ec-bbca-e8c839057179"}, {"reference": "MedicationAdministration/a2b92530-cc90-f097-9d66-cd0671c3374c"}, {"reference": "MedicationAdministration/c2813503-f062-cac0-d78f-f280f80ff9c7"}, {"reference": "MedicationAdministration/1ae002e0-9d8f-9ddd-09e4-33ce0a139b09"}, {"reference": "MedicationAdministration/a1dbd8fa-a1ba-7b57-5e40-8b4a6e52cc50"}, {"reference": "MedicationAdministration/a6a746a1-b3d3-3a91-cfe4-49bcfb6aa6b8"}, {"reference": "MedicationAdministration/86ffca5e-e7c0-d43b-ca7c-9badab35e0cc"}, {"reference": "MedicationAdministration/352faa93-2f54-236a-83ec-cc345423f009"}, {"reference": "MedicationAdministration/2a70d19e-7263-b04a-5142-f576c6de25a2"}, {"reference": "MedicationAdministration/fa92a93f-15f7-ed9e-a25b-56cfce2d9121"}, {"reference": "MedicationAdministration/69e8e59e-5f9d-4694-20f9-d92281b07b6d"}, {"reference": "MedicationAdministration/f1b9c6b0-19b6-3bf9-140c-a85500fe5e81"}, {"reference": "MedicationAdministration/6a038284-f170-fb82-b2ba-f7de37896225"}, {"reference": "MedicationAdministration/43ba9182-6997-0926-510a-f1de01242a25"}, {"reference": "MedicationAdministration/ce68e61c-a510-e8c1-c8d8-7786043253aa"}]}, {"id": "2e102c8d-b676-abd2-efae-1715a8604c8e", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
08/08/2024 3:30 PM EDTAppointmentMaineHealth Vascular Surgery Radiology Ultrasound Scarborough92 Campus DrSte DScarborough, ME 04074-7229207-662-8900
08/09/2024 8:00 AM EDTOffice VisitMaineHealth Wound Care Brighton Ave Portland335 Brighton AvePortland, ME 04102-2363207-662-4325Hughes, Holland M, NP335 Brighton AvePortland, ME 04102207-662-4325 (Work)207-662-8068 (Fax)
09/18/2024 2:00 PM EDTOffice VisitMaineHealth Cancer Care and IV Therapy South Portland265 Western AveSte 2South Portland, ME 04106-2458207-661-0200Rogers, Andrew M, MD265 Western AveSte 2South Portland, ME 04106-2458207-661-0200 (Work)207-661-0299 (Fax)
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture Blood - #1 of 1MicrobiologySTAT08/03/2024 12:51 PM EDT
RED BLOOD CELL, LEUKOREDUCED 1 Unit; IRRADIATEDBlood BankTimed08/04/2024 9:45 AM EDT
Red Blood Cell Transfusion OrderNursing TransfusionSTAT08/04/2024 11:49 AM EDT
FerritinLabAdd-On08/04/2024 7:47 AM EDT
HaptoglobinLabAdd-On08/04/2024 7:47 AM EDT
Iron + Iron Binding CapacityLabAdd-On08/04/2024 7:47 AM EDT
Red Blood Cell Transfusion OrderNursing TransfusionSTAT08/04/2024 11:44 AM EDT
Mycoplasma Pneumoniae Ab IgG IgMLabRoutine08/05/2024 12:03 AM EDT
US Vascular Upper Extremities Arteries LeftVascular ImagingRoutine08/05/2024 11:31 AM EDT
CBC + DifferentialLabRoutine08/05/2024 5:17 AM EDT
CBC and DifferentialLabRoutine08/05/2024 5:17 AM EDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
POC Bedside Glucose TestPoint of Care TestingSTATAs Needed until discontinued starting 8/3/24
FerritinLabAdd-OnRoutine Today Routine Today for 1 Occurrences starting 8/4/24 until 8/4/24
HaptoglobinLabAdd-OnRoutine Today Routine Today for 1 Occurrences starting 8/4/24 until 8/4/24
Iron + Iron Binding CapacityLabAdd-OnRoutine Today Routine Today for 1 Occurrences starting 8/4/24 until 8/4/24, 1 completed
CBC + DifferentialLabRoutineOrders placed after 4am will default to tomorr for 1 Occurrences starting 8/5/24 until 8/5/24
Mycoplasma Pneumoniae Ab IgG IgMLabAdd-OnRoutine Today Routine Today for 1 Occurrences starting 8/4/24 until 8/4/24
US Vascular Upper Extremities Arteries LeftVascular ImagingRoutineOne time imaging One time imaging for 1 Occurrences starting 8/5/24 until 8/5/24
Culture Blood - single specimenMicrobiologyRoutineOrders placed after 4am will default to tomorr for 1 Occurrences starting 8/6/24 until 8/6/24
Culture Anaerobic + Aerobic w/ Gram StainMicrobiologySTATSTAT for 1 Occurrences starting 8/5/24 until 8/5/24
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/c3ab7650-aec6-2d85-5a17-4c82ee0071d9"}]}, {"id": "00000000-25E7-74D1-D69B-FFA4C7D55C45", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
Fever in adult08/04/2024
ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS)08/04/2024
Immunosuppressed status (CMS-HCC V24)08/03/2024
Transplant recipient08/03/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Pancreas stable, lipase 11Now ESRD with some urine productionS/p kidney and pancreas transplant at MGH
MSSA bacteremia08/03/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
-Repeat blood culture to evaluate for clearance of bacteremia tomorrow (8/5) -Narrow antibiotics to cefazolin (will review with ID whether any additional coverage is needed for question of pneumonia)-F/u TTE and fistula US Cefazolin 2g q8h for 6 weeks for osteo-Appreciate ID recs:-Treat osteomyelitis (below)Source likely R ankle osteomyelitis seen on MRI. Warrants workup for valvular involvement via TTE and involvement of fistula via US.Blood culture resulted positive for methicillin-susceptible S. aureus.Presented with high fevers (first fever reported 7/30/24), malaise, dry cough.
Osteomyelitis of right ankle (CMS/HHS)08/03/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Mesalt gauze tucked into the depth of the wound followed by ABD pad, rolled gauze, Ace wrap for higher level of compression than he is achieving currently with his own compression stocking. Change dressing daily. -Wound care per prior outpatient recommendations:-Wound care nursing consult with low threshold for burn and soft tissue surgery consult-Consult ortho re: drainage for septic jointOsteomyelitis seen on 8/3 MRI. Likely related to medial malleolar ulcer present for 3 months, which started as a burn. The patient is followed by the wound care clinic. Per MRI, cannot exclude septic joint.
Urethral polyp06/21/2024
Condyloma acuminatum06/21/2024
Diabetic ulcer of right ankle (CMS/HHS)06/21/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Return to see us next Friday.Patient to begin taking doxycycline, prescribed 10-day course to be completed on 8/12/24Mesalt gauze tucked into the depth of the wound followed by ABD pad, rolled gauze, Ace wrap for higher level of compression than he is achieving currently with his own compression stocking. Change dressing daily.Until he sees us back next Friday I would like him to dress the wounds with the following:Ryan states that he would be agreeable to this at this time.I did discuss with Ryan today that I believe he would benefit from negative pressure wound therapy assuming that the MRI was negative for any underlying infection in the bone.He will return to see us next Friday.He has arterial studies next Thursday.Patient does have an MRI coming up next Wednesday.Was not able to express any wispy thick yellow fluid as I was last week.Heavy amount of drainage continues to flow from the open area of the wound, lower leg is significantly edematous 3+ pitting to foot ankle and lower leg.Right ankle ulceration with increased depth, noted 2.5 cm straight and. Was not able to palpate any bone at the base but I anticipate this is very close.
Type 2 diabetes mellitus without complication, without long-term current use of insulin (CMS-HCC) (CMS/HHS)11/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
Continue to track yearly A1c Discussed fructosamine declines at this time Well controlled
Primary hypertension11/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
Continue current regiment amlodipine and lisinopril Well controlled at home and during dialysis 147/70 today On amlodipine and lisinoril
Diabetic autonomic neuropathy associated with type 2 diabetes mellitus (CMS/HHS)11/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
Bilateral neuropathy, well controlled on low-dose gabapentin, uses 100 to 300 mg nightly. Foot exam done today. No open wounds. No concerning findings.On gabapentin In the bilateral feet
Healthcare maintenance11/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
- His fasting glucose has always been within normal limits.- Discussed using fructosamine instead; however, he declines at this time.- Up to date with all blood work. We will do a lipid panel, hemoglobin A1c yearly. UTD COVID booster Got flu shot through MaineHealth PCV 20 TDAP today
COVID-1906/05/2023
History of amputation of right great toe (CMS-HCC) (CMS-HCC V24)01/29/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
Stable no concern for infection
Other specified coagulation defects (CMS-HCC V24)01/29/2023
Type 2 diabetes mellitus with foot ulcer (CMS/HHS)10/11/2022
AV fistula (CMS-HCC) (CMS-HCC V24)10/11/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- Obtain US Soft Tissue left upper extremityR/o active infection/abscess along fistula.
Anemia in other chronic diseases classified elsewhere10/11/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Check LDH, haptoglobin, fibrinogen, INR, iron studies, ferritin-Epogen per nephrology recommendations-Transfuse RBCs for hemoglobin less than 7 - he wants to be notified before additional RBC units are ordered, as he is on a kidney transplant listHemoglobin below goal. Likely superimposed acute and chronic anemias. Differential diagnosis includes DIC/hemolysis, anemia of chronic inflammation, ESRD. Schistocytes seen on blood smear, raising concern for DIC/hemolysis, but high fibrinogen is reassuring that this is not DIC. No evidence of acute blood loss.
Open toe wound04/28/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
Unfortunately today Ryan has a extensive wound over the great toe on the left foot. This is malodorous. The wound beds are actively leaking a purulent material and there is gas production. The toe overall is very soft. This is very concerning for extensive necrotic tissue and also gangrene. I spoke with the wound care center to see if we can get him in urgently, the physician on-call they reviewed the pictures and expected extensive soft tissue infection and possible osteomyelitis and recommended an emergency department assessment. I discussed this with Ryan. The final recommendation is to present to the emergency department given the concern for this wound which is certainly toe threatening if not foot threatening. He states today that he is not sure if he will present to the emergency room. I was very frank with Ryan, I told him that I can certainly understand the stress he has been through recently and the fact the last place he wants to be is back in the hospital but the formal medical advice is to present urgently as I suspect he needs IV antibiotics and urgent imaging. He asked if this could be coordinated as an outpatient, this is virtually impossible at this time given delays in our imaging capabilities and the fact there is an active infection at this time. I asked Ryan again if he will present and he states he is not sure. I encouraged he and his wife who are each capable adults to have this conversation but again reemphasized the formal medical advice to present urgently to the emergency room. I did provide handoff to the emergency department providers so they are aware of his potential arrival.
Osteomyelitis of great toe of right foot (CMS-HCC) (CMS/HHS)04/28/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
He will continue vancomycin and cefepime through infectious diseases. Estimated completion date in Mid June. I wrote a letter to his place of employment to reflect this restriction.He should remain nonweightbearing or at least have his foot upright when he is sitting down until he is off his antibiotics.Followed by vascular now.
Copper deficiency02/17/2022
Chronic diastolic congestive heart failure (CMS-HCC) (CMS/HHS)01/25/2022
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Clapp DO agreed with CDI query for Acute on chronic diastolic (congestive) heart failure on 01/24/22 1620 Formatting of this note might be different from the original.
On asa and statin Euvolemic on exam Had a 80% blockage with PCI and stent placed Stable no recent exacerbations
Status post simultaneous kidney and pancreas transplant 5/31/201801/21/2022
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
WIT: 25 mins, CIT 3 hours, 44minsKDPI%: 29%Kidney: Donor ID: AFE2322CMV D-/R -Day of DC creatinine: 7.236Pre-operative creatinine: 8.36Initiation date:4/10/2015 Dialysis pre-transplant? yesFunctional Status: 80%DSA: noClass I PRA: 0% Class II PRA0 % HLA A2 B50 B62 Bw6 Cw4 Cw6 DR7 DR9 DR53 DQ2 DQ9Type of kidney transplant: DBDComplicated by Delayed graft function in the early postoperative periodCMV D-R- Standard Criteria Donor . KDPI 29% Transplant Surgery: MGH 5/31/2018 Formatting of this note might be different from the original.
I have asked him to address whether or not he would be a candidate for Evusheld with his transplant docs.
Nephrotic syndrome01/20/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- Nutrition consult placed for hypoalbuminemia - Low salt diet, 2L fluid restriction diet- Daily standing weights- Strict in/outs (with urinary retention protocol)- consider renal biopsy if 24 hr UPC is elevated- 24 hr urine protein, creatinine- Telemetry to assess for tachy mediated cause of CHF, patient has been refusing- Change Bumex 2 mg IV BID to Bumex 4 mg PO BID Plan:Transplant US demonstrated minimal pelvicaliectasis with small amount of adjacent fluid with elevated resistive indices and urinary bladder distention to 459 mL. Spot urine protein to creatinine ratio 7.5.Currently diuresing with Bumex with good output. Had been prescribed Bumex 1 mg prn in outpatient setting due to nephrotic syndrome after receiving rituxin last year but has not been taking recentlyPatient has a history of nephrotic syndrome managed by MGH with asa 325 mg and lisinopril. Patient with notable proteinuria and hypoalbuminemia on admission. Of note he was seen at BWH in March 2020 with 3+ nephrotic range proteinuria, dx with Antibody Mediated Rejection and was given rituxin. Considered protal vein thrombosis with elevated liver enzymes on admission but resolved so less likely. CHF less likely given TTE demonstrating normal LV size with moderately increased wall thickness, EF 65%, normal right ventricular size and systolic function. Hypervolemia noted on admission. Pro-BNP 6K. Received Bumex 2 mg IV in ED, put out 500cc independently. CXR with bilateral pleural effusions.
Decreased libido10/08/2021
Last Assessment & Plan:Formatting of this note might be different from the original.
Discussed with endocrine, they do not suspect hypogonadismThis is been a relatively new finding for Ryan, we review his prior testosterone readings which were in the lower ranges of normal. We discussed that there is some variability with testosterone readings depending on the time of day this is done. Would also want to consider upstream signaling. We discussed that decreased libido can be multifaceted in etiology, overall he is in a very strong relationship and can identify no additional stressors. We will go ahead and work this up and screen for low testosterone again.
PVD (peripheral vascular disease) (CMS-HCC V24)10/06/2021
Immunosuppression (CMS-HCC)01/16/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
-Follow-up tacrolimus level ordered for 8/5/2024-Continue tacrolimus 2 mg in the morning and 1 mg in the evening-Continue prednisone 5 mg daily-Continue azathioprine 100 mg daily-Appreciate nephrology/transplant consultation
Coronary artery disease involving native coronary artery11/24/2017
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PTCA of LAD and diag1 Dec 2017DES to mid LAD April 2015 Formatting of this note might be different from the original.
Continues on asa and plavixHx of PCI to LAD 5/2015 and POBA to LAD/diagonal bifurcation with POBA to existing LAD stent 12/2017
Acute respiratory failure with hypoxia with question of pneumonia09/25/2017
Last Assessment & Plan:Formatting of this note might be different from the original.
-Appreciate nephrology assistance with volume management via dialysis-Continue supplemental oxygen as needed with goal SpO2 greater than 92%-Will discuss antibiotic regimen with ID today Azithromycin 3 days 500mg in case this is CAP Consider CrAg, bdglucan, asp ag, silver stain for PJP F/u legionella, mycoplasma, MRSA nares-Appreciate ID recs:Has had a dry cough for ~1 month. The patient was started on 2 L of oxygen in the emergency department. Chest CT shows calcified nodules, ground glass, and lymphadenopathy. Differential diagnosis for hypoxemia includes pneumonia versus pulmonary edema. Potential exposures to mold in his workplace.
Hypertension09/25/2017
Last Assessment & Plan:Formatting of this note might be different from the original.
-Continue outpatient doses of losartan, amlodipine, carvedilol-Continue to monitor blood pressure closely
Hypertension secondary to other renal disorders05/18/2016
Last Assessment & Plan:Formatting of this note might be different from the original.
Monitor daily serum magnesium Labetalol 10 mg IV q 6 hr prn for systolic > 160 Hydralazine 50 mg po TID Carvedilol 25 mg po BID Aim for net negative 1 liter/24 hrs Bumetanide 4 mg po am and Bumetanide tablet 2 mg po daily before dinner. Rx:- lisinopril 2.5- carvedilol 25 bid- bumex 2&1 ( am & pm)Home meds:B/P 145/72 - 129/73 AP 80 + Anasarca. He is ~ 8 kg above his pre hospital weight Hx of HTN
Secondary hyperparathyroidism, renal (CMS-HCC)05/06/2016
Last Assessment & Plan:Formatting of this note might be different from the original.
-Continue cholecalciferol -Continue calcitriol 0.75 mcg 3 times weekly
Urinary retention01/22/2015
Last Assessment & Plan:Formatting of this note is different from the original.
- PVR Bladder scans 1-2x a day- Monitor for constipation - Acute urinary retention protocol- Hold desipramine\u00a0Able to urinate independently nowRequired straight cath on admission, traumatic with obstruction met per RN documentationUA non-infectious appearingEpisode of urinary retention on admission. Uncertain etiology. Potentially secondary to desipramine (which patient reports is a new diagnosis) vs autonomic dysfunction
Hyperlipidemia09/22/2010
Last Assessment & Plan:Formatting of this note might be different from the original.
- Well controlled on atorvastatin, LDL at goal.
ED (erectile dysfunction)01/15/2009
Last Assessment & Plan:Formatting of this note might be different from the original.
Using TRIMIX as prescribed through urology, he uses this PRN prior to sexual activity.
Chronic anemia with concern for possible GIB
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Stool occult blood negative and capsule study did not show any GI bleedingBone marrow suppression/MDS is possible though would likely see all cell lines decreased vs isolated anemiaLDH, haptoglobin, and bili are normal so less likely to be consumption/hemolysis, though tacro can cause MTA. Fe 96, TIBC low at 133, % sat 72, not c/w iron deficiency.Anemia is likely chronic in the setting of his CKD however MCV elevated 103, though B12 elevated to ~2000 and folate normalHemoglobin 7 on admission which may be contributing to his weakness and fatigue. Wbc and plt normal on admission. Baseline hemoglobin around 10 (December 2021) Formatting of this note might be different from the original.
- restarted oral iron- ldh and haptoglobin for evidence of hemolysis were not c/w that- monitor for overt GI bleeding- cont to monitor hgb/hct- GI not to scope this admission, however if continues to require transfusion would re-engage; outpatient EGD and colonoscopy with propofol with Dr. Stefan (his outpatient gastroenterologist)- transfuse for Hgb < 5 -(irradiated, cmv negative); or symptomatic- PO PPIS/p 5 units of blood. Patient denies black/bloody stools, hematemesisSemi- recent EGD and colonoscopy 10/2021, both of which grossly normal at that time as well as pathology results -- follow-up capsule study 1/2022 --also grossly normal.Labs on 4/27 showing hemoglobin of 5.6 --> he presented to the emergency department to receive 2 units of bloodPatient has anemia of chronic disease as well as iron deficiency
ESRD on hemodialysis (CMS-HCC) (CMS/HHS)
Last Assessment & Plan:Formatting of this note might be different from the original.
-Left arm precautions-Renal diet-Appreciate nephrology consultation-HD T/T/S while in patient
Resolved ProblemsNoted DateDiagnosed DateResolved Date
Protein-calorie malnutrition, unspecified severity (CMS-HCC) (CMS-HCC V24)01/29/202311/09/2023
Bacteremia10/11/202211/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
-US fistula pending-Continue with IV antibiotics: cefepime for now. Bactrim at dischargemri thoracic and lumbar spine negativeNow blood cultures with serratiaSource not obvious, however chronic wounds - DM foot ulcer (though look good), home dialysis line
Pancytopenia (CMS/HHS)10/11/202211/09/2023
Pancytopenia (CMS/HHS)10/11/202211/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
- consider DIC if worsening TCP with AM labs- HIV, chronic hep panel- trendPlan:Now WBC rapidly transitioned to leukocytosis, 19 today.Suspect related to acute illness. Macrocytic anemia (not new and HgB improved from previously)New thrombocytopenia, mild at 124WBC 1.5, lymphopenia, mild absolute neutropenia
Unresponsive episode10/11/202211/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
-tele x24 hours, uneventful. Removing. Plan:Suspect his syncope was secondary to a low flow state with hypotension. Additionally he reports restarting his lisinopril today for the first time in 2 weeks.Reportedly EMS found him unresponsive with low systolic? Wife reports he became unresponsive w BP 94/60 and tachycardic
Inadequate flow of dialysis arteriovenous fistula, initial encounter (CMS-HCC) (CMS-HCC V24)05/05/202211/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
- has a stitch in place that will need to be removed 5/9 at dialysisFistulogram and angioplasty 5/6.
Leukopenia05/04/202205/13/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- continue current abx regimen pending specificitiesWondering if cefepime is causing marrow suppression and if he needs other antibiotic however multiple other causes. Patient with leukopenia.
Tenosynovitis of right foot05/03/202205/13/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
Immunosuppressed status does push the duration of treatment to longer (4 vs 3 weeks), but would be considered effectively treated at 3 week mark, at which point he would from an infectious perspective be able to okay for transplantation. Initially presenting with diabetic foot wound that progressed to osteomyelitis and tracked into the tendon. No growth on culture of tendon specifically, but right toe amputation growing 4+ alpha strep (likely culprit for purulent material found in tendon), 1+ corynebacterium, and 4+ gram positive organism that by gross appearance looks like Actinomyces. Additional organism have identified including campylobacter ureolyticus, finegoldia (pepto strep) magna. Path shows residual inflammation at margins on right toe but not from right toe tendon.
Sepsis (CMS/HHS)04/29/202205/02/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-blood culture?-UA?- monitor inflammatory labs- continue vancomycin + cefepime
Hemoperitoneum02/07/202202/09/2022
Last Assessment & Plan:Formatting of this note is different from the original.
- pain well controlled not requiring PRNs overnight- Wound:\u00a0midline incision closed with staples, dressed with gauze and tape, change prn for soiling; wicks to be removed POD 3 (?by surg)- Monitor abdominal exam closely, low threshold to re-engage surgery if needed- Transfuse for <6 given immunocompromised- Trend HgB - 1500 check. Access: LIJHgB this AM slightly lower than priors (7.3 from 7.9 )Overnight HDSKidney biopsy on c/b hemoperitoneum and hemorrhagic shock requiring pressors, intubation for ex-lap on 2/3, and fascial closure on 2/3
Hemorrhagic shock (CMS-HCC) (CMS/HHS)02/03/202202/07/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-plan for hemodialysis for hyperkalemia-patient will be transferred to surgery ICU primary after OR procedure-OR with surgery for control of bleedingPlan:Noted to be hypotensive to 70 systolic with dropping hemoglobin in the setting of post procedure for renal biopsy to evaluate for nephrotic syndrome. CT of abdomen/pelvis demonstrated left rectus sheath hematoma. CT was done without contrast due to poor renal function, creatinine 2.6. Patient was initially admitted to transplant service. Given that patient remained hypotensive with altered mental status with further driving hemoglobin to 5.3 status post 3 L of IV fluids, general surgery consulted for control of bleed and went to the OR. Critical care was involved at this time. Patient received three units of packed red blood cells. Transfusion complicated by patient having co-current refractory hyperkalemia with with peaked T waves on stat EKG.
Anemia, unspecified01/21/202202/04/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- Vitamin with minerals given low copper- Monitor for nowHgb 8.2 on admission was down to 6.9 with improvement to 8.2 on repeat. Zinc slightly low at 36. Appreciate work-up at last admission and given darbopoeitin at that time.
Elevated troponin level01/20/202201/23/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- STAT EKG for chest pain- Monitor closely for ACS- Telemetry, patient refusingDelta troponin 0.04Refused telemetry, risks awknowledgedSuspect elevated troponin is secondary to myocardial injury due to hypervolemia, in addition to elevation in the setting of ESRD.Troponin 0.05 on admission with EKG that appears similar to previous without convincing signs of active ischemia and without symptoms concerning for ACS (though with history of type 1 diabetes could present with silent ischemia)
Elevated liver enzymes01/20/202201/21/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- Consider abdominal ultrasound of portal venous system if further work-up of hypervolemia is unrevealing.- Will need further assessment if not improved with diuresis- Continue to monitor for nowR factor of 1 suggestive of cholestatic injury, suspect from hepatic congestion in light of hypervolemia. Less likely infiltrative disease (Ferritin last checked 1/13/22 and was 391, no elevated calcium to suspect granulomatous disease). Lipase last checked and was 82 (1/12/2022). CMV PCR 1/13/22 not detected.
Metabolic acidosis, normal anion gap (NAG)01/12/202201/16/2022
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Serum ketones negative, Elevated serum osm 308 with a calculated osm of 316, serum osm gap is 6, less than 8 so less likely to be a toxic ingestion Formatting of this note might be different from the original.
- Compression stockings for LE edema- Discontinue bicarb ggtPresented with anion gap of less than 7 on initial CMP, corrected to 12 when accounting for albumin; Likely 2/2 GI losses of bicarb; less likely to be RTA or ingestion, and no pancreatic diverticula or ureteral fistula seen on CTAP
Electrolyte disturbance01/12/202201/17/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Replace Mag prn, will try magnesium gluconnate to see if this is a better option than mag oxide for outpatient use-Replet prn-Monitor with daily BMP, mag-Hold home lokelmaPlan:K now low as wellK normal on presentation but mag low likely 2/2 diarrhea vs tacroHas h/o of hyperkalemia, on lokelma every 2 to 3 days at home
Weakness01/12/202201/17/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Consider PT/OT consults pending functional status-Encourage p.o. intake as toleratedLikely due to dehydration and non-anion gap metabolic acidosis as well as anemia versus infection versus electrolyte abnormalities
AKI (acute kidney injury) (CMS-HCC V24)01/12/202201/17/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Monitor daily BMPPlan:Creatinine now nearly at baseline Creatinine on admission 2.63 likely iso volume depletion/hypotensionBaseline creatinine ~1.9-2.1 as of December 2021, however was at a baseline of approximately 1.5 in the summer 2021
Vaccine counseling10/08/202101/21/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
Pleasant 43-year-old who who request the high-dose flu vaccination, we discussed that the indication for this is age over 65 not for underlying immunosuppression. He discusses that he has received a high-dose flu vaccine as the recommendation of his transplant team for numerous years. There shared decision making we do administer this vaccine today. He is fully vaccinated against COVID-19.
Skin ulcer of left foot, limited to breakdown of skin (CMS/HHS)10/06/202110/06/2021
Diarrhea, unspecified10/06/202102/04/2022
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
CTAP w/ fluid in distal colon suggestive of diarrhea, no calcification or diverticula of pancreas seen Etiology remains unclear however differential includes infectious (C. difficile versus CMV versus norovirus versus other bacterial or viral gastroenteritis versus influenza versus COVID) versus, medication side effects with the most likely culprit being microscopic colitis secondary to mycophenolate versus PPI versus magnesium oxide. Less likely to be pancreatic insufficiency as synthetic function of the pancreas remains intact. Also less likely to be IBD or other autoimmune colitis as he has been on immunosuppressionIn October he had an endoscopy and colonoscopy which unfortunately was limited by poor prep but visualized mucosa appeared normal. Random biopsies obtained showed some chronic gastritis, otherwise unrevealing for cause. Per outpatient GI notes a capsule endoscopy was planned.Records from Portland Gastroenterology show patient has a history of C. difficile in 2016, as well as norovirus in 2019. Initial Portland GI consult note indicates that the patient has been having intermittent bouts of severe diarrhea for roughly 1 year, despite high amounts of Imodium. Has also tried cholestyramine without much effect. Has been on desipramine nightly. Formatting of this note might be different from the original.
-Continue to hold mycophenolate; may need to switch to Myfortic or azathioprine, so far unsuccessful at contacting transplant team at MGH to discuss due to weekend/holiday hours-Follow-up Fecal elastase-Stool leukocyte ordered-GI consulted, appreciate recommendations-Imodium 2 mg q2h prn w/ max of 16 mg dailyPlanNorovirus G2 detected. Of note, he was positive for Norovirus G2 in December 2019, ~1 year prior to this episode of prolonged diarrhea. In an immunocompromise patient, norovirus can cause protracted diarrhea after initial exposure but unlikely to be causing this long of a course. Although he was positive in 2019, it is unclear if his PCR would remain positive for 2+ years but very unlikely that that initial exposure in 2019 is causing his current diarrhea. Regardless, treatment is typically supportive care.Fecal calprotectin normalCapsule endoscopy unrevealingC. Diff negative, CMV negative, Giardia negativeEtiology remains unclear however differential includes medication side effects with the most likely culprit being microscopic colitis secondary to mycophenolate (versus PPI versus magnesium oxide. Vs infectious~10-12 months of diarrhea
Family hx of prostate cancer08/05/202102/04/2022
Weak urine stream08/05/202102/04/2022
Nausea vomiting and diarrhea12/19/201912/21/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
- Will check in around noon, if nausea/vomiting continues to improve - will restart oral home meds. May hold myfortic for one more day given side effect of GI upset. Received 8 mg methylprednisone this AM (higher dose than home prednisone as may need to hold myfortic today).- Replete Mg IV, hold oral magnesium given diarrhea- PRN compazine- IVF LR maintanence fluid- Will progress diet to clear liquidsTx:- Follow-up C Diff- Follow-up blood cultures x2, Stool cultures (bacterial and viral), CMV Serum PCRDx:Improving with conservative treatment (anti-emetics, bowel rest, IV fluids). Leading differential: viral gastroenteritis. Though given transplant status, need to consider CMV, C Diff, bacterial infections.
Renal transplant recipient11/11/201901/21/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Immunosuppression as elsewhere Plan:CTAP without obvious concern in the kidneys though transplanted kidney not able to be fully evaluated without contrastBaseline creatinine from last labs done in December 2021 appears to be ~1.9-2.1Followed by Dr. GilliganRenal transplant MGH in May 2018
Osteomyelitis of ankle or foot, acute, left (CMS/HHS)04/16/201910/06/2021
Last Assessment & Plan:Formatting of this note might be different from the original.
- Consult to PICC team placed- Blood cultures, wound cultures pending- Vascular consulted, wound culture sent, follow-up with wound center and Dr. Aranson set up- Will follow-up ID re: antibiotics after culture returns- Continue IV vancomycin and cefepimePlan:Patient presenting with left foot wound after stepping on stone 5 weeks prior to admission 4/5, found to have osteomyelitis by MRI, poor pulse with associated loss of waveform in left foot on US doppler 4/7. Refused surgical intervention at prior admission and left AMA on 4/8. Representing today as planned admission. Interval drainage of left foot wound since 4/15
History of orthostatic hypotension04/06/201902/04/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Maintenance fluids, clear liquid diet, monitor BP-Restarting fludrocortisone when able to tolerate PO.History of orthostatic hypotension and has been taking fludrocortisone for this.
Diabetic foot infection (CMS-HCC) (CMS/HCC) (CMS/HHS)04/05/201910/06/2021
Last Assessment & Plan:Formatting of this note might be different from the original.
- Dressings: betadine paint to the ulcer with dry guaze.- F/u with primary team and ID reguarding optimal PO abx and plan for IV abx initiation after return from trip. - Continue vancomycin, cefepime- MR: Positive for left TM head/phalanx osteomyelitis.Left plantar foot ulcer, ?probed to 5th TMA head. No wet gangrene or drainage. Erythema improving.
Pancreas transplant status (CMS/HHS)01/16/201902/04/2022
Overview:Last Assessment & Plan:Formatting of this note is different from the original.
Received on ice, stayed on iceWIT: 25 mins, CIT 3 hours, 44minsKDPI%: 29%\u00a0Kidney: Donor ID: AFE2322CMV D-/R -Day of DC creatinine: 7.236Pre-operative creatinine: 8.36Initiation date:4/10/2015 Dialysis pre-transplant? yesFunctional Status: 80%DSA: noClass I PRA: 0% Class II PRA0 % HLA A2 B50 B62 Bw6 Cw4 Cw6 DR7 DR9 DR53 DQ2 DQ9Type of kidney transplant: DBDOriginal kidney disease: DiabetesTransplant date:5/31/2018 Formatting of this note might be different from the original.
- Immunosuppression as elsewhereSynthetic function of pancreas evaluated on last admission and was wnlReceived islet cell transplant in 2018 at MGH
Preop cardiovascular exam12/05/201701/16/2019
Diabetes type I09/25/201701/16/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
- hypoglycemia protocol in place. - diabetic diet.- continue correctional short acting. - reduce his am dose to 28 units and his night dose to 24 units.Reportedly last A1c 7.4.Takes detemir 35 units in am and 30 units at night along with correctional insulin. Apparently well controlled but with complications as above.
End-stage renal disease on hemodialysis09/25/201701/16/2019
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Casco Bay dialysis - MWF; Dr. Cantlin Formatting of this note might be different from the original.
I talked to the nurse and arranged for that So the decision was done to dc him to do his hd session at Cascobay center today as scheduledCardio team will dc pt today before doing cathPotassium 6, would like to do HD prior to the cardiac cathPlan on next dialysis: todayCurrent Situation: StablePrimary outpatient nephrologist: CantlinDialysis Duration 5 hrsDialysis Days Mon/Wed/Fri Arm Precautions NAccess Function: NormalLocation: Left Access: AVF fistulaAttends renal replacement therapy at Casco Bay Dialysis Facility Patient has ESRD due to DM1Nephrology Assessment and Plan
Fatigue11/02/201601/16/2019
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Worsened anemia probably playing a partial role, but he has tolerated as bad previously - see anemia plan aboveReceiving empiric antibiotics for pneumoniaHas tolerated volume removal wellNo clear single etiologySignificantly improved
Hypertensive urgency09/09/201601/16/2019
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- Will hold on addition more antihypertensives this AM, to avoid hypotension/reletive hypotension in HD. Will reconsider after HD today. - dialysis this AM- labetalol 10 mg IV prn SBP > 160- continue home oral anti-hypertensives including labetalol 400 mg TID, hydralazine 50 mg TID, lisinopril 40 mg, amlodipine 10 mgNo clear end organ dysfunction (troponin at baseline, creatinine elevated in setting of ESRD, no chest pain, no changes in mentation). Unclear etiology, patient reports he was compliant with all of his home meds and does not appearing significantly fluid overloaded on exam. Has had similar hypertensive episodes in the past that have been unprovoked.
Near syncope05/18/201601/16/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
-no indication to broaden antibiotics or reculture at this time. -hold antihypertensives-500cc fluid bolus-hold on dialysis todayPresyncope event in dialysis with SBP in 90''s which increased to 120''s once patient was laying flat. Likely due to volume depletion from aggressive dialysis for pericardial effusion and now with diarrhea. No new signs to suggest respiratory process. Echo from yesterday was improved so doubt any enlargement of pericardial effusion or tamponade physiology. WBC is improving with treatment of C.diff
Clostridium difficile diarrhea05/16/201601/16/2019
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-Enteric precautions-cont Metronidazole day 2/10Acute onset of frequent liquid stools 5/16 without abdominal pain - C.diff +
Acute hypoxemic respiratory failure05/12/201602/08/2022
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-O2 protocol, wean as tolerated-HD per Nephrology-ABX as aboveLikely multifactorial, due to pleural effusions R >> L, new opacity of RLL
Pericardial effusion05/11/201601/16/2019
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Repeat echo with cardiology follow up arranged
Uremic pericarditis05/11/201601/16/2019
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Short course of steroids completed todayWill monitor on regular hemodialysis Very much improved clinically
End-stage renal disease on hemodialysis05/11/201601/16/2019
Renovascular hypertension05/11/201605/15/2016
Last Assessment & Plan:Formatting of this note might be different from the original.
-Continue amlodipineBPs elevated, likely some aspect of volume overload contributing
Type 1 diabetes mellitus complicated by ESRD now s/p kidney and pancreaus transplant 201805/11/201602/04/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- See immunosuppressionAlso c/b autonomic dysfunction w/ known gastroparesis. History of type 1 diabetes mellitus now s/p kidney and pancreatic transplant 2018 followed by Dr. Gilligan (Massachusetts General Hospital).
Coronary artery disease involving native coronary artery of native heart without angina pectoris05/11/201601/16/2019
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Labetalol and high intensity statinDual antiplatelet therapy (DAPT) with Aspirin (ASA) 81 mg daily and Clopidogrel (Plavix) 75 mg daily History of coronary stents
Volume overload05/11/201602/04/2022
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-Fluid restriction, low Na diet-Continue daily HD (except Sundays)HD again today for further volume overload, will continue to challenge EDW as tolerated
Hyponatremia05/11/201601/16/2019
Pneumonia05/11/201605/17/2016
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- O2 support PRN- stop vancomycin and cefepime (pt s/p a 10 day treatment course)Blood cultures negative at 48 hoursRecently discharged on PO treatment of RML PNA on levofloxacin, now presenting with profound weakness, increased O2 requirement.
Hypoxia05/09/201601/16/2019
Esophagitis05/08/201601/16/2019
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- Also takes TUMS for renal indications - Omeprazole 40 mg PO daily - F/up biopsies PPI started per GI recs; as discussed with the patient by Dr. Buzanoski today, this is not for relief of symptoms (he denies any) but for prevention of long-term damage and Barrett''s Esophagus. Found on EGD; likely caused by his chronic vomiting 2/2 gastroparesis.
Colon polyps05/07/201601/16/2019
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- Will need a follow-up colonoscopy in 1 year with better prep - F/up biopsy results - Monitor for further GI bleeding Unusual finding in a young patient. New finding on colonoscopy today. Prep quality was poor, therefore possibly not all polyps were visualized.
Coronary artery disease05/07/201601/21/2022
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-Continue home meds: ASA, statin, plavix, blockerDiffuse ST elevations on admission due to pericarditis. Flat troponins x3 likely elevated due to ESRDHistory of DES to LAD in 2015 following MI.
Murmur, cardiac05/06/201601/16/2019
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- Monitor clinically - Further dialysis per Nephrology Unable to follow through with prior plan of obtaining fluid sample from pleural effusion, as the effusion is reduced today.Given also pleural effusion and profound anemia, this is suspicious for an additional systemic inflammatory process e.g lupus. Infections (viral) pericarditis with effusion also possible. However, as the rub appears to improve after he received extra HD yesterday, uremic etiology is supported. Discussed with Nephrology, their impression is that this is possibly uremic pericarditis. TTE showed mild MR and mild TR and a small circumferential pericardial effusion.Most likely transmitted noise from fistula vs flow murmur vs pericardial rub.
Healthcare-associated pneumonia05/05/201601/16/2019
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- Blood cultures reported sent from Casco HD on 5/2 -- no results of this found at NorDx Microbiology - we will follow up with the dialysis center prior to discharge. - Supplemental O2- Incentive spirometry- D/c IV antibiotics and will complete treatment with PO levofloxacin dosed for dialysis - 250 mg Q 48 hrs Plan:Not likely this is a MRSA pneumonia given his rapid improvement, relative stability from a pulmonary point of view, and no dramatic findings on lung exam or imaging. Antibiotics narrowed to vancomycin + cefepime on 5/8. This effusion appears reduced in side on repeat CXR today and on bedside ultrasound by Pulmonology fellow Dr. Ranganath. Therefore thoracentesis was not attempted. Upright and lateral CXRs showed sizeable, mobile pleural effusion on the right -- likely infectious vs inflammatory in origin. Sputum culture with polymicrobial mix (GPC, GPR, GNR). Flu swab negative in ED.Treated for HCAP with cefepime + vancomycin given HD exposure, with ciprofloxacin added initially for GI coverage. Hemodynamically stable, on 2L O2 (none at baseline), does not meet SIRS criteria. Pattern appears most consistent with a bacterial infection given loculation on CXR. Primary complaint of dyspnea on exertion and weakness on presentation.
Complication of AV dialysis fistula03/01/201611/09/2023
Vitreous hemorrhage of right eye12/10/201501/16/2019
Type 1 diabetes mellitus with nephropathy (CMS/HHS)12/10/201505/13/2022
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
IMO Dx Update Formatting of this note might be different from the original.
Remote history of diabetes type 1 insulin-dependent, since his islet cell transplantation he no longer has insulin dependency and is making his own endogenous insulin.
Encounter for removal of vascular catheter10/09/201501/16/2019
Syncope09/16/201505/05/2016
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- f/u with cards next week, consideration for loop recorder if arrhythmia is felt as likely cause of syncope, although anemia is first on DDx- teleAtraumatic/non LOC syncopal event x 1 yesterday with preceding dizziness. Sugar wnl, found to be orthostatic upon standing. With Hgb 6.3, first concern is for anemia induced syncope. Does have CAD with recent elective stent placement, but denies palpitations during the event. No neuro deficits to suggest central process
NSTEMI (non-ST elevated myocardial infarction) (CMS-HCC) (CMS/HHS)09/15/201505/05/2016
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- f/u with outpatient cardiologist next week- no more tropTrop > 0.3, now trending down. No baseline trop. Given anemia, difficult to convince myself this is not a type 2. Has underlying atherosclerosis d/t years of IDDM
Intracranial hypertension09/03/201501/16/2019
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Ryan has a complex ophthalmologic history given multiple pathology in the eye related to his diabetes. From review of his ophthalmologists records, it seems pretty clear that he had an acute change a week ago. Prior eye exams did not demonstrate papilledema in contrast to his ophthalmologic exam from September 1, 2015. His neuro imaging suggests that this is idiopathic intracranial hypertension at least in so much as there is no structural problem and no venous sinus thrombosis. This condition has been known to develop in the setting of hypertensive crisis and profound hypotension such as cardiogenic shock. I find nothing in the literature to suggest it could be a delayed complication of profound hypoglycemia although he was hospitalized 2 weeks or earlier with severe hypoglycemia. This is not a condition typically associated with end-stage renal disease and dialysis. The kidney problem complicates management of ICP following today''s lumbar puncture. It is my opinion that Diamox would not be effective although I will discuss it tomorrow with his nephrologist. Because this is such an unusual presentation in a patient with severe chronic conditions, there is no way of predicting whether the ICP will rise again and over what period of time. It will be hard to monitor her vision complaints because of coexisting diabetic retinopathy, vitreal hemorrhages and cataracts. I think the better part of valor is to refer him for a neuro-ophthalmology to evaluation at Tufts University with Dr. Hedges. I spoke to the patient''s ophthalmologist who will arrange to see him and repeat his funduscopic and visual assessment tomorrow and arrange for subsequent periodic visits in conjunction with a neuro-ophthalmologist.
Hyperkalemia08/07/201502/04/2022
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-sodium bicarb 150 mEq at 100 cc/h-plan for hemodialysis for hyperkalemia-remain on telemetryPlan:Potassium elevated to 7 post procedure of renal bx. Peaked T waves noted on EKG. potassium remained elevated despite sodium bicarb, insulin, calcium gluconate,lokelma.
Severe diabetic hypoglycemia (CMS-HCC) (CMS/HHS)08/07/201508/08/2015
Type 1 diabetes mellitus (CMS/HHS)08/07/201509/16/2015
ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS)08/07/201509/15/2015
Renovascular hypertension08/07/201509/16/2015
CKD (chronic kidney disease), stage V (CMS-HCC) (CMS/HHS)08/04/201509/15/2015
Last Assessment & Plan:Formatting of this note might be different from the original.
I will need to discuss with his nephrologist whether there could be any relationship between his kidney failure and This otherwise idiopathic intracranial hypertension. I am also uncertain whether it would be safe or even effective to use Diamox.
Renovascular hypertension06/19/201509/15/2015
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Now with hypertensive urgency. Plan and medications as above.
Hypertensive urgency06/19/201505/05/2016
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The patient had a hospitalization in June with hypertensive crisis with symptoms of headache. Interestingly with his intracranial hypertension he did not have headache, only vision loss. I do not believe that his episode of hypertensive crisis in June was the proximate cause to be intracranial hypertension since he did not have papilledema on funduscopic exam until his most recent visit on September 1..
Shortness of breath06/19/201509/15/2015
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Shortness of breath at rest without oxygen requirement, cough/sputum, or chest pain. Also without increased work of breathing. Previously pulmonary edema seen on CXR about 10 days ago. Patient associates with HA and elevated BP, so there may be some pain or anxiety component. CXR with increased institial markings
CAD (coronary artery disease)04/14/201501/21/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
Follows with Dr. Vasiwalla @ MMP Cardiology, history of PCI with stenting in 2015.
ESRD (end stage renal disease) on dialysis (CMS/HHS)04/10/201501/16/2019
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Reason for dialysis: solute clearance, volume removalReceives dialysis MWF at Casco Bay. Fistula functioning well. EDW 70.2 kg. Formatting of this note is different from the original.
Special Instructions 2.5 Ca, low dose heparin \u00a0 Bicarb 30 mEq \u00a0 Na+ 137 mEq \u00a0 K+ 2 mEq \u00a0 Dialysate type Bicarbonate \u00a0 Dialysate Flow Rate (ml/min) 800 ml/min \u00a0 Blood Flow Rate (cc/min) 400 cc/min \u00a0 Dialyzer Optiflux 160 \u00a0 Duration of Treatment 5 Hours \u00a0 Fluid removal goal To be determined \u00a0 Target Dry Weight Other (please specify) 72 kg Ultrafiltration only No Dialysis today and resume his normal scheduleHome prescription 5 hrs, Optiflux 160, BFR 400, EDW 72 kg, 2K, 2.5Ca, 1 Mg - we are using bigger dialyzer and doing 4 hoursAccess right AV fistulaMWF at Casco Bay, last dialysis Monday
Uremia04/09/201509/15/2015
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- Nephrology followingFollowing. Improving with dialysis.
Hypoglycemia01/22/201506/19/2015
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-if trends up and stabilizes, may be ok to discharge later this afternoon- prandial dosing if needed- regular diet for now until BS stabilize- basal insulin decreased from 54 units BID to 15 units BID- have dose his meds according to home schedule- has ordered breakfast- 1/2 amp dextrose given with BS 128Plan:BS 27 this am- patient has not eaten since 7pm last night (finally got to floor and fell asleep)Felt to be secondary to decreased oral intake prior and post surgery. Confusion multifactorial with hypoglycemia and oxycodone playing roles. Clear now. Assessment:
Intervertebral lumbar disc disorder with myelopathy, lumbar region01/20/201501/16/2019
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-Recheck CK pending-scheduled tylenol and lower oxycodone 5-10 mg prn to 2.5 prn. -Follow up as previously directed.Plan:CK elevated to 632-1398.Procedure performed 1/20. Wound appears stable.Assessment:
Anemia of chronic renal failure, stage 5 (CMS/HCC) (CMS/HHS)06/04/201201/16/2019
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-Convert to Aranesp 25 mcg q7 days while here-Hold IV iron until infection ruled outOutpatient regimen - Epogen 1300 mg TIW, Venofer 50 mg q4 weeks with last dose 9/18Hgb 8.7 today, stable
Hyperphosphatemia08/03/201101/16/2019
HTN (hypertension)08/18/200901/16/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
Would continue home meds amlodipine, labetalol, and lisinoprilHypertension improved as expected with volume removalHas struggled with high intradialytic weight gains and is on a multidrug antihypertensive regimen
Type 1 diabetes mellitus (CMS/HHS)01/15/200909/15/2015
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
(DX 1996) JOHN DEVLIN MD Formatting of this note might be different from the original.
- low dose correctional coverage at ac and hs- POC BG ac and hs- Reduce home regimen of detemir to 22 units BID given decreased oral intakeHome regimen of detemir 44units BID
Type 1 diabetes mellitus with diabetic chronic kidney disease (CMS/HHS)09/16/2015
Last Assessment & Plan:Formatting of this note might be different from the original.
I do not believe that his current issue of intracranial hypertension with papilledema was caused by his hypoglycemic episode on August 7, 2015. I could not find anything in the literature relating these 2 and it seems like the onset of his symptoms was later in August.
Anemia due to subacute blood loss01/16/2019
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- Pt is a transplant candidate, so transfusion goal will be Hgb <6 with discussion with Nephrology prior- Try to avoid blood transfusion if possible- Holding off further work-up for inflammatory disease at this time - F/up polyp pathology - Omeprazole 40 mg daily per GI - Will need GI follow up including repeat colonoscopy per GI - Monitor Hgb Q 12 hrs through tomorrow and clinically for any worsening - Iron replacement and Mircera per Nephrology Plan: Iron panel consistent with iron storage depletion, likely due to chronic GI blood loss vs depletion from long-standing inflammatory process.Elevated inflammatory markers (CRP 204, ESR 97) suspicious for further anemia of inflammatory disease. PPI started for esophagitis -- see separate. Now s/p EGD with Dr. Stefan on 5/7 which revealed esophagitis and a hiatal hernia, and colonoscopy on the same day finding multiple adenomatous-appearing polyps including two that were oozing blood. Polyps were removed and the source of bleeding clipped. Pathology pending. History of unexplained anemia (beyond that expected for anemia of ESRD), with Hgb as low as 5 in the past requiring transfusion, and a previous attempt at GI work-up during hospitalization in 2015 deferred due to other health issues.
Pleural effusion01/16/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
See under pneumonia
High blood pressure01/16/2019
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
IMO Dx Update Formatting of this note might be different from the original.
-will hold anti-hypertensives at this timePre syncope event with low BP in 90''s Lisinopril 40mg Labetalol 800mg TID on dialysis days, 200mg TID on alternating days Hydralazine 50mg TID Sun, Tue, Thurs Amlodipine 10mg dailyHome regimen:
Hospital-acquired pneumonia01/16/2019
Type 1 diabetes mellitus with stage 1 chronic kidney disease (CMS-HCC) (CMS/HCC) (CMS/HHS)05/18/2016
Acute nonintractable headache01/16/2019
Coronary artery disease involving native heart without angina pectoris01/16/2019
Type 1 diabetes mellitus with chronic kidney disease on chronic dialysis, with long-term current use of insulin01/16/2019
Acute pulmonary edema (CMS-HCC) (CMS/HHS)11/03/2016
Pneumonia of right lung due to infectious organism01/16/2019
Hemorrhage of arteriovenous fistula, initial encounter01/16/2019
Chronic diarrhea02/04/2022
Open wound of anterior abdominal wall02/09/2022
Acute blood loss anemia11/09/2023
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(chronic kidney disease), stage V (CMS-HCC) (CMS/HHS)", "reference": "Condition/46d95a44-7fc4-e89f-a247-15a4d61ffcb8"}, {"display": "Problem - Hyperkalemia", "reference": "Condition/02c15dc6-729f-1982-be7e-f40e3db61427"}, {"display": "Problem - Severe diabetic hypoglycemia (CMS-HCC) (CMS/HHS)", "reference": "Condition/c8f45f19-40b1-d08a-9eb9-1908d714ae58"}, {"display": "Problem - Type 1 diabetes mellitus (CMS/HHS)", "reference": "Condition/409f300b-5fb3-521f-5bdb-4f0fd1c820b5"}, {"display": "Problem - ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS)", "reference": "Condition/c6fc98e6-4238-2954-b863-782e7a94b1c4"}, {"display": "Problem - Renovascular hypertension", "reference": "Condition/2980ed90-a774-f777-9cff-fae7f7df076c"}, {"display": "Problem - Type 1 diabetes mellitus with diabetic chronic kidney disease (CMS/HHS)", "reference": "Condition/4c730e7b-ff75-8af4-6625-7f06744e1c51"}, {"display": "Problem - Intracranial hypertension", "reference": "Condition/2274e26b-3906-27fb-f257-762670546774"}, {"display": "Problem - NSTEMI (non-ST elevated myocardial infarction) (CMS-HCC) (CMS/HHS)", "reference": "Condition/c11e9c84-2a79-6926-5991-a913001b4a71"}, {"display": "Problem - Syncope", "reference": "Condition/549bbab2-98f3-a436-cec0-3e38c1abeea5"}, {"display": "Problem - Encounter for removal of vascular catheter", "reference": "Condition/1fd319ff-e55e-cde6-c967-68dae1451d35"}, {"display": "Problem - Vitreous hemorrhage of right eye (CMS-HCC) (CMS/HHS)", "reference": "Condition/78536afd-cc26-8181-e02d-a29d0d180123"}, {"display": "Problem - Type 1 diabetes mellitus with nephropathy (CMS/HHS)", "reference": "Condition/485fc8c2-9985-da7c-52c2-7f6e65d37690"}, {"display": "Problem - Complication of AV dialysis fistula", "reference": "Condition/2bb775b9-6c39-9112-70bf-07e9cb7ce07f"}, {"display": "Problem - Healthcare-associated pneumonia", "reference": "Condition/7949b5d4-767b-dff7-e6c8-c5610f23aabe"}, {"display": "Problem - Murmur, cardiac", "reference": "Condition/d10c6027-5864-a4ed-067c-b250b528a866"}, {"display": "Problem - Secondary hyperparathyroidism, renal (CMS-HCC V24)", "reference": "Condition/7c1ad36f-a76f-95d9-08d5-5cb1a756979c"}, {"display": "Problem - Anemia due to blood loss, chronic", "reference": "Condition/b05a7c7b-bc1b-2e53-220a-de0ad1ef9f6f"}, {"display": "Problem - Pleural effusion", "reference": "Condition/5f42a2aa-b07e-2188-886b-df4b9f4bfd1b"}, {"display": "Problem - Colon polyps", "reference": "Condition/e3719be2-3c7b-c5d9-9806-4ffd1a2668b0"}, {"display": "Problem - Coronary artery disease", "reference": "Condition/850767a8-2037-29d9-711e-ec8b60192bac"}, {"display": "Problem - High blood pressure", "reference": "Condition/5b706556-1bc3-a777-361c-124eb73ba71f"}, {"display": "Problem - Esophagitis", "reference": "Condition/7a921454-a5d3-b7fd-33c7-98c4fcfde749"}, {"display": "Problem - Anemia, unspecified", "reference": "Condition/718dd906-9458-b778-39f6-e770b7e7f491"}, {"display": "Problem - 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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: FormerCigarettes113Quit: 02/01/2007
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Not Currently0 (1 standard drink = 0.6 oz pure alcohol)very infrequent 1 glass of wine a month
Humiliation, Afraid, Rape, and Kick questionnaireAnswerDate Recorded
Within the last year, have you been afraid of your partner or ex-partner?No08/03/2024
Within the last year, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?No08/03/2024
Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?No08/03/2024
Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?No08/03/2024
AUDIT-CAnswerDate Recorded
Q1: How often do you have a drink containing alcohol?Monthly or less08/03/2024
Q2: How many drinks containing alcohol do you have on a typical day when you are drinking?1 or 208/03/2024
Q3: How often do you have six or more drinks on one occasion?Never08/03/2024
PHQ-2AnswerDate Recorded
Patient Health Questionnaire-2 Score008/03/2024
Hunger Vital SignAnswerDate Recorded
Within the past 12 months, you worried that your food would run out before you got the money to buy more.Never true08/03/2024
Within the past 12 months, the food you bought just didn''t last and you didn''t have money to get more.Never true08/03/2024
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthMale12/19/2019 1:56 PM EST
Gender IdentityMale12/19/2019 1:56 PM EST
Sexual OrientationStraight04/28/2022 11:54 PM EDT
Job Start DateOccupationIndustry
Not on fileNot on fileNot on file
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DateTypeDepartmentCare Team (Latest Contact Info)Description
08/03/2024 12:31 PM EDT - PresentHospital EncounterMaineHealth Maine Medical Center Portland Richards 522 Bramhall StPortland, ME 04102-3134207-662-2217Sanders, Stephen Patrick, MD22 Bramhall StPortland, ME 04102207-662-7010 (Work)207-662-7025 (Fax)Zarookian, Emily I, MD22 Bramhall StRm 2227Portland, ME 04102-3134207-662-4618 (Work)207-662-6254 (Fax)Klein, Raymond, MD22 Bramhall StRm 2227Portland, ME 04102-3134207-662-4618 (Work)207-662-6254 (Fax)
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Overview:
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Last Assessment & Plan:
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(DX 1996) JOHN DEVLIN MD
problemNote137
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System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/3038c5e1-8a36-6a58-4cde-8331a824543f"}}, {"fullUrl": "urn:uuid:8c99f1cb-cd89-44e9-0ce7-347b5497754c", "resource": {"resourceType": "Condition", "id": "8c99f1cb-cd89-44e9-0ce7-347b5497754c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "182048"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N52.9", "display": "ED (erectile dysfunction)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2009-01-15", "note": [{"text": "Last Assessment & Plan:
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Using TRIMIX as prescribed through urology, he uses this PRN prior to sexual activity. "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8c99f1cb-cd89-44e9-0ce7-347b5497754c"}}, {"fullUrl": "urn:uuid:8f3e1344-bbf0-cdf1-8ce0-568d8a12144d", "resource": {"resourceType": "Condition", "id": "8f3e1344-bbf0-cdf1-8ce0-568d8a12144d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "753141"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I10", "display": "HTN (hypertension)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2009-08-18", "note": [{"text": "Last Assessment & Plan:
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Has struggled with high intradialytic weight gains and is on a multidrug antihypertensive regimen
Hypertension improved as expected with volume removal
Would continue home meds amlodipine, labetalol, and lisinopril"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8f3e1344-bbf0-cdf1-8ce0-568d8a12144d"}}, {"fullUrl": "urn:uuid:4474edf1-b4aa-f5f4-92bb-5bca83623054", "resource": {"resourceType": "Condition", "id": "4474edf1-b4aa-f5f4-92bb-5bca83623054", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "1219953"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E78.5", "display": "Hyperlipidemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2010-09-22", "note": [{"text": "Last Assessment & Plan:
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- Well controlled on atorvastatin, LDL at goal. "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4474edf1-b4aa-f5f4-92bb-5bca83623054"}}, {"fullUrl": "urn:uuid:83ea6255-cdd2-79cd-1fa4-030cda6acc0d", "resource": {"resourceType": "Condition", "id": "83ea6255-cdd2-79cd-1fa4-030cda6acc0d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "1990988"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E83.39", "display": "Hyperphosphatemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2011-08-03", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/83ea6255-cdd2-79cd-1fa4-030cda6acc0d"}}, {"fullUrl": "urn:uuid:0eb5fad4-1f1b-a068-e715-6856b46adc71", "resource": {"resourceType": "Condition", "id": "0eb5fad4-1f1b-a068-e715-6856b46adc71", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "2539950"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.5", "display": "Anemia of chronic renal failure, stage 5 (CMS/HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2012-06-04", "note": [{"text": "Last Assessment & Plan:
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Hgb 8.7 today, stable
Outpatient regimen - Epogen 1300 mg TIW, Venofer 50 mg q4 weeks with last dose 9/18
-Hold IV iron until infection ruled out
-Convert to Aranesp 25 mcg q7 days while here"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/0eb5fad4-1f1b-a068-e715-6856b46adc71"}}, {"fullUrl": "urn:uuid:a205c507-7bfc-be4b-1e5b-bf4dfdbc68f0", "resource": {"resourceType": "Condition", "id": "a205c507-7bfc-be4b-1e5b-bf4dfdbc68f0", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4738407"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M51.06", "display": "Intervertebral lumbar disc disorder with myelopathy, lumbar region", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-01-20", "note": [{"text": "Last Assessment & Plan:
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Assessment:
Procedure performed 1/20. Wound appears stable.
CK elevated to 632-1398.
Plan:
-Follow up as previously directed.
-scheduled tylenol and lower oxycodone 5-10 mg prn to 2.5 prn.
-Recheck CK pending"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a205c507-7bfc-be4b-1e5b-bf4dfdbc68f0"}}, {"fullUrl": "urn:uuid:8d1ed8a7-6d93-f589-73b0-8bc3cae67a7d", "resource": {"resourceType": "Condition", "id": "8d1ed8a7-6d93-f589-73b0-8bc3cae67a7d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4741809"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E16.2", "display": "Hypoglycemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-01-22", "note": [{"text": "Last Assessment & Plan:
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Assessment:
Felt to be secondary to decreased oral intake prior and post surgery. Confusion multifactorial with hypoglycemia and oxycodone playing roles. Clear now.
BS 27 this am- patient has not eaten since 7pm last night (finally got to floor and fell asleep)
Plan:
- 1/2 amp dextrose given with BS 128
- has ordered breakfast
- have dose his meds according to home schedule
- basal insulin decreased from 54 units BID to 15 units BID
- regular diet for now until BS stabilize
- prandial dosing if needed
-if trends up and stabilizes, may be ok to discharge later this afternoon"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8d1ed8a7-6d93-f589-73b0-8bc3cae67a7d"}}, {"fullUrl": "urn:uuid:107349d2-48eb-f5ff-2303-3fca9096850b", "resource": {"resourceType": "Condition", "id": "107349d2-48eb-f5ff-2303-3fca9096850b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4743469"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R33.9", "display": "Urinary retention", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-01-22", "note": [{"text": "Last Assessment & Plan:
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Episode of urinary retention on admission. Uncertain etiology. Potentially secondary to desipramine (which patient reports is a new diagnosis) vs autonomic dysfunction
UA non-infectious appearing
Required straight cath on admission, traumatic with obstruction met per RN documentation
Able to urinate independently now
\u00a0
- Hold desipramine
- Acute urinary retention protocol
- Monitor for constipation
- PVR Bladder scans 1-2x a day"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/107349d2-48eb-f5ff-2303-3fca9096850b"}}, {"fullUrl": "urn:uuid:5d3926cd-dd89-df8e-22ae-081cbf1dcb0b", "resource": {"resourceType": "Condition", "id": "5d3926cd-dd89-df8e-22ae-081cbf1dcb0b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4924680"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N19", "display": "Uremia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-04-09", "note": [{"text": "Last Assessment & Plan:
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Following. Improving with dialysis.
- Nephrology following"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5d3926cd-dd89-df8e-22ae-081cbf1dcb0b"}}, {"fullUrl": "urn:uuid:02d22905-515a-d3b2-5be4-57e57593ca66", "resource": {"resourceType": "Condition", "id": "02d22905-515a-d3b2-5be4-57e57593ca66", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4927025"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "ESRD (end stage renal disease) on dialysis (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-04-10", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
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System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/02d22905-515a-d3b2-5be4-57e57593ca66"}}, {"fullUrl": "urn:uuid:8bebc841-1edb-42c7-b2b7-6e55c2f92813", "resource": {"resourceType": "Condition", "id": "8bebc841-1edb-42c7-b2b7-6e55c2f92813", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4931897"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I25.10", "display": "CAD (coronary artery disease)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-04-14", "note": [{"text": "Last Assessment & Plan:
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Follows with Dr. Vasiwalla @ MMP Cardiology, history of PCI with stenting in 2015. "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8bebc841-1edb-42c7-b2b7-6e55c2f92813"}}, {"fullUrl": "urn:uuid:5bc7541c-7f08-b157-b5ba-28b80f43e944", "resource": {"resourceType": "Condition", "id": "5bc7541c-7f08-b157-b5ba-28b80f43e944", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5085587"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I15.0", "display": "Renovascular hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-06-19", "note": [{"text": "Last Assessment & Plan:
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Now with hypertensive urgency. Plan and medications as above."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5bc7541c-7f08-b157-b5ba-28b80f43e944"}}, {"fullUrl": "urn:uuid:01202d2e-e5c0-0d31-1424-031113c60fa9", "resource": {"resourceType": "Condition", "id": "01202d2e-e5c0-0d31-1424-031113c60fa9", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5085868"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I16.0", "display": "Hypertensive urgency", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-06-19", "note": [{"text": "Last Assessment & Plan:
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The patient had a hospitalization in June with hypertensive crisis with symptoms of headache. Interestingly with his intracranial hypertension he did not have headache, only vision loss. I do not believe that his episode of hypertensive crisis in June was the proximate cause to be intracranial hypertension since he did not have papilledema on funduscopic exam until his most recent visit on September 1.."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/01202d2e-e5c0-0d31-1424-031113c60fa9"}}, {"fullUrl": "urn:uuid:bd9c60f7-29a6-5c1c-0a01-9afa5d6b46ff", "resource": {"resourceType": "Condition", "id": "bd9c60f7-29a6-5c1c-0a01-9afa5d6b46ff", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5086107"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R06.02", "display": "Shortness of breath", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-06-19", "note": [{"text": "Last Assessment & Plan:
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Shortness of breath at rest without oxygen requirement, cough/sputum, or chest pain. Also without increased work of breathing. Previously pulmonary edema seen on CXR about 10 days ago. Patient associates with HA and elevated BP, so there may be some pain or anxiety component. CXR with increased institial markings"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/bd9c60f7-29a6-5c1c-0a01-9afa5d6b46ff"}}, {"fullUrl": "urn:uuid:46d95a44-7fc4-e89f-a247-15a4d61ffcb8", "resource": {"resourceType": "Condition", "id": "46d95a44-7fc4-e89f-a247-15a4d61ffcb8", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5186003"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.5", "display": "CKD (chronic kidney disease), stage V (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-04", "note": [{"text": "Last Assessment & Plan:
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I will need to discuss with his nephrologist whether there could be any relationship between his kidney failure and This otherwise idiopathic intracranial hypertension. I am also uncertain whether it would be safe or even effective to use Diamox."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/46d95a44-7fc4-e89f-a247-15a4d61ffcb8"}}, {"fullUrl": "urn:uuid:02c15dc6-729f-1982-be7e-f40e3db61427", "resource": {"resourceType": "Condition", "id": "02c15dc6-729f-1982-be7e-f40e3db61427", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5194532"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E87.5", "display": "Hyperkalemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-07", "note": [{"text": "Last Assessment & Plan:
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Potassium elevated to 7 post procedure of renal bx. Peaked T waves noted on EKG. potassium remained elevated despite sodium bicarb, insulin, calcium gluconate,lokelma.
Plan:
-remain on telemetry
-plan for hemodialysis for hyperkalemia
-sodium bicarb 150 mEq at 100 cc/h"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/02c15dc6-729f-1982-be7e-f40e3db61427"}}, {"fullUrl": "urn:uuid:c8f45f19-40b1-d08a-9eb9-1908d714ae58", "resource": {"resourceType": "Condition", "id": "c8f45f19-40b1-d08a-9eb9-1908d714ae58", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5194728"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.649", "display": "Severe diabetic hypoglycemia (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-07", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/c8f45f19-40b1-d08a-9eb9-1908d714ae58"}}, {"fullUrl": "urn:uuid:409f300b-5fb3-521f-5bdb-4f0fd1c820b5", "resource": {"resourceType": "Condition", "id": "409f300b-5fb3-521f-5bdb-4f0fd1c820b5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5194868"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.9", "display": "Type 1 diabetes mellitus (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-07", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/409f300b-5fb3-521f-5bdb-4f0fd1c820b5"}}, {"fullUrl": "urn:uuid:c6fc98e6-4238-2954-b863-782e7a94b1c4", "resource": {"resourceType": "Condition", "id": "c6fc98e6-4238-2954-b863-782e7a94b1c4", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5194869"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-07", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/c6fc98e6-4238-2954-b863-782e7a94b1c4"}}, {"fullUrl": "urn:uuid:2980ed90-a774-f777-9cff-fae7f7df076c", "resource": {"resourceType": "Condition", "id": "2980ed90-a774-f777-9cff-fae7f7df076c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5194874"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I15.0", "display": "Renovascular hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-07", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/2980ed90-a774-f777-9cff-fae7f7df076c"}}, {"fullUrl": "urn:uuid:4c730e7b-ff75-8af4-6625-7f06744e1c51", "resource": {"resourceType": "Condition", "id": "4c730e7b-ff75-8af4-6625-7f06744e1c51", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5196442"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.22", "display": "Type 1 diabetes mellitus with diabetic chronic kidney disease (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-09-16T07:35:25-04:00", "note": [{"text": "Last Assessment & Plan:
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I do not believe that his current issue of intracranial hypertension with papilledema was caused by his hypoglycemic episode on August 7, 2015. I could not find anything in the literature relating these 2 and it seems like the onset of his symptoms was later in August."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4c730e7b-ff75-8af4-6625-7f06744e1c51"}}, {"fullUrl": "urn:uuid:2274e26b-3906-27fb-f257-762670546774", "resource": {"resourceType": "Condition", "id": "2274e26b-3906-27fb-f257-762670546774", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5257628"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "G93.2", "display": "Intracranial hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-09-03", "note": [{"text": "Last Assessment & Plan:
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Ryan has a complex ophthalmologic history given multiple pathology in the eye related to his diabetes. From review of his ophthalmologists records, it seems pretty clear that he had an acute change a week ago. Prior eye exams did not demonstrate papilledema in contrast to his ophthalmologic exam from September 1, 2015. His neuro imaging suggests that this is idiopathic intracranial hypertension at least in so much as there is no structural problem and no venous sinus thrombosis. This condition has been known to develop in the setting of hypertensive crisis and profound hypotension such as cardiogenic shock. I find nothing in the literature to suggest it could be a delayed complication of profound hypoglycemia although he was hospitalized 2 weeks or earlier with severe hypoglycemia. This is not a condition typically associated with end-stage renal disease and dialysis. The kidney problem complicates management of ICP following today''s lumbar puncture. It is my opinion that Diamox would not be effective although I will discuss it tomorrow with his nephrologist. Because this is such an unusual presentation in a patient with severe chronic conditions, there is no way of predicting whether the ICP will rise again and over what period of time. It will be hard to monitor her vision complaints because of coexisting diabetic retinopathy, vitreal hemorrhages and cataracts. I think the better part of valor is to refer him for a neuro-ophthalmology to evaluation at Tufts University with Dr. Hedges. I spoke to the patient''s ophthalmologist who will arrange to see him and repeat his funduscopic and visual assessment tomorrow and arrange for subsequent periodic visits in conjunction with a neuro-ophthalmologist."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/2274e26b-3906-27fb-f257-762670546774"}}, {"fullUrl": "urn:uuid:c11e9c84-2a79-6926-5991-a913001b4a71", "resource": {"resourceType": "Condition", "id": "c11e9c84-2a79-6926-5991-a913001b4a71", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5283442"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I21.4", "display": "NSTEMI (non-ST elevated myocardial infarction) (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-09-15", "note": [{"text": "Last Assessment & Plan:
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Trop > 0.3, now trending down. No baseline trop. Given anemia, difficult to convince myself this is not a type 2. Has underlying atherosclerosis d/t years of IDDM
- no more trop
- f/u with outpatient cardiologist next week"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/c11e9c84-2a79-6926-5991-a913001b4a71"}}, {"fullUrl": "urn:uuid:549bbab2-98f3-a436-cec0-3e38c1abeea5", "resource": {"resourceType": "Condition", "id": "549bbab2-98f3-a436-cec0-3e38c1abeea5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5283782"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R55", "display": "Syncope", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-09-16", "note": [{"text": "Last Assessment & Plan:
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Atraumatic/non LOC syncopal event x 1 yesterday with preceding dizziness. Sugar wnl, found to be orthostatic upon standing. With Hgb 6.3, first concern is for anemia induced syncope. Does have CAD with recent elective stent placement, but denies palpitations during the event. No neuro deficits to suggest central process
- tele
- f/u with cards next week, consideration for loop recorder if arrhythmia is felt as likely cause of syncope, although anemia is first on DDx"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/549bbab2-98f3-a436-cec0-3e38c1abeea5"}}, {"fullUrl": "urn:uuid:1fd319ff-e55e-cde6-c967-68dae1451d35", "resource": {"resourceType": "Condition", "id": "1fd319ff-e55e-cde6-c967-68dae1451d35", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5355340"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z45.2", "display": "Encounter for removal of vascular catheter", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-10-09", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1fd319ff-e55e-cde6-c967-68dae1451d35"}}, {"fullUrl": "urn:uuid:78536afd-cc26-8181-e02d-a29d0d180123", "resource": {"resourceType": "Condition", "id": "78536afd-cc26-8181-e02d-a29d0d180123", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5534389"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "H43.11", "display": "Vitreous hemorrhage of right eye (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-12-10", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/78536afd-cc26-8181-e02d-a29d0d180123"}}, {"fullUrl": "urn:uuid:485fc8c2-9985-da7c-52c2-7f6e65d37690", "resource": {"resourceType": "Condition", "id": "485fc8c2-9985-da7c-52c2-7f6e65d37690", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5534393"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.21", "display": "Type 1 diabetes mellitus with nephropathy (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-12-10", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote234
System.Collections.Generic.Dictionary`2[System.String,System.Object]

IMO Dx Update
problemNote235
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Remote history of diabetes type 1 insulin-dependent, since his islet cell transplantation he no longer has insulin dependency and is making his own endogenous insulin."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/485fc8c2-9985-da7c-52c2-7f6e65d37690"}}, {"fullUrl": "urn:uuid:2bb775b9-6c39-9112-70bf-07e9cb7ce07f", "resource": {"resourceType": "Condition", "id": "2bb775b9-6c39-9112-70bf-07e9cb7ce07f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5729952"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "T82.9XXA", "display": "Complication of AV dialysis fistula", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-03-01", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/2bb775b9-6c39-9112-70bf-07e9cb7ce07f"}}, {"fullUrl": "urn:uuid:7949b5d4-767b-dff7-e6c8-c5610f23aabe", "resource": {"resourceType": "Condition", "id": "7949b5d4-767b-dff7-e6c8-c5610f23aabe", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5890088"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J18.9", "display": "Healthcare-associated pneumonia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-05", "note": [{"text": "Last Assessment & Plan:
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Primary complaint of dyspnea on exertion and weakness on presentation.
Pattern appears most consistent with a bacterial infection given loculation on CXR.
Hemodynamically stable, on 2L O2 (none at baseline), does not meet SIRS criteria.
Treated for HCAP with cefepime + vancomycin given HD exposure, with ciprofloxacin added initially for GI coverage.
Flu swab negative in ED.
Sputum culture with polymicrobial mix (GPC, GPR, GNR).
Upright and lateral CXRs showed sizeable, mobile pleural effusion on the right -- likely infectious vs inflammatory in origin.
This effusion appears reduced in side on repeat CXR today and on bedside ultrasound by Pulmonology fellow Dr. Ranganath. Therefore thoracentesis was not attempted.
Antibiotics narrowed to vancomycin + cefepime on 5/8.
Not likely this is a MRSA pneumonia given his rapid improvement, relative stability from a pulmonary point of view, and no dramatic findings on lung exam or imaging.
Plan:
- D/c IV antibiotics and will complete treatment with PO levofloxacin dosed for dialysis - 250 mg Q 48 hrs
- Incentive spirometry
- Supplemental O2
- Blood cultures reported sent from Casco HD on 5/2 -- no results of this found at NorDx Microbiology - we will follow up with the dialysis center prior to discharge. "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7949b5d4-767b-dff7-e6c8-c5610f23aabe"}}, {"fullUrl": "urn:uuid:d10c6027-5864-a4ed-067c-b250b528a866", "resource": {"resourceType": "Condition", "id": "d10c6027-5864-a4ed-067c-b250b528a866", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5890161"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R01.1", "display": "Murmur, cardiac", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-06", "note": [{"text": "Last Assessment & Plan:
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Most likely transmitted noise from fistula vs flow murmur vs pericardial rub.
TTE showed mild MR and mild TR and a small circumferential pericardial effusion.
Discussed with Nephrology, their impression is that this is possibly uremic pericarditis.
Given also pleural effusion and profound anemia, this is suspicious for an additional systemic inflammatory process e.g lupus. Infections (viral) pericarditis with effusion also possible. However, as the rub appears to improve after he received extra HD yesterday, uremic etiology is supported.
Unable to follow through with prior plan of obtaining fluid sample from pleural effusion, as the effusion is reduced today.
- Further dialysis per Nephrology
- Monitor clinically "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/d10c6027-5864-a4ed-067c-b250b528a866"}}, {"fullUrl": "urn:uuid:7c1ad36f-a76f-95d9-08d5-5cb1a756979c", "resource": {"resourceType": "Condition", "id": "7c1ad36f-a76f-95d9-08d5-5cb1a756979c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5891603"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N25.81", "display": "Secondary hyperparathyroidism, renal (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-06", "note": [{"text": "Last Assessment & Plan:
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-Continue calcitriol 0.75 mcg 3 times weekly
-Continue cholecalciferol "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7c1ad36f-a76f-95d9-08d5-5cb1a756979c"}}, {"fullUrl": "urn:uuid:b05a7c7b-bc1b-2e53-220a-de0ad1ef9f6f", "resource": {"resourceType": "Condition", "id": "b05a7c7b-bc1b-2e53-220a-de0ad1ef9f6f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5892458"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D50.0", "display": "Anemia due to blood loss, chronic", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:05-05:00", "note": [{"text": "Last Assessment & Plan:
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History of unexplained anemia (beyond that expected for anemia of ESRD), with Hgb as low as 5 in the past requiring transfusion, and a previous attempt at GI work-up during hospitalization in 2015 deferred due to other health issues.
Now s/p EGD with Dr. Stefan on 5/7 which revealed esophagitis and a hiatal hernia, and colonoscopy on the same day finding multiple adenomatous-appearing polyps including two that were oozing blood. Polyps were removed and the source of bleeding clipped. Pathology pending.
PPI started for esophagitis -- see separate.
Elevated inflammatory markers (CRP 204, ESR 97) suspicious for further anemia of inflammatory disease.
Iron panel consistent with iron storage depletion, likely due to chronic GI blood loss vs depletion from long-standing inflammatory process.
Plan:
- Iron replacement and Mircera per Nephrology
- Monitor Hgb Q 12 hrs through tomorrow and clinically for any worsening
- Will need GI follow up including repeat colonoscopy per GI
- Omeprazole 40 mg daily per GI
- F/up polyp pathology
- Holding off further work-up for inflammatory disease at this time
- Try to avoid blood transfusion if possible
- Pt is a transplant candidate, so transfusion goal will be Hgb <6 with discussion with Nephrology prior"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/b05a7c7b-bc1b-2e53-220a-de0ad1ef9f6f"}}, {"fullUrl": "urn:uuid:5f42a2aa-b07e-2188-886b-df4b9f4bfd1b", "resource": {"resourceType": "Condition", "id": "5f42a2aa-b07e-2188-886b-df4b9f4bfd1b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5892459"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J90", "display": "Pleural effusion", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:07-05:00", "note": [{"text": "Last Assessment & Plan:
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See under pneumonia"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5f42a2aa-b07e-2188-886b-df4b9f4bfd1b"}}, {"fullUrl": "urn:uuid:e3719be2-3c7b-c5d9-9806-4ffd1a2668b0", "resource": {"resourceType": "Condition", "id": "e3719be2-3c7b-c5d9-9806-4ffd1a2668b0", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5893500"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K63.5", "display": "Colon polyps", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-07", "note": [{"text": "Last Assessment & Plan:
problemNote268
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New finding on colonoscopy today. Prep quality was poor, therefore possibly not all polyps were visualized.
Unusual finding in a young patient.
- Monitor for further GI bleeding
- F/up biopsy results
- Will need a follow-up colonoscopy in 1 year with better prep "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e3719be2-3c7b-c5d9-9806-4ffd1a2668b0"}}, {"fullUrl": "urn:uuid:850767a8-2037-29d9-711e-ec8b60192bac", "resource": {"resourceType": "Condition", "id": "850767a8-2037-29d9-711e-ec8b60192bac", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5893521"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I25.10", "display": "Coronary artery disease", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-07", "note": [{"text": "Last Assessment & Plan:
problemNote270
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History of DES to LAD in 2015 following MI.
Diffuse ST elevations on admission due to pericarditis. Flat troponins x3 likely elevated due to ESRD
-Continue home meds: ASA, statin, plavix, blocker"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/850767a8-2037-29d9-711e-ec8b60192bac"}}, {"fullUrl": "urn:uuid:5b706556-1bc3-a777-361c-124eb73ba71f", "resource": {"resourceType": "Condition", "id": "5b706556-1bc3-a777-361c-124eb73ba71f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5893544"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I10", "display": "High blood pressure", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-06-05T18:43:09-04:00", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote273
System.Collections.Generic.Dictionary`2[System.String,System.Object]

IMO Dx Update
problemNote274
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5b706556-1bc3-a777-361c-124eb73ba71f"}}, {"fullUrl": "urn:uuid:7a921454-a5d3-b7fd-33c7-98c4fcfde749", "resource": {"resourceType": "Condition", "id": "7a921454-a5d3-b7fd-33c7-98c4fcfde749", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5894176"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K20.90", "display": "Esophagitis", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-08", "note": [{"text": "Last Assessment & Plan:
problemNote276
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Found on EGD; likely caused by his chronic vomiting 2/2 gastroparesis.
PPI started per GI recs; as discussed with the patient by Dr. Buzanoski today, this is not for relief of symptoms (he denies any) but for prevention of long-term damage and Barrett''s Esophagus.
- F/up biopsies
- Omeprazole 40 mg PO daily
- Also takes TUMS for renal indications "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7a921454-a5d3-b7fd-33c7-98c4fcfde749"}}, {"fullUrl": "urn:uuid:718dd906-9458-b778-39f6-e770b7e7f491", "resource": {"resourceType": "Condition", "id": "718dd906-9458-b778-39f6-e770b7e7f491", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5894213"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D64.9", "display": "Anemia, unspecified", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-04-29T12:43:14-04:00", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote278
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote279
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/718dd906-9458-b778-39f6-e770b7e7f491"}}, {"fullUrl": "urn:uuid:9b9372e1-f6e5-73ba-9780-0636fa745c08", "resource": {"resourceType": "Condition", "id": "9b9372e1-f6e5-73ba-9780-0636fa745c08", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5894214"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J18.9", "display": "Hospital-acquired pneumonia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:10-05:00", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/9b9372e1-f6e5-73ba-9780-0636fa745c08"}}, {"fullUrl": "urn:uuid:dcc87aa2-0d98-05dd-9920-164019884713", "resource": {"resourceType": "Condition", "id": "dcc87aa2-0d98-05dd-9920-164019884713", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5896518"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R09.02", "display": "Hypoxia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-09", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/dcc87aa2-0d98-05dd-9920-164019884713"}}, {"fullUrl": "urn:uuid:ae288c1c-a44b-7703-b582-65d9ab673e8b", "resource": {"resourceType": "Condition", "id": "ae288c1c-a44b-7703-b582-65d9ab673e8b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904272"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I31.39", "display": "Pericardial effusion", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote288
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Repeat echo with cardiology follow up arranged"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ae288c1c-a44b-7703-b582-65d9ab673e8b"}}, {"fullUrl": "urn:uuid:06afe382-4c94-9cba-aee1-331f9aeb098c", "resource": {"resourceType": "Condition", "id": "06afe382-4c94-9cba-aee1-331f9aeb098c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904365"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.9", "display": "Uremic pericarditis", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote290
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Very much improved clinically
Will monitor on regular hemodialysis
Short course of steroids completed today"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/06afe382-4c94-9cba-aee1-331f9aeb098c"}}, {"fullUrl": "urn:uuid:b3f477b9-8c68-8449-b38e-ccd1cd439fb1", "resource": {"resourceType": "Condition", "id": "b3f477b9-8c68-8449-b38e-ccd1cd439fb1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904366"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "End-stage renal disease on hemodialysis (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/b3f477b9-8c68-8449-b38e-ccd1cd439fb1"}}, {"fullUrl": "urn:uuid:8e598dd5-86c2-14ef-2be7-eb4029201a94", "resource": {"resourceType": "Condition", "id": "8e598dd5-86c2-14ef-2be7-eb4029201a94", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904368"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I15.0", "display": "Renovascular hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote297
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BPs elevated, likely some aspect of volume overload contributing
-Continue amlodipine"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8e598dd5-86c2-14ef-2be7-eb4029201a94"}}, {"fullUrl": "urn:uuid:4b63a48b-c54f-3aed-30a1-f39278b0b670", "resource": {"resourceType": "Condition", "id": "4b63a48b-c54f-3aed-30a1-f39278b0b670", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904371"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.22", "display": "Type 1 diabetes mellitus with diabetic chronic kidney disease (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote299
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History of type 1 diabetes mellitus now s/p kidney and pancreatic transplant 2018 followed by Dr. Gilligan (Massachusetts General Hospital).
Also c/b autonomic dysfunction w/ known gastroparesis.
- See immunosuppression"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4b63a48b-c54f-3aed-30a1-f39278b0b670"}}, {"fullUrl": "urn:uuid:3a068841-c6ad-ef07-72e7-598491e9d15c", "resource": {"resourceType": "Condition", "id": "3a068841-c6ad-ef07-72e7-598491e9d15c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904373"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I25.10", "display": "Coronary artery disease involving native coronary artery of native heart without angina pectoris", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote304
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History of coronary stents
Dual antiplatelet therapy (DAPT) with Aspirin (ASA) 81 mg daily and Clopidogrel (Plavix) 75 mg daily
Labetalol and high intensity statin"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/3a068841-c6ad-ef07-72e7-598491e9d15c"}}, {"fullUrl": "urn:uuid:e2276a15-9584-c248-94f9-d10c4ad49147", "resource": {"resourceType": "Condition", "id": "e2276a15-9584-c248-94f9-d10c4ad49147", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904626"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E87.70", "display": "Volume overload", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote306
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HD again today for further volume overload, will continue to challenge EDW as tolerated
-Continue daily HD (except Sundays)
-Fluid restriction, low Na diet"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e2276a15-9584-c248-94f9-d10c4ad49147"}}, {"fullUrl": "urn:uuid:5f8d6cad-c773-1e3e-d880-2aa88110cd9f", "resource": {"resourceType": "Condition", "id": "5f8d6cad-c773-1e3e-d880-2aa88110cd9f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904637"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E87.1", "display": "Hyponatremia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5f8d6cad-c773-1e3e-d880-2aa88110cd9f"}}, {"fullUrl": "urn:uuid:7c0126b4-7f33-871e-2862-855ee868f565", "resource": {"resourceType": "Condition", "id": "7c0126b4-7f33-871e-2862-855ee868f565", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904662"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J18.9", "display": "Pneumonia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote309
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Recently discharged on PO treatment of RML PNA on levofloxacin, now presenting with profound weakness, increased O2 requirement.
Blood cultures negative at 48 hours
- stop vancomycin and cefepime (pt s/p a 10 day treatment course)
- O2 support PRN"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7c0126b4-7f33-871e-2862-855ee868f565"}}, {"fullUrl": "urn:uuid:07b988c8-4f74-d04a-416a-1c3940751ea7", "resource": {"resourceType": "Condition", "id": "07b988c8-4f74-d04a-416a-1c3940751ea7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5907834"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J96.01", "display": "Acute hypoxemic respiratory failure (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-12", "note": [{"text": "Last Assessment & Plan:
problemNote311
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Likely multifactorial, due to pleural effusions R >> L, new opacity of RLL
-ABX as above
-HD per Nephrology
-O2 protocol, wean as tolerated"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/07b988c8-4f74-d04a-416a-1c3940751ea7"}}, {"fullUrl": "urn:uuid:765a8744-1fd3-aebb-f503-f6d17017daf4", "resource": {"resourceType": "Condition", "id": "765a8744-1fd3-aebb-f503-f6d17017daf4", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5909355"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.22", "display": "Type 1 diabetes mellitus with stage 1 chronic kidney disease (CMS-HCC) (CMS/HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-18T13:50:09-04:00", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/765a8744-1fd3-aebb-f503-f6d17017daf4"}}, {"fullUrl": "urn:uuid:ce63193f-b7d7-f443-908e-ee70869591d7", "resource": {"resourceType": "Condition", "id": "ce63193f-b7d7-f443-908e-ee70869591d7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5914166"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "A04.72", "display": "Clostridium difficile diarrhea", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-16", "note": [{"text": "Last Assessment & Plan:
problemNote316
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Acute onset of frequent liquid stools 5/16 without abdominal pain - C.diff +
-cont Metronidazole day 2/10
-Enteric precautions"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ce63193f-b7d7-f443-908e-ee70869591d7"}}, {"fullUrl": "urn:uuid:ca95c441-6cdd-aba7-4341-252557eacb1e", "resource": {"resourceType": "Condition", "id": "ca95c441-6cdd-aba7-4341-252557eacb1e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5919909"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I15.1", "display": "Hypertension secondary to other renal disorders", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-18", "note": [{"text": "Last Assessment & Plan:
problemNote318
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Hx of HTN
+ Anasarca. He is ~ 8 kg above his pre hospital weight
B/P 145/72 - 129/73 AP 80
Home meds:
- bumex 2&1 ( am & pm)
- carvedilol 25 bid
- lisinopril 2.5
Rx:
Bumetanide 4 mg po am and Bumetanide tablet 2 mg po daily before dinner.
Aim for net negative 1 liter/24 hrs
Carvedilol 25 mg po BID
Hydralazine 50 mg po TID
Labetalol 10 mg IV q 6 hr prn for systolic > 160
Monitor daily serum magnesium "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ca95c441-6cdd-aba7-4341-252557eacb1e"}}, {"fullUrl": "urn:uuid:59823cf1-e6f4-1c4a-53fb-25cee87f8b02", "resource": {"resourceType": "Condition", "id": "59823cf1-e6f4-1c4a-53fb-25cee87f8b02", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5920988"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R55", "display": "Near syncope", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-18", "note": [{"text": "Last Assessment & Plan:
problemNote322
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Presyncope event in dialysis with SBP in 90''s which increased to 120''s once patient was laying flat. Likely due to volume depletion from aggressive dialysis for pericardial effusion and now with diarrhea. No new signs to suggest respiratory process. Echo from yesterday was improved so doubt any enlargement of pericardial effusion or tamponade physiology. WBC is improving with treatment of C.diff
-hold on dialysis today
-500cc fluid bolus
-hold antihypertensives
-no indication to broaden antibiotics or reculture at this time. "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/59823cf1-e6f4-1c4a-53fb-25cee87f8b02"}}, {"fullUrl": "urn:uuid:af02a647-50f9-88e6-cc19-aab79bb013d5", "resource": {"resourceType": "Condition", "id": "af02a647-50f9-88e6-cc19-aab79bb013d5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6195210"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I16.0", "display": "Hypertensive urgency", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-09-09", "note": [{"text": "Last Assessment & Plan:
problemNote324
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No clear end organ dysfunction (troponin at baseline, creatinine elevated in setting of ESRD, no chest pain, no changes in mentation). Unclear etiology, patient reports he was compliant with all of his home meds and does not appearing significantly fluid overloaded on exam. Has had similar hypertensive episodes in the past that have been unprovoked.
- continue home oral anti-hypertensives including labetalol 400 mg TID, hydralazine 50 mg TID, lisinopril 40 mg, amlodipine 10 mg
- labetalol 10 mg IV prn SBP > 160
- dialysis this AM
- Will hold on addition more antihypertensives this AM, to avoid hypotension/reletive hypotension in HD. Will reconsider after HD today. "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/af02a647-50f9-88e6-cc19-aab79bb013d5"}}, {"fullUrl": "urn:uuid:efb04477-2de9-60f0-1ada-9102d88896bc", "resource": {"resourceType": "Condition", "id": "efb04477-2de9-60f0-1ada-9102d88896bc", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6195598"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R51.9", "display": "Acute nonintractable headache", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:17:41-05:00", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/efb04477-2de9-60f0-1ada-9102d88896bc"}}, {"fullUrl": "urn:uuid:a9176f51-2827-27d8-1eae-5905347521b3", "resource": {"resourceType": "Condition", "id": "a9176f51-2827-27d8-1eae-5905347521b3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6195599"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "ESRD on hemodialysis (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03T14:34:54-04:00", "note": [{"text": "Last Assessment & Plan:
problemNote327
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-HD T/T/S while in patient
-Appreciate nephrology consultation
-Renal diet
-Left arm precautions"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a9176f51-2827-27d8-1eae-5905347521b3"}}, {"fullUrl": "urn:uuid:a7c8ed4d-85cc-5c47-2a2e-b794cbc02ff3", "resource": {"resourceType": "Condition", "id": "a7c8ed4d-85cc-5c47-2a2e-b794cbc02ff3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6196322"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I25.10", "display": "Coronary artery disease involving native heart without angina pectoris", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:50-05:00", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a7c8ed4d-85cc-5c47-2a2e-b794cbc02ff3"}}, {"fullUrl": "urn:uuid:3c273341-65c3-54ab-2e4f-da457d2ca651", "resource": {"resourceType": "Condition", "id": "3c273341-65c3-54ab-2e4f-da457d2ca651", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6196323"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.22", "display": "Type 1 diabetes mellitus with chronic kidney disease on chronic dialysis, with long-term current use of insulin (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:47-05:00", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/3c273341-65c3-54ab-2e4f-da457d2ca651"}}, {"fullUrl": "urn:uuid:ccabb0c8-ca79-b084-ac63-2d10bfdeef0f", "resource": {"resourceType": "Condition", "id": "ccabb0c8-ca79-b084-ac63-2d10bfdeef0f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6370914"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R53.83", "display": "Fatigue", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-11-02", "note": [{"text": "Last Assessment & Plan:
problemNote342
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Significantly improved
No clear single etiology
Has tolerated volume removal well
Receiving empiric antibiotics for pneumonia
Worsened anemia probably playing a partial role, but he has tolerated as bad previously - see anemia plan above"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ccabb0c8-ca79-b084-ac63-2d10bfdeef0f"}}, {"fullUrl": "urn:uuid:a4463fe6-68df-3223-c4d0-907cc817be4f", "resource": {"resourceType": "Condition", "id": "a4463fe6-68df-3223-c4d0-907cc817be4f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6371242"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J81.0", "display": "Acute pulmonary edema (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-11-03T15:18:09-04:00", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a4463fe6-68df-3223-c4d0-907cc817be4f"}}, {"fullUrl": "urn:uuid:ceee7958-1db4-0d19-ebb2-7bb95e3c1f14", "resource": {"resourceType": "Condition", "id": "ceee7958-1db4-0d19-ebb2-7bb95e3c1f14", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6371243"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J18.9", "display": "Pneumonia of right lung due to infectious organism", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:28-05:00", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ceee7958-1db4-0d19-ebb2-7bb95e3c1f14"}}, {"fullUrl": "urn:uuid:26a0b0ac-7491-9f88-241b-0ae4fda9fd78", "resource": {"resourceType": "Condition", "id": "26a0b0ac-7491-9f88-241b-0ae4fda9fd78", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6540175"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "T82.838A", "display": "Hemorrhage of arteriovenous fistula, initial encounter (CMS-HCC) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:18:22-05:00", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/26a0b0ac-7491-9f88-241b-0ae4fda9fd78"}}, {"fullUrl": "urn:uuid:5057e963-0027-c69b-9c0c-05132914e12a", "resource": {"resourceType": "Condition", "id": "5057e963-0027-c69b-9c0c-05132914e12a", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8133274"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J96.01", "display": "Acute respiratory failure with hypoxia (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-09-25", "note": [{"text": "Last Assessment & Plan:
problemNote348
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Has had a dry cough for ~1 month. The patient was started on 2 L of oxygen in the emergency department. Chest CT shows calcified nodules, ground glass, and lymphadenopathy. Differential diagnosis for hypoxemia includes pneumonia versus pulmonary edema. Potential exposures to mold in his workplace.
-Appreciate ID recs:
F/u legionella, mycoplasma, MRSA nares
Consider CrAg, bdglucan, asp ag, silver stain for PJP
Azithromycin 3 days 500mg in case this is CAP
-Will discuss antibiotic regimen with ID today
-Continue supplemental oxygen as needed with goal SpO2 greater than 92%
-Appreciate nephrology assistance with volume management via dialysis"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5057e963-0027-c69b-9c0c-05132914e12a"}}, {"fullUrl": "urn:uuid:d5e68d06-5e4e-d485-73b3-0d1c42257f99", "resource": {"resourceType": "Condition", "id": "d5e68d06-5e4e-d485-73b3-0d1c42257f99", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8133328"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.9", "display": "Diabetes type I (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-09-25", "note": [{"text": "Last Assessment & Plan:
problemNote357
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Apparently well controlled but with complications as above.
Takes detemir 35 units in am and 30 units at night along with correctional insulin.
Reportedly last A1c 7.4.
- reduce his am dose to 28 units and his night dose to 24 units.
- continue correctional short acting.
- diabetic diet.
- hypoglycemia protocol in place. "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/d5e68d06-5e4e-d485-73b3-0d1c42257f99"}}, {"fullUrl": "urn:uuid:5476e1b3-75fe-466f-bc8a-2c07215f51a1", "resource": {"resourceType": "Condition", "id": "5476e1b3-75fe-466f-bc8a-2c07215f51a1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8133338"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "End-stage renal disease on hemodialysis (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-09-25", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote359
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Casco Bay dialysis - MWF; Dr. Cantlin
problemNote360
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5476e1b3-75fe-466f-bc8a-2c07215f51a1"}}, {"fullUrl": "urn:uuid:c39a0be9-4e53-2124-2d0f-ea69070a863d", "resource": {"resourceType": "Condition", "id": "c39a0be9-4e53-2124-2d0f-ea69070a863d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8133340"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I10", "display": "Hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-09-25", "note": [{"text": "Last Assessment & Plan:
problemNote364
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-Continue to monitor blood pressure closely
-Continue outpatient doses of losartan, amlodipine, carvedilol"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/c39a0be9-4e53-2124-2d0f-ea69070a863d"}}, {"fullUrl": "urn:uuid:5ae62d33-11ae-7fdf-4063-662347ba0d42", "resource": {"resourceType": "Condition", "id": "5ae62d33-11ae-7fdf-4063-662347ba0d42", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8480745"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I25.10", "display": "Coronary artery disease involving native coronary artery", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-11-24", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote376
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote377
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5ae62d33-11ae-7fdf-4063-662347ba0d42"}}, {"fullUrl": "urn:uuid:257fde15-9024-e3f3-43fd-9a1ca4695879", "resource": {"resourceType": "Condition", "id": "257fde15-9024-e3f3-43fd-9a1ca4695879", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8529725"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z01.810", "display": "Preop cardiovascular exam", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-12-05", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/257fde15-9024-e3f3-43fd-9a1ca4695879"}}, {"fullUrl": "urn:uuid:9135d9da-34e8-f952-8ad5-abb86fcbc860", "resource": {"resourceType": "Condition", "id": "9135d9da-34e8-f952-8ad5-abb86fcbc860", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10122254"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z94.83", "display": "Pancreas transplant status (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote383
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote384
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/9135d9da-34e8-f952-8ad5-abb86fcbc860"}}, {"fullUrl": "urn:uuid:eb973ccf-0337-8117-6890-112ed73867db", "resource": {"resourceType": "Condition", "id": "eb973ccf-0337-8117-6890-112ed73867db", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10122255"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D84.9", "display": "Immunosuppression (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16", "note": [{"text": "Last Assessment & Plan:
problemNote394
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-Appreciate nephrology/transplant consultation
-Continue azathioprine 100 mg daily
-Continue prednisone 5 mg daily
-Continue tacrolimus 2 mg in the morning and 1 mg in the evening
-Follow-up tacrolimus level ordered for 8/5/2024"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/eb973ccf-0337-8117-6890-112ed73867db"}}, {"fullUrl": "urn:uuid:59d0eda9-5826-805d-9c52-3c16e107373f", "resource": {"resourceType": "Condition", "id": "59d0eda9-5826-805d-9c52-3c16e107373f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10574190"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.628", "display": "Diabetic foot infection (CMS-HCC) (CMS/HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-04-05", "note": [{"text": "Last Assessment & Plan:
problemNote408
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Left plantar foot ulcer, ?probed to 5th TMA head. No wet gangrene or drainage. Erythema improving.
- MR: Positive for left TM head/phalanx osteomyelitis.
- Continue vancomycin, cefepime
- F/u with primary team and ID reguarding optimal PO abx and plan for IV abx initiation after return from trip.
- Dressings: betadine paint to the ulcer with dry guaze."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/59d0eda9-5826-805d-9c52-3c16e107373f"}}, {"fullUrl": "urn:uuid:47d1e7cc-d5dc-8387-49df-5b6bae6e7426", "resource": {"resourceType": "Condition", "id": "47d1e7cc-d5dc-8387-49df-5b6bae6e7426", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10575958"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z86.79", "display": "History of orthostatic hypotension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-04-06", "note": [{"text": "Last Assessment & Plan:
problemNote413
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History of orthostatic hypotension and has been taking fludrocortisone for this.
-Restarting fludrocortisone when able to tolerate PO.
-Maintenance fluids, clear liquid diet, monitor BP"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/47d1e7cc-d5dc-8387-49df-5b6bae6e7426"}}, {"fullUrl": "urn:uuid:0984763d-8df8-beb4-bcf8-3d5eee0e79f7", "resource": {"resourceType": "Condition", "id": "0984763d-8df8-beb4-bcf8-3d5eee0e79f7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10619592"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M86.172", "display": "Osteomyelitis of ankle or foot, acute, left (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-04-16", "note": [{"text": "Last Assessment & Plan:
problemNote417
Formatting of this note might be different from the original.

Patient presenting with left foot wound after stepping on stone 5 weeks prior to admission 4/5, found to have osteomyelitis by MRI, poor pulse with associated loss of waveform in left foot on US doppler 4/7. Refused surgical intervention at prior admission and left AMA on 4/8. Representing today as planned admission. Interval drainage of left foot wound since 4/15
Plan:
- Continue IV vancomycin and cefepime
- Will follow-up ID re: antibiotics after culture returns
- Vascular consulted, wound culture sent, follow-up with wound center and Dr. Aranson set up
- Blood cultures, wound cultures pending
- Consult to PICC team placed"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/0984763d-8df8-beb4-bcf8-3d5eee0e79f7"}}, {"fullUrl": "urn:uuid:edda6ba9-d349-ecf5-a678-83e375883ff3", "resource": {"resourceType": "Condition", "id": "edda6ba9-d349-ecf5-a678-83e375883ff3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "13709591"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z94.0", "display": "Renal transplant recipient", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-11-11", "note": [{"text": "Last Assessment & Plan:
problemNote419
Formatting of this note might be different from the original.

Renal transplant MGH in May 2018
Followed by Dr. Gilligan
Baseline creatinine from last labs done in December 2021 appears to be ~1.9-2.1
CTAP without obvious concern in the kidneys though transplanted kidney not able to be fully evaluated without contrast
Plan:
-Immunosuppression as elsewhere"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/edda6ba9-d349-ecf5-a678-83e375883ff3"}}, {"fullUrl": "urn:uuid:642c9f48-a88c-5bd6-c942-a5ed25159c66", "resource": {"resourceType": "Condition", "id": "642c9f48-a88c-5bd6-c942-a5ed25159c66", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "14218494"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R11.2", "display": "Nausea vomiting and diarrhea", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-12-19", "note": [{"text": "Last Assessment & Plan:
problemNote422
Formatting of this note might be different from the original.

Improving with conservative treatment (anti-emetics, bowel rest, IV fluids). Leading differential: viral gastroenteritis. Though given transplant status, need to consider CMV, C Diff, bacterial infections.
Dx:
- Follow-up blood cultures x2, Stool cultures (bacterial and viral), CMV Serum PCR
- Follow-up C Diff
Tx:
- Will progress diet to clear liquids
- IVF LR maintanence fluid
- PRN compazine
- Replete Mg IV, hold oral magnesium given diarrhea
- Will check in around noon, if nausea/vomiting continues to improve - will restart oral home meds. May hold myfortic for one more day given side effect of GI upset. Received 8 mg methylprednisone this AM (higher dose than home prednisone as may need to hold myfortic today)."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/642c9f48-a88c-5bd6-c942-a5ed25159c66"}}, {"fullUrl": "urn:uuid:8a014617-d76b-804b-0114-393b19cbc577", "resource": {"resourceType": "Condition", "id": "8a014617-d76b-804b-0114-393b19cbc577", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "30148542"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z80.42", "display": "Family hx of prostate cancer", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-08-05", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8a014617-d76b-804b-0114-393b19cbc577"}}, {"fullUrl": "urn:uuid:979e58f2-9f3b-4200-f7b5-da69cedd494a", "resource": {"resourceType": "Condition", "id": "979e58f2-9f3b-4200-f7b5-da69cedd494a", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "30148543"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R39.12", "display": "Weak urine stream", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-08-05", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/979e58f2-9f3b-4200-f7b5-da69cedd494a"}}, {"fullUrl": "urn:uuid:fb2cca4e-7626-ff80-f9ee-b4a55abec1b2", "resource": {"resourceType": "Condition", "id": "fb2cca4e-7626-ff80-f9ee-b4a55abec1b2", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "31732743"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "L97.521", "display": "Skin ulcer of left foot, limited to breakdown of skin (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-10-06", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/fb2cca4e-7626-ff80-f9ee-b4a55abec1b2"}}, {"fullUrl": "urn:uuid:8b706be8-17b9-c88e-2bd8-47f194ec5405", "resource": {"resourceType": "Condition", "id": "8b706be8-17b9-c88e-2bd8-47f194ec5405", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "31732744"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I73.9", "display": "PVD (peripheral vascular disease) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-10-06", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8b706be8-17b9-c88e-2bd8-47f194ec5405"}}, {"fullUrl": "urn:uuid:fc997077-5aae-7fed-2df2-8e7654e06806", "resource": {"resourceType": "Condition", "id": "fc997077-5aae-7fed-2df2-8e7654e06806", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "31732763"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R19.7", "display": "Diarrhea, unspecified", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-10-06", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote428
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote429
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/fc997077-5aae-7fed-2df2-8e7654e06806"}}, {"fullUrl": "urn:uuid:217a801e-4399-7874-d180-b9c21e77c950", "resource": {"resourceType": "Condition", "id": "217a801e-4399-7874-d180-b9c21e77c950", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "31784041"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R68.82", "display": "Decreased libido", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-10-08", "note": [{"text": "Last Assessment & Plan:
problemNote432
Formatting of this note might be different from the original.

This is been a relatively new finding for Ryan, we review his prior testosterone readings which were in the lower ranges of normal. We discussed that there is some variability with testosterone readings depending on the time of day this is done. Would also want to consider upstream signaling. We discussed that decreased libido can be multifaceted in etiology, overall he is in a very strong relationship and can identify no additional stressors. We will go ahead and work this up and screen for low testosterone again.
Discussed with endocrine, they do not suspect hypogonadism"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/217a801e-4399-7874-d180-b9c21e77c950"}}, {"fullUrl": "urn:uuid:e894b7bf-19aa-3209-468e-286aabd823ba", "resource": {"resourceType": "Condition", "id": "e894b7bf-19aa-3209-468e-286aabd823ba", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "31784053"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z71.85", "display": "Vaccine counseling", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-10-08", "note": [{"text": "Last Assessment & Plan:
problemNote435
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Pleasant 43-year-old who who request the high-dose flu vaccination, we discussed that the indication for this is age over 65 not for underlying immunosuppression. He discusses that he has received a high-dose flu vaccine as the recommendation of his transplant team for numerous years. There shared decision making we do administer this vaccine today. He is fully vaccinated against COVID-19."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e894b7bf-19aa-3209-468e-286aabd823ba"}}, {"fullUrl": "urn:uuid:40cd57c9-9f69-10f8-ecd6-8decffc9e2fe", "resource": {"resourceType": "Condition", "id": "40cd57c9-9f69-10f8-ecd6-8decffc9e2fe", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35121498"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E87.20", "display": "Metabolic acidosis, normal anion gap (NAG)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-12", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote437
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Serum ketones negative, Elevated serum osm 308 with a calculated osm of 316, serum osm gap is 6, less than 8 so less likely to be a toxic ingestion
problemNote438
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/40cd57c9-9f69-10f8-ecd6-8decffc9e2fe"}}, {"fullUrl": "urn:uuid:a2d8c876-f5e0-38d7-c6df-e1bc439f606d", "resource": {"resourceType": "Condition", "id": "a2d8c876-f5e0-38d7-c6df-e1bc439f606d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35121831"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E87.8", "display": "Electrolyte disturbance", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-12", "note": [{"text": "Last Assessment & Plan:
problemNote440
Formatting of this note might be different from the original.

Has h/o of hyperkalemia, on lokelma every 2 to 3 days at home
K normal on presentation but mag low likely 2/2 diarrhea vs tacro
K now low as well
Plan:
-Hold home lokelma
-Monitor with daily BMP, mag
-Replet prn
-Replace Mag prn, will try magnesium gluconnate to see if this is a better option than mag oxide for outpatient use"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a2d8c876-f5e0-38d7-c6df-e1bc439f606d"}}, {"fullUrl": "urn:uuid:14bc3a7b-7eaa-885c-f7ab-d3e0b60851b3", "resource": {"resourceType": "Condition", "id": "14bc3a7b-7eaa-885c-f7ab-d3e0b60851b3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35123356"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R53.1", "display": "Weakness", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-12", "note": [{"text": "Last Assessment & Plan:
problemNote442
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Likely due to dehydration and non-anion gap metabolic acidosis as well as anemia versus infection versus electrolyte abnormalities
-Encourage p.o. intake as tolerated
-Consider PT/OT consults pending functional status"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/14bc3a7b-7eaa-885c-f7ab-d3e0b60851b3"}}, {"fullUrl": "urn:uuid:37b680b4-f738-d25a-9018-2b0b80ebd94a", "resource": {"resourceType": "Condition", "id": "37b680b4-f738-d25a-9018-2b0b80ebd94a", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35123592"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N17.9", "display": "AKI (acute kidney injury) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-12", "note": [{"text": "Last Assessment & Plan:
problemNote444
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Baseline creatinine ~1.9-2.1 as of December 2021, however was at a baseline of approximately 1.5 in the summer 2021
Creatinine on admission 2.63 likely iso volume depletion/hypotension
Creatinine now nearly at baseline
Plan:
-Monitor daily BMP"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/37b680b4-f738-d25a-9018-2b0b80ebd94a"}}, {"fullUrl": "urn:uuid:426c32a2-0b2d-9d11-26c0-c240094ddc6a", "resource": {"resourceType": "Condition", "id": "426c32a2-0b2d-9d11-26c0-c240094ddc6a", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35157547"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K52.9", "display": "Chronic diarrhea", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-04T11:32:39-05:00", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/426c32a2-0b2d-9d11-26c0-c240094ddc6a"}}, {"fullUrl": "urn:uuid:69ed940b-bda5-d6ac-6a01-406a6986d362", "resource": {"resourceType": "Condition", "id": "69ed940b-bda5-d6ac-6a01-406a6986d362", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35387803"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N04.9", "display": "Nephrotic syndrome", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-20", "note": [{"text": "Last Assessment & Plan:
problemNote447
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Hypervolemia noted on admission. Pro-BNP 6K. Received Bumex 2 mg IV in ED, put out 500cc independently. CXR with bilateral pleural effusions.
Patient has a history of nephrotic syndrome managed by MGH with asa 325 mg and lisinopril. Patient with notable proteinuria and hypoalbuminemia on admission. Of note he was seen at BWH in March 2020 with 3+ nephrotic range proteinuria, dx with Antibody Mediated Rejection and was given rituxin. Considered protal vein thrombosis with elevated liver enzymes on admission but resolved so less likely. CHF less likely given TTE demonstrating normal LV size with moderately increased wall thickness, EF 65%, normal right ventricular size and systolic function.
Had been prescribed Bumex 1 mg prn in outpatient setting due to nephrotic syndrome after receiving rituxin last year but has not been taking recently
Currently diuresing with Bumex with good output.
Spot urine protein to creatinine ratio 7.5.
Transplant US demonstrated minimal pelvicaliectasis with small amount of adjacent fluid with elevated resistive indices and urinary bladder distention to 459 mL.
Plan:
- Change Bumex 2 mg IV BID to Bumex 4 mg PO BID
- Telemetry to assess for tachy mediated cause of CHF, patient has been refusing
- 24 hr urine protein, creatinine
- consider renal biopsy if 24 hr UPC is elevated
- Strict in/outs (with urinary retention protocol)
- Daily standing weights
- Low salt diet, 2L fluid restriction diet
- Nutrition consult placed for hypoalbuminemia "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/69ed940b-bda5-d6ac-6a01-406a6986d362"}}, {"fullUrl": "urn:uuid:9643c53a-6c24-1dd2-9f76-171df6ba78ae", "resource": {"resourceType": "Condition", "id": "9643c53a-6c24-1dd2-9f76-171df6ba78ae", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35388834"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R79.89", "display": "Elevated troponin level", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-20", "note": [{"text": "Last Assessment & Plan:
problemNote450
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Troponin 0.05 on admission with EKG that appears similar to previous without convincing signs of active ischemia and without symptoms concerning for ACS (though with history of type 1 diabetes could present with silent ischemia)
Suspect elevated troponin is secondary to myocardial injury due to hypervolemia, in addition to elevation in the setting of ESRD.
Refused telemetry, risks awknowledged
Delta troponin 0.04
- Telemetry, patient refusing
- Monitor closely for ACS
- STAT EKG for chest pain"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/9643c53a-6c24-1dd2-9f76-171df6ba78ae"}}, {"fullUrl": "urn:uuid:5ab1a3d0-dc53-316e-5603-3620e94206aa", "resource": {"resourceType": "Condition", "id": "5ab1a3d0-dc53-316e-5603-3620e94206aa", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35388849"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R74.8", "display": "Elevated liver enzymes", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-20", "note": [{"text": "Last Assessment & Plan:
problemNote453
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R factor of 1 suggestive of cholestatic injury, suspect from hepatic congestion in light of hypervolemia. Less likely infiltrative disease (Ferritin last checked 1/13/22 and was 391, no elevated calcium to suspect granulomatous disease). Lipase last checked and was 82 (1/12/2022). CMV PCR 1/13/22 not detected.
- Continue to monitor for now
- Will need further assessment if not improved with diuresis
- Consider abdominal ultrasound of portal venous system if further work-up of hypervolemia is unrevealing."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5ab1a3d0-dc53-316e-5603-3620e94206aa"}}, {"fullUrl": "urn:uuid:a36619ef-6bc3-fab7-50ac-6ca6f4149bbf", "resource": {"resourceType": "Condition", "id": "a36619ef-6bc3-fab7-50ac-6ca6f4149bbf", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35388853"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D64.9", "display": "Anemia, unspecified", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-21", "note": [{"text": "Last Assessment & Plan:
problemNote456
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Appreciate work-up at last admission and given darbopoeitin at that time.
Hgb 8.2 on admission was down to 6.9 with improvement to 8.2 on repeat. Zinc slightly low at 36.
- Monitor for now
- Vitamin with minerals given low copper"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a36619ef-6bc3-fab7-50ac-6ca6f4149bbf"}}, {"fullUrl": "urn:uuid:7f3cea94-00b9-993c-3f93-22dd5f8e6c18", "resource": {"resourceType": "Condition", "id": "7f3cea94-00b9-993c-3f93-22dd5f8e6c18", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35415541"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z94.0", "display": "Status post simultaneous kidney and pancreas transplant (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-21", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote459
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote460
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I have asked him to address whether or not he would be a candidate for Evusheld with his transplant docs."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7f3cea94-00b9-993c-3f93-22dd5f8e6c18"}}, {"fullUrl": "urn:uuid:14caedb6-bbd1-0747-f3d3-ba1ce977c9b0", "resource": {"resourceType": "Condition", "id": "14caedb6-bbd1-0747-f3d3-ba1ce977c9b0", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35484397"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I50.32", "display": "Chronic diastolic congestive heart failure (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-25", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote467
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Clapp DO agreed with CDI query for Acute on chronic diastolic (congestive) heart failure on 01/24/22 1620
problemNote468
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/14caedb6-bbd1-0747-f3d3-ba1ce977c9b0"}}, {"fullUrl": "urn:uuid:a696d069-05bd-e188-ad55-ed9aace759a8", "resource": {"resourceType": "Condition", "id": "a696d069-05bd-e188-ad55-ed9aace759a8", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35782814"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R57.8", "display": "Hemorrhagic shock (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-03", "note": [{"text": "Last Assessment & Plan:
problemNote470
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Noted to be hypotensive to 70 systolic with dropping hemoglobin in the setting of post procedure for renal biopsy to evaluate for nephrotic syndrome. CT of abdomen/pelvis demonstrated left rectus sheath hematoma. CT was done without contrast due to poor renal function, creatinine 2.6. Patient was initially admitted to transplant service. Given that patient remained hypotensive with altered mental status with further driving hemoglobin to 5.3 status post 3 L of IV fluids, general surgery consulted for control of bleed and went to the OR. Critical care was involved at this time. Patient received three units of packed red blood cells. Transfusion complicated by patient having co-current refractory hyperkalemia with with peaked T waves on stat EKG.
Plan:
-OR with surgery for control of bleeding
-patient will be transferred to surgery ICU primary after OR procedure
-plan for hemodialysis for hyperkalemia"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a696d069-05bd-e188-ad55-ed9aace759a8"}}, {"fullUrl": "urn:uuid:1d35164f-85be-83ca-971c-9614b0aec62b", "resource": {"resourceType": "Condition", "id": "1d35164f-85be-83ca-971c-9614b0aec62b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35809427"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "S31.109A", "display": "Open wound of anterior abdominal wall", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-09T07:46:51-05:00", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1d35164f-85be-83ca-971c-9614b0aec62b"}}, {"fullUrl": "urn:uuid:a47f6be5-261e-6a81-98f7-2c3a15985284", "resource": {"resourceType": "Condition", "id": "a47f6be5-261e-6a81-98f7-2c3a15985284", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35834040"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K66.1", "display": "Hemoperitoneum", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-07", "note": [{"text": "Last Assessment & Plan:
problemNote473
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Kidney biopsy on c/b hemoperitoneum and hemorrhagic shock requiring pressors, intubation for ex-lap on 2/3, and fascial closure on 2/3
Overnight HDS
HgB this AM slightly lower than priors (7.3 from 7.9 )
Access: LIJ
- Trend HgB - 1500 check.
- Transfuse for <6 given immunocompromised
- Monitor abdominal exam closely, low threshold to re-engage surgery if needed
- Wound:\u00a0midline incision closed with staples, dressed with gauze and tape, change prn for soiling; wicks to be removed POD 3 (?by surg)
- pain well controlled not requiring PRNs overnight"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a47f6be5-261e-6a81-98f7-2c3a15985284"}}, {"fullUrl": "urn:uuid:fbf3b8e1-4463-129a-b1ba-52d85ad7b3f3", "resource": {"resourceType": "Condition", "id": "fbf3b8e1-4463-129a-b1ba-52d85ad7b3f3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "36135934"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E61.0", "display": "Copper deficiency", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-17", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/fbf3b8e1-4463-129a-b1ba-52d85ad7b3f3"}}, {"fullUrl": "urn:uuid:e8660799-35fd-aca6-0426-7ae5ffe9bf2f", "resource": {"resourceType": "Condition", "id": "e8660799-35fd-aca6-0426-7ae5ffe9bf2f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37789459"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "S91.109A", "display": "Open toe wound", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-04-28", "note": [{"text": "Last Assessment & Plan:
problemNote476
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Unfortunately today Ryan has a extensive wound over the great toe on the left foot. This is malodorous. The wound beds are actively leaking a purulent material and there is gas production. The toe overall is very soft. This is very concerning for extensive necrotic tissue and also gangrene. I spoke with the wound care center to see if we can get him in urgently, the physician on-call they reviewed the pictures and expected extensive soft tissue infection and possible osteomyelitis and recommended an emergency department assessment. I discussed this with Ryan. The final recommendation is to present to the emergency department given the concern for this wound which is certainly toe threatening if not foot threatening. He states today that he is not sure if he will present to the emergency room. I was very frank with Ryan, I told him that I can certainly understand the stress he has been through recently and the fact the last place he wants to be is back in the hospital but the formal medical advice is to present urgently as I suspect he needs IV antibiotics and urgent imaging. He asked if this could be coordinated as an outpatient, this is virtually impossible at this time given delays in our imaging capabilities and the fact there is an active infection at this time. I asked Ryan again if he will present and he states he is not sure. I encouraged he and his wife who are each capable adults to have this conversation but again reemphasized the formal medical advice to present urgently to the emergency room. I did provide handoff to the emergency department providers so they are aware of his potential arrival."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e8660799-35fd-aca6-0426-7ae5ffe9bf2f"}}, {"fullUrl": "urn:uuid:84deb6c8-1a55-b0f0-9d42-ca2339a4c9f1", "resource": {"resourceType": "Condition", "id": "84deb6c8-1a55-b0f0-9d42-ca2339a4c9f1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37810082"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M86.9", "display": "Osteomyelitis of great toe of right foot (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-04-28", "note": [{"text": "Last Assessment & Plan:
problemNote478
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Followed by vascular now.
He should remain nonweightbearing or at least have his foot upright when he is sitting down until he is off his antibiotics.
I wrote a letter to his place of employment to reflect this restriction.
He will continue vancomycin and cefepime through infectious diseases. Estimated completion date in Mid June. "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/84deb6c8-1a55-b0f0-9d42-ca2339a4c9f1"}}, {"fullUrl": "urn:uuid:14144666-fcd1-98b5-0e02-c9f12ae384fc", "resource": {"resourceType": "Condition", "id": "14144666-fcd1-98b5-0e02-c9f12ae384fc", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37811607"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "A41.9", "display": "Sepsis (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-04-29", "note": [{"text": "Last Assessment & Plan:
problemNote484
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- continue vancomycin + cefepime
- monitor inflammatory labs
-UA?
-blood culture?"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/14144666-fcd1-98b5-0e02-c9f12ae384fc"}}, {"fullUrl": "urn:uuid:508e0d6b-4b20-2e56-d779-c8658a117aa6", "resource": {"resourceType": "Condition", "id": "508e0d6b-4b20-2e56-d779-c8658a117aa6", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37844025"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D62", "display": "Acute blood loss anemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-11-09T07:49:30-05:00", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/508e0d6b-4b20-2e56-d779-c8658a117aa6"}}, {"fullUrl": "urn:uuid:6a5ba3ab-0932-2d22-005e-c5dc4b4a8911", "resource": {"resourceType": "Condition", "id": "6a5ba3ab-0932-2d22-005e-c5dc4b4a8911", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37906140"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M65.9", "display": "Tenosynovitis of right foot", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-05-03", "note": [{"text": "Last Assessment & Plan:
problemNote488
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Initially presenting with diabetic foot wound that progressed to osteomyelitis and tracked into the tendon. No growth on culture of tendon specifically, but right toe amputation growing 4+ alpha strep (likely culprit for purulent material found in tendon), 1+ corynebacterium, and 4+ gram positive organism that by gross appearance looks like Actinomyces. Additional organism have identified including campylobacter ureolyticus, finegoldia (pepto strep) magna. Path shows residual inflammation at margins on right toe but not from right toe tendon.
Immunosuppressed status does push the duration of treatment to longer (4 vs 3 weeks), but would be considered effectively treated at 3 week mark, at which point he would from an infectious perspective be able to okay for transplantation. "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/6a5ba3ab-0932-2d22-005e-c5dc4b4a8911"}}, {"fullUrl": "urn:uuid:edc8c34b-a259-d5c2-2753-1fd29a12cc1c", "resource": {"resourceType": "Condition", "id": "edc8c34b-a259-d5c2-2753-1fd29a12cc1c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37946108"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D72.819", "display": "Leukopenia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-05-04", "note": [{"text": "Last Assessment & Plan:
problemNote490
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Patient with leukopenia.
Wondering if cefepime is causing marrow suppression and if he needs other antibiotic however multiple other causes.
- continue current abx regimen pending specificities"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/edc8c34b-a259-d5c2-2753-1fd29a12cc1c"}}, {"fullUrl": "urn:uuid:94425ecc-d151-41a4-10f5-1fa60b7c6dc9", "resource": {"resourceType": "Condition", "id": "94425ecc-d151-41a4-10f5-1fa60b7c6dc9", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37981476"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "T82.898A", "display": "Inadequate flow of dialysis arteriovenous fistula, initial encounter (CMS-HCC) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-05-05", "note": [{"text": "Last Assessment & Plan:
problemNote493
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Fistulogram and angioplasty 5/6.
- has a stitch in place that will need to be removed 5/9 at dialysis"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/94425ecc-d151-41a4-10f5-1fa60b7c6dc9"}}, {"fullUrl": "urn:uuid:1f58bd67-c6e4-a2ef-c1fb-ffef5d396a9f", "resource": {"resourceType": "Condition", "id": "1f58bd67-c6e4-a2ef-c1fb-ffef5d396a9f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41053735"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R78.81", "display": "Bacteremia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "note": [{"text": "Last Assessment & Plan:
problemNote495
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Source not obvious, however chronic wounds - DM foot ulcer (though look good), home dialysis line
Now blood cultures with serratia
mri thoracic and lumbar spine negative
-Continue with IV antibiotics: cefepime for now. Bactrim at discharge
-US fistula pending"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1f58bd67-c6e4-a2ef-c1fb-ffef5d396a9f"}}, {"fullUrl": "urn:uuid:6d421cf7-7378-208f-7e1a-e09179c185d0", "resource": {"resourceType": "Condition", "id": "6d421cf7-7378-208f-7e1a-e09179c185d0", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41053749"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D61.818", "display": "Pancytopenia (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/6d421cf7-7378-208f-7e1a-e09179c185d0"}}, {"fullUrl": "urn:uuid:6c017f61-87f9-d26a-dc7a-7ad0fdce6484", "resource": {"resourceType": "Condition", "id": "6c017f61-87f9-d26a-dc7a-7ad0fdce6484", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41053750"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.621", "display": "Type 2 diabetes mellitus with foot ulcer (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/6c017f61-87f9-d26a-dc7a-7ad0fdce6484"}}, {"fullUrl": "urn:uuid:4a0d686f-da94-1739-374f-6d4bc67c9d24", "resource": {"resourceType": "Condition", "id": "4a0d686f-da94-1739-374f-6d4bc67c9d24", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41053822"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D61.818", "display": "Pancytopenia (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "note": [{"text": "Last Assessment & Plan:
problemNote502
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WBC 1.5, lymphopenia, mild absolute neutropenia
New thrombocytopenia, mild at 124
Macrocytic anemia (not new and HgB improved from previously)
Suspect related to acute illness.
Now WBC rapidly transitioned to leukocytosis, 19 today.
Plan:
- trend
- HIV, chronic hep panel
- consider DIC if worsening TCP with AM labs"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4a0d686f-da94-1739-374f-6d4bc67c9d24"}}, {"fullUrl": "urn:uuid:a3b1bb7d-ec94-1e4c-8230-af431aaef1d5", "resource": {"resourceType": "Condition", "id": "a3b1bb7d-ec94-1e4c-8230-af431aaef1d5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41053827"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R40.4", "display": "Unresponsive episode", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "note": [{"text": "Last Assessment & Plan:
problemNote504
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Reportedly EMS found him unresponsive with low systolic? Wife reports he became unresponsive w BP 94/60 and tachycardic
Suspect his syncope was secondary to a low flow state with hypotension. Additionally he reports restarting his lisinopril today for the first time in 2 weeks.
Plan:
-tele x24 hours, uneventful. Removing. "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a3b1bb7d-ec94-1e4c-8230-af431aaef1d5"}}, {"fullUrl": "urn:uuid:932062a2-1e24-334c-fdb9-2b9a6d11ab6b", "resource": {"resourceType": "Condition", "id": "932062a2-1e24-334c-fdb9-2b9a6d11ab6b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41074580"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I77.0", "display": "AV fistula (CMS-HCC) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "note": [{"text": "Last Assessment & Plan:
problemNote506
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R/o active infection/abscess along fistula.
- Obtain US Soft Tissue left upper extremity"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/932062a2-1e24-334c-fdb9-2b9a6d11ab6b"}}, {"fullUrl": "urn:uuid:07a9c828-fde0-47f4-c05f-f477e230bc6c", "resource": {"resourceType": "Condition", "id": "07a9c828-fde0-47f4-c05f-f477e230bc6c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41074674"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D63.8", "display": "Anemia in other chronic diseases classified elsewhere", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "note": [{"text": "Last Assessment & Plan:
problemNote509
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Hemoglobin below goal. Likely superimposed acute and chronic anemias. Differential diagnosis includes DIC/hemolysis, anemia of chronic inflammation, ESRD. Schistocytes seen on blood smear, raising concern for DIC/hemolysis, but high fibrinogen is reassuring that this is not DIC. No evidence of acute blood loss.
-Transfuse RBCs for hemoglobin less than 7 - he wants to be notified before additional RBC units are ordered, as he is on a kidney transplant list
-Epogen per nephrology recommendations
-Check LDH, haptoglobin, fibrinogen, INR, iron studies, ferritin"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/07a9c828-fde0-47f4-c05f-f477e230bc6c"}}, {"fullUrl": "urn:uuid:4cb27556-8324-e5ee-7a70-279506c898db", "resource": {"resourceType": "Condition", "id": "4cb27556-8324-e5ee-7a70-279506c898db", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "42980322"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z89.411", "display": "History of amputation of right great toe (CMS-HCC) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-01-29", "note": [{"text": "Last Assessment & Plan:
problemNote516
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Stable no concern for infection "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4cb27556-8324-e5ee-7a70-279506c898db"}}, {"fullUrl": "urn:uuid:4a652ed5-3434-d89e-1509-c8dca60035a8", "resource": {"resourceType": "Condition", "id": "4a652ed5-3434-d89e-1509-c8dca60035a8", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "42980323"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E46", "display": "Protein-calorie malnutrition, unspecified severity (CMS-HCC) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-01-29", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4a652ed5-3434-d89e-1509-c8dca60035a8"}}, {"fullUrl": "urn:uuid:95c66594-62e9-3711-162e-edb323192554", "resource": {"resourceType": "Condition", "id": "95c66594-62e9-3711-162e-edb323192554", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "42980324"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D68.8", "display": "Other specified coagulation defects (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-01-29", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/95c66594-62e9-3711-162e-edb323192554"}}, {"fullUrl": "urn:uuid:cfe7936c-00dd-3bb8-5533-50d119dd1507", "resource": {"resourceType": "Condition", "id": "cfe7936c-00dd-3bb8-5533-50d119dd1507", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "44878599"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "U07.1", "display": "COVID-19", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-06-05", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/cfe7936c-00dd-3bb8-5533-50d119dd1507"}}, {"fullUrl": "urn:uuid:8fb96c7c-732a-8636-24ff-19f0edf804ec", "resource": {"resourceType": "Condition", "id": "8fb96c7c-732a-8636-24ff-19f0edf804ec", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "47252423"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.9", "display": "Type 2 diabetes mellitus without complication, without long-term current use of insulin (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-11-09", "note": [{"text": "Last Assessment & Plan:
problemNote521
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Well controlled
Discussed fructosamine declines at this time
Continue to track yearly A1c "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8fb96c7c-732a-8636-24ff-19f0edf804ec"}}, {"fullUrl": "urn:uuid:0a0953b8-0289-4b88-8776-7f88c38a63be", "resource": {"resourceType": "Condition", "id": "0a0953b8-0289-4b88-8776-7f88c38a63be", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "47252487"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I10", "display": "Primary hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-11-09", "note": [{"text": "Last Assessment & Plan:
problemNote523
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On amlodipine and lisinoril
147/70 today
Well controlled at home and during dialysis
Continue current regiment amlodipine and lisinopril "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/0a0953b8-0289-4b88-8776-7f88c38a63be"}}, {"fullUrl": "urn:uuid:d866c1e8-8068-15e1-4332-8ec402652eb3", "resource": {"resourceType": "Condition", "id": "d866c1e8-8068-15e1-4332-8ec402652eb3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "47252612"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.43", "display": "Diabetic autonomic neuropathy associated with type 2 diabetes mellitus (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-11-09", "note": [{"text": "Last Assessment & Plan:
problemNote525
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In the bilateral feet
On gabapentin
Bilateral neuropathy, well controlled on low-dose gabapentin, uses 100 to 300 mg nightly. Foot exam done today. No open wounds. No concerning findings."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/d866c1e8-8068-15e1-4332-8ec402652eb3"}}, {"fullUrl": "urn:uuid:db0af2db-b8d3-3526-3468-00e5afca180b", "resource": {"resourceType": "Condition", "id": "db0af2db-b8d3-3526-3468-00e5afca180b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "47253039"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z00.00", "display": "Healthcare maintenance", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-11-09", "note": [{"text": "Last Assessment & Plan:
problemNote527
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TDAP today
PCV 20
Got flu shot through MaineHealth
UTD COVID booster
- Up to date with all blood work. We will do a lipid panel, hemoglobin A1c yearly.
- Discussed using fructosamine instead; however, he declines at this time.
- His fasting glucose has always been within normal limits."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/db0af2db-b8d3-3526-3468-00e5afca180b"}}, {"fullUrl": "urn:uuid:9645b737-19b5-78c9-18e8-ce697b2b7632", "resource": {"resourceType": "Condition", "id": "9645b737-19b5-78c9-18e8-ce697b2b7632", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50329936"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N36.2", "display": "Urethral polyp", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-06-21", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/9645b737-19b5-78c9-18e8-ce697b2b7632"}}, {"fullUrl": "urn:uuid:5e8e7f01-a70f-a0d6-dec4-fc9b812f58f7", "resource": {"resourceType": "Condition", "id": "5e8e7f01-a70f-a0d6-dec4-fc9b812f58f7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50329937"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "A63.0", "display": "Condyloma acuminatum", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-06-21", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5e8e7f01-a70f-a0d6-dec4-fc9b812f58f7"}}, {"fullUrl": "urn:uuid:8009a824-d947-f556-7de9-90c10f28bd21", "resource": {"resourceType": "Condition", "id": "8009a824-d947-f556-7de9-90c10f28bd21", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50337107"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.622", "display": "Diabetic ulcer of right ankle (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-06-21", "note": [{"text": "Last Assessment & Plan:
problemNote531
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Right ankle ulceration with increased depth, noted 2.5 cm straight and. Was not able to palpate any bone at the base but I anticipate this is very close.
Heavy amount of drainage continues to flow from the open area of the wound, lower leg is significantly edematous 3+ pitting to foot ankle and lower leg.
Was not able to express any wispy thick yellow fluid as I was last week.
Patient does have an MRI coming up next Wednesday.
He has arterial studies next Thursday.
He will return to see us next Friday.
I did discuss with Ryan today that I believe he would benefit from negative pressure wound therapy assuming that the MRI was negative for any underlying infection in the bone.
Ryan states that he would be agreeable to this at this time.
Until he sees us back next Friday I would like him to dress the wounds with the following:
Mesalt gauze tucked into the depth of the wound followed by ABD pad, rolled gauze, Ace wrap for higher level of compression than he is achieving currently with his own compression stocking. Change dressing daily.
Patient to begin taking doxycycline, prescribed 10-day course to be completed on 8/12/24
Return to see us next Friday."}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8009a824-d947-f556-7de9-90c10f28bd21"}}, {"fullUrl": "urn:uuid:dff1a842-fe5c-4f0a-19cf-b1977399cdd9", "resource": {"resourceType": "Condition", "id": "dff1a842-fe5c-4f0a-19cf-b1977399cdd9", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924407"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D84.9", "display": "Immunosuppressed status (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/dff1a842-fe5c-4f0a-19cf-b1977399cdd9"}}, {"fullUrl": "urn:uuid:457adb01-1630-2c1c-a604-4b07e2a3b972", "resource": {"resourceType": "Condition", "id": "457adb01-1630-2c1c-a604-4b07e2a3b972", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924442"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z94.89", "display": "Transplant recipient", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Last Assessment & Plan:
problemNote537
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S/p kidney and pancreas transplant at MGH
Now ESRD with some urine production
Pancreas stable, lipase 11"}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/457adb01-1630-2c1c-a604-4b07e2a3b972"}}, {"fullUrl": "urn:uuid:54e3b0bd-6a63-b094-8f7b-418b87b88b78", "resource": {"resourceType": "Condition", "id": "54e3b0bd-6a63-b094-8f7b-418b87b88b78", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924763"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R78.81", "display": "MSSA bacteremia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Last Assessment & Plan:
problemNote539
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Presented with high fevers (first fever reported 7/30/24), malaise, dry cough.
Blood culture resulted positive for methicillin-susceptible S. aureus.
Source likely R ankle osteomyelitis seen on MRI. Warrants workup for valvular involvement via TTE and involvement of fistula via US.
-Treat osteomyelitis (below)
-Appreciate ID recs:
Cefazolin 2g q8h for 6 weeks for osteo
-F/u TTE and fistula US
-Narrow antibiotics to cefazolin (will review with ID whether any additional coverage is needed for question of pneumonia)
-Repeat blood culture to evaluate for clearance of bacteremia tomorrow (8/5) "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/54e3b0bd-6a63-b094-8f7b-418b87b88b78"}}, {"fullUrl": "urn:uuid:7ba81e30-0c52-3d80-c247-f14d1ed7a8ce", "resource": {"resourceType": "Condition", "id": "7ba81e30-0c52-3d80-c247-f14d1ed7a8ce", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924764"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M86.9", "display": "Osteomyelitis of right ankle (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Last Assessment & Plan:
problemNote543
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Osteomyelitis seen on 8/3 MRI. Likely related to medial malleolar ulcer present for 3 months, which started as a burn. The patient is followed by the wound care clinic. Per MRI, cannot exclude septic joint.
-Consult ortho re: drainage for septic joint
-Wound care nursing consult with low threshold for burn and soft tissue surgery consult
-Wound care per prior outpatient recommendations:
Mesalt gauze tucked into the depth of the wound followed by ABD pad, rolled gauze, Ace wrap for higher level of compression than he is achieving currently with his own compression stocking. Change dressing daily. "}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7ba81e30-0c52-3d80-c247-f14d1ed7a8ce"}}, {"fullUrl": "urn:uuid:49511150-fca1-ab3c-7e67-54b5759bdd46", "resource": {"resourceType": "Condition", "id": "49511150-fca1-ab3c-7e67-54b5759bdd46", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50927212"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R50.9", "display": "Fever in adult", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-04", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/49511150-fca1-ab3c-7e67-54b5759bdd46"}}, {"fullUrl": "urn:uuid:45b5366d-e6d3-3744-6b9c-e66825969a31", "resource": {"resourceType": "Condition", "id": "45b5366d-e6d3-3744-6b9c-e66825969a31", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50927213"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-04", "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/45b5366d-e6d3-3744-6b9c-e66825969a31"}}, {"fullUrl": "urn:uuid:91bc1e05-8b85-6901-5dec-03a6826f358b", "resource": {"resourceType": "DiagnosticReport", "id": "91bc1e05-8b85-6901-5dec-03a6826f358b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "353417712"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.206.2.798268.2.353417712.1"}], "status": "final", "code": {"coding": [{"code": "33480", "display": "XR Chest PA And Lateral", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-08-03T16:30:00Z", "end": "2024-08-03T16:30:00Z"}, "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "performer": [{"reference": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}], "result": [{"reference": "Observation/886a8a96-b98d-a9f3-bb01-8449be8536f5"}, {"reference": "Observation/b8412ac2-a738-3286-c93e-769de7306ac9"}, {"reference": "Observation/c381eed1-336a-3436-294d-d4ef70f13600"}, {"reference": "Observation/ea475221-55e7-209f-eefb-30ceab60ee3a"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/91bc1e05-8b85-6901-5dec-03a6826f358b"}}, {"fullUrl": "urn:uuid:6785067f-cee7-c612-c204-069a2bb67949", "resource": {"resourceType": "Organization", "id": "6785067f-cee7-c612-c204-069a2bb67949", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}}, {"fullUrl": "urn:uuid:886a8a96-b98d-a9f3-bb01-8449be8536f5", "resource": {"resourceType": "Observation", "id": "886a8a96-b98d-a9f3-bb01-8449be8536f5", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.3.696580.52175", "value": "33480"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-08-03T17:17:00Z", "end": "2024-08-03T17:48:03Z"}, "bodySite": {"coding": [{"code": "101", "display": "Chest", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.10.696580.52010"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T16:30:00Z"}]}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}}, "request": {"method": "PUT", "url": "Observation/886a8a96-b98d-a9f3-bb01-8449be8536f5"}}, {"fullUrl": "urn:uuid:b8412ac2-a738-3286-c93e-769de7306ac9", "resource": {"resourceType": "Observation", "id": "b8412ac2-a738-3286-c93e-769de7306ac9", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.7.798268.1000", "value": "353417712"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-03T17:56:51Z", "valueString": "EXAM: XR CHEST PA AND LATERAL
INDICATION: Sepsis
COMPARISON: 10/11/2022.
TECHNIQUE: AP and lateral radiographs of the chest.
FINDINGS:
The lungs are well expanded.
Diffuse bibasilar and bihilar predominant pulmonary interstitial alveolar opacities. There is the appearance of early confluent consolidation associated with the retrocardiac lungs. The remainder lungs otherwise clear of focal consolidative change.
Costophrenic sulci blunting posteriorly may reflect trace effusions and/or more confluent pulmonary opacification. There is no pneumothorax.
Cardiomegaly and pulmonary vascular congestion appears more pronounced from prior examination.
No acute osseous or joint abnormality.
IMPRESSION:
Pulmonary interstitial and alveolar opacities with early confluent consolidation of the retrocardiac position which is likely reflective of early organizing pneumonia given the clinical history. There could be some possible associated trace pleural
effusion. Prominence of the heart and pulmonary vascularity could be somewhat due to technique, however, cardiogenic pulmonary edema may also be within the differential. Clinical correlation for concomitant congestive heart failure would be recommended.
WORKSTATION: WS30
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/3/2024 1:54 PM \u00a0Christopher Mutter, DO", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T16:30:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.353417712.Narrative"}]}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/b8412ac2-a738-3286-c93e-769de7306ac9"}}, {"fullUrl": "urn:uuid:cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "resource": {"resourceType": "Organization", "id": "cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}}, {"fullUrl": "urn:uuid:c381eed1-336a-3436-294d-d4ef70f13600", "resource": {"resourceType": "Observation", "id": "c381eed1-336a-3436-294d-d4ef70f13600", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051849932"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-03T17:56:51Z", "valueString": "RECOGNITION * * 8/3/2024 1:54 PM Christopher Mutter, DO
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: WS30
congestive heart failure would be recommended.
be within the differential. Clinical correlation for concomitant
somewhat due to technique, however, cardiogenic pulmonary edema may also
effusion. Prominence of the heart and pulmonary vascularity could be
possible associated trace pleural
early organizing pneumonia given the clinical history. There could be some
consolidation of the retrocardiac position which is likely reflective of
Pulmonary interstitial and alveolar opacities with early confluent
IMPRESSION:
No acute osseous or joint abnormality.
from prior examination.
Cardiomegaly and pulmonary vascular congestion appears more pronounced
more confluent pulmonary opacification. There is no pneumothorax.
Costophrenic sulci blunting posteriorly may reflect trace effusions and/or
clear of focal consolidative change.
associated with the retrocardiac lungs. The remainder lungs otherwise
opacities. There is the appearance of early confluent consolidation
Diffuse bibasilar and bihilar predominant pulmonary interstitial alveolar
The lungs are well expanded.
FINDINGS:
TECHNIQUE: AP and lateral radiographs of the chest.
COMPARISON: 10/11/2022.
INDICATION: Sepsis
EXAM: XR CHEST PA AND LATERAL
Formatting of this note might be different from the original.
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Date: 8/4/2024 5:00 PM
History: Male, 46 years old. INDICATIONS: 46 yo M with immunocompromised status due to kidney transplant, presents with high fevers. Chronic wound of R ankle followed by wound care. Please evaluate for evidence of osteomyelitis. \u00a0STUDY NOTES: \u00a0Prior
imaging on pacs. Patient presenting with medial right ankle ulceration. Evaluate for osteomyelitis. \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Hx Questions: \u00a0Hx \u00a0of Diabetes, Renal Insuf., Multiple Myeloma? Yes \u00a0 \u00a0
COMPARISON: \u00a0None.
Technique: Right foot and ankle imaged. Routine MRI was performed without intravenous contrast.
FINDINGS:
Soft tissues: Diffuse superficial edema. There is no muscular edema or atrophy.
Bones: Abnormal marrow edema of the medial malleolus and talus noted. Talar dome is intact; no fracture or bone lesion.
Joints: Mild ankle joint effusion with heterogeneous signal within the. No loose body. \u00a0
Medial Flexor Tendons: Fluid in tendon sheath. Otherwise visualized PT, FDL and FHL are intact. \u00a0Peroneal Tendons: Fluid in the tendon; otherwise peroneus longus and brevis are intact.
Anterior Extensor Tendons: The AT, EHL and EDL are intact. \u00a0
Lateral Ligaments: Tibiofibular, talofibular and calcaneofibular ligaments are intact.
Medial Ligaments: The deltoid (deep and superficial) ligaments are intact.
Achilles Tendon: Intact.
Plantar Fascia: Intact. Small plantar calcaneal enthesophyte noted.
Additional comments: None.
IMPRESSION: Cellulitis with findings suggestive for early medial malleoli relating talar osteomyelitis.
Nonspecific small ankle joint effusion. Cannot exclude septic joint.
Nonspecific fluid or tenosynovitis of medial flexor and peroneal tendons.
WSN:SHU-CA91301
* * * THIS IS AN ELECTRONICALLY VERIFIED REPORT * * *
8/4/2024 8:18:54 PM \u00a0Fred Shu
For questions regarding this report, Monday through Friday, 8am-5pm, please contact Spectrum Radiology Support at 1-844-764-7237. \u00a0Otherwise, please contact Synergy at 1-877-671-6119.", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T21:00:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355151809.Narrative"}]}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/9509befa-603e-e04d-dc7c-643b18b61b36"}}, {"fullUrl": "urn:uuid:732ad115-8904-c4eb-475a-149d8e14c17e", "resource": {"resourceType": "Observation", "id": "732ad115-8904-c4eb-475a-149d8e14c17e", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2052100449"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-05T00:19:46Z", "valueString": "please contact Synergy at 1-877-671-6119.
please contact Spectrum Radiology Support at 1-844-764-7237. Otherwise,
For questions regarding this report, Monday through Friday, 8am-5pm,
8/4/2024 8:18:54 PM Fred Shu
* * * THIS IS AN ELECTRONICALLY VERIFIED REPORT * * *
WSN:SHU-CA91301
tendons.
Nonspecific fluid or tenosynovitis of medial flexor and peroneal
Nonspecific small ankle joint effusion. Cannot exclude septic joint.
relating talar osteomyelitis.
IMPRESSION: Cellulitis with findings suggestive for early medial malleoli
Additional comments: None.
Plantar Fascia: Intact. Small plantar calcaneal enthesophyte noted.
Achilles Tendon: Intact.
intact.
Medial Ligaments: The deltoid (deep and superficial) ligaments are
are intact.
Lateral Ligaments: Tibiofibular, talofibular and calcaneofibular ligaments
Anterior Extensor Tendons: The AT, EHL and EDL are intact.
peroneus longus and brevis are intact.
FDL and FHL are intact. Peroneal Tendons: Fluid in the tendon; otherwise
Medial Flexor Tendons: Fluid in tendon sheath. Otherwise visualized PT,
loose body.
Joints: Mild ankle joint effusion with heterogeneous signal within the. No
Talar dome is intact; no fracture or bone lesion.
Bones: Abnormal marrow edema of the medial malleolus and talus noted.
atrophy.
Soft tissues: Diffuse superficial edema. There is no muscular edema or
FINDINGS:
intravenous contrast.
Technique: Right foot and ankle imaged. Routine MRI was performed without
COMPARISON: None.
Renal Insuf., Multiple Myeloma? Yes
Evaluate for osteomyelitis. Hx Questions: Hx of Diabetes,
imaging on pacs. Patient presenting with medial right ankle ulceration.
osteomyelitis. STUDY NOTES: Prior
of R ankle followed by wound care. Please evaluate for evidence of
status due to kidney transplant, presents with high fevers. Chronic wound
History: Male, 46 years old. INDICATIONS: 46 yo M with immunocompromised
Date: 8/4/2024 5:00 PM
EXAMINATION: MRI ANKLE RT, W/O CONTRAST
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INDICATION: 46 yo M with immuncompromised status from renal transplant, presents with MSSA bacteremia, question of pneumonia. History of potential mold exposures.
COMPARISON: August 3, 2024
TECHNIQUE: CT of the chest was performed without intravenous contrast. Axial, sagittal, coronal, and MIP images.
FINDINGS:
Lungs/Pleura: Small bilateral pleural effusions are noted. Calcific granulomas are seen in both lungs. There also several noncalcified nodules measuring up to 8 mm. Follow up CT scanning is recommended in 6 months for reevaluation. Septal line prominence
is seen and mild pulmonary edema may be present. Mild groundglass opacity is also seen bilaterally.
Heart: The heart is enlarged. Coronary artery calcification is noted. No pericardial effusion is seen.
Mediastinum: No vascular abnormality, mass, or inflammation.
Lymph Nodes: Bilateral hilar lymphadenopathy is suggested with lymph nodes measuring up to 1.5 cm.
Thyroid: There is a 3.3 cm left thyroid nodule with calcifications. Sonographic correlation is recommended.
Esophagus: Negative.
Chest Wall: Intact without mass.
Upper Abdomen: The spleen is not completely included though it appears to be enlarged. A right renal cyst is noted.
Musculoskeletal: The bones are diffusely hyperdense in appearance this finding may be related to secondary hyperparathyroidism given the patient''s history. Clinical correlation is recommended.
IMPRESSION: Small bilateral pleural effusions are noted. Calcified and noncalcified lung nodules are seen. Noncalcified nodules measuring up to 8 mm and follow up CT scan is recommended in 6 months for reevaluation. Possible mild pulmonary edema is
suspected. Mild groundglass opacity is also seen bilaterally. Cardiomegaly and coronary artery calcification are noted. Bilateral hilar lymphadenopathy. A large left thyroid nodule is noted with calcifications and sonographic evaluation is indicated.
Splenomegaly. Right renal cyst. The bones are hyperdense appearance which may be related to secondary hyperparathyroidism though clinical and laboratory correlation recommended.
WORKSTATION: MILES-MG-DS1
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/4/2024 6:23 PM \u00a0Charles Mullen, MD", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T22:15:34Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355119233.Narrative"}]}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/8d428a2f-306b-f328-c735-cb706f2e30b9"}}, {"fullUrl": "urn:uuid:27432093-40ef-9949-745c-7051c5c74e81", "resource": {"resourceType": "Observation", "id": "27432093-40ef-9949-745c-7051c5c74e81", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2052088598"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T22:23:42Z", "valueString": "RECOGNITION * * 8/4/2024 6:23 PM Charles Mullen, MD
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: MILES-MG-DS1
laboratory correlation recommended.
may be related to secondary hyperparathyroidism though clinical and
Splenomegaly. Right renal cyst. The bones are hyperdense appearance which
and sonographic evaluation is indicated.
lymphadenopathy. A large left thyroid nodule is noted with calcifications
and coronary artery calcification are noted. Bilateral hilar
suspected. Mild groundglass opacity is also seen bilaterally. Cardiomegaly
Possible mild pulmonary edema is
mm and follow up CT scan is recommended in 6 months for reevaluation.
noncalcified lung nodules are seen. Noncalcified nodules measuring up to 8
IMPRESSION: Small bilateral pleural effusions are noted. Calcified and
patient''s history. Clinical correlation is recommended.
finding may be related to secondary hyperparathyroidism given the
Musculoskeletal: The bones are diffusely hyperdense in appearance this
be enlarged. A right renal cyst is noted.
Upper Abdomen: The spleen is not completely included though it appears to
Chest Wall: Intact without mass.
Esophagus: Negative.
Sonographic correlation is recommended.
Thyroid: There is a 3.3 cm left thyroid nodule with calcifications.
measuring up to 1.5 cm.
Lymph Nodes: Bilateral hilar lymphadenopathy is suggested with lymph nodes
Mediastinum: No vascular abnormality, mass, or inflammation.
pericardial effusion is seen.
Heart: The heart is enlarged. Coronary artery calcification is noted. No
is also seen bilaterally.
is seen and mild pulmonary edema may be present. Mild groundglass opacity
reevaluation. Septal line prominence
measuring up to 8 mm. Follow up CT scanning is recommended in 6 months for
granulomas are seen in both lungs. There also several noncalcified nodules
Lungs/Pleura: Small bilateral pleural effusions are noted. Calcific
FINDINGS:
Axial, sagittal, coronal, and MIP images.
TECHNIQUE: CT of the chest was performed without intravenous contrast.
COMPARISON: August 3, 2024
mold exposures.
presents with MSSA bacteremia, question of pneumonia. History of potential
INDICATION: 46 yo M with immuncompromised status from renal transplant,
EXAM: CT CHEST WO CONTRAST
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60%.
Normal right ventricular cavity size and systolic function.
There is an echodensity seen in the LVOT just in the vicinity of the right
coronary cusp. This may represent calcium versus possible vegetation.
Moderate mitral annular calcification. \u00a0There is trace mitral
regurgitation.
Compared to prior study of 1/21/2022, the aortic valve findings are new. \u00a0
If clinically indicated, TEE would better evaluate for infective
endocarditis.
Left Ventricle
Left ventricular cavity is normal in size. Normal wall thickness. Normal wall motion. Normal systolic function with a visually estimated EF of 55 - 60%. Diastolic dysfunction present, indeterminate grade.
Right Ventricle
Right ventricle size is normal. Normal systolic function.
Left Atrium
Left atrium is mildly dilated.
Right Atrium
Right atrium size is normal. The right atrial pressure is estimated at 15 mmHg.
IVC/SVC
IVC diameter is greater than 21 mm and decreases less than 50% during inspiration.
Mitral Valve
Mildly calcified leaflets. Moderate posterior mitral annular calcification. Trace regurgitation. No stenosis.
Tricuspid Valve
Valve structure is normal. Trace regurgitation. No stenosis.
Aortic Valve
Trileaflet. Mildly calcified cusps. There is an echodensity seen in the LVOT just in the vicinity of the right coronary cusp. This may represent calcium versus possible vegetation. No Doppler abnormalities.
Pulmonic Valve
Not well visualized. No Doppler abnormalities.
Ascending Aorta
Normal sized sinuses of Valsalva and ascending aorta.
Pericardium
No pericardial effusion.
Pulmonary Artery
Not well visualized but probably normal.
Study Details
A complete echo was performed using complete 2D, color flow Doppler and spectral Doppler. Overall the study quality was adequate.
Wall Scoring Baseline
Score Index: 1.00
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>12 months post renal transplant: 3.0-6.0 ng/mL
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prophylaxis prior to surgery/invasive procedure, if the
FFP is rarely indicated in a bleeding patient, or as
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15.0 ng/mL", "low": {"value": 3.0, "unit": "ng/mL"}, "high": {"value": 15.0, "unit": "ng/mL"}}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-08-05T09:17:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-08-05T09:26:03Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355151815.Comp1"}]}], "subject": {"reference": "Patient/c979fc05-ec7a-4dc6-88e1-726aea732984"}, "performer": [{"display": "NORDX SCARBOROUGH CAMPUS", "reference": "Organization/1ca32bd4-a375-5d91-e841-645ef1d85abf"}]}, "request": {"method": "PUT", "url": "Observation/13728631-0177-0624-a820-11bf4b04aa8f"}}, {"fullUrl": "urn:uuid:8e888b22-e8ee-0b0c-75f9-ba614ac5cbb0", "resource": {"resourceType": "Observation", "id": "8e888b22-e8ee-0b0c-75f9-ba614ac5cbb0", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.7.798268.1000", "value": "355151815"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-05T16:01:24Z", "valueString": "Therapeutic Ranges for 12 hour Trough samples:
<= 3 months post renal transplant: 12.0-15.0 ng/mL
3-12 months post renal transplant: 8.0-12.0 ng/mL
>12 months post renal transplant: 3.0-6.0 ng/mL
Potentially toxic: 15.1-20.0 ng/mL
Toxic: > 20.0 ng/mL
Analytical Method: Chemiluminescence Microparticle
Immunoassay (CMIA)
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"HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E6-B5CB-D69B-FFA4C7D55C45", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
HH Influenza Vaccine Quadrivalent 0.5ML IM10/25/2021
Moderna Red Cap(12+)Covid-19,Monovalent,mrna,lnp-s,pf,.5mL (IMM10222)02/11/2021 01/14/2021 ,
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E6-B5D7-D69B-FFA4C7D55C45", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
cefTRIAXone (Rocephin) syringe infusion 1 gm1 gm, Intravenous, Daily, First dose on Sun 8/4/24 at 0300, For 5 doses, Ceftriaxone: NOT admin. via Y-site with calcium-containing (ie: Lactated Ringers). Flush lines between sequent. admin. of ceftriaxone and calcium-containing soln. Possible side effects: Nausea, diarrhea, rash Reconstitute 1gm vial of ceftriaxone in 20 mL of SWFI or 0.9% NaCl. For locations with access to Plum360 pump: Connect syringe to Plum360 Pump and infuse over 5 minutes (4 mL/min). Upon completion of infusion, flush with 20 mL at the same rate to ensure all antibiotic in tubing has been administered. In locations where Plum360 pump is unavailable: push syringe over 2 minutes. Upon completion of IV push, flush with 20 mL of NS or maintenance fluid to ensure all antibiotic in tubing has been administered.Given08/05/2024 9:02 AM EDT1 gm
Given08/04/2024 3:33 AM EDT1 gm
enoxaparin (Lovenox) injection 40 mg40 mg, Subcutaneous, Every 24 hours, First dose on Sun 8/4/24 at 0900, Abdomen is the preferred site of administration. Possible side effects: bleeding & bruising, mild pain at injection siteGiven08/04/2024 9:14 AM EDT40 mgLeft Lower Abdomen
lactated ringers infusion100 mL/hr, Intravenous, Continuous, Starting on Sun 8/4/24 at 0845New Bag08/04/2024 5:57 PM EDT100 mL/hr100 mL/hr
New Bag08/04/2024 9:15 AM EDT100 mL/hr100 mL/hr
remdesivir (Veklury) 100 mg in NaCl 0.9% 250 mL infusion100 mg, Intravenous, Administer over 30 Minutes, Every 24 hours, First dose on Mon 8/5/24 at 0500, For 2 days, The entire volume of the prepared remdesivir solution for infusion in 0.9% saline should be infused. When the administration of remdesivir solution is complete, flush the IV line with at least 30 mL of 0.9% saline at the same rate to ensure that all of the remdesivir solution has been administered.New Bag08/05/2024 5:48 AM EDT100 mg500 mL/hr
senna (Senokot) tablet 2 Tablet2 Tablet, Oral, Daily, First dose on Sun 8/4/24 at 0900, 1st line therapy (Adult Bowel Management - 1 or more Risk Factors): Switch to 2nd line therapy if no BM by 48 hours after using 1st line therapy. Hold for Bristol Type 6 or 7 stoolsGiven08/05/2024 9:00 AM EDT2 Tablets
Given08/04/2024 2:56 PM EDT2 Tablets
sodium chloride (NS) 0.9 % flush 5 mL5 mL, Intravenous, As needed, Line Care, Starting on Sat 8/3/24 at 2027
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (Ofirmev) 10 MG/ML injection 1,000 mg1,000 mg, Intravenous, at 400 mL/hr, Every 6 hours, First dose on Sun 8/4/24 at 0300, For 2 doses, Infuse over 15 minutes, Indications: Patient NPO and cannot take oral medications, want take PONew Bag08/04/2024 9:14 AM EDT1,000 mg400 mL/hr
New Bag08/04/2024 2:14 AM EDT1,000 mg400 mL/hr
acetaminophen (TYLENOL) 32 mg/mL oral solution (650mg cup) 650 mg650 mg, Oral, Once, On Sat 8/3/24 at 1945, For 1 dose, Maximum dose of acetaminophen is 4000 mg from all sources in 24 hours. Possible side effects: upset stomach, rashGiven08/03/2024 7:51 PM EDT650 mg
iohexol (OMNIPAQUE) 350 MG/ML injection 70 mL70 mL, Intravenous, Once PRN, Starting on Sun 8/4/24 at 0207, For 1 doseGiven08/04/2024 2:07 AM EDT70 mL
lactated ringers infusion bolus 1,000 mL1,000 mL, Intravenous, Administer over 1 Hours, Every hour, First dose on Sat 8/3/24 at 2100, For 1 doseNew Bag08/03/2024 9:22 PM EDT1,000 mL1000 mL/hr
lactated ringers infusion bolus 1,000 mL1,000 mL, Intravenous, Administer over 2 Hours, Once, On Sun 8/4/24 at 0345, For 1 doseNew Bag08/04/2024 3:43 AM EDT1,000 mL500 mL/hr
midazolam (Versed) injection 2 mg2 mg, Intramuscular, Once, On Sat 8/3/24 at 2045, For 1 doseGiven08/03/2024 8:42 PM EDT2 mgLeft Anterior Thigh
morphine (PF) 2 MG/ML injection 4 mg4 mg, Intravenous, Once, On Sat 8/3/24 at 2245, For 1 dose, For IV Push: May be administered undiluted as IV push over 4-5 minutes; however further dilution with 5 ml Sterile Water or 0.9% NS to facilitate dose titration is appropriate. Use injectable agent if urgent/rapid analgesia is required or patient unable to take oral agent or oral agent ineffective after 60 minutes. Possible side effects: drowsiness, constipation, nausea/vomiting, rash.Given08/03/2024 10:48 PM EDT4 mg
remdesivir (Veklury) 200 mg in NaCl 0.9% 250 mL infusion200 mg, Intravenous, Administer over 30 Minutes, Every 24 hours, First dose on Sun 8/4/24 at 0145, For 1 day, The entire volume of the prepared remdesivir solution for infusion in 0.9% saline should be infused. When the administration of remdesivir solution is complete, flush the IV line with at least 30 mL of 0.9% saline at the same rate to ensure that all of the remdesivir solution has been administered.New Bag08/04/2024 5:00 AM EDT200 mg500 mL/hr
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture Blood - #1 of 1MicrobiologySTAT08/03/2024 9:13 PM EDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
POC Bedside Glucose TestPoint of Care TestingSTATAs Needed until discontinued starting 8/4/24
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/0007b46d-3f28-5741-6258-898730fe28db"}]}, {"id": "00000000-25E6-B5E5-D69B-FFA4C7D55C45", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
COVID08/03/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Gentle IVF given soft BPWill d/w CM if group home can take back if continues asymptomatic course.3 day course remdesivir Plan:Treated with remdesivir given dev. DelayTested positive for COVID upon admission. No resp symptoms, satting fine, CXR neg.
Right hip pain08/03/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
-observe-ceftriaxone for possible UTI, culture pendingPlan:Appears resolved. Suspect is was related to myalgia/arthralgias from COVID although UTI symptoms also possible. CT without joint effusion and hardware of R hip intact. CRP <3
Obstipation05/01/2023
Fever in adult10/03/2020
Rash, fever10/03/2020
Last Assessment & Plan:Formatting of this note might be different from the original.
- f/u viral serologies but neg so far - prn benadryl but would try to avoid- will cont pred for short course, will change to oral and 30 today Patient came in with her biggest complaint being increased agitation and appearing extremely uncomfortable per her father. Very abnormal for her and normally very nice and sweet. Unclear the etiology but almost gone after 1 dose of steroids and does not look like she is itching it
Status post total hip replacement, right06/03/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
- needs to ambulate - tylenol - foot area looks more like bruise to me - XR already done that is negIt is unclear if it her hip or foot that is causing to not put weight on it. The pain she had when I touched her right foot are makes me think that is the etiology
Urinary retention06/03/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
Likely due to constipation. No evidence of retention, constipation controlled. Urinalysis was negative for infection. Continue to monitor for constipation.
Constipation06/03/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
-Continue magnesium supplement natural,-Will make MiraLAX as needed if no BM for greater than 2 days-Continue Colace-Family to make prunes available, staff to offer for prunes dailyPatient starting to have softer stools and concern for incontinence with patient using a pool to swim throughout the week. Discussed at length with parents with plan as follows:
Osteoarthritis resulting from right hip dysplasia05/28/2019
Cellulitis of foot, right02/01/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
- hold abx for now As above
Angelman syndrome12/26/2017
Last Assessment & Plan:Formatting of this note might be different from the original.
-Continue PT/OTPatient to return to supportive environment at group home with parents support.
Abnormality of gait and mobility03/13/2017
Last Assessment & Plan:Formatting of this note might be different from the original.
Note that today''s visit total time 1 hour and 10 minutes greater than 50% in discussionWe will discuss this with the joint replacement team and get back to the family on thisHer parents are very interested in pursuing thisI suspect that the only thing that would substantially alter this for her would be hip replacement surgeryI suspect that her deteriorating gait and difficulty with pain is related to issues with her hipsBilateral hips she has what appears to be considerable issues with the hips the right appears to be perhaps subluxed and there is significant arthritic change in both hips with the right being more prominent than leftWe will obtain radiology review of theseFusion of spine as expectedX-rays taken today of her lumbar spine reveal hardware in place there is not seem to be any malalignment or issues with the hardwareMultifactorial gait abnormality
Seizures (CMS/HHS)
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Tapered off Depakote at ~ 19 Y/O Formatting of this note might be different from the original.
No recurrence of seizure activity, likely medication related, suspect oxycodone.
Resolved ProblemsNoted DateDiagnosed DateResolved Date
Suspected COVID-19 virus infection10/03/202010/05/2020
Last Assessment & Plan:Formatting of this note might be different from the original.
-Remove covid precautions. PLAN:A: COVID-19 Testing obtained due to symptoms which could be consistent with coronavirus infection. Covid swab negative x 1.
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Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
Job Start DateOccupationIndustry
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"Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "medicationReference": {"reference": "Medication/1c468002-ae9b-71b8-0aa4-94f8a73a6909"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/2304edf2-d0e2-bfe9-c7d5-4a743b1fea90"}}, {"fullUrl": "urn:uuid:1c468002-ae9b-71b8-0aa4-94f8a73a6909", "resource": {"resourceType": "Medication", "id": "1c468002-ae9b-71b8-0aa4-94f8a73a6909", "code": {"coding": [{"code": "216989", "system": "urn:oid:2.16.840.1.113883.6.253"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/1c468002-ae9b-71b8-0aa4-94f8a73a6909"}}, {"fullUrl": "urn:uuid:c9375ae5-9e6e-5115-e994-63e4cf8c381e", "resource": {"resourceType": "MedicationAdministration", "id": "c9375ae5-9e6e-5115-e994-63e4cf8c381e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355103327"}], "status": "in-progress", "effectivePeriod": {"start": "2024-08-05T09:00:00Z", "end": "2024-08-07T08:59:00Z"}, "dosage": {"route": {"coding": [{"code": "C38276", "display": "Intravenous", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 100, "unit": "mg"}}, "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "medicationReference": {"reference": "Medication/0118b4e3-86a3-cd1f-d574-855b195b83b8"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/c9375ae5-9e6e-5115-e994-63e4cf8c381e"}}, {"fullUrl": "urn:uuid:0118b4e3-86a3-cd1f-d574-855b195b83b8", "resource": {"resourceType": "Medication", "id": "0118b4e3-86a3-cd1f-d574-855b195b83b8", "code": {"coding": [{"display": "remdesivir (Veklury) 100 mg in NaCl 0.9% 250 mL infusion", "system": "http://www.nlm.nih.gov/research/umls/rxnorm"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/0118b4e3-86a3-cd1f-d574-855b195b83b8"}}, {"fullUrl": "urn:uuid:d1d182ea-a312-34e5-3950-70a3fecb7fd1", "resource": {"resourceType": "MedicationAdministration", "id": "d1d182ea-a312-34e5-3950-70a3fecb7fd1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355103302"}], "status": "completed", "effectiveDateTime": "2024-08-04T02:45:00Z", "dosage": {"route": {"coding": [{"code": "C38276", "display": "Intravenous", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 4, "unit": "mg"}}, "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "medicationReference": {"reference": "Medication/1fd65b9e-e0f8-883f-60be-f76c4383818f"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/d1d182ea-a312-34e5-3950-70a3fecb7fd1"}}, {"fullUrl": "urn:uuid:1fd65b9e-e0f8-883f-60be-f76c4383818f", "resource": {"resourceType": "Medication", "id": "1fd65b9e-e0f8-883f-60be-f76c4383818f", "code": {"coding": [{"code": "0409-1890-01", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/1fd65b9e-e0f8-883f-60be-f76c4383818f"}}, {"fullUrl": "urn:uuid:a17d39f8-2936-6490-3d11-bb8ff11f7797", "resource": {"resourceType": "MedicationAdministration", "id": "a17d39f8-2936-6490-3d11-bb8ff11f7797", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355099956"}], "status": "completed", "effectiveDateTime": "2024-08-04T00:30:00Z", "dosage": {"route": {"coding": [{"code": "C28161", "display": "Intramuscular", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 2, "unit": "mg"}}, "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "medicationReference": {"reference": "Medication/f54a322b-08ac-bc98-e9b0-48a9c6c27fde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/a17d39f8-2936-6490-3d11-bb8ff11f7797"}}, {"fullUrl": "urn:uuid:f54a322b-08ac-bc98-e9b0-48a9c6c27fde", "resource": {"resourceType": "Medication", "id": "f54a322b-08ac-bc98-e9b0-48a9c6c27fde", "code": {"coding": [{"code": "63323-412-25", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/f54a322b-08ac-bc98-e9b0-48a9c6c27fde"}}, {"fullUrl": "urn:uuid:f69b4cdf-3243-fa85-c60b-bac20aee5594", "resource": {"resourceType": "MedicationAdministration", "id": "f69b4cdf-3243-fa85-c60b-bac20aee5594", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355099933"}], "status": "in-progress", "effectivePeriod": {"start": "2024-08-04T00:27:00Z"}, "dosage": {"route": {"coding": [{"code": "C38276", "display": "Intravenous", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 5, "unit": "mL"}}, "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "medicationReference": {"reference": "Medication/45537cdd-cfb0-9e72-21d6-a0faefc787c4"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/f69b4cdf-3243-fa85-c60b-bac20aee5594"}}, {"fullUrl": "urn:uuid:45537cdd-cfb0-9e72-21d6-a0faefc787c4", "resource": {"resourceType": "Medication", "id": "45537cdd-cfb0-9e72-21d6-a0faefc787c4", "code": {"coding": [{"code": "64253-111-21", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/45537cdd-cfb0-9e72-21d6-a0faefc787c4"}}, {"fullUrl": "urn:uuid:08bbaca1-d382-1376-23ea-6f980693a554", "resource": {"resourceType": "MedicationAdministration", "id": "08bbaca1-d382-1376-23ea-6f980693a554", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "301061479"}], "status": "completed", "effectiveDateTime": "2024-08-03T23:45:00Z", "dosage": {"route": {"coding": [{"code": "C38288", "display": "Oral", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 650, "unit": "mg"}}, "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "medicationReference": {"reference": "Medication/ae94bad8-912a-cf33-9ac7-cf917556be06"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/08bbaca1-d382-1376-23ea-6f980693a554"}}, {"fullUrl": "urn:uuid:ae94bad8-912a-cf33-9ac7-cf917556be06", "resource": {"resourceType": "Medication", "id": "ae94bad8-912a-cf33-9ac7-cf917556be06", "code": {"coding": [{"code": "0904-7014-16", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/ae94bad8-912a-cf33-9ac7-cf917556be06"}}, {"fullUrl": "urn:uuid:9a640d37-ed14-25c3-497b-5645af44caa2", "resource": {"resourceType": "RelatedPerson", "id": "9a640d37-ed14-25c3-497b-5645af44caa2", "relationship": [{"coding": [{"display": "Guardian"}]}], "telecom": [{"system": "phone", "value": "+1-207-272-4878", "use": "mobile"}, {"system": "phone", "value": "+1-207-772-5629", "use": "home"}], "address": [{"use": "home", "line": ["34 Whitney Ave"], "city": "PORTLAND", "state": "ME", "country": "US", "postalCode": "04102", "district": "CUMBERLAND"}], "patient": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "RelatedPerson/9a640d37-ed14-25c3-497b-5645af44caa2"}}, {"fullUrl": "urn:uuid:ec726500-8b2a-90f0-d9ad-ca3b2f59c108", "resource": {"resourceType": "Condition", "id": "ec726500-8b2a-90f0-d9ad-ca3b2f59c108", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6799651"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R26.9", "display": "Abnormality of gait and mobility", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-03-13", "note": [{"text": "Last Assessment & Plan:
problemNote68
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Multifactorial gait abnormality
X-rays taken today of her lumbar spine reveal hardware in place there is not seem to be any malalignment or issues with the hardware
Fusion of spine as expected
We will obtain radiology review of these
Bilateral hips she has what appears to be considerable issues with the hips the right appears to be perhaps subluxed and there is significant arthritic change in both hips with the right being more prominent than left
I suspect that her deteriorating gait and difficulty with pain is related to issues with her hips
I suspect that the only thing that would substantially alter this for her would be hip replacement surgery
Her parents are very interested in pursuing this
We will discuss this with the joint replacement team and get back to the family on this
Note that today''s visit total time 1 hour and 10 minutes greater than 50% in discussion"}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ec726500-8b2a-90f0-d9ad-ca3b2f59c108"}}, {"fullUrl": "urn:uuid:8cce3789-8238-31aa-0160-04a2e5d7da01", "resource": {"resourceType": "Condition", "id": "8cce3789-8238-31aa-0160-04a2e5d7da01", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8622909"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Q93.51", "display": "Angelman syndrome", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-12-26", "note": [{"text": "Last Assessment & Plan:
problemNote73
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Patient to return to supportive environment at group home with parents support.
-Continue PT/OT"}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8cce3789-8238-31aa-0160-04a2e5d7da01"}}, {"fullUrl": "urn:uuid:38b74520-06a0-8a67-e999-27095ce304c5", "resource": {"resourceType": "Condition", "id": "38b74520-06a0-8a67-e999-27095ce304c5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10829469"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M16.31", "display": "Osteoarthritis resulting from right hip dysplasia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-05-28", "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/38b74520-06a0-8a67-e999-27095ce304c5"}}, {"fullUrl": "urn:uuid:e0a58a6e-df6f-88ce-c0ab-3a6c8b093279", "resource": {"resourceType": "Condition", "id": "e0a58a6e-df6f-88ce-c0ab-3a6c8b093279", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10856509"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z96.641", "display": "Status post total hip replacement, right", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-06-03", "note": [{"text": "Last Assessment & Plan:
problemNote76
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It is unclear if it her hip or foot that is causing to not put weight on it. The pain she had when I touched her right foot are makes me think that is the etiology
- XR already done that is neg
- foot area looks more like bruise to me
- tylenol
- needs to ambulate "}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e0a58a6e-df6f-88ce-c0ab-3a6c8b093279"}}, {"fullUrl": "urn:uuid:770d83e6-1144-f80a-3e81-85b882f6c7f7", "resource": {"resourceType": "Condition", "id": "770d83e6-1144-f80a-3e81-85b882f6c7f7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10856543"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R56.9", "display": "Seizures (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-06-03T10:42:29-04:00", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote85
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Tapered off Depakote at ~ 19 Y/O
problemNote86
System.Collections.Generic.Dictionary`2[System.String,System.Object]

No recurrence of seizure activity, likely medication related, suspect oxycodone."}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/770d83e6-1144-f80a-3e81-85b882f6c7f7"}}, {"fullUrl": "urn:uuid:5ee3bf04-b857-bd5e-fc0c-f5695f57668e", "resource": {"resourceType": "Condition", "id": "5ee3bf04-b857-bd5e-fc0c-f5695f57668e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10856580"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R33.9", "display": "Urinary retention", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-06-03", "note": [{"text": "Last Assessment & Plan:
problemNote91
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Likely due to constipation. No evidence of retention, constipation controlled. Urinalysis was negative for infection. Continue to monitor for constipation."}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5ee3bf04-b857-bd5e-fc0c-f5695f57668e"}}, {"fullUrl": "urn:uuid:4a90b937-cd2e-34d1-a6ba-c473beba0f3b", "resource": {"resourceType": "Condition", "id": "4a90b937-cd2e-34d1-a6ba-c473beba0f3b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10857287"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K59.00", "display": "Constipation", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-06-03", "note": [{"text": "Last Assessment & Plan:
problemNote95
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Patient starting to have softer stools and concern for incontinence with patient using a pool to swim throughout the week. Discussed at length with parents with plan as follows:
-Family to make prunes available, staff to offer for prunes daily
-Continue Colace
-Will make MiraLAX as needed if no BM for greater than 2 days
-Continue magnesium supplement natural,"}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4a90b937-cd2e-34d1-a6ba-c473beba0f3b"}}, {"fullUrl": "urn:uuid:565230a9-73bd-62de-cd59-17e24b88d16b", "resource": {"resourceType": "Condition", "id": "565230a9-73bd-62de-cd59-17e24b88d16b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "22035894"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R50.9", "display": "Fever in adult", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2020-10-03", "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/565230a9-73bd-62de-cd59-17e24b88d16b"}}, {"fullUrl": "urn:uuid:e9653872-52e9-193c-c799-e8d4fddb6105", "resource": {"resourceType": "Condition", "id": "e9653872-52e9-193c-c799-e8d4fddb6105", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "22036033"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R21", "display": "Rash", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2020-10-03", "note": [{"text": "Last Assessment & Plan:
problemNote101
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Patient came in with her biggest complaint being increased agitation and appearing extremely uncomfortable per her father. Very abnormal for her and normally very nice and sweet. Unclear the etiology but almost gone after 1 dose of steroids and does not look like she is itching it
- will cont pred for short course, will change to oral and 30 today
- prn benadryl but would try to avoid
- f/u viral serologies but neg so far "}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e9653872-52e9-193c-c799-e8d4fddb6105"}}, {"fullUrl": "urn:uuid:ffd96a59-d0a5-ab28-8f62-be5af3f1301b", "resource": {"resourceType": "Condition", "id": "ffd96a59-d0a5-ab28-8f62-be5af3f1301b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "22036036"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z20.822", "display": "Suspected COVID-19 virus infection", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2020-10-03", "note": [{"text": "Last Assessment & Plan:
problemNote105
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A: COVID-19 Testing obtained due to symptoms which could be consistent with coronavirus infection. Covid swab negative x 1.
PLAN:
-Remove covid precautions. "}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ffd96a59-d0a5-ab28-8f62-be5af3f1301b"}}, {"fullUrl": "urn:uuid:42d0f244-82bb-6001-ace3-dd186d4a0ec2", "resource": {"resourceType": "Condition", "id": "42d0f244-82bb-6001-ace3-dd186d4a0ec2", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "22038215"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "L03.115", "display": "Cellulitis of foot, right", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-02-01", "note": [{"text": "Last Assessment & Plan:
problemNote107
Formatting of this note might be different from the original.

As above
- hold abx for now "}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/42d0f244-82bb-6001-ace3-dd186d4a0ec2"}}, {"fullUrl": "urn:uuid:adf320a7-a4c1-b16c-6098-b7a2e319a305", "resource": {"resourceType": "Condition", "id": "adf320a7-a4c1-b16c-6098-b7a2e319a305", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "44365008"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K59.00", "display": "Obstipation", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-05-01", "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/adf320a7-a4c1-b16c-6098-b7a2e319a305"}}, {"fullUrl": "urn:uuid:f6bf6993-4834-f742-1f37-65a62409a8ee", "resource": {"resourceType": "Condition", "id": "f6bf6993-4834-f742-1f37-65a62409a8ee", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50925367"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "U07.1", "display": "COVID", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Last Assessment & Plan:
problemNote112
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Tested positive for COVID upon admission. No resp symptoms, satting fine, CXR neg.
Treated with remdesivir given dev. Delay
Plan:
3 day course remdesivir
Will d/w CM if group home can take back if continues asymptomatic course.
Gentle IVF given soft BP"}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}, "extension": [{"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "840539006", "system": "http://snomed.info/sct"}]}]}, "request": {"method": "PUT", "url": "Condition/f6bf6993-4834-f742-1f37-65a62409a8ee"}}, {"fullUrl": "urn:uuid:a4711a0c-9b26-d2ea-8d13-b5d420ad36f8", "resource": {"resourceType": "Condition", "id": "a4711a0c-9b26-d2ea-8d13-b5d420ad36f8", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50925372"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M25.551", "display": "Right hip pain", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Last Assessment & Plan:
problemNote114
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Appears resolved. Suspect is was related to myalgia/arthralgias from COVID although UTI symptoms also possible. CT without joint effusion and hardware of R hip intact. CRP <3
Plan:
-ceftriaxone for possible UTI, culture pending
-observe"}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a4711a0c-9b26-d2ea-8d13-b5d420ad36f8"}}, {"fullUrl": "urn:uuid:f3c11085-1e91-313d-1380-b62712aaef8e", "resource": {"resourceType": "DiagnosticReport", "id": "f3c11085-1e91-313d-1380-b62712aaef8e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355110765"}], "status": "final", "code": {"coding": [{"code": "509", "display": "EKG 12 lead", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-08-04T15:11:33Z", "end": "2024-08-04T15:11:33Z"}, "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "performer": [{"reference": "Organization/880f0079-d8c3-956f-caa4-2373a91a4047"}], "result": [{"reference": "Observation/2d8afbab-62a3-4726-d420-e2a235b8a0d3"}, {"reference": "Observation/2fac14ad-aedf-bf50-5b94-70233e56d42c"}, {"reference": 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"effectiveDateTime": "2024-08-04T16:18:08Z", "valueQuantity": {"value": 22, "unit": "deg"}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T15:11:33Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355110765.Comp7"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "performer": [{"display": "TRACEMASTER VUE", "reference": "Organization/e08532e0-ef77-fac2-14ef-e5570f973c02"}]}, "request": {"method": "PUT", "url": "Observation/e2c61823-9ca6-3fa4-3f26-fc21a02455f0"}}, {"fullUrl": "urn:uuid:18a13855-7329-bd9a-54f9-f43157c99d33", "resource": {"resourceType": "Observation", "id": "18a13855-7329-bd9a-54f9-f43157c99d33", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.7.798268.1010", "value": "355110765"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "IMP", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T16:18:08Z", "valueString": "Sinus rhythm
Ventricular premature complex
Borderline \u00a0low voltage, extremity leads
RSR'' in V1 or V2, right VCD or RVH
Baseline artifact precludes further analysis, repeat tracing suggested ", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T15:11:33Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355110765.Impression"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "performer": [{"display": "TRACEMASTER VUE", "reference": "Organization/e08532e0-ef77-fac2-14ef-e5570f973c02"}]}, "request": {"method": "PUT", "url": "Observation/18a13855-7329-bd9a-54f9-f43157c99d33"}}, {"fullUrl": "urn:uuid:11fbaebb-7b5a-a7c5-7047-1c25794debad", "resource": {"resourceType": "Observation", "id": "11fbaebb-7b5a-a7c5-7047-1c25794debad", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2052031767"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T16:18:08Z", "valueString": "Baseline artifact precludes further analysis, repeat tracing suggested
RSR'' in V1 or V2, right VCD or RVH
Borderline low voltage, extremity leads
Ventricular premature complex
Sinus rhythm
IMPRESSION
Formatting of this note might be different from the original.
", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T15:11:33Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355110765.ProcedureNote2052031767"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}}, "request": {"method": "PUT", "url": "Observation/11fbaebb-7b5a-a7c5-7047-1c25794debad"}}, {"fullUrl": "urn:uuid:78143d8f-5da4-9416-8357-4877ca2a264a", "resource": {"resourceType": "Observation", "id": "78143d8f-5da4-9416-8357-4877ca2a264a", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355110765"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2024-08-04T16:18:08Z", "valueCodeableConcept": {"coding": [{"code": "6", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T15:11:33Z"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}}, "request": {"method": "PUT", "url": "Observation/78143d8f-5da4-9416-8357-4877ca2a264a"}}, {"fullUrl": "urn:uuid:922ec7ab-a429-0b91-2787-6570e568a543", "resource": {"resourceType": "DiagnosticReport", "id": "922ec7ab-a429-0b91-2787-6570e568a543", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "301061478"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.206.2.798268.2.301061478.1"}], "status": "final", "code": {"coding": [{"code": "10215653", "display": "XR Hip Right 2 or 3 VW With or without Pelvis", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-08-03T23:35:00Z", "end": "2024-08-03T23:35:00Z"}, "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "performer": [{"reference": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}], "result": [{"reference": "Observation/38de3813-9458-f4bf-74f7-0227d98b82e3"}, {"reference": "Observation/672aa703-a80d-d1d0-1f53-8cc51a5a1fb5"}, {"reference": "Observation/92be5d78-1c66-5053-00da-f9eab2dd5522"}, {"reference": "Observation/a2ac4ebd-4ee3-f386-6a2a-860aad75255e"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/922ec7ab-a429-0b91-2787-6570e568a543"}}, {"fullUrl": "urn:uuid:6785067f-cee7-c612-c204-069a2bb67949", "resource": {"resourceType": "Organization", "id": "6785067f-cee7-c612-c204-069a2bb67949", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}}, {"fullUrl": "urn:uuid:38de3813-9458-f4bf-74f7-0227d98b82e3", "resource": {"resourceType": "Observation", "id": "38de3813-9458-f4bf-74f7-0227d98b82e3", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.3.696580.52175", "value": "10215653"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-08-04T03:30:00Z", "end": "2024-08-04T04:05:49Z"}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:35:00Z"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}}, "request": {"method": "PUT", "url": "Observation/38de3813-9458-f4bf-74f7-0227d98b82e3"}}, {"fullUrl": "urn:uuid:672aa703-a80d-d1d0-1f53-8cc51a5a1fb5", "resource": {"resourceType": "Observation", "id": "672aa703-a80d-d1d0-1f53-8cc51a5a1fb5", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.7.798268.1000", "value": "301061478"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T12:18:17Z", "valueString": "EXAM: XR HIP RIGHT 2 OR 3 VW WITH OR WITHOUT PELVIS
INDICATION: History of replacement
COMPARISON: Abdominal radiograph dated 9/1/2023 and priors.
TECHNIQUE: Two views of the right hip, including the pelvis were obtained.
FINDINGS: There is no fracture or dislocation. Right total hip arthroplasty prosthesis appears stable when compared to prior. Left hip dysplasia, similar to prior. Partially visualized spinal fusion hardware.
IMPRESSION: Stable right hip arthroplasty.
This report has been read by David Lehman, DO and will be reviewed by the attending radiologist covering this service. 8/4/2024 12:48 AM
I, Sarah Ebert, MD have personally reviewed the images and interpretation and agree with the final report. \u00a0Dictated by David Lehman, DO.
WORKSTATION: SPECTRUMHOME24
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/4/2024 8:16 AM \u00a0Sarah Ebert, MD", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:35:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.301061478.Narrative"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/672aa703-a80d-d1d0-1f53-8cc51a5a1fb5"}}, {"fullUrl": "urn:uuid:cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "resource": {"resourceType": "Organization", "id": "cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}}, {"fullUrl": "urn:uuid:92be5d78-1c66-5053-00da-f9eab2dd5522", "resource": {"resourceType": "Observation", "id": "92be5d78-1c66-5053-00da-f9eab2dd5522", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051981140"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T12:18:17Z", "valueString": "RECOGNITION * * 8/4/2024 8:16 AM Sarah Ebert, MD
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: SPECTRUMHOME24
and agree with the final report. Dictated by David Lehman, DO.
I, Sarah Ebert, MD have personally reviewed the images and interpretation
attending radiologist covering this service. 8/4/2024 12:48 AM
This report has been read by David Lehman, DO and will be reviewed by the
IMPRESSION: Stable right hip arthroplasty.
hardware.
dysplasia, similar to prior. Partially visualized spinal fusion
arthroplasty prosthesis appears stable when compared to prior. Left hip
FINDINGS: There is no fracture or dislocation. Right total hip
TECHNIQUE: Two views of the right hip, including the pelvis were obtained.
COMPARISON: Abdominal radiograph dated 9/1/2023 and priors.
INDICATION: History of replacement
EXAM: XR HIP RIGHT 2 OR 3 VW WITH OR WITHOUT PELVIS
Formatting of this note might be different from the original.
", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:35:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.301061478.ProcedureNote2051981140"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}}, "request": {"method": "PUT", "url": "Observation/92be5d78-1c66-5053-00da-f9eab2dd5522"}}, {"fullUrl": "urn:uuid:a2ac4ebd-4ee3-f386-6a2a-860aad75255e", "resource": {"resourceType": "Observation", "id": "a2ac4ebd-4ee3-f386-6a2a-860aad75255e", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "301061478"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2024-08-04T12:18:17Z", "valueCodeableConcept": {"coding": [{"code": "7", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:35:00Z"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}}, "request": {"method": "PUT", "url": "Observation/a2ac4ebd-4ee3-f386-6a2a-860aad75255e"}}, {"fullUrl": "urn:uuid:3f4d67c6-d237-4ac6-cd50-3462165f8cad", "resource": {"resourceType": "DiagnosticReport", "id": "3f4d67c6-d237-4ac6-cd50-3462165f8cad", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "301061477"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.206.2.798268.2.301061477.1"}], "status": "final", "code": {"coding": [{"code": "33716", "display": "XR Abdomen 1 VW", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-08-03T23:40:00Z", "end": "2024-08-03T23:40:00Z"}, "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "performer": [{"reference": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}], "result": [{"reference": "Observation/63ba3999-7efb-6b5b-f0e8-dc8fcf26d44e"}, {"reference": "Observation/57a95df9-f3ef-1b46-f3db-5fa2e7f2f755"}, {"reference": "Observation/d2ed483e-8c83-4535-22cc-77274b82fb2d"}, {"reference": "Observation/35a607c6-30e1-1fe6-b1a0-99596473fc63"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/3f4d67c6-d237-4ac6-cd50-3462165f8cad"}}, {"fullUrl": "urn:uuid:63ba3999-7efb-6b5b-f0e8-dc8fcf26d44e", "resource": {"resourceType": "Observation", "id": "63ba3999-7efb-6b5b-f0e8-dc8fcf26d44e", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.3.696580.52175", "value": "33716"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-08-04T03:30:00Z", "end": "2024-08-04T04:06:17Z"}, "bodySite": {"coding": [{"code": "10", "display": "Abdomen", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.10.696580.52010"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:40:00Z"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}}, "request": {"method": "PUT", "url": "Observation/63ba3999-7efb-6b5b-f0e8-dc8fcf26d44e"}}, {"fullUrl": "urn:uuid:57a95df9-f3ef-1b46-f3db-5fa2e7f2f755", "resource": {"resourceType": "Observation", "id": "57a95df9-f3ef-1b46-f3db-5fa2e7f2f755", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.7.798268.1000", "value": "301061477"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T12:19:27Z", "valueString": "EXAM: XR ABDOMEN 1VW
INDICATION: History of constipation
COMPARISON: Abdominal radiograph dated 9/1/2023 and priors.
TECHNIQUE: A single view of the abdomen was obtained.
FINDINGS: \u00a0There is a nonobstructive bowel gas pattern. Mild to moderate colonic stool burden.
Stable appearance of extensive spinal fusion hardware.
IMPRESSION: Nonobstructive bowel gas pattern.
This report has been read by David Lehman, DO and will be reviewed by the attending radiologist covering this service. 8/4/2024 12:49 AM
I, Sarah Ebert, MD have personally reviewed the images and interpretation and agree with the final report. \u00a0Dictated by David Lehman, DO.
WORKSTATION: SPECTRUMHOME24
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/4/2024 8:17 AM \u00a0Sarah Ebert, MD", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:40:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.301061477.Narrative"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/57a95df9-f3ef-1b46-f3db-5fa2e7f2f755"}}, {"fullUrl": "urn:uuid:d2ed483e-8c83-4535-22cc-77274b82fb2d", "resource": {"resourceType": "Observation", "id": "d2ed483e-8c83-4535-22cc-77274b82fb2d", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051981315"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T12:19:27Z", "valueString": "RECOGNITION * * 8/4/2024 8:17 AM Sarah Ebert, MD
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: SPECTRUMHOME24
and agree with the final report. Dictated by David Lehman, DO.
I, Sarah Ebert, MD have personally reviewed the images and interpretation
attending radiologist covering this service. 8/4/2024 12:49 AM
This report has been read by David Lehman, DO and will be reviewed by the
IMPRESSION: Nonobstructive bowel gas pattern.
Stable appearance of extensive spinal fusion hardware.
colonic stool burden.
FINDINGS: There is a nonobstructive bowel gas pattern. Mild to moderate
TECHNIQUE: A single view of the abdomen was obtained.
COMPARISON: Abdominal radiograph dated 9/1/2023 and priors.
INDICATION: History of constipation
EXAM: XR ABDOMEN 1VW
Formatting of this note might be different from the original.
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INDICATION: Sepsis
COMPARISON: Chest radiograph dated 10/3/2020.
TECHNIQUE: Two views of the chest.
FINDINGS:
Low lung volumes. Patchy left basilar opacity. There is no pleural effusion or pneumothorax. Mediastinal contour, hilar contour, heart size and pulmonary vascularity are within normal limits.
Spinal fusion hardware appears unchanged. Old right proximal humeral fracture is noted.
IMPRESSION:
Patchy left basilar opacity, possibly atelectasis, aspiration or pneumonia.
This report has been read by David Lehman, DO and will be reviewed by the attending radiologist covering this service. 8/4/2024 12:53 AM
I, Sarah Ebert, MD have personally reviewed the images and interpretation and agree with the final report. \u00a0Dictated by David Lehman, DO.
WORKSTATION: SPECTRUMHOME24
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/4/2024 8:18 AM \u00a0Sarah Ebert, MD", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T00:30:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355099951.Narrative"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/5c7b8491-0a21-a45a-f582-38503906377b"}}, {"fullUrl": "urn:uuid:d43b114b-8945-e968-7592-0f5d15c6b6b4", "resource": {"resourceType": "Observation", "id": "d43b114b-8945-e968-7592-0f5d15c6b6b4", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051981417"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T12:20:40Z", "valueString": "RECOGNITION * * 8/4/2024 8:18 AM Sarah Ebert, MD
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: SPECTRUMHOME24
and agree with the final report. Dictated by David Lehman, DO.
I, Sarah Ebert, MD have personally reviewed the images and interpretation
attending radiologist covering this service. 8/4/2024 12:53 AM
This report has been read by David Lehman, DO and will be reviewed by the
pneumonia.
Patchy left basilar opacity, possibly atelectasis, aspiration or
IMPRESSION:
fracture is noted.
Spinal fusion hardware appears unchanged. Old right proximal humeral
and pulmonary vascularity are within normal limits.
effusion or pneumothorax. Mediastinal contour, hilar contour, heart size
Low lung volumes. Patchy left basilar opacity. There is no pleural
FINDINGS:
TECHNIQUE: Two views of the chest.
COMPARISON: Chest radiograph dated 10/3/2020.
INDICATION: Sepsis
EXAM: XR CHEST PA AND LATERAL
Formatting of this note might be different from the original.
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Date: 8/4/2024 1:45 AM
History: Female, 44 years old. Hip pain, infection
COMPARISON: \u00a0None.
Technique: Routine CT of the pelvis with intravenous contrast. One or more of these dose optimization techniques were utilized: Automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to
clinical indication); or iterative reconstruction.
FINDINGS:
Abdomen (visible): Unremarkable.
Vessels: Normal.
Lymph nodes: No adenopathy.
Small bowel: Unremarkable visualized small bowel; no obstruction. Colon: Unremarkable visualized colon.
Appendix: No findings of appendicitis.
Peritoneum: No free air or fluid.
GU: Unremarkable.
Bones: Right hip arthroplasty is intact. There is a left hip dysplasia and moderate arthropathy. No joint effusion identified. There are surgical fusion of the lumbosacral spine.
Soft tissue including the abdominal wall: No acute abnormality.
Additional comments: None.
IMPRESSION:
1. \u00a0There is a left hip dysplasia and moderate arthropathy. No joint effusion identified.
2. \u00a0Right hip arthroplasty is intact. No joint effusion identified.
3. \u00a0Surgical fusion of the lumbosacral spine.
WSN:CLI-SC29407
* * * THIS IS AN ELECTRONICALLY VERIFIED REPORT * * *
8/4/2024 4:37:49 AM \u00a0Richard Clinton
For questions regarding this report, Monday through Friday, 8am-5pm, please contact Spectrum Radiology Support at 1-844-764-7237. \u00a0Otherwise, please contact Synergy at 1-877-671-6119.", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T05:45:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355110761.Narrative"}]}], "subject": {"reference": "Patient/a0782c10-cd55-4954-aae7-6bfe08edc8aa"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/1e991eac-52d4-4d6b-eadf-a53e1fc0c44f"}}, {"fullUrl": "urn:uuid:0355288f-d1b0-1f6f-b0fd-d257d306a3bd", "resource": {"resourceType": "Observation", "id": "0355288f-d1b0-1f6f-b0fd-d257d306a3bd", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051963944"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T08:38:49Z", "valueString": "please contact Synergy at 1-877-671-6119.
please contact Spectrum Radiology Support at 1-844-764-7237. Otherwise,
For questions regarding this report, Monday through Friday, 8am-5pm,
8/4/2024 4:37:49 AM Richard Clinton
* * * THIS IS AN ELECTRONICALLY VERIFIED REPORT * * *
WSN:CLI-SC29407
3. Surgical fusion of the lumbosacral spine.
2. Right hip arthroplasty is intact. No joint effusion identified.
effusion identified.
1. There is a left hip dysplasia and moderate arthropathy. No joint
IMPRESSION:
Additional comments: None.
Soft tissue including the abdominal wall: No acute abnormality.
fusion of the lumbosacral spine.
moderate arthropathy. No joint effusion identified. There are surgical
Bones: Right hip arthroplasty is intact. There is a left hip dysplasia and
GU: Unremarkable.
Peritoneum: No free air or fluid.
Appendix: No findings of appendicitis.
Unremarkable visualized colon.
Small bowel: Unremarkable visualized small bowel; no obstruction. Colon:
Lymph nodes: No adenopathy.
Vessels: Normal.
Abdomen (visible): Unremarkable.
FINDINGS:
clinical indication); or iterative reconstruction.
where dose is matched to
control; mA and/or kV adjustment per patient size (includes targeted exams
of these dose optimization techniques were utilized: Automated exposure
Technique: Routine CT of the pelvis with intravenous contrast. One or more
COMPARISON: None.
History: Female, 44 years old. Hip pain, infection
Date: 8/4/2024 1:45 AM
EXAMINATION: CT PELVIS W/ CONTRAST
Formatting of this note might be different from the original.
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Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
07/26/2024 1:00 PM EDTOffice VisitKDMS TRI-STATE HEMATOLOGY ONCOLOGY617 23rd STSUITE 2789Louisville, KY 40203-2845606-325-2221Benty, Tad, MD234 LaneSUITE 2789Louisville, KY 40203606-325-2221 (Work)606-324-1326 (Fax)
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
ErythropoietinLabRoutinePolycythemia03/26/2024 2:04 PM EDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
ErythropoietinLabRoutinePolycythemiaExpected: 3/26/24, Expires: 3/26/25
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: FormerCigarettesQuit: 02/26/2020
Smokeless Tobacco: Never
Tobacco Cessation:
Counseling Given: Not Answered
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
PHQ-2AnswerDate Recorded
PHQ-2 SCORE003/26/2024
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
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DateTypeDepartmentCare Team (Latest Contact Info)Description
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Chronic hepatitis C without hepatic coma (CMS/HCC) Polycythemia; Thrombocytopenia (CMS/HCC) (Primary Dx);
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"effectivePeriod": {"end": "2020-02-26"}, "valueCodeableConcept": {"coding": [{"code": "65568007", "display": "Cigarette Smoker", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/0f25768f-2971-4342-bb52-7d41bb6dd76c"}}, "request": {"method": "PUT", "url": "Observation/f5845edc-0eea-0353-1081-83069ce69066"}}, {"fullUrl": "urn:uuid:95aedb77-f134-e0ea-5461-41c93715ece8", "resource": {"resourceType": "Observation", "id": "95aedb77-f134-e0ea-5461-41c93715ece8", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.205.2.7.1.1040.8", "value": "Z776744^^713914004"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "229819007", "display": "Tobacco use and exposure", "system": "http://snomed.info/sct"}]}, "effectiveDateTime": 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{"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}]}') ON CONFLICT (ecr_id) DO NOTHING; -INSERT INTO fhir (ecr_id, data) VALUES ('2.16.840.1.113883.4.6.70100819.50711007', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:2.16.840.1.113883.4.6.70100819.50711007", "resource": {"resourceType": "Composition", "id": "2.16.840.1.113883.4.6.70100819.50711007", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-27b7-cd91-8dac-1e9de913fa0a", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "6"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-03-26T07:58:25-05:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "e0d1a0db-5825-d48a-8475-17d2d22c3b00", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-0160-4AF5-E2B9-97C06EE89637", "title": "Immunizations", "text": {"status": "generated", "div": "Not on file documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-0160-4AF6-E2B9-97C06EE89637", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
0.9% NaCl intermittent flush25 mL, Intravenous, Continuous PRN, Flush, Starting on Mon 3/25/24 at 2227, Use 0.9% NaCl flush for IVPBs mixed in 0.9% NaCl.
acetaminophen (TYLENOL) tablet 650 mg650 mg, Oral, Every 4 Hours PRN, Mild Pain (1-4), Starting on Mon 3/25/24 at 2232
bisacodyL (DULCOLAX) suppository 10 mg10 mg, Rectal, Daily PRN, Constipation unrelieved by Milk of Magnesia., Starting on Mon 3/25/24 at 2229
dextrose 5 % intermittent flush25 mL, Intravenous, Continuous PRN, Flush, Starting on Mon 3/25/24 at 2227, Use dextrose 5% flush for IVPBs mixed in dextrose 5%.
magnesium hydroxide (MILK OF MAGNESIA) 400 mg/5 mL suspension 30 mL30 mL, Oral, Daily PRN, Constipation, Starting on Mon 3/25/24 at 2229
ondansetron (ZOFRAN-ODT) disintegrating tablet 4 mg4 mg, Oral, Every 6 Hours PRN, Nausea, Vomiting, Use prior to IV unless NPO., Starting on Mon 3/25/24 at 2229
ondansetron HCl (PF) (ZOFRAN) injection 4 mg4 mg, Intravenous, Every 6 Hours PRN, Nausea, Vomiting if PO is ineffective or patient is NPO., Starting on Mon 3/25/24 at 2229
ondansetron HCl (PF) (ZOFRAN) injection 4 mg4 mg, Intramuscular, Every 6 Hours PRN, Nausea, Vomiting if patient is NPO and no IV access., Starting on Mon 3/25/24 at 2229
pantoprazole (PROTONIX) EC tablet 40 mg40 mg, Oral, Every Morning Before Breakfast, First dose on Tue 3/26/24 at 0630Given03/26/2024 7:38 AM CDT40 mg
sodium chloride injection 10 mL10 mL, Intravenous Flush, Every 12 Hours Scheduled (2 times per day), First dose on Mon 3/25/24 at 2300Given03/26/2024 7:38 AM CDT10 mLs
Given03/25/2024 11:48 PM CDT10 mLs
sodium chloride injection 10 mL10 mL, Intravenous Flush, PRN, Other, pre (ensure placement) & post medications (clear line), Starting on Mon 3/25/24 at 2227
sodium chloride injection 20 mL20 mL, Intravenous Flush, PRN, Other, prior to and after blood draw, Starting on Mon 3/25/24 at 2227
sodium phosphate (FLEET) enema 1 enema1 enema, Rectal, Daily PRN, Constipation unrelieved by Dulcolax suppository, Starting on Mon 3/25/24 at 2229
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (OFIRMEV) IV 1,000 mg1,000 mg, Intravenous, Administer over 15 Minutes, Once, On Mon 3/25/24 at 1645, For 1 dose, Please send in-basket MAR message to pharmacy 1 hour before new bag is needed. Maximum dose of acetaminophen is 4000mg from all sources in 24 hours. Per the organization''s medication management policy, may administer less potent pain medication, if ordered, based on patient request. Use within 6 hours of vial puncture.New Bag03/25/2024 4:31 PM CDT1,000 mg400 mL/hr
albumin human 25 % IV solution 25 g25 g, Intravenous, Once, On Mon 3/25/24 at 2045, For 1 dose, Do not exceed 1 mL/minute in patients with normal plasma volume; 2 to 3 mL/minute in patients with hypoproteinemiaNew Bag03/25/2024 9:49 PM CDT25 g60 mL/hr
iohexoL (OMNIPAQUE) 350 mg iodine/mL injection 100 mL100 mL, Intravenous, img Once PRN, contrast, Starting on Mon 3/25/24 at 1639, For 1 doseGiven03/25/2024 4:51 PM CDT100 mLs
lidocaine 10 mg/mL (1 %) injectionStarting on Mon 3/25/24 at 1857, For 1 doseGiven03/25/2024 7:51 PM CDT100 mgRight Lower Abdomen
sodium chloride 0.9% mini-bag flush100 mL, Intravenous, img Once PRN, flush, Starting on Mon 3/25/24 at 1639, For 1 doseGiven03/25/2024 4:51 PM CDT100 mLs
sodium chloride injection 10 mL10 mL, Intravenous Flush, img Once PRN, Other, flush, Starting on Mon 3/25/24 at 1639, For 1 doseGiven03/25/2024 4:51 PM CDT10 mLs
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/0a9aec3e-7448-9fae-1133-7172257d5710"}, {"reference": "MedicationAdministration/04c0fdce-55fe-fa15-e94f-c0ca38678247"}, {"reference": "MedicationAdministration/bc4d58d3-c892-ab4a-eae8-32a0f89ca7e1"}, {"reference": "MedicationAdministration/0a16bbc9-b254-2122-1b73-d030706768af"}, {"reference": "MedicationAdministration/5ed6a1a2-0c60-59d2-3009-2c99a3d433c6"}, {"reference": "MedicationAdministration/48025cdf-2750-664b-8d70-647f150963d2"}, {"reference": "MedicationAdministration/62d888c3-3a75-b738-b11f-d404c782a6b4"}, {"reference": "MedicationAdministration/e50e7fe8-1355-efc1-490b-9395d401d56f"}, {"reference": "MedicationAdministration/701a01fb-185a-3f91-310e-54ece3316edb"}, {"reference": "MedicationAdministration/c94e5543-acde-6a49-d8de-c04777f372a1"}, {"reference": "MedicationAdministration/73f52a72-9fb9-ff6e-cf7d-aa41f892687c"}, {"reference": "MedicationAdministration/bbbcd3f9-092a-d84a-03da-6c030132a021"}, {"reference": "MedicationAdministration/ebe9022e-e4cc-412b-0868-935e636c185f"}, {"reference": "MedicationAdministration/551be827-89e2-d797-4899-cfb65d84a6c4"}, {"reference": "MedicationAdministration/f52b7039-ad85-e31e-5543-7cd8f2c22437"}, {"reference": "MedicationAdministration/f95da995-17a4-72c7-76df-88f60a0fb437"}, {"reference": "MedicationAdministration/97223b4f-05da-a650-7a17-94f26880aeef"}]}, {"id": "8fd37a64-3d26-8bd1-ea89-7ef7fafc96b2", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
ED EKG 12 lead W/INTERP93005ECGSTAT03/25/2024 4:31 PM CDT
Ultrasound guided paracentesisImagingSTAT03/25/2024 8:43 PM CDT
Culture-fluid/aspirate (includes gram stain)MicrobiologySTAT03/25/2024 8:03 PM CDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
Occult blood-feces (hemoccult)LabSTATSTAT - one time for 1 Occurrences starting 3/25/24 until 3/25/24
Ultrasound guided paracentesisImagingSTATOne time imaging One time imaging for 1 Occurrences starting 3/25/24 until 3/25/24
CBC With DifferentialLabRoutineDaily at 0600 until discontinued starting 3/26/24, 1 completed
Comprehensive metabolic panelLabRoutineDaily at 0600 until discontinued starting 3/26/24, 1 completed
Magnesium (Mg) (Blood)LabRoutineDaily at 0600 until discontinued starting 3/26/24, 1 completed
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/8ce7ed82-7925-e3ee-b98a-66c5c3b5ce76"}]}, {"id": "00000000-0160-4AF7-E2B9-97C06EE89637", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
Pancytopenia03/26/2024
Cirrhosis of liver with ascites03/25/2024
Liver cancer03/25/2024
Hypertension03/25/2024
Gastroesophageal reflux disease03/25/2024
Blood per rectum03/25/2024
documented as of this encounter (statuses as of 03/26/2024) One or more reportable conditions added to problem list during processing"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Cirrhosis of liver with ascites", "reference": "Condition/129670ad-6add-2217-96c1-0e5528e8bf99"}, {"display": "Problem - Liver cancer", "reference": "Condition/5ffc1ca1-2fa8-1ed1-6ef4-40cab977f294"}, {"display": "Problem - Hypertension", "reference": "Condition/1ee9dea2-8d83-373b-05c0-a7d2b3a83a14"}, {"display": "Problem - Gastroesophageal reflux disease", "reference": "Condition/81c53140-add2-5038-d5cb-950b80c4116c"}, {"display": "Problem - Blood per rectum", "reference": "Condition/1e63d06f-3bf6-3780-5f45-da194a2066ba"}, {"display": "Problem - Pancytopenia", "reference": "Condition/9b254173-3dd6-654e-3e59-1fde24501f27"}, {"display": "Problem - Viral hepatitis type C (disorder)", "reference": "Condition/5bf407e1-1cdc-f28e-a276-51aa2d973426"}]}, {"id": "9d96874d-6ce9-91a8-8bff-c2e23b151dfd", "title": "Reason for Visit", "text": {"status": "generated", "div": ""}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Abdominal Pain"}]}, {"id": "00000000-0160-4AF9-E2B9-97C06EE89637", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Radiology Study observation (narrative)", "reference": "Observation/841f17e6-a916-5ebc-d278-fd3fd5f63eb5"}, {"display": "Radiology Study observation (narrative)", "reference": 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"Observation/ef418944-cffd-60ae-d1b2-88fa3e7c5cb0"}, {"display": "Alkaline Phosphatase", "reference": "Observation/e7b1704c-868e-c14a-338f-a1a4611a95e3"}, {"display": "Glomerular Filtration Rate, Est.", "reference": "Observation/16d3b54f-03c2-c8ef-a850-3954647ab6c6"}, {"display": "Anion Gap", "reference": "Observation/d109b8d5-fea8-370c-6d4f-f0006497093b"}, {"display": "Lab Interpretation", "reference": "Observation/40788d79-45a7-d4dd-c460-6ac8bdc4a297"}, {"display": "Magnesium", "reference": "Observation/e92d5772-bbe7-2bd9-0ceb-85ba9e3cbfc0"}, {"display": "Lab Interpretation", "reference": "Observation/0232bc78-3544-2a12-419a-433f5f87a223"}, {"display": "Hepatitis B Surface Antigen", "reference": "Observation/f2760263-6e81-a8f2-ed19-76f3b699f295"}, {"display": "Hepatitis B Core IgM", "reference": "Observation/bed0bb49-1855-e2af-b723-d6a8e56529ec"}, {"display": "Anti Hepatitis A Virus IgM", "reference": "Observation/1bed15ef-15c9-8b92-b73f-4e7a03ab4f2c"}, {"display": "Hepatitis C Virus", "reference": "Observation/987a1a48-957f-a7c4-3f63-cea2887af631"}, {"display": "Lab Interpretation", "reference": "Observation/4239be2e-ac07-42b9-0637-7fe4bbda4d23"}, {"display": "HIV-1 and 2 Antibodies", "reference": "Observation/f76c5378-a453-d65b-aeb2-93d1b49a048d"}]}, {"id": "7a715c65-611d-47c5-aa74-caaba9dfe799", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
AHC UtilitiesAnswerDate Recorded
In the past 12 months has the electric, gas, oil or water company threatened to shut off services in your home?03/25/2024
AUDIT-CAnswerDate Recorded
Q1: How often do you have a drink containing alcohol?Monthly or less03/25/2024
Q2: How many drinks containing alcohol do you have on a typical day when you are drinking?Patient unable to answer03/25/2024
Q3: How often do you have six or more drinks on one occasion?Patient unable to answer03/25/2024
Overall Financial Resource Strain (CARDIA)AnswerDate Recorded
How hard is it for you to pay for the very basics like food, housing, medical care, and heating?Patient declined03/25/2024
Finnish Institute of Occupational Health - Occupational Stress QuestionnaireAnswerDate Recorded
Do you feel stress - tense, restless, nervous, or anxious, or unable to sleep at night because your mind is troubled all the time - these days?Patient declined03/25/2024
Exercise Vital SignAnswerDate Recorded
On average, how many days per week do you engage in moderate to strenuous exercise (like a brisk walk)?Patient declined03/25/2024
On average, how many minutes do you engage in exercise at this level?Patient declined03/25/2024
Hunger Vital SignAnswerDate Recorded
Within the past 12 months, you worried that your food would run out before you got the money to buy more.Patient declined03/25/2024
Within the past 12 months, the food you bought just didn''t last and you didn''t have money to get more.Patient declined03/25/2024
PRAPARE - TransportationAnswerDate Recorded
In the past 12 months, has lack of transportation kept you from medical appointments or from getting medications?Patient declined03/25/2024
In the past 12 months, has lack of transportation kept you from meetings, work, or from getting things needed for daily living?Patient declined03/25/2024
UtilitiesAnswerDate Recorded
In the past 12 months has the electric, gas, oil or water company threatened to shut off services in your home?patient declined03/25/2024
OH Housing Stability Vital SignAnswerDate Recorded
What is your living situation today?steady place to live03/25/2024
Think about the place you live. Do you have problems with any of the following?patient declined03/25/2024
Safety and EnvironmentAnswerDate Recorded
How often does anyone, including family and friends, physically hurt you?never03/25/2024
How often does anyone, including family and friends, insult or talk down to you?never03/25/2024
How often does anyone, including family and friends, threaten you with harm?never03/25/2024
How often does anyone, including family and friends, scream or curse at you?never03/25/2024
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "046910f0-5586-dcdf-bb92-d401e9e5b341", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare Team (Latest Contact Info)Description
03/25/2024 2:38 PM CDT - PresentHospital EncounterOHRH ONCOLOGY-MEDICAL UNIT1201 Pleasant Valley RoadOwensboro, KY 40245270-417-2800Jerry, Benny, MD811 E Parrish AveSuite 102OWENSBORO, KY 40245270-688-2077 (Work)270-688-2078 (Fax)
Pleural effusion on rightPrimary malignant neoplasm of liver (CMS/HCC); Alcoholic cirrhosis of liver with ascites (CMS/HCC) (Primary Dx);
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Hospitalizations+Outpatient visits Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "caf7c61a-870e-ef9b-7f23-bee74065462c", "title": "RCKMS Trigger Summary", "text": {"status": "generated", "div": "; Detection of Hepatitis C virus antibody in a clinical specimen by any method"}, "code": {"coding": [{"code": "81218-0", "display": "RCKMS Trigger Summary", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "b5ae8972-91ca-4cc3-9bc4-16c4835bd403", "title": "Derived Reportability Response Information", "text": {"status": "generated", "div": "
Derived Reportability Response Information
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"1.2.840.114350.2.276.2.798268.2.152882674.1"}], "status": "final", "code": {"coding": [{"code": "61611", "display": "X-ray chest AP portable", "system": "urn:oid:1.2.840.114350.1.13.276.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-03-25T21:36:41Z", "end": "2024-03-25T21:36:41Z"}, "subject": {"reference": "Patient/328a3f72-b9b5-4c71-9fea-63b6fa3bafd3"}, "performer": [{"reference": "Organization/8c99b003-2ee9-f49c-428d-2b2a337659ae"}], "result": [{"reference": "Observation/841f17e6-a916-5ebc-d278-fd3fd5f63eb5"}, {"reference": "Observation/a5d68ff0-cb03-758f-d2be-797dc48bbdce"}, {"reference": "Observation/4014c566-28e5-8247-f898-3b77fd7093e6"}, {"reference": "Observation/66b9baa4-df04-1a9c-8bbe-fb33d320b550"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/4ada8dbc-6af9-2ad5-155e-3e6988c1b078"}}, {"fullUrl": "urn:uuid:8c99b003-2ee9-f49c-428d-2b2a337659ae", "resource": {"resourceType": "Organization", "id": "8c99b003-2ee9-f49c-428d-2b2a337659ae", "name": "EMC RAD", "address": [{"line": ["5301 Tokay Blvd."], "city": "Madison", "state": "WI", "postalCode": "53711"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/8c99b003-2ee9-f49c-428d-2b2a337659ae"}}, {"fullUrl": "urn:uuid:841f17e6-a916-5ebc-d278-fd3fd5f63eb5", "resource": {"resourceType": "Observation", "id": "841f17e6-a916-5ebc-d278-fd3fd5f63eb5", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.3.696580.52175", "value": "61611"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-03-25T21:36:41Z", "end": "2024-03-25T21:46:06Z"}, "bodySite": {"coding": [{"code": "101", "display": "Chest", "system": "urn:oid:1.2.840.114350.1.13.276.2.7.10.696580.52010"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:36:41Z"}]}], "subject": {"reference": "Patient/328a3f72-b9b5-4c71-9fea-63b6fa3bafd3"}}, "request": {"method": "PUT", "url": "Observation/841f17e6-a916-5ebc-d278-fd3fd5f63eb5"}}, {"fullUrl": "urn:uuid:a5d68ff0-cb03-758f-d2be-797dc48bbdce", "resource": {"resourceType": "Observation", "id": "a5d68ff0-cb03-758f-d2be-797dc48bbdce", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.7.798268.1000", "value": "152882674"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-03-25T22:05:24Z", "valueString": "PORTABLE CHEST
HISTORY: Abdominal pain.
Portable AP supine semierect upright film of the chest was obtained at.
COMPARISON: None
FINDINGS:
Chronic obstructive pulmonary disease.
Small to moderate-sized right pleural effusion.
There may be underlying atelectasis or infiltrate at the right lung base.
Some elevation of the left hemidiaphragm.
The heart is not enlarged.
The pulmonary vasculature is not increased.
No pneumothorax.
No acute osseous abnormality.
Conclusion:
Chronic obstructive pulmonary disease.
Small to moderate-sized right pleural effusion.
There may be underlying atelectasis or infiltrate at the right lung base.
37205
Workstation: 109-1130", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:36:41Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.276.2.7.2.798268.152882674.Narrative"}]}], "subject": {"reference": "Patient/328a3f72-b9b5-4c71-9fea-63b6fa3bafd3"}, "performer": [{"display": "EMC RAD", "reference": "Organization/58d6b643-fc97-c7bc-c97d-be7495f13477"}]}, "request": {"method": "PUT", "url": "Observation/a5d68ff0-cb03-758f-d2be-797dc48bbdce"}}, {"fullUrl": "urn:uuid:58d6b643-fc97-c7bc-c97d-be7495f13477", "resource": {"resourceType": "Organization", "id": "58d6b643-fc97-c7bc-c97d-be7495f13477", "name": "EMC RAD", "address": [{"line": ["5301 Tokay Blvd."], "city": "Madison", "state": "WI", "postalCode": "53711"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/58d6b643-fc97-c7bc-c97d-be7495f13477"}}, {"fullUrl": "urn:uuid:4014c566-28e5-8247-f898-3b77fd7093e6", "resource": {"resourceType": "Observation", "id": "4014c566-28e5-8247-f898-3b77fd7093e6", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.2.727879", "value": "673563981"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-03-25T22:05:24Z", "valueString": "Workstation: 109-1130
37205
base.
There may be underlying atelectasis or infiltrate at the right lung
Small to moderate-sized right pleural effusion.
Chronic obstructive pulmonary disease.
Conclusion:
No acute osseous abnormality.
No pneumothorax.
The pulmonary vasculature is not increased.
The heart is not enlarged.
Some elevation of the left hemidiaphragm.
base.
There may be underlying atelectasis or infiltrate at the right lung
Small to moderate-sized right pleural effusion.
Chronic obstructive pulmonary disease.
FINDINGS:
COMPARISON: None
Portable AP supine semierect upright film of the chest was obtained at.
HISTORY: Abdominal pain.
PORTABLE CHEST
Formatting of this note might be different from the original.
", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:36:41Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.276.2.7.2.798268.152882674.ProcedureNote673563981"}]}], "subject": {"reference": "Patient/328a3f72-b9b5-4c71-9fea-63b6fa3bafd3"}}, "request": {"method": "PUT", "url": "Observation/4014c566-28e5-8247-f898-3b77fd7093e6"}}, {"fullUrl": "urn:uuid:66b9baa4-df04-1a9c-8bbe-fb33d320b550", "resource": {"resourceType": "Observation", "id": "66b9baa4-df04-1a9c-8bbe-fb33d320b550", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.2.798268", "value": "152882674"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2024-03-25T22:05:24Z", "valueCodeableConcept": {"coding": [{"code": "7", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:36:41Z"}]}], "subject": {"reference": "Patient/328a3f72-b9b5-4c71-9fea-63b6fa3bafd3"}}, "request": {"method": "PUT", "url": "Observation/66b9baa4-df04-1a9c-8bbe-fb33d320b550"}}, {"fullUrl": "urn:uuid:f4221d31-fca7-ba85-179d-33429ce57b4f", "resource": {"resourceType": "DiagnosticReport", "id": "f4221d31-fca7-ba85-179d-33429ce57b4f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.2.798268", "value": "152882665"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.276.2.798268.2.152882665.1"}], "status": "final", "code": {"coding": [{"code": "96030", "display": "CT Abdomen Pelvis w/Contrast IV Only per Contrast Protocol", "system": "urn:oid:1.2.840.114350.1.13.276.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-03-25T21:39:35Z", "end": "2024-03-25T21:39:35Z"}, "subject": {"reference": "Patient/328a3f72-b9b5-4c71-9fea-63b6fa3bafd3"}, "performer": [{"reference": "Organization/8c99b003-2ee9-f49c-428d-2b2a337659ae"}], "result": [{"reference": "Observation/4b6154cf-31fe-0683-8222-d188cfe26fb3"}, {"reference": "Observation/40b510df-777d-a6c2-6c83-24a5e35ed947"}, {"reference": "Observation/e07d4107-29b1-25d4-08d3-b1ba2a36cefb"}, {"reference": "Observation/54c09f48-5eaf-4010-b5f5-2f8bda9abee9"}, {"reference": "Observation/c60dd5a8-2ad3-13fb-723e-2f9d7f218aff"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/f4221d31-fca7-ba85-179d-33429ce57b4f"}}, {"fullUrl": "urn:uuid:4b6154cf-31fe-0683-8222-d188cfe26fb3", "resource": {"resourceType": "Observation", "id": "4b6154cf-31fe-0683-8222-d188cfe26fb3", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.3.696580.52175", "value": "96030"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-03-25T21:39:35Z", "end": "2024-03-25T22:04:33Z"}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:39:35Z"}]}], "subject": {"reference": "Patient/328a3f72-b9b5-4c71-9fea-63b6fa3bafd3"}}, "request": {"method": "PUT", "url": "Observation/4b6154cf-31fe-0683-8222-d188cfe26fb3"}}, {"fullUrl": "urn:uuid:40b510df-777d-a6c2-6c83-24a5e35ed947", "resource": {"resourceType": "Observation", "id": "40b510df-777d-a6c2-6c83-24a5e35ed947", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.7.798268.1010", "value": "152882665"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "IMP", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-03-25T22:34:50Z", "valueString": " \ufffd
1. \ufffdCirrhosis with sequela of portal hypertension including large volume ascites, splenomegaly, and extensive gastric and esophageal varices.
2. \ufffdA 5.2 x 5.8 cm mass in hepatic segment 4 is incompletely characterized. Recommend further evaluation with a nonemergent MRI liver protocol. If the patient is not MR compatible, recommend evaluation with CT.
3. \ufffdDiffuse wall thickening of the colon is nonspecific and could represent infectious/inflammatory colitis or portal colopathy from significant portal hypertension. Recommend clinical correlation.
4. \ufffdSmall to moderate right pleural effusion.
Workstation: 109-93730WH", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:39:35Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.276.2.7.2.798268.152882665.Impression"}]}], "subject": {"reference": "Patient/328a3f72-b9b5-4c71-9fea-63b6fa3bafd3"}, "performer": [{"display": "EMC RAD", "reference": "Organization/58d6b643-fc97-c7bc-c97d-be7495f13477"}]}, "request": {"method": "PUT", "url": "Observation/40b510df-777d-a6c2-6c83-24a5e35ed947"}}, {"fullUrl": "urn:uuid:e07d4107-29b1-25d4-08d3-b1ba2a36cefb", "resource": {"resourceType": "Observation", "id": "e07d4107-29b1-25d4-08d3-b1ba2a36cefb", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.7.798268.1000", "value": "152882665"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-03-25T22:34:50Z", "valueString": "EXAM: CT ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST
INDICATION: 60 years year old Male with Abdominal pain, acute, nonlocalized
COMPARISON: None
TECHNIQUE: Computed tomographic imaging was performed of the abdomen and pelvis with intravenous contrast. This examination was performed according to our departmental dose optimization program which includes automated exposure control, adjustment of the
MA and kV according to patient size, and/or use of iterative reconstruction technique.
FINDINGS:
There is a small moderate right pleural effusion. Airspace opacity in the lower lungs most likely represents atelectasis.
There is significant contour nodularity of the liver surface with enlargement of the caudate lobe and left lateral section in addition to capsular retraction. These findings are compatible with cirrhosis. There is a 5.2 x 5.8 cm mass in hepatic segment 4
which is incompletely characterized. Extensive sequela of portal hypertension including large volume ascites, splenomegaly which measures up to 17.7 cm in greatest dimension, and extensive gastric and esophageal varices which measure up to 0.9 cm in
transverse diameter.
Large volume ascites results in significant mass effect with displacement of bowel towards the central abdomen. There is diffuse wall thickening involving the colon which is nonspecific and could represent colitis or portal colopathy. No evidence of a
high-grade bowel obstruction. The adrenals and pancreas are unremarkable.
No free peritoneal gas is identified. The abdominal aorta is patent normal caliber. The urinary bladder is poorly distended. No aggressive lytic or sclerotic bone lesions are identified. There is multilevel disc space narrowing, most prominent at L4-5
and L5-S1. No major abdominal wall hernia is identified. Kidneys have normal size and symmetric enhancement with no hydronephrosis.", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:39:35Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.276.2.7.2.798268.152882665.Narrative"}]}], "subject": {"reference": "Patient/328a3f72-b9b5-4c71-9fea-63b6fa3bafd3"}, "performer": [{"display": "EMC RAD", "reference": "Organization/58d6b643-fc97-c7bc-c97d-be7495f13477"}]}, "request": {"method": "PUT", "url": "Observation/e07d4107-29b1-25d4-08d3-b1ba2a36cefb"}}, {"fullUrl": "urn:uuid:54c09f48-5eaf-4010-b5f5-2f8bda9abee9", "resource": {"resourceType": "Observation", "id": "54c09f48-5eaf-4010-b5f5-2f8bda9abee9", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.2.727879", "value": "673567852"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-03-25T22:34:50Z", "valueString": "Workstation: 109-93730WH
4. Small to moderate right pleural effusion.
significant portal hypertension. Recommend clinical correlation.
represent infectious/inflammatory colitis or portal colopathy from
3. Diffuse wall thickening of the colon is nonspecific and could
CT.
protocol. If the patient is not MR compatible, recommend evaluation with
characterized. Recommend further evaluation with a nonemergent MRI liver
2. A 5.2 x 5.8 cm mass in hepatic segment 4 is incompletely
ascites, splenomegaly, and extensive gastric and esophageal varices.
1. Cirrhosis with sequela of portal hypertension including large volume
IMPRESSION:
normal size and symmetric enhancement with no hydronephrosis.
and L5-S1. No major abdominal wall hernia is identified. Kidneys have
narrowing, most prominent at L4-5
sclerotic bone lesions are identified. There is multilevel disc space
caliber. The urinary bladder is poorly distended. No aggressive lytic or
No free peritoneal gas is identified. The abdominal aorta is patent normal
unremarkable.
high-grade bowel obstruction. The adrenals and pancreas are
portal colopathy. No evidence of a
involving the colon which is nonspecific and could represent colitis or
of bowel towards the central abdomen. There is diffuse wall thickening
Large volume ascites results in significant mass effect with displacement
transverse diameter.
varices which measure up to 0.9 cm in
up to 17.7 cm in greatest dimension, and extensive gastric and esophageal
hypertension including large volume ascites, splenomegaly which measures
which is incompletely characterized. Extensive sequela of portal
is a 5.2 x 5.8 cm mass in hepatic segment 4
capsular retraction. These findings are compatible with cirrhosis. There
enlargement of the caudate lobe and left lateral section in addition to
There is significant contour nodularity of the liver surface with
lower lungs most likely represents atelectasis.
There is a small moderate right pleural effusion. Airspace opacity in the
FINDINGS:
reconstruction technique.
MA and kV according to patient size, and/or use of iterative
exposure control, adjustment of the
to our departmental dose optimization program which includes automated
pelvis with intravenous contrast. This examination was performed according
TECHNIQUE: Computed tomographic imaging was performed of the abdomen and
COMPARISON: None
nonlocalized
INDICATION: 60 years year old Male with Abdominal pain, acute,
EXAM: CT ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST
Formatting of this note might be different from the original.
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Drugs Of Abuse Comprehensive Screen, UrLabSTAT12/23/2022 11:13 AM PST
Scheduled Orders
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Active ProblemsNoted Date
Coronavirus infection12/14/22
PregnantEstimated Date of DeliveryComments
Yes3/13/23
documented as of this encounter (statuses as of 12/20/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Coronavirus infection", "reference": "Condition/bf5669b6-650b-a7f4-b6b0-ef3c12a61432"}]}, {"id": "73e873d9-5336-4470-02cf-abb2740c876d", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "622C60F2-80B3-11ED-9CEB-005056AC13DC", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Lab Interpretation", "reference": "Observation/d679042c-0029-f362-cbfa-d650a9e1823d"}]}, {"id": "04039dfb-0a38-d275-fcaa-ac28731e342e", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
Travel HistoryTravel StartTravel End
Mexico12/15/2212/17/22
Brazil11/30/2212/7/22
COVID-19 ExposureResponseDate Recorded
In the last 10 days, have you been in contact with someone who was confirmed or suspected to have Coronavirus/COVID-19?No / Unsure12/20/2022 2:07 PM PST
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DateTypeDepartmentCare TeamDescription
12/20/22Office VisitFAMILY CARE SPECIALISTS MEDICAL CORPORATION1701 CESAR E. CHAVEZ AVE., STE 230LOS ANGELES, CA 90033-2642323-226-1100Castro, Edward, MD1701 CESAR E. CHAVEZ AVE., STE 230LOS ANGELES, CA 90033-2642323-226-1100 (Work)323-226-1101 (Fax)Coronavirus infection (Primary Dx)
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Reportability Response Information Section
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BENZODIAZEPINES \u00a0 \u00a0 \u00a0 \u00a0 > 200 ng/mL
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OPIATES \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 300 ng/mL
PCP \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a025 ng/mL
THC \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a050 ng/mL
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DR DEBRA A ALEXANDER JR, PHDFAMILYActive
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Assigned Birth SexFemale
Gender Identityunknown
Sexual OrientationDo not know
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Problem or DiagnosisProblem Status
POTS (postural orthostatic tachycardia syndrome)Active
Crohn''s disease of perianal regionActive
Colostomy in placeActive
Ileostomy prolapse (disorder)Active
Anxiety (finding)Active
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Lab Test NameLab Test Result ValueLab Test Result Date
SARS-CoV-2, NAA CLPOS
Symptomatic as defined by CDC?YES
In ICU?NO
Group care resident?NO
Employed in healthcare?NO
Estimated Creatinine Clearance75.63|http://unitsofmeasure.org|mL/min
U Beta hCG QlNegative.
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Ur Urobilinogen0.2 EU/dL
Ur BloodSmall
Ur BiliNegative
Ur Leuk EstNegative
Ur ProteinTrace mg/dL
Ur NitriteNegative
Ur KetonesTrace mg/dL
UR GlucoseNegative mg/dL
eGFR PediatricNot Reported
Calc Osmo273|http://unitsofmeasure.org|mOsmol/kg
A/G RatioUnknown
eGFR Non-African American60.0|http://unitsofmeasure.org|mL/min/1.73m2
eGFR African American60.0|http://unitsofmeasure.org|mL/min/1.73m2
Sodium138|http://unitsofmeasure.org|mmol/L
Potassium3.2|http://unitsofmeasure.org|mmol/L
Albumin. Level4.1|http://unitsofmeasure.org|gm/dL
Calcium8.7|http://unitsofmeasure.org|mg/dL
RDW-CV13.0|http://unitsofmeasure.org|%
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BUN5|http://unitsofmeasure.org|mg/dL
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RBC4.01|http://unitsofmeasure.org|x10e6/mcL
MPV9.2|http://unitsofmeasure.org|Femtoliters
MCV85.8|http://unitsofmeasure.org|Femtoliters
MCHC34.0|http://unitsofmeasure.org|gm/dL
MCH29.2|http://unitsofmeasure.org|pg
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Hct34.4|http://unitsofmeasure.org|%
Glucose Level95|http://unitsofmeasure.org|mg/dL
CO225|http://unitsofmeasure.org|mmol/L
T Bili0.1|http://unitsofmeasure.org|mg/dL
AST16|http://unitsofmeasure.org|Intl_units/L
ALT21|http://unitsofmeasure.org|Intl_units/L
Alk Phos53|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio7|http://unitsofmeasure.org|Ratio
Anion Gap11|http://unitsofmeasure.org|mmol/L
Creatinine0.76|http://unitsofmeasure.org|mg/dL
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Travel HistoryCOVID- 19 Testing Reason-Screening
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Travel HistoryTB Risk Score-
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Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
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MULTIPLE COMPLAINTS
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Reportability Response Information Section
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MemberRoleStatusDates
Adam Sheradmitting physicianActive
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MCUTLERattending physicianActive
Start: March 12th, 2022
DR MEDITECHprimary care physicianActive
Start: March 12th, 2022
AMANDA NOELREFERRINGActive
Start: March 12th, 2022
AMANDA PARLATOFAMILYActive
Start: March 12th, 2022
Rickey RobertsOTHERActive
Start: March 12th, 2022
Stephen NewtonCONSULTINGActive
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Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
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RIGRAPID HEART BEAT
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Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
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"occurrenceString": "Unknown", "note": {"text": "Date patient received Moderna COVID-19 vaccine?"}, "vaccineCode": {"coding": [{"display": "Date patient received Moderna COVID-19 vaccine?"}]}, "manufacturer": {"reference": "Organization/81335318-8424-a5e6-822b-3f53ce03b63f"}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/2d1c8280-bfde-5e93-e96e-2300eb5cfc2d"}}, {"fullUrl": "urn:uuid:81335318-8424-a5e6-822b-3f53ce03b63f", "resource": {"resourceType": "Organization", "id": "81335318-8424-a5e6-822b-3f53ce03b63f", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/81335318-8424-a5e6-822b-3f53ce03b63f"}}, {"fullUrl": "urn:uuid:52c1e871-4aef-8ab1-f854-45099bee3749", "resource": {"resourceType": "Immunization", "id": "52c1e871-4aef-8ab1-f854-45099bee3749", "identifier": [{"system": "urn:ietf:rfc:3986", "value": "urn:uuid:f388d4f7-a451-11ec-81e0-9e7eef92c510"}], "occurrenceString": 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"request": {"method": "PUT", "url": "Immunization/81ff4e99-dc85-a8a8-80ec-46788c03571e"}}, {"fullUrl": "urn:uuid:6a8ae7b7-e46b-7b29-8082-bf332be553dd", "resource": {"resourceType": "Immunization", "id": "6a8ae7b7-e46b-7b29-8082-bf332be553dd", "identifier": [{"system": "urn:ietf:rfc:3986", "value": "urn:uuid:f388d4f9-a451-11ec-81e0-9e7eef92c510"}], "protocolApplied": [{"doseNumberPositiveInt": "1"}], "occurrenceDateTime": "2022-03-15T07:20:00-04:00", "note": {"text": "anthrax"}, "vaccineCode": {"coding": [{"code": "24", "display": "anthrax", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "LOT9911Z", "manufacturer": {"reference": "Organization/1e2d10a1-e4d3-ac11-3b25-56396aee4ba2"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/4e7ce557-5e66-447b-a7af-78db8a2106b9"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/6a8ae7b7-e46b-7b29-8082-bf332be553dd"}}, {"fullUrl": "urn:uuid:1e2d10a1-e4d3-ac11-3b25-56396aee4ba2", "resource": {"resourceType": "Organization", "id": "1e2d10a1-e4d3-ac11-3b25-56396aee4ba2", "name": "PFIZER & OTHER CHARACTERS", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/1e2d10a1-e4d3-ac11-3b25-56396aee4ba2"}}, {"fullUrl": "urn:uuid:efc69dae-16b1-10e2-e609-82bfdf6dd46a", "resource": {"resourceType": "Immunization", "id": "efc69dae-16b1-10e2-e609-82bfdf6dd46a", "identifier": [{"system": "urn:ietf:rfc:3986", "value": "urn:uuid:8bdb0ffa-a9d2-11ec-81e0-9e7eef92c510"}], "occurrenceString": "Unknown", "note": {"text": "RIG"}, "vaccineCode": {"coding": [{"code": "34", "display": "RIG", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "manufacturer": {"reference": "Organization/81335318-8424-a5e6-822b-3f53ce03b63f"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/4e7ce557-5e66-447b-a7af-78db8a2106b9"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": 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"Organization", "id": "fb121477-4011-40b3-40fe-f884cdfecd6a", "name": "JOHNSON AND JOHNSON", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/fb121477-4011-40b3-40fe-f884cdfecd6a"}}]}') ON CONFLICT (ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('f14889a0-e28f-47b2-9260-c73d38133938', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:f14889a0-e28f-47b2-9260-c73d38133938", "resource": {"resourceType": "Composition", "id": "f14889a0-e28f-47b2-9260-c73d38133938", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "28109659|65128172"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "2"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-05-21T12:01:02Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "28c67070-3e59-9749-0b22-75c480826ad3", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Ineffective airway clearanceActive
Alteration in nutrition (finding)Active
Rheumatoid arthritis (disorder)Active
At risk for injury due to fall (finding)Active
Chronic obstructive lung disease (disorder)Active
Aortic stenosisActive
Bowel dysfunction (disorder)Active
Diabetes mellitus (disorder)Active
Systolic heart failure (disorder)Active
History of malignant neoplasm of prostate (situation)Active
DiabetesActive
At risk for fallsActive
Atrial fibrillation (disorder)Active
Hypertensive disorder, systemic arterial (disorder)Active
Acute painActive
HypertensionActive
Bloody stoolsActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Ineffective airway clearance (finding)", "reference": "Condition/64a739b3-2854-5868-df1d-1949f6ae1fef"}, {"display": "Problem - Alteration in nutrition (finding)", "reference": "Condition/52280af5-612d-3140-4080-0d23a0f571c7"}, {"display": "Problem - Rheumatoid arthritis (disorder)", "reference": "Condition/cda5ae1c-47c3-d7ff-6501-8672df4b125a"}, {"display": "Problem - At risk for injury due to fall (finding)", "reference": "Condition/6e2fd739-7997-b985-78f9-623466d140d2"}, {"display": "Problem - Chronic obstructive lung disease (disorder)", "reference": "Condition/82e380a6-0cc6-dc4f-0978-e3bbbddcbb59"}, {"display": "Problem - Aortic valve stenosis (disorder)", "reference": "Condition/d139d835-2bea-d850-3233-a16e55ae6593"}, {"display": "Problem - Bowel dysfunction (disorder)", "reference": "Condition/1cf1659e-01ea-32e6-8cd3-c623b9779ea9"}, {"display": "Problem - Diabetes mellitus (disorder)", "reference": "Condition/1f6f997e-1bb6-76ca-e106-6ae9c5037326"}, {"display": "Problem - Systolic heart failure (disorder)", "reference": "Condition/19373c76-4df9-50e6-5155-685adcab5620"}, {"display": "Problem - History of malignant neoplasm of prostate (situation)", "reference": "Condition/66b26b96-a776-d0a6-fd03-10ddc85ce037"}, {"display": "Problem - Diabetes mellitus (disorder)", "reference": "Condition/be49290f-4769-1d4d-1873-4c7ce57afb34"}, {"display": "Problem - At risk for falls (finding)", "reference": "Condition/d1822e79-d8fb-2cd9-b4d7-ba2df3571c1f"}, {"display": "Problem - Atrial fibrillation (disorder)", "reference": "Condition/b6660c4a-4a09-1dac-2388-ca50c6904a87"}, {"display": "Problem - Hypertensive disorder, systemic arterial (disorder)", "reference": "Condition/c54a639a-0084-07aa-4518-88148d9a7df6"}, {"display": "Problem - Acute pain (finding)", "reference": "Condition/1a2bcef3-7fc6-027f-3fff-d532981e0efd"}, {"display": "Problem - Hypertensive disorder, systemic arterial (disorder)", "reference": "Condition/6f7712f7-a0ed-d5b0-50b7-c3ccd7522943"}, {"display": "Problem - Hematochezia (finding)", "reference": "Condition/2cee354e-d907-b2fa-bf84-f9f2f1df5a0d"}]}, {"id": "e919e7ad-f6f5-981c-8402-0f3b330d9bf4", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
inpatient encounter20220514125500+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "e2d758a5-40fc-2c8a-0c22-0e82b14db6e5", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
POC Glucose223|http://unitsofmeasure.org|mg/dL
POC Glucose148|http://unitsofmeasure.org|mg/dL
POC Glucose120|http://unitsofmeasure.org|mg/dL
POC Glucose90|http://unitsofmeasure.org|mg/dL
POC Glucose264|http://unitsofmeasure.org|mg/dL
POC Glucose133|http://unitsofmeasure.org|mg/dL
Plt MorphologyNormal
eGFR PediatricNot Reported
Magnesium S LC2.1 mg/dL
Calc Osmo288|http://unitsofmeasure.org|mOsmol/L
Eos # Man1.04|http://unitsofmeasure.org|x10e3/mcL
Segs # Man3.17|http://unitsofmeasure.org|x10e3/mcL
Mono # Man1.38|http://unitsofmeasure.org|x10e3/mcL
Lymphs # Man1.10|http://unitsofmeasure.org|x10e3/mcL
Mono Man20|http://unitsofmeasure.org|%
Lymphs Man16|http://unitsofmeasure.org|%
eGFR Non-African American42.87 mL/min/1.73m2
eGFR African American49.69 mL/min/1.73m2
RBC MorphAbnormal
Sodium140|http://unitsofmeasure.org|mmol/L
Potassium3.5|http://unitsofmeasure.org|mmol/L
Ferritin Lvl260|http://unitsofmeasure.org|ng/mL
Myelo # Man0.21|http://unitsofmeasure.org|x10e3/mcL
Segs Man46|http://unitsofmeasure.org|%
Calcium8.3|http://unitsofmeasure.org|mg/dL
Plt GiantPresent
Schistocytes1+
RDW-CV18.7|http://unitsofmeasure.org|%
Chloride105|http://unitsofmeasure.org|mmol/L
BUN35|http://unitsofmeasure.org|mg/dL
Plt126|http://unitsofmeasure.org|x10e3/mcL
WBC6.9|http://unitsofmeasure.org|x10e3/mcL
RBC3.52|http://unitsofmeasure.org|x10e6/mcL
Myelo Man3|http://unitsofmeasure.org|%
MPV10.7|http://unitsofmeasure.org|Femtoliters
MCV94.0|http://unitsofmeasure.org|Femtoliters
MCHC30.8|http://unitsofmeasure.org|gm/dL
MCH29.0|http://unitsofmeasure.org|pg
Mg LvlTNP mg/dL
Hgb10.2|http://unitsofmeasure.org|gm/dL
Hct33.1|http://unitsofmeasure.org|%
Glucose Level108|http://unitsofmeasure.org|mg/dL
Eos Man15|http://unitsofmeasure.org|%
D Dimer1.15|http://unitsofmeasure.org|mg/L
CRP5.5|http://unitsofmeasure.org|mg/dL
CO226.8|http://unitsofmeasure.org|mmol/L
BUN/Creat Ratio25.0|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Ovalocytes1+
EchinocytesPresent
Plt LargePresent
Plt EstAdequate
Aniso1+
Acanthocyte1+
Hypo1+
Polychrom1+
Macro1+
Creatinine1.4|http://unitsofmeasure.org|mg/dL
POC Glucose233|http://unitsofmeasure.org|mg/dL
POC Glucose107|http://unitsofmeasure.org|mg/dL
POC Glucose266|http://unitsofmeasure.org|mg/dL
POC Glucose120|http://unitsofmeasure.org|mg/dL
Estimated Creatinine Clearance34.37|http://unitsofmeasure.org|mL/min
eGFR PediatricNot Reported
Calc Osmo286|http://unitsofmeasure.org|mOsmol/L
eGFR Non-African American41.80 mL/min/1.73m2
eGFR African American48.45 mL/min/1.73m2
Sodium138|http://unitsofmeasure.org|mmol/L
Potassium3.5|http://unitsofmeasure.org|mmol/L
Baso # Auto0.02|http://unitsofmeasure.org|x10e3/mcL
Mono # Auto1.4|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto5.2|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.2|http://unitsofmeasure.org|%
Eos % Auto7.0|http://unitsofmeasure.org|%
Lymph % Auto12.3|http://unitsofmeasure.org|%
Neut % Auto62.7|http://unitsofmeasure.org|%
Calcium8.6|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.10|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto1.0|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto16.6|http://unitsofmeasure.org|%
RDW-CV19.0|http://unitsofmeasure.org|%
Immature Grans %1.2|http://unitsofmeasure.org|%
Eos # Auto0.6|http://unitsofmeasure.org|x10e3/mcL
Chloride105|http://unitsofmeasure.org|mmol/L
BUN38|http://unitsofmeasure.org|mg/dL
Plt118|http://unitsofmeasure.org|x10e3/mcL
WBC8.3|http://unitsofmeasure.org|x10e3/mcL
RBC3.33|http://unitsofmeasure.org|x10e6/mcL
MPV10.9|http://unitsofmeasure.org|Femtoliters
MCV92.5|http://unitsofmeasure.org|Femtoliters
MCHC31.2|http://unitsofmeasure.org|gm/dL
MCH28.8|http://unitsofmeasure.org|pg
Mg Lvl1.8|http://unitsofmeasure.org|mg/dL
Hgb9.6|http://unitsofmeasure.org|gm/dL
Hct30.8|http://unitsofmeasure.org|%
Glucose Level122|http://unitsofmeasure.org|mg/dL
CO226.8|http://unitsofmeasure.org|mmol/L
BUN/Creat Ratio27.1|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine1.4|http://unitsofmeasure.org|mg/dL
POC Glucose180|http://unitsofmeasure.org|mg/dL
POC Glucose158|http://unitsofmeasure.org|mg/dL
POC Glucose199|http://unitsofmeasure.org|mg/dL
eGFR PediatricNot Reported
Calc Osmo293|http://unitsofmeasure.org|mOsmol/L
eGFR Non-African American34.24 mL/min/1.73m2
eGFR African American39.69 mL/min/1.73m2
Sodium140|http://unitsofmeasure.org|mmol/L
Potassium3.6|http://unitsofmeasure.org|mmol/L
Ferritin Lvl221|http://unitsofmeasure.org|ng/mL
Baso # Auto0.04|http://unitsofmeasure.org|x10e3/mcL
Mono # Auto0.8|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto7.2|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.4|http://unitsofmeasure.org|%
Eos % Auto2.5|http://unitsofmeasure.org|%
Lymph % Auto13.1|http://unitsofmeasure.org|%
Neut % Auto74.7|http://unitsofmeasure.org|%
Calcium8.6|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.12|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto1.3|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.0|http://unitsofmeasure.org|%
RDW-CV19.3|http://unitsofmeasure.org|%
Immature Grans %1.3|http://unitsofmeasure.org|%
Eos # Auto0.2|http://unitsofmeasure.org|x10e3/mcL
Chloride108|http://unitsofmeasure.org|mmol/L
BUN47|http://unitsofmeasure.org|mg/dL
Plt127|http://unitsofmeasure.org|x10e3/mcL
WBC9.6|http://unitsofmeasure.org|x10e3/mcL
RBC3.29|http://unitsofmeasure.org|x10e6/mcL
MPV11.0|http://unitsofmeasure.org|Femtoliters
MCV90.0|http://unitsofmeasure.org|Femtoliters
MCHC32.4|http://unitsofmeasure.org|gm/dL
MCH29.2|http://unitsofmeasure.org|pg
Mg Lvl1.7|http://unitsofmeasure.org|mg/dL
Hgb9.6|http://unitsofmeasure.org|gm/dL
Hct29.6|http://unitsofmeasure.org|%
Glucose Level115|http://unitsofmeasure.org|mg/dL
D Dimer3.17|http://unitsofmeasure.org|mg/L
CRP10.5|http://unitsofmeasure.org|mg/dL
CO224.0|http://unitsofmeasure.org|mmol/L
BUN/Creat Ratio27.6|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine1.7|http://unitsofmeasure.org|mg/dL
POC Glucose125|http://unitsofmeasure.org|mg/dL
POC Glucose220|http://unitsofmeasure.org|mg/dL
POC Glucose129|http://unitsofmeasure.org|mg/dL
POC Glucose195|http://unitsofmeasure.org|mg/dL
POC Glucose235|http://unitsofmeasure.org|mg/dL
Symptomatic as defined by CDC?Yes
In ICU?Yes
Group care resident?No
Employed in healthcare?No
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRPositive
Flu B PCRNot Detected
Flu A PCRNot Detected
POC Glucose158|http://unitsofmeasure.org|mg/dL
Ur pHUnknown
Ur Spec GravUnknown
Ur Urobilinogen<2.0 mg/dL
Ur Blood3+ mg/dL
Ur BiliNegative mg/dL
Ur Leuk EstTrace
Ur ColorRed
Ur MucousRare /LPF
Ur Squam Epithelial1|http://unitsofmeasure.org|/HPF
Ur WBC33|http://unitsofmeasure.org|/HPF
Ur RBC182|http://unitsofmeasure.org|/HPF
Ur Protein1+ mg/dL
Ur NitriteNegative
Ur KetonesNegative mg/dL
UR GlucoseNegative mg/dL
Ur BacteriaNone Seen /HPF
Ur ClarityCloudy
Estimated Creatinine Clearance28.30|http://unitsofmeasure.org|mL/min
POC Glucose177|http://unitsofmeasure.org|mg/dL
eGFR PediatricNot Reported
Calc Osmo295|http://unitsofmeasure.org|mOsmol/L
A/G Ratio0.9|http://unitsofmeasure.org|Ratio
eGFR Non-African American34.98 mL/min/1.73m2
eGFR African American40.55 mL/min/1.73m2
Sodium141|http://unitsofmeasure.org|mmol/L
Potassium4.4|http://unitsofmeasure.org|mmol/L
Ferritin Lvl192|http://unitsofmeasure.org|ng/mL
Albumin. Level3.0|http://unitsofmeasure.org|gm/dL
Calcium9.1|http://unitsofmeasure.org|mg/dL
RDW-CV18.9|http://unitsofmeasure.org|%
Chloride111|http://unitsofmeasure.org|mmol/L
BUN40|http://unitsofmeasure.org|mg/dL
Plt114|http://unitsofmeasure.org|x10e3/mcL
WBC15.6|http://unitsofmeasure.org|x10e3/mcL
TP6.5|http://unitsofmeasure.org|gm/dL
RBC3.28|http://unitsofmeasure.org|x10e6/mcL
MPV10.8|http://unitsofmeasure.org|Femtoliters
MCV93.0|http://unitsofmeasure.org|Femtoliters
MCHC31.5|http://unitsofmeasure.org|gm/dL
MCH29.3|http://unitsofmeasure.org|pg
Mg Lvl1.6|http://unitsofmeasure.org|mg/dL
Hgb9.6|http://unitsofmeasure.org|gm/dL
Hct30.5|http://unitsofmeasure.org|%
Glucose Level178|http://unitsofmeasure.org|mg/dL
CRP12.5|http://unitsofmeasure.org|mg/dL
CO221.6|http://unitsofmeasure.org|mmol/L
T Bili0.8|http://unitsofmeasure.org|mg/dL
AST19|http://unitsofmeasure.org|Intl_units/L
ALT21|http://unitsofmeasure.org|Intl_units/L
Alk Phos88|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio23.5|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine1.7|http://unitsofmeasure.org|mg/dL
POC Glucose169|http://unitsofmeasure.org|mg/dL
POC Glucose213|http://unitsofmeasure.org|mg/dL
POC Glucose225|http://unitsofmeasure.org|mg/dL
Troponin TNIH258.7|http://unitsofmeasure.org|ng/L
POC Glucose207|http://unitsofmeasure.org|mg/dL
Troponin TNIH137.1|http://unitsofmeasure.org|ng/L
HCO3 Art21.3|http://unitsofmeasure.org|mmol/L
POC PEEP5|http://unitsofmeasure.org|cm H2O
POC PIP24|http://unitsofmeasure.org|cm H2O
POC Pt Temp37.0|http://unitsofmeasure.org|DegC
POC Set RR24|http://unitsofmeasure.org|br/min
POC Total RR24|http://unitsofmeasure.org|br/min
POC FIO270|http://unitsofmeasure.org|%
POC Allen TestPOS
Art Base Excess-3.7|http://unitsofmeasure.org|mmol/L
Art sO298|http://unitsofmeasure.org|%
Art pO2112.0|http://unitsofmeasure.org|mmHg
pH ArterialUnknown
Art pCO237.5|http://unitsofmeasure.org|mmHg
Estimated Creatinine Clearance32.08|http://unitsofmeasure.org|mL/min
Troponin TNIH72.4|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
Calc Osmo294|http://unitsofmeasure.org|mOsmol/L
A/G Ratio1.0|http://unitsofmeasure.org|Ratio
eGFR Non-African American41.46 mL/min/1.73m2
eGFR African American48.05 mL/min/1.73m2
Sodium142|http://unitsofmeasure.org|mmol/L
Potassium3.5|http://unitsofmeasure.org|mmol/L
Albumin. Level2.8|http://unitsofmeasure.org|gm/dL
Calcium7.7|http://unitsofmeasure.org|mg/dL
Chloride112|http://unitsofmeasure.org|mmol/L
BUN32|http://unitsofmeasure.org|mg/dL
TP5.7|http://unitsofmeasure.org|gm/dL
Glucose Level171|http://unitsofmeasure.org|mg/dL
CO221.1|http://unitsofmeasure.org|mmol/L
T Bili1.8|http://unitsofmeasure.org|mg/dL
AST17|http://unitsofmeasure.org|Intl_units/L
ALT19|http://unitsofmeasure.org|Intl_units/L
Alk Phos99|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio21.3|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine1.5|http://unitsofmeasure.org|mg/dL
Lactic Acid Lvl1.8|http://unitsofmeasure.org|mmol/L
HCO3 Art19.0|http://unitsofmeasure.org|mmol/L
POC PEEP5|http://unitsofmeasure.org|cm H2O
POC PIP27|http://unitsofmeasure.org|cm H2O
POC Pt Temp37.0|http://unitsofmeasure.org|DegC
POC Set RR18|http://unitsofmeasure.org|br/min
POC Total RR18|http://unitsofmeasure.org|br/min
POC FIO280|http://unitsofmeasure.org|%
POC Allen TestPOS
Art Base Excess-6.7|http://unitsofmeasure.org|mmol/L
Art sO298|http://unitsofmeasure.org|%
Art pO2130.0|http://unitsofmeasure.org|mmHg
pH ArterialUnknown
Art pCO257.3|http://unitsofmeasure.org|mmHg
POC Glucose172|http://unitsofmeasure.org|mg/dL
Troponin TNIH18.0|http://unitsofmeasure.org|ng/L
NT-ProBNP1846|http://unitsofmeasure.org|pg/mL
Baso # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Mono # Auto0.5|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto10.2|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.2|http://unitsofmeasure.org|%
Eos % Auto1.4|http://unitsofmeasure.org|%
Lymph % Auto23.9|http://unitsofmeasure.org|%
Neut % Auto70.2|http://unitsofmeasure.org|%
Immature Grans # Auto0.16|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto3.5|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto3.2|http://unitsofmeasure.org|%
RDW-CV18.9|http://unitsofmeasure.org|%
Immature Grans %1.1|http://unitsofmeasure.org|%
Eos # Auto0.2|http://unitsofmeasure.org|x10e3/mcL
Plt167|http://unitsofmeasure.org|x10e3/mcL
WBC14.6|http://unitsofmeasure.org|x10e3/mcL
RBC3.68|http://unitsofmeasure.org|x10e6/mcL
PTT27.2|http://unitsofmeasure.org|Seconds
PT11.0|http://unitsofmeasure.org|Seconds
MPV10.7|http://unitsofmeasure.org|Femtoliters
MCV93.8|http://unitsofmeasure.org|Femtoliters
MCHC31.3|http://unitsofmeasure.org|gm/dL
MCH29.3|http://unitsofmeasure.org|pg
Lipase Lvl132|http://unitsofmeasure.org|Intl_units/L
Hgb10.8|http://unitsofmeasure.org|gm/dL
Hct34.5|http://unitsofmeasure.org|%
INRUnknown
Lactic Acid Lvl3.7|http://unitsofmeasure.org|mmol/L
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Medication NameMedication Start Date
atorvastatin (Lipitor 20 mg oral tablet)20220516202400+0000
fluticasone-salmeterol (Wixela Inhub 500 mcg-50 mcg inhalation powder)20220516202400+0000
glipiZIDE (glipiZIDE 5 mg oral tablet)20220516202200+0000
metFORMIN (metFORMIN 1000 mg oral tablet)20220516202200+0000
methotrexate (methotrexate 2.5 mg oral tablet)20220516202300+0000
sacubitril-valsartan (Entresto 24 mg-26 mg oral tablet)20220519203100+0000
spironolactone (spironolactone 25 mg oral tablet)20220519203100+0000
torsemide (torsemide 20 mg oral tablet)20220516202300+0000
traMADol (traMADol 50 mg oral tablet)20220516202100+0000
guaiFENesin-dextromethorphan (guaifenesin-dextromethorphan 100 mg-10 mg/5 mL oral liquid)20220519203000+0000
cefuroxime (Ceftin 500 mg oral tablet)20220519203100+0000
albuterol (albuterol CFC free 90 mcg/inh inhalation aerosol)20220516101600+0000
carvedilol (Coreg)20220519160000+0000
cefTRIAXone20220514163400+0000
furosemide20220517143000+0000
guaiFENesin-dextromethorphan (guaifenesin-dextromethorphan 100 mg-10 mg/5 mL oral liquid)20220516193900+0000
insulin aspart (insulin aspart NovoLog correctional scale High)20220514190000+0000
ipratropium-albuterol (DuoNeb)20220514161000+0000
lidocaine (lidocaine 1% injectable solution)20220514220700+0000
pantoprazole (Protonix 40 mg oral enteric coated tablet)20220517133000+0000
sacubitril-valsartan (Entresto 24 mg-26 mg oral tablet)20220519143700+0000
spironolactone20220517160000+0000
carvedilol (Coreg 12.5 mg oral tablet)20220516202400+0000
potassium chloride (K-Tab 10 mEq oral tablet, extended release)20220516202300+0000
haloperidol (Haldol)20220519181500+0000
Sodium Chloride 0.9% intravenous solution (NS Bolus (ADULT))20220518201300+0000
carvedilol20220517045300+0000
sacubitril-valsartan (Entresto 24 mg-26 mg oral tablet)20220518042800+0000
Sodium Chloride 0.9% intravenous solution (NS Bolus (ADULT))20220518191000+0000
azithromycin (Zithromax 250 mg oral tablet)20220517160000+0000
heparin20220514210000+0000
magnesium sulfate20220517170000+0000
dilTIAZem (Cardizem)Unknown
furosemide20220516233000+0000
atorvastatin (Lipitor 20 mg oral tablet)20220514181400+0000
fluticasone-salmeterol (Wixela Inhub 500 mcg-50 mcg inhalation powder)20220514181800+0000
torsemide20220514203600+0000
traMADol (traMADol 50 mg oral tablet)20220514181800+0000
magnesium sulfate20220516200000+0000
furosemide20220516143000+0000
Azithromycin20220514163700+0000
pantoprazole (Protonix)20220515133000+0000
furosemide20220516000000+0000
furosemide (Lasix)20220514160400+0000
magnesium sulfate20220515160000+0000
Fentanyl20220514154000+0000
Propofol20220514142500+0000
magnesium sulfate20220515130000+0000
potassium chloride20220515070000+0000
lisinopril (lisinopril 5 mg oral tablet)20220514181600+0000
magnesium oxide (magnesium oxide 400 mg (241.3 mg elemental magnesium) oral tablet)20220514181600+0000
Diltiazem20220514142600+0000
D5/NS 1,000 mL20220514182100+0000
furosemide (Lasix)20220514151600+0000
levalbuterol (Xopenex 1.25 mg/3 mL inhalation solution)20220514134000+0000
propofol20220514143500+0000
dilTIAZem20220514133900+0000
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Genetics, CLL Culture FISH PanelLabRoutineCLL (chronic lymphocytic leukemia) (HCC)08/31/2022 1:30 PM CDT
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
COVID-19 ExposureResponseDate Recorded
In the last 10 days, have you been in contact with someone who was confirmed or suspected to have Coronavirus/COVID-19?Unable to assess8/31/2022 1:19 PM CDT
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DateTypeDepartmentCare TeamDescription
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and who is not shedding SARS-CoV-2 virus would expect to have a
consistent with COVID-19. An individual without symptoms of COVID-19
recent exposures and the presence of clinical signs and symptoms
negative result should be considered in the context of a patient''s
When diagnostic testing is negative, the possibility of a false
sooner.
360bbb-3(b) (1), unless the authorization is terminated or revoked
of COVID-19 infection under section 564(b)(1) of the Act, 21 U.S.C.
diagnostic tests for detection of SARS-CoV-2 virus and/or diagnosis
justifying the authorization of the emergency use of in vitro
for the duration of time the declaration that circumstances exist
an Emergency Use Authorization (EUA). This test is only authorized
FDA cleared or approved. This test has been authorized by FDA under
amplification tests include RT-PCR and TMA. This test has not been
characteristics determined by LabCorp Laboratories. Nucleic acid
This nucleic acid amplification test was developed and its performance
resources and information.
Visit our website at https://www.labcorp.com/COVID19 for
with mild to moderate symptoms and for hospitalized patients.
treatment options. Treatment options are available for patients
Patients who have a positive COVID-19 test result may now have"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2022-12-16T08:00:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-12-16T08:00:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.202.3.7.2.798268.476859550.Comp1"}]}, {"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "840539006", "system": "http://snomed.info/sct"}]}], "subject": {"reference": "Patient/9d031a29-1364-4290-b7fb-f52741ecc218"}, "performer": [{"display": "LABCORP", "reference": "Organization/cdcee673-8d7c-d7f5-79f8-09ecfc30200c"}]}, "request": {"method": "PUT", "url": "Observation/d4f01a0f-8f67-d6dc-dc78-ace26e80efcb"}}, {"fullUrl": "urn:uuid:cdcee673-8d7c-d7f5-79f8-09ecfc30200c", "resource": {"resourceType": "Organization", "id": "cdcee673-8d7c-d7f5-79f8-09ecfc30200c", "name": "LABCORP", "address": [{"line": ["13112 Evening Creek Dr, Ste 200"], "city": "San Diego", "state": "CA", "postalCode": "92128"}], "telecom": [{"system": "phone", "value": "+1-858-668-3700"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/cdcee673-8d7c-d7f5-79f8-09ecfc30200c"}}, {"fullUrl": "urn:uuid:dd4f67ed-7878-ce98-2d33-d0d3a3a2172f", "resource": {"resourceType": "Observation", "id": "dd4f67ed-7878-ce98-2d33-d0d3a3a2172f", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.202.3.7.7.798268.1000", "value": "476859550"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2022-12-16T08:00:00Z", "valueString": "Performed at: 01 - Integrated Genetics Sequenom
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NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "08AD5644-5A39-11ED-815F-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "576c9b22-b1f8-fc85-539e-f688ca7add3f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Stool Pathogens, NAAT, 12 to 25 TargetsMicrobiologyRoutine11/01/2022 3:23 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/f79f7fbc-cf8a-55d2-34b4-108ebff26173"}]}, {"id": "08C99EF8-5A39-11ED-815F-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "
ProblemNoted Date
Bipolar I disorder11/19/20
Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Yes0 (1 standard drink = 0.6 oz pure alcohol)
Sex Assigned at BirthDate Recorded
Not on file
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DateTypeDepartmentCare TeamDescription
11/1/22Lab RequisitionPROVIDENCE ST JOSEPH MED CTR LABORATORY501 S Buena Vista StBurbank, CA 91505-4809818-847-6060Test, Ambhp1, MD2001 LIND AVERENTON, WA 98059
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Reportability Response Information Section
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"identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "58353"}], "occurrenceDateTime": "2020-11-16", "note": {"text": "MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)"}, "vaccineCode": {"coding": [{"code": "50090-1890-1", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "1", "manufacturer": {"reference": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/b89f019a-ecfb-4eac-be97-e962b5e767f5"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/35c0d7fc-0bc0-5a24-e65e-dc30321d7e2e"}}, {"fullUrl": "urn:uuid:50fc36a0-b859-c4a4-de8f-53c149080081", "resource": {"resourceType": "Immunization", "id": "50fc36a0-b859-c4a4-de8f-53c149080081", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "58354"}], "occurrenceDateTime": "1974-03-21", "note": {"text": "HEP B (PED,ADOLESCENT) 3 DOSE"}, "vaccineCode": {"coding": [{"display": "HEP B (PED,ADOLESCENT) 3 DOSE"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/50fc36a0-b859-c4a4-de8f-53c149080081"}}]}') ON CONFLICT (ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.134.3.7.8.688883.49556', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.134.3.7.8.688883.49556", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.134.3.7.8.688883.49556", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00434126-48ff-11ed-88ac-8b040cab2e6b", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "1"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-10-10T17:52:57-07:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "b7a7ed08-af88-4a31-cc4e-8dddd58b7fc8", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "0C57098E-48FF-11ED-A9C1-8B04F0D33E31", "title": "Immunizations", "text": {"status": "generated", "div": "Not on file documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "0CA0A710-48FF-11ED-A9C1-8B04F0D33E31", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
diphenhydrAMINE (BENADRYL) 50 mg/ml injection 11 mgIntravenous, PRN Conditional, Starting on Tue 9/20/22 at 0907, Until Discontinued, other (enter comment), For Anaphylactic Reaction that includes CUTANEOUS SYMPTOMS (e.g. localized itching, flushing, hives, swelling) from Pegaspargase
EPINEPHrine PF (ADRENALIN) 1 mg/mL (1 mL) injection 0.11 mgIntramuscular, PRN Conditional, Starting on Tue 9/20/22 at 0907, Until Discontinued, other (enter comment), For Anaphylactic Reaction that includes RESPIRATORY SYMPTOMS (e.g. swallowing/breathing difficulty, throat tightening/closing, hoarseness) and/or CARDIOVASCULAR SYMPTOMS (e.g. hypotension/decreased blood perfusion) from Pegaspargase If both respiratory/cardiovascular systems and cutaneous symptoms of anaphylaxis present, give EPINEPHrine first, followed by BENADRYL. Repeat doses of EPINEPHrine can be given every 5-15 minutes as needed for unresolved symptoms. Please contact MD for additional EPINEPHrine orders.
famotidine (PEPCID) 10 mg/ml injection 11 mgIntravenous, PRN Conditional, Starting on Tue 9/20/22 at 0907, Until Discontinued, other (enter comment), For Anaphylactic Reaction that includes CUTANEOUS SYMPTOMS (e.g. localized itching, flushing, hives, swelling) that are UNRESOLVED following dose of BENADRYL for Pegaspargase
famotidine (PEPCID) 40 mg/5 mL oral liquid 5.52 mgOral, 2 Times a Day, First dose on Tue 9/20/22 at 0915, Until DiscontinuedGiven09/20/2022 9:15 AM PDT5.52 mg
famotidine (PEPCID) tablet 10 mgOral, 2 Times a Day, First dose on Tue 9/20/22 at 0915, Until Discontinued
methylPREDNISolone PF (SOLU-Medrol) injection 11.2 mgIntravenous, PRN Conditional, Starting on Tue 9/20/22 at 0907, Until Discontinued, other (enter comment), For Anaphylactic Reaction that includes RESPIRATORY SYMPTOMS (e.g. swallowing/breathing difficulty, throat tightening/closing, hoarseness) that are UNRESOLVED following doses of EPINEPHrine, from Pegaspargase
metoCLOPramide (REGLAN) injection 11 mgIntravenous, Every 6 Hours PRN, Starting on Thu 9/22/22 at 1510, Until Discontinued, nausea/vomiting
ondansetron (ZOFRAN) 2 mg/mL injection 1.66 mgIntravenous, Every 8 Hours PRN, Starting on Thu 9/22/22 at 0000, Until Discontinued, nausea/vomiting, To give Q8H PRN when ondansetron (zofran) Q8H order is completed. Give IV or oral ondansetron.
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
DAUNOrubicin (CERUBIDINE) 12 mg in D5W 250 mL infusionIntravenous, Once, 1 dose, On Tue 9/20/22 at 0915, Give on day 1. VESICANT; Protect from light. HAZARDOUS DRUG: Antineoplastic- Handle and dispose of properly. See Hyperlinks in MAR for PPE. , 25 mg/m2/doseNew Bag/Syringe09/20/2022 9:15 AM PDT12 mg
dexamethasone (DECADRON) tablet 2.5 mgOral, 2 Times a Day With Meals, 28 doses, First dose on Tue 9/20/22 at 0915, Last dose on Mon 10/3/22 at 1800, To be given with meals on day 1-14 (do not taper). (May give IV in the equivalent dose), 5 mg/m2/dose (round upward to the nearest 0.25 mg)Given09/20/2022 9:15 AM PDT2.5 mg
ondansetron (ZOFRAN) 1.66 mg in NS 6.6 mL injectionIntravenous, Every 8 Hours, 6 doses, First dose on Tue 9/20/22 at 0915, Last dose on Thu 9/22/22 at 0115, For nausea/vomiting. Give first dose prior to starting chemotherapy. Give IV or oral ondansetron.Given09/20/2022 9:15 AM PDT1.66 mg
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/ef2c6243-c6a4-ec46-3364-45fc9db4cd14"}, {"reference": "MedicationAdministration/57a0e00f-0829-9631-0ea3-00fe5b967998"}, {"reference": "MedicationAdministration/9d4dc5e2-eaf4-fab2-6b5e-f6d493ff1f4e"}, {"reference": "MedicationAdministration/8f513006-7d4d-4646-fc15-bddea376e0f1"}, {"reference": "MedicationAdministration/a3813f26-df0a-3f76-46bd-f66fbf2d0cdf"}, {"reference": "MedicationAdministration/742fe100-da6b-a773-f23a-5822460a0da9"}, {"reference": "MedicationAdministration/69707afa-31e1-659f-d6ce-dd961d64103a"}, {"reference": "MedicationAdministration/ce13dbbd-5972-4f8e-4b83-d9b2e5d02f91"}, {"reference": "MedicationAdministration/92869311-ac38-d46e-a1c1-7276b23fa000"}, {"reference": "MedicationAdministration/6c68e630-db43-6569-7a2f-d19c74eb3d7c"}, {"reference": "MedicationAdministration/f833e855-b0e0-2726-7808-093613e39fc8"}]}, {"id": "e0198fc2-f190-4f32-7c3b-5bc1d5d7ba9b", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
CBC WITH AUTO DIFFERENTIAL, REFLEX MANUAL DIFFERENTIAL IF INDICATEDLabRoutineAcute lymphoblastic leukemia (ALL) in remission (HCC)Daily (Include Now if Desired) for 7 Days starting 9/20/22 until 9/26/22
NUTRITIONAL PANEL, COMPLETELabRoutineAcute lymphoblastic leukemia (ALL) in remission (HCC)Daily (Include Now if Desired) for 7 Days starting 9/20/22 until 9/26/22
URIC ACIDLabRoutineAcute lymphoblastic leukemia (ALL) in remission (HCC)Daily (Include Now if Desired) for 7 Days starting 9/20/22 until 9/26/22
LIPASELabSTATAcute lymphoblastic leukemia (ALL) in remission (HCC)Once - Starting Now for 1 Occurrences starting 9/20/22 until 9/20/22
TPMT AND NUDT15LabRoutineAcute lymphoblastic leukemia (ALL) in remission (HCC)Once - Starting Now for 1 Occurrences starting 9/20/22 until 9/20/22
TPMT AND NUDT15LabRoutineAcute lymphoblastic leukemia (ALL) in remission (HCC)Once - Starting Now for 1 Occurrences starting 9/20/22 until 9/20/22
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/5c994725-b0c1-14ec-c6be-618943253965"}]}, {"id": "0CC3A74C-48FF-11ED-A9C1-8B04F0D33E31", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
Alpha thalassemia9/23/21
Asthma4/3/20
ALL (acute lymphoblastic leukemia)9/19/19
documented as of this encounter (statuses as of 10/10/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - ALL (acute lymphoblastic leukemia)", "reference": "Condition/304d71d3-8b9d-14db-2966-029a4dec531b"}, {"display": "Problem - Asthma", "reference": "Condition/0ff12079-aae9-78b9-9317-7cedaafd4090"}, {"display": "Problem - Alpha thalassemia", "reference": "Condition/624c5282-5c77-1886-9f59-99139e5c1a7d"}]}, {"id": "6561d619-c5d2-d0c6-d6f0-8907bf43b83c", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "0CCBB158-48FF-11ED-A9C1-8B04F0D33E31", "title": "Results", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "58a395b7-bdd9-98c0-bf4a-3110a499b4c7", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
Job Start DateOccupationIndustry
Not on fileNot on fileNot on file
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "f3b51d5d-9bf8-513b-ecd1-94a34c6656af", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
9/19/22 - 10/10/22Hospital EncounterMCH B3P1-PEDIATRICS2801 Atlantic AvenueLONG BEACH, CA 90808562-933-2000Temko, Jamie2801 Atlantic AveLong Beach, CA 90806562-933-3800 (Work)Dx: Acute lymphoblastic leukemia (ALL) in remission (HCC) (Primary Dx)
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Hospitalizations+Outpatient visits Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "0a79c18c-5d74-cf38-273d-13fe4018c870", "title": "Reportability Response Information Section", "text": {"status": "generated", "div": "
Reportability Response Information Section
"}, "extension": [{"url": "http://hl7.org/fhir/us/ecr/StructureDefinition/rr-composition", "valueIdentifier": {"use": "official", "type": {"coding": [{"code": "88085-6", "display": "Reportability response report Document Public health", "system": "http://loinc.org"}]}, "value": "b9da36e8-6087-4999-88b3-288dfeeaa0cc"}}, {"url": "http://hl7.org/fhir/us/ecr/StructureDefinition/rr-eicr-processing-status-extension", "valueCodeableConcept": {"coding": [{"code": "RRVS19", "display": "eICR processed", "system": "urn:oid:2.16.840.1.114222.4.5.274"}]}}], "code": {"coding": [{"code": "88085-6", "display": "Reportability response report Document Public health", "system": "http://loinc.org"}]}, "entry": [{"display": "Relevant Reportable Condition Observation - Malignant neoplastic disease (disorder)", "reference": "Observation/02b17930-a41f-4d53-b193-cc6d58cb247d"}]}], "subject": {"reference": "Patient/5879d3c0-f344-446b-a169-2d64880f116a"}, "encounter": {"reference": "Encounter/e3600169-d34b-a455-fe5e-dec383c99667"}, "custodian": {"reference": "Organization/810f60e0-8702-1434-3f04-59a8b22749c2"}, "author": [{"reference": "Practitioner/70a38010-7500-3d67-2e18-d46d49fd79b3"}, {"reference": "Device/3c6bb696-927b-c67f-f52b-675a2e750e72"}]}, "request": {"method": "PUT", "url": "Composition/1.2.840.114350.1.13.134.3.7.8.688883.49556"}}, {"fullUrl": "urn:uuid:e3600169-d34b-a455-fe5e-dec383c99667", "resource": {"resourceType": "Encounter", "id": "e3600169-d34b-a455-fe5e-dec383c99667", "status": "unknown", "class": {"code": "IMP", "display": "Inpatient Encounter", "system": "urn:oid:2.16.840.1.113883.5.4"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.134.3.7.3.698084.8", "value": "981235089040"}], "period": {"start": "2022-09-19T14:56:00-07:00", "end": "2022-10-10T17:52:00-07:00"}, "hospitalization": {"dischargeDisposition": {"coding": [{"code": "1", "display": "Home", "system": "urn:oid:1.2.840.114350.1.13.134.3.7.4.698084.18888"}]}}, "subject": {"reference": "Patient/5879d3c0-f344-446b-a169-2d64880f116a"}, "location": [{"id": "1.2.840.114350.1.13.134.3.7.2.686980", "location": {"reference": "Location/eca82bc2-f3e2-76e7-4295-594bd785e64d", "display": "MCH B3P1-PEDIATRICS"}, "extension": [{"url": "http://build.fhir.org/ig/HL7/case-reporting/StructureDefinition-us-ph-location-definitions.html#Location.type", "valueCodeableConcept": {"coding": [{"code": "1235-1", "display": "Oncology Pediatric General Hematology-Oncology Ward", "system": "urn:oid:2.16.840.1.113883.6.259"}]}}]}], "serviceProvider": {"reference": "Organization/c27e9785-3467-3a77-74eb-1d0863245a17"}, "participant": [{"type": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType", "code": "ATND"}]}], "individual": {"reference": "PractitionerRole/353076fe-8876-44ea-027e-c3d9f595e516"}}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Encounter/e3600169-d34b-a455-fe5e-dec383c99667"}}, {"fullUrl": "urn:uuid:eca82bc2-f3e2-76e7-4295-594bd785e64d", "resource": {"resourceType": "Location", "id": "eca82bc2-f3e2-76e7-4295-594bd785e64d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.134.3.7.2.686980", "value": "2020089"}], "name": "MCH B3P1-PEDIATRICS", "address": {"use": "work", "line": ["2801 Atlantic Avenue"], "city": "LONG BEACH", "state": "CA", "country": "US", "postalCode": "90808", "district": "LOS ANGELES"}, "type": [{"coding": [{"code": "1235-1", "display": "Oncology Pediatric General Hematology-Oncology Ward", "system": "urn:oid:2.16.840.1.113883.6.259"}]}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Location/eca82bc2-f3e2-76e7-4295-594bd785e64d"}}, {"fullUrl": "urn:uuid:c27e9785-3467-3a77-74eb-1d0863245a17", "resource": {"resourceType": "Organization", "id": "c27e9785-3467-3a77-74eb-1d0863245a17", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.134.3.7.2.696570", "value": "2020"}], "name": "MemorialCare Miller Children''s & Women''s Hospital Long Beach", "address": [{"use": "work", "line": ["2801 Atlantic Avenue"], "city": "LONG BEACH", "state": "CA", "country": "US", "postalCode": "90808", "district": "LOS ANGELES"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/c27e9785-3467-3a77-74eb-1d0863245a17"}}, {"fullUrl": "urn:uuid:203870a9-947d-f845-0e6f-75b29c72de69", "resource": {"resourceType": "Practitioner", "id": "203870a9-947d-f845-0e6f-75b29c72de69", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner"], "source": "ecr"}, "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/_datatype", "valueString": "Responsible Party"}], "name": [{"family": "Temko", "given": ["Jamie"]}], "address": [{"use": "work", "line": ["2801 Atlantic Ave"], "city": "Long Beach", "state": "CA", "postalCode": "90806"}], "telecom": [{"system": "phone", "value": "+1-562-933-3800", "use": "work"}]}, "request": {"method": "PUT", "url": 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Disease caused by 2019-nCoVActive
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remdesivir20221215000000+0000
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Occupation HistoryStudent
Travel HistoryGender Identification-Female (finding)
Travel HistorySexually active (finding)-Not applicable (qualifier value)
Travel HistorySexual Orientation-Not applicable (qualifier value)
Travel HistoryBreastfeeding-Not applicable (qualifier value)
Travel HistoryNausea-No (qualifier value)
Travel HistoryVomiting (disorder)-No (qualifier value)
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Travel HistoryAbdominal (Stomach Pain)-No (qualifier value)
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Travel HistoryDroplet, Contact Isolation Verification-Not applicable (qualifier value)
Travel HistorySymptomatic Health Care Professional/SNF-No (qualifier value)
Travel HistorySymptomatic After Exposure to Contagion-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
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Unknown History of Present Illness
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Blood Gas, ArterialLabRoutine08/15/2022 1:01 PM PDT
Blood Gas, ArterialLabRoutine08/15/2022 1:10 PM PDT
Blood Gas, VenousLabRoutine08/16/2022 11:26 AM PDT
Blood Gas, Cord, VenousLabRoutine08/16/2022 11:26 AM PDT
Blood Gas, Mixed VenousLabRoutine08/16/2022 11:26 AM PDT
Blood Gas, Cord, ArterialLabRoutine08/16/2022 11:26 AM PDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
Basic Metabolic PanelLabRoutineOne Time for 1 Occurrences starting 8/9/21 until 8/9/21
CBC with DifferentialLabRoutineOne Time for 1 Occurrences starting 8/9/21 until 8/9/21
Basic Metabolic PanelLabRoutineAM Lab Morning Lab for 1 Days starting 8/10/21 until 8/10/21
CBC with DifferentialLabRoutineAM Lab Morning Lab for 1 Days starting 8/10/21 until 8/10/21
Blood Gas, ArterialLabRoutineOne Time for 1 Occurrences starting 8/15/22 until 8/15/22
Blood Gas, ArterialLabRoutineOne Time for 1 Occurrences starting 8/15/22 until 8/15/22
Blood Gas, VenousLabRoutineOne Time for 1 Occurrences starting 8/16/22 until 8/16/22
Blood Gas, Cord, VenousLabRoutineOne Time for 1 Occurrences starting 8/16/22 until 8/16/22
Blood Gas, Mixed VenousLabRoutineOne Time for 1 Occurrences starting 8/16/22 until 8/16/22
Blood Gas, Cord, ArterialLabRoutineOne Time for 1 Occurrences starting 8/16/22 until 8/16/22
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MemberRoleStatusDates
Adam Sheradmitting physicianActive
Start: March 12th, 2022
MCUTLERattending physicianActive
Start: March 12th, 2022
DR MEDITECHprimary care physicianActive
Start: March 12th, 2022
AMANDA NOELREFERRINGActive
Start: March 12th, 2022
AMANDA PARLATOFAMILYActive
Start: March 12th, 2022
Rickey RobertsOTHERActive
Start: March 12th, 2022
Stephen NewtonCONSULTINGActive
Start: March 12th, 2022
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Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
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RIGRAPID HEART BEAT
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Height65 [in_i]March 14th, 2022 1:48pm
Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
Weight68.039 kgMarch 14th, 2022 1:48pm
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Recent DiagnosisOnset Date
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Medication NameStart DateInstructions
Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 24th, 2022 9:38am
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Reportability Response Information Section
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Team Status: Active
MemberRoleStatusDates
Adam Sheradmitting physicianActive
Start: March 12th, 2022
MCUTLERattending physicianActive
Start: March 12th, 2022
DR MEDITECHprimary care physicianActive
Start: March 12th, 2022
AMANDA NOELREFERRINGActive
Start: March 12th, 2022
AMANDA PARLATOFAMILYActive
Start: March 12th, 2022
Rickey RobertsOTHERActive
Start: March 12th, 2022
Stephen NewtonCONSULTINGActive
Start: March 12th, 2022
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Assigned Birth SexMale
Gender Identityunknown
Sexual OrientationDo not know
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Medical ProblemOnset DateStatus
AnthraxActive
COVID-19Active
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Anthrax", "reference": "Condition/6df7d710-f8f0-f388-f9f7-9b4fc17212c1"}, {"display": "Problem - Infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)", "reference": "Condition/5e42206e-2ca8-5e52-35c9-01c77984dfe5"}]}, {"id": "5b4e468a-93a9-0719-ea5c-a1de4efc2d14", "title": "Immunizations", "text": {"status": "generated", "div": "
ImmunizationEvent DateNot Given ReasonDose NumberManufacturerLot NumberVaccine Information Statement (VIS) Detail
Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
anthraxMarch 15th, 2022 7:20am1PFIZER & OTHER CHARACTERSLOT9911Z
RIGRAPID HEART BEAT
anthraxMarch 24th, 2022 9:34am2JOHNSON AND JOHNSONLOT942X
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Vital ReadingResultReference RangeCollection Date/Time
Height65 [in_i]March 14th, 2022 1:48pm
Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
Weight68.039 kgMarch 14th, 2022 1:48pm
BMI (Body Mass Index)25.0 kg/m2March 14th, 2022 1:48pm
"}, "code": {"coding": [{"code": "8716-3", "display": "VITAL SIGNS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "67f7a7ed-6fe7-4c8c-0351-29a72804599a", "title": "Administered Medications", "text": {"status": "generated", "div": "
MedicationDoseUnitsRouteDirectionsQtyDaysStart DateEnd DateInstructions
ZIDO100C4 (Zidovudine ) 100 MG TABLET100MGORALQ6HMarch 12th, 2022 7:49pmMarch 12th, 2022 7:49pm
RIFA150C15 (Rifampin ) 150 MG CAPSULE150MGORALQ6HMarch 24th, 2022 9:34amMarch 24th, 2022 9:34am
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"Organization/fb121477-4011-40b3-40fe-f884cdfecd6a"}}]}') ON CONFLICT (ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('5da4c0ae-92d2-424c-b038-4e104e48235d', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:5da4c0ae-92d2-424c-b038-4e104e48235d", "resource": {"resourceType": "Composition", "id": "5da4c0ae-92d2-424c-b038-4e104e48235d", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "30470272|65157249"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "1"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-05-18T16:48:23Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "db5530c3-e644-7369-7cfb-f0d2183c2ada", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Vaginal bleedingActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Bleeding from vagina (finding)", "reference": "Condition/e7cc40bf-8d4e-da3e-104f-dd109944651b"}]}, {"id": "41f59314-c298-9c2f-13b6-084a3bfd9501", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
Outpatient20220517192300+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "54c47fc3-c151-3122-4416-6fef42c84841", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
Estimated Creatinine Clearance121.78|http://unitsofmeasure.org|mL/min
Symptomatic as defined by CDC?Yes
In ICU?No
Group care resident?No
Employed in healthcare?No
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRNegative
eGFR PediatricNot Reported
Flu B PCRNot Detected
Flu A PCRDetected
Calc Osmo264|http://unitsofmeasure.org|mOsmol/L
A/G Ratio0.7|http://unitsofmeasure.org|Ratio
eGFR Non-African American120.46 mL/min/1.73m2
eGFR African American139.62 mL/min/1.73m2
Sodium134|http://unitsofmeasure.org|mmol/L
Potassium3.7|http://unitsofmeasure.org|mmol/L
Baso # Auto0.01|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.1|http://unitsofmeasure.org|gm/dL
Mono # Auto0.6|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto10.8|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.1|http://unitsofmeasure.org|%
Eos % Auto0.2|http://unitsofmeasure.org|%
Lymph % Auto4.3|http://unitsofmeasure.org|%
Neut % Auto89.7|http://unitsofmeasure.org|%
Calcium9.0|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.06|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto0.5|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto5.2|http://unitsofmeasure.org|%
RDW-CV14.8|http://unitsofmeasure.org|%
Immature Grans %0.5|http://unitsofmeasure.org|%
Eos # Auto0.0|http://unitsofmeasure.org|x10e3/mcL
Chloride102|http://unitsofmeasure.org|mmol/L
BUN2|http://unitsofmeasure.org|mg/dL
Plt324|http://unitsofmeasure.org|x10e3/mcL
WBC12.1|http://unitsofmeasure.org|x10e3/mcL
TP7.5|http://unitsofmeasure.org|gm/dL
RBC4.11|http://unitsofmeasure.org|x10e6/mcL
MPV10.1|http://unitsofmeasure.org|Femtoliters
MCV83.5|http://unitsofmeasure.org|Femtoliters
MCHC33.2|http://unitsofmeasure.org|gm/dL
MCH27.7|http://unitsofmeasure.org|pg
Lactic Acid Lvl1.2|http://unitsofmeasure.org|mmol/L
Hgb11.4|http://unitsofmeasure.org|gm/dL
Hct34.3|http://unitsofmeasure.org|%
Glucose Level82|http://unitsofmeasure.org|mg/dL
CO220.5|http://unitsofmeasure.org|mmol/L
T Bili0.3|http://unitsofmeasure.org|mg/dL
AST15|http://unitsofmeasure.org|Intl_units/L
ALT17|http://unitsofmeasure.org|Intl_units/L
Alk Phos66|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio2.9|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine0.7|http://unitsofmeasure.org|mg/dL
Ur pH8.0
Ur Spec Grav1.020 mg/dL
Ur Urobilinogen0.2 EU/dL
Ur BloodTrace-intact
Ur BiliNegative
Ur Leuk EstNegative
Ur ProteinNegative mg/dL
Ur NitriteNegative
Ur KetonesNegative mg/dL
UR GlucoseNegative mg/dL
"}, "code": {"coding": [{"code": "30954-2", "display": "RESULTS", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/edab8a14-5cf2-c53f-8639-b73dd405f1a1"}, {"reference": "Observation/6fd761bc-cef6-8c35-4cb2-29d4787662f0"}, {"reference": "Observation/7298c580-1536-e040-c2c4-e986f3eae90d"}, {"reference": "Observation/d7ea14e0-5564-ae7d-5896-b17dd40de3b3"}, {"reference": "Observation/1f143dad-f270-83f6-203c-407c6efc813a"}, {"reference": "Observation/a55eb11c-76cd-3a2f-355d-ee8cdf0f4c70"}, {"reference": "Observation/6e67512a-f3c6-8646-c3e1-b85f2e58cceb"}, {"reference": "Observation/7d6997a1-1a8e-9a0e-f934-3bff4893c9ee"}, {"reference": "Observation/16bbb7a1-6af6-7f28-d638-e29699ed2b68"}, {"reference": "Observation/89536e15-d2b0-07ad-6123-a7773ef83991"}, {"reference": "Observation/fedd5028-bc13-835d-4c9c-e8a144683c92"}, {"reference": "Observation/cc9f5f2f-5623-a965-29ab-ecef5dabeb6f"}, {"reference": "Observation/37c2dd52-7cef-153d-4de1-3861e3f54596"}, {"reference": "Observation/ace4c9c7-59cd-826e-278b-0db700371cde"}, {"reference": "Observation/6d52bdc7-2403-3cac-a56d-8261bfb51cfb"}, {"reference": "Observation/d59342c0-1661-a516-7056-55cce1fd22be"}, {"reference": "Observation/1b3b3dc4-638c-3863-4c98-abed420e995e"}, {"reference": "Observation/960edf71-4d81-ba3d-2b9a-9ed20353be50"}, {"reference": "Observation/5f60cd1d-c8b0-18f2-5483-be3c305d903a"}, {"reference": "Observation/350acddb-569d-2aaa-7286-9b59dc408139"}, {"reference": "Observation/bf802f2f-e5b3-85b0-d0c7-b670f3bbad28"}, {"reference": "Observation/6fe58d13-c176-a5d0-4edb-5da0749f645a"}, {"reference": "Observation/266d3e70-92aa-4fb5-f37c-269f12b8f7f0"}, {"reference": "Observation/b0813bc6-8ddc-2ed9-8330-1ce648082095"}, {"reference": "Observation/05360b92-6fc8-8c37-d4ad-fcb9e6d9b8a2"}, {"reference": "Observation/9c52f094-eaa4-fccf-7c6c-f6e92e2e57c0"}, {"reference": "Observation/22811b85-9a31-28cc-ff01-3490af40dd9f"}, {"reference": "Observation/7b9953cc-013d-a9d7-b4ce-794b32aed495"}, {"reference": "Observation/d168c0e1-f3de-a706-34ca-a864eaf39d43"}, {"reference": "Observation/0684b2d1-f70b-339a-c4c8-bb6e8266d7d4"}, {"reference": "Observation/84295b3a-1ac8-1d25-b9b5-823dfc776425"}, {"reference": "Observation/8999fafb-e74b-7b65-3086-1588351af0a0"}, {"reference": "Observation/8286acce-0f8d-a439-8b0c-852f1ff691ca"}, {"reference": "Observation/379f5b28-7891-64c5-42aa-8db52de78dd0"}, {"reference": "Observation/eb048fa7-d75c-40ba-2aa0-d317840a8033"}, {"reference": "Observation/aa3464f8-9c20-5b2e-d148-0280aa6f0eba"}, {"reference": "Observation/147facae-97ee-8937-25ac-6725a64dde97"}, {"reference": "Observation/3ccbec34-61cd-0daa-5510-71b9238d75b6"}, {"reference": "Observation/9ef3fca9-5c04-436d-cccb-eb4badbd7db1"}, {"reference": "Observation/f2e928c9-538e-4acc-ecfe-17f48bcb8fb9"}, {"reference": "Observation/4a0b1cb3-b737-27e1-6310-3b4040f3a936"}, {"reference": "Observation/d15bb05a-6bd3-bfa9-a7c3-f7d5f74976f4"}, {"reference": "Observation/9b54b60d-66d7-ed9d-d897-7a16fd0b904b"}, {"reference": "Observation/17f0c771-0213-d076-0164-8582aa4bdc87"}, {"reference": "Observation/8a1696c7-d613-ad5e-31cc-14a111806868"}, {"reference": "Observation/135717ab-52eb-7f3e-c65c-91ad19823122"}, {"reference": "Observation/5b72336c-6449-60da-3acb-fc488905cde6"}, {"reference": "Observation/73600b01-407c-2b54-3f3b-93216e24a94c"}, {"reference": "Observation/a4a289bc-6a64-2721-153a-968fbbf1597d"}, {"reference": "Observation/d4d29fc4-6452-afa9-0572-641fd058bbfb"}, {"reference": "Observation/ad56e514-cb18-228b-9997-eb26b35da923"}, {"reference": "Observation/dcd86663-22e0-024f-ff54-022ffb52b9a3"}, {"reference": "Observation/4b467c81-106a-95ec-d317-7566a4fb108f"}, {"reference": "Observation/65bd51ae-f37e-335a-666f-7e8309266c0e"}, {"reference": "Observation/b8e94121-a889-980d-11fc-b3e8ba6f34f9"}, {"reference": "Observation/8c953767-18a0-2fdc-624e-017d9b6f5dc8"}, {"reference": "Observation/4e3caa0c-1f30-e592-6d2a-0e669a3ab3d9"}, {"reference": "Observation/2c706caf-bff6-69e7-8a82-e7b6fc76054c"}, {"reference": "Observation/aa0464a9-837d-1c80-9fd8-6d62970e35d0"}, {"reference": "Observation/9fe93302-e2f6-48ff-b304-1cade8ba5e0e"}, {"reference": "Observation/71a2209b-ca3d-31d9-2229-deab17519a07"}, {"reference": "Observation/4366dfb6-70f3-3378-fa2e-e964c47dc456"}, {"reference": "Observation/0b6ac3a1-c62c-f520-b99f-c81e4e34e116"}]}, {"id": "65da9acc-0190-4e14-4147-b1561a6705fa", "title": "Medications Administered", "text": {"status": "generated", "div": "
Medication NameMedication Start Date
oseltamivir (Tamiflu 75 mg oral capsule)20220517222600+0000
Lactated Ringers (Lactated Ringers Bolus)20220517202600+0000
acetaminophen (Ofirmev)20220517210000+0000
"}, "code": {"coding": [{"code": "29549-3", "display": "Medications Administered", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/e7957a48-029f-f229-316d-307facabd99b"}, {"reference": "MedicationAdministration/3f2fbfde-3c61-e931-8e87-c5ed9e932d79"}, {"reference": "MedicationAdministration/6e242488-ca4b-ce3e-6cc8-bc5c99931567"}]}, {"id": "dd08df91-869b-46df-dd36-c5c0f2ad2eae", "title": "IMMUNIZATIONS", "text": {"status": "generated", "div": "No ImmunizationInformation"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "c2282a27-2c38-2db0-3eef-8e91a0653e81", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Birth SexF
Pregnancy ConditionPatient currently pregnant (finding)
Travel HistoryCOVID- 19 Testing Reason-Screening
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryExposure to severe acute respiratory syndrome coronavirus 2 (event)-No (qualifier value)
Travel HistoryMERS-CoV Travel History-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMERS-CoV Symptoms-
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryMRSA Sceen Dialysis or Venous Access-No (qualifier value)
Travel HistoryMRSA Screen Admit From Non-home Loc-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
"}, "code": {"coding": [{"code": "29762-2", "display": "Social History", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/a080c563-5775-7da1-1b7e-f648e6d4c886"}, {"reference": "Observation/bf462174-4971-24bb-c25b-0d79de202934"}, {"reference": "Observation/51908a5c-9136-71d1-db63-91d5d11d009e"}, {"reference": "Observation/e04e13ea-0e7d-80a0-2307-1b8a7eb51a05"}, {"reference": "Observation/64b1a647-3417-570c-233a-2a33067e0de3"}, {"reference": "Observation/c2c94ede-504b-1f39-3f49-2f5e7a571890"}, {"reference": "Observation/0e675665-5c10-a7e2-f3db-62513562be90"}, {"reference": "Observation/7076ee50-1e9e-d911-cd1d-2f815192cc84"}, {"reference": "Observation/bb395019-8787-107f-5ed4-f12522b15ec8"}, {"reference": "Observation/5485d2c1-e9d7-99b8-2bfa-10d5494f8552"}, {"reference": "Observation/44321877-c8b8-6df0-3c63-0c367f48d702"}, {"reference": "Observation/7119b77d-928c-1fb4-3570-bf2dd62ae0df"}, {"reference": "Observation/f313d071-c772-2b1e-19cc-3eab66180e78"}]}, {"id": "7dbd51e8-1c15-8cfa-cbce-f6f4b9a1ed5d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "No Plan Of Treatment Information"}, "code": {"coding": [{"code": "18776-5", "display": "Treatment Plan", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/ec77d178-de8a-915a-311a-1f11f2838946"}]}, {"id": "01506440-638a-cf2d-f07b-8604022acea2", "title": "History of Present Illness", "text": {"status": "generated", "div": "
Narrative Text
Back pain affecting pregnancy
Influenza
Febrile illness
Influenza A
Antepartum fetal tachycardia affecting care of mother
23 weeks gestation of pregnancy
"}, "code": {"coding": [{"code": "10164-2", "display": "History of Present Illness", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "b184ecfd-49d2-8f01-8f2b-efb1104e7957", "title": "Reason For Visit", "text": {"status": "generated", "div": "
text
23 WK LOWER BACK PAI
"}, "code": {"coding": [{"code": "29299-5", "display": "Reason For Visit", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "23 WK LOWER BACK PAI"}]}, {"id": "eb5827c6-ca8a-9645-3c80-05e6157820a9", "title": "Reportability Response Information Section", "text": {"status": "generated", "div": "
Reportability Response Information Section
"}, "extension": [{"url": "http://hl7.org/fhir/us/ecr/StructureDefinition/rr-composition", "valueIdentifier": {"use": "official", "type": {"coding": [{"code": "88085-6", "display": "Reportability response report Document Public health", "system": "http://loinc.org"}]}, "value": "542e65d9-a76b-4a86-8ed6-cf85ab6c6081"}}, {"url": "http://hl7.org/fhir/us/ecr/StructureDefinition/rr-eicr-processing-status-extension", "valueCodeableConcept": {"coding": [{"code": "RRVS19", "display": "eICR processed", "system": "urn:oid:2.16.840.1.114222.4.5.274"}]}}], "code": {"coding": [{"code": "88085-6", "display": "Reportability response report Document Public health", "system": "http://loinc.org"}]}, "entry": [{"display": "Relevant Reportable Condition Observation - Influenza caused by Influenza A virus subtype H5N1 (disorder)", "reference": "Observation/f132efef-5188-471d-8f39-151df76641d4"}]}], "subject": {"reference": "Patient/76404851-4554-44f9-a034-e43ad345ec60"}, "encounter": {"reference": "Encounter/f06900fa-902c-1304-7637-c721558a6ebb"}, "custodian": {"reference": "Organization/91c4d2ba-e324-5b1a-a4cb-84d9690511d3"}, "author": [{"reference": "Practitioner/cf70b68e-4184-074e-8181-a3d8a0521307"}]}, "request": {"method": "PUT", "url": "Composition/5da4c0ae-92d2-424c-b038-4e104e48235d"}}, {"fullUrl": "urn:uuid:f06900fa-902c-1304-7637-c721558a6ebb", "resource": {"resourceType": "Encounter", "id": "f06900fa-902c-1304-7637-c721558a6ebb", "status": "unknown", "class": {"code": "O", "display": "Outpatient", "system": "urn:oid:2.16.840.1.113883.18.5"}, "identifier": [{"system": "urn:oid:2.16.840.1.113883", "value": "Encounter/65157249/_history/13"}, {"system": "urn:oid:2.16.840.1.113883.3.3316.200", "value": "3012602946"}], "period": {"start": "2022-05-17T19:23:00Z", "end": "2022-05-17T23:10:00Z"}, "subject": {"reference": "Patient/76404851-4554-44f9-a034-e43ad345ec60"}, "location": [{"id": "2.16.840.1.113883.4.6", "location": {"reference": 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Problem or DiagnosisProblem Status
DiverticulosisActive
Mantoux: positive (finding)Active
OsteoarthritisActive
Stasis dermatitisActive
Intermittent asthmaActive
Anemia (disorder)Active
Hypertensive disorder, systemic arterial (disorder)Active
DM2 (diabetes mellitus, type 2)Active
Allergic rhinitisActive
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Encounter ReasonDate of Encounter
inpatient encounter20220511201400+0000
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Lab Test NameLab Test Result ValueLab Test Result Date
POC Glucose182|http://unitsofmeasure.org|mg/dL
POC Glucose229|http://unitsofmeasure.org|mg/dL
Estimated Creatinine Clearance49.88|http://unitsofmeasure.org|mL/min
eGFR PediatricNot Reported
Calc Osmo282|http://unitsofmeasure.org|mOsmol/L
A/G Ratio0.5|http://unitsofmeasure.org|Ratio
eGFR Non-African American80.56 mL/min/1.73m2
eGFR African American93.37 mL/min/1.73m2
Sodium138|http://unitsofmeasure.org|mmol/L
Potassium4.1|http://unitsofmeasure.org|mmol/L
Ferritin Lvl1320|http://unitsofmeasure.org|ng/mL
Baso # Auto0.01|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level2.6|http://unitsofmeasure.org|gm/dL
Mono # Auto0.2|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto4.3|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.2|http://unitsofmeasure.org|%
Lymph % Auto12.8|http://unitsofmeasure.org|%
Neut % Auto82.0|http://unitsofmeasure.org|%
Calcium10.5|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.02|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto0.7|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto4.6|http://unitsofmeasure.org|%
RDW-CV15.7|http://unitsofmeasure.org|%
Immature Grans %0.4|http://unitsofmeasure.org|%
Chloride105|http://unitsofmeasure.org|mmol/L
BUN11|http://unitsofmeasure.org|mg/dL
Plt326|http://unitsofmeasure.org|x10e3/mcL
WBC5.2|http://unitsofmeasure.org|x10e3/mcL
TP7.5|http://unitsofmeasure.org|gm/dL
RBC3.27|http://unitsofmeasure.org|x10e6/mcL
PT12.3|http://unitsofmeasure.org|Seconds
MPV10.8|http://unitsofmeasure.org|Femtoliters
MCV86.5|http://unitsofmeasure.org|Femtoliters
MCHC30.4|http://unitsofmeasure.org|gm/dL
MCH26.3|http://unitsofmeasure.org|pg
Mg Lvl2.3|http://unitsofmeasure.org|mg/dL
Hgb8.6|http://unitsofmeasure.org|gm/dL
Hct28.3|http://unitsofmeasure.org|%
Glucose Level216|http://unitsofmeasure.org|mg/dL
D Dimer1.21|http://unitsofmeasure.org|mg/L
CRP16.7|http://unitsofmeasure.org|mg/dL
CO224.0|http://unitsofmeasure.org|mmol/L
T Bili0.2|http://unitsofmeasure.org|mg/dL
D Bili0.05|http://unitsofmeasure.org|mg/dL
AST23|http://unitsofmeasure.org|Intl_units/L
ALT34|http://unitsofmeasure.org|Intl_units/L
Alk Phos118|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio15.7|http://unitsofmeasure.org|Ratio
INRUnknown
Anion GapUnknown
Creatinine0.7|http://unitsofmeasure.org|mg/dL
Ferritin Lvl1280|http://unitsofmeasure.org|ng/mL
NT-ProBNP726|http://unitsofmeasure.org|pg/mL
Hgb A1c %6.6|http://unitsofmeasure.org|%
LD170|http://unitsofmeasure.org|units/L
Hgb9.0|http://unitsofmeasure.org|gm/dL
D Dimer1.48|http://unitsofmeasure.org|mg/L
CRP12.0|http://unitsofmeasure.org|mg/dL
POC Glucose144|http://unitsofmeasure.org|mg/dL
Ur pHUnknown
Ur Spec GravUnknown
Ur Urobilinogen<2.0 mg/dL
Ur BloodNegative mg/dL
Ur BiliNegative mg/dL
Ur Leuk EstNegative
Ur ColorStraw
Ur ProteinNegative mg/dL
Ur NitriteNegative
Ur KetonesNegative mg/dL
UR GlucoseNegative mg/dL
Ur ClarityClear
Estimated Creatinine Clearance34.91|http://unitsofmeasure.org|mL/min
Troponin TNIH8.9|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
Calc Osmo261|http://unitsofmeasure.org|mOsmol/L
A/G Ratio0.6|http://unitsofmeasure.org|Ratio
eGFR Non-African American55.74 mL/min/1.73m2
eGFR African American64.60 mL/min/1.73m2
Sodium129|http://unitsofmeasure.org|mmol/L
Potassium4.6|http://unitsofmeasure.org|mmol/L
Baso # Auto0.02|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.1|http://unitsofmeasure.org|gm/dL
Mono # Auto0.8|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto5.5|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.3|http://unitsofmeasure.org|%
Eos % Auto0.3|http://unitsofmeasure.org|%
Lymph % Auto15.4|http://unitsofmeasure.org|%
Neut % Auto73.1|http://unitsofmeasure.org|%
Calcium11.3|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto1.2|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto10.5|http://unitsofmeasure.org|%
TSH Ultrasensitive1.105|http://unitsofmeasure.org|mc Intl units/mL
RDW-CV15.5|http://unitsofmeasure.org|%
Immature Grans %0.4|http://unitsofmeasure.org|%
Eos # Auto0.0|http://unitsofmeasure.org|x10e3/mcL
Chloride96|http://unitsofmeasure.org|mmol/L
BUN15|http://unitsofmeasure.org|mg/dL
Plt389|http://unitsofmeasure.org|x10e3/mcL
WBC7.5|http://unitsofmeasure.org|x10e3/mcL
TP8.4|http://unitsofmeasure.org|gm/dL
RBC3.58|http://unitsofmeasure.org|x10e6/mcL
MPV10.3|http://unitsofmeasure.org|Femtoliters
MCV85.5|http://unitsofmeasure.org|Femtoliters
MCHC30.4|http://unitsofmeasure.org|gm/dL
MCH26.0|http://unitsofmeasure.org|pg
Lactic Acid Lvl1.1|http://unitsofmeasure.org|mmol/L
Hgb9.3|http://unitsofmeasure.org|gm/dL
Hct30.6|http://unitsofmeasure.org|%
Glucose Level119|http://unitsofmeasure.org|mg/dL
CO224.8|http://unitsofmeasure.org|mmol/L
T Bili0.5|http://unitsofmeasure.org|mg/dL
AST26|http://unitsofmeasure.org|Intl_units/L
Ammonia Level10|http://unitsofmeasure.org|mmol/L
ALT41|http://unitsofmeasure.org|Intl_units/L
Alk Phos140|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio15.0|http://unitsofmeasure.org|Ratio
Anion GapUnknown
Creatinine1.0|http://unitsofmeasure.org|mg/dL
Symptomatic as defined by CDC?Yes
In ICU?No
Group care resident?No
Employed in healthcare?No
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRPositive
Flu B PCRNot Detected
Flu A PCRNot Detected
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Medication NameMedication Start Date
amLODIPine (Norvasc 5 mg oral tablet)20220511233400+0000
aspirin (aspirin 81 mg oral enteric coated tablet)20220511233900+0000
atenolol (Tenormin 25 mg oral tablet)20220511233600+0000
atorvastatin (Lipitor 10 mg oral tablet)20220511233600+0000
diclofenac topical (Voltaren 1% topical gel)20220511233700+0000
ferrous gluconate (ferrous gluconate 324 mg (38 mg elemental iron) oral tablet)20220511233400+0000
hydrocortisone topical (Proctozone HC 2.5% rectal cream with applicator)20220511233600+0000
losartan (Cozaar 50 mg oral tablet)20220511233800+0000
potassium chloride (Klor-Con 8 oral tablet, extended release)20220511233500+0000
atenolol (Tenormin)20220512160000+0000
atorvastatin (Lipitor)20220512160000+0000
losartan (Cozaar)20220512160000+0000
aspirin20220512150000+0000
enoxaparin20220512133000+0000
insulin regular (insulin regular correctional scale Low)20220512050000+0000
amLODIPine (Norvasc)20220512040000+0000
sennosides-docusate (docusate-senna 50 mg-8.6 mg oral tablet)20220512025200+0000
guaiFENesin-dextromethorphan (guaifenesin-dextromethorphan 100 mg-10 mg/5 mL oral liquid)20220512023300+0000
ondansetron20220512023200+0000
acetaminophen (Tylenol)20220512023000+0000
famotidine (Pepcid)20220512040000+0000
dexamethasone20220512030000+0000
remdesivir20220513000000+0000
remdesivir20220512030000+0000
acetaminophen (Tylenol)20220511223600+0000
Sodium Chloride 0.9% intravenous solution (Sodium Chloride 0.9% Bolus (ADULT SEPSIS))20220511203200+0000
"}, "code": {"coding": [{"code": "29549-3", "display": "Medications Administered", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/263d3180-d878-8633-1d60-fe7ce355d124"}, {"reference": "MedicationAdministration/cb4a4262-7fe6-b48f-efbd-8070950134b0"}, {"reference": "MedicationAdministration/0caa6d1f-0128-7b71-9784-93710d70ba02"}, {"reference": "MedicationAdministration/40af8879-767e-d4bd-adec-9ea3db756ae3"}, {"reference": "MedicationAdministration/2a40b1cb-07c6-02ab-059d-276eda812688"}, {"reference": "MedicationAdministration/74889231-50b5-dcf9-b9ac-2641613f6464"}, {"reference": "MedicationAdministration/593b757b-69bf-2671-1bc9-b5d5a06c4c3c"}, {"reference": "MedicationAdministration/66f96186-1953-b156-6486-29f73d0f1001"}, {"reference": "MedicationAdministration/05ebdd11-fef3-57bb-0428-36eeb92a07a4"}, {"reference": "MedicationAdministration/d89ad29f-7a8a-7541-8768-abacdbf38365"}, {"reference": "MedicationAdministration/7585f41b-82bd-2cf0-44af-da7ce2856256"}, {"reference": "MedicationAdministration/1a14e06a-a357-ac9b-68b1-4e29ae995c43"}, {"reference": "MedicationAdministration/6a4dd08c-3770-bf05-8a71-6cddb266835e"}, {"reference": "MedicationAdministration/bd017bb5-e7c3-5d1a-511c-aadc22322514"}, {"reference": "MedicationAdministration/99a3e579-fbcf-04cf-9f63-54cbaf0a8990"}, {"reference": "MedicationAdministration/ee7e7fd1-6d27-6111-5877-89757ea7f401"}, {"reference": "MedicationAdministration/1025ebec-6369-b333-cccb-524126c49e4a"}, {"reference": "MedicationAdministration/03df4c86-e495-1c80-6cea-c46c01a29d82"}, {"reference": "MedicationAdministration/835ca994-6ae1-1880-c2d0-72bff52533ef"}, {"reference": "MedicationAdministration/efe31e36-310d-a0c5-479f-c75ac6c1034a"}, {"reference": "MedicationAdministration/6368c9f0-86f8-8544-d100-638c622dcaf7"}, {"reference": "MedicationAdministration/10e82e54-b5f0-c7e1-791d-907604bd5b51"}, {"reference": "MedicationAdministration/00a4a72c-ddad-5a39-fa5f-f39d19cd85a7"}, {"reference": "MedicationAdministration/d7a2cba9-045c-ac32-db65-11a3ca7fb2b5"}, {"reference": "MedicationAdministration/1e0d7e69-cf40-ba05-0b2c-4fb8fca90fe3"}, {"reference": "MedicationAdministration/6384ed31-e5aa-737d-ddcd-caa683820bac"}]}, {"id": "dd08df91-869b-46df-dd36-c5c0f2ad2eae", "title": "IMMUNIZATIONS", "text": {"status": "generated", "div": "No ImmunizationInformation"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "af929c8d-39eb-550f-c352-c897f2955a48", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Birth SexF
Travel HistoryInfluenza vaccination status (observable entity)-Received prior to admission, during current flu season
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryMRSA Sceen Dialysis or Venous Access-No (qualifier value)
Travel HistoryMRSA Screen Admit From Non-home Loc-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryPregnancy Status-Not applicable (qualifier value)
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryCOVID- 19 Testing Reason-Diagnostic
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Tobacco Cessation:
Counseling Given: Not Answered
Alcohol UseStandard Drinks/WeekComments
Not Currently0 (1 standard drink = 0.6 oz pure alcohol)
Sex Assigned at BirthDate Recorded
Not on file
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DateTypeDepartmentCare TeamDescription
12/9/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Soh, Isabelle Ying-Ying, MD8767 WILSHIRE BLVDSTE 301BEVERLY HILLS, CA 90211310-248-7077 (Work)424-314-8735 (Fax)Isabelle.Soh@cshs.org
Laboratory confirmed diagnosis of COVID-19Suspected COVID-19 virus infection (Primary Dx);
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and who is not shedding SARS-CoV-2 virus would expect to have a
consistent with COVID-19. An individual without symptoms of COVID-19
recent exposures and the presence of clinical signs and symptoms
negative result should be considered in the context of a patient''s
When diagnostic testing is negative, the possibility of a false
sooner.
360bbb-3(b) (1), unless the authorization is terminated or revoked
of COVID-19 infection under section 564(b)(1) of the Act, 21 U.S.C.
diagnostic tests for detection of SARS-CoV-2 virus and/or diagnosis
justifying the authorization of the emergency use of in vitro
for the duration of time the declaration that circumstances exist
an Emergency Use Authorization (EUA). This test is only authorized
FDA cleared or approved. This test has been authorized by FDA under
amplification tests include RT-PCR and TMA. This test has not been
characteristics determined by LabCorp Laboratories. Nucleic acid
This nucleic acid amplification test was developed and its performance
resources and information.
Visit our website at https://www.labcorp.com/COVID19 for
with mild to moderate symptoms and for hospitalized patients.
treatment options. Treatment options are available for patients
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CORONAVIRUS (COVID-19), PCRLabRoutineCOVID-19 virus detectedExpected: 12/6/22, Expires: 12/6/23
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Oct-17-2022SanDiego Carmen. 1234 Provider Street, Sacramento, CA, 94203, US. tel:+1-5557770123
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No Information
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No Information
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No Information
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No Information
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Reportability Response Information Section
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine03/31/2022 11:31 AM PDT
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["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "39491972|65203906"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "1"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-05-23T19:01:51Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "e6617896-cfff-ef90-588d-0da9f71fd002", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Acute COVID-19Active
Acute pulmonary embolism (disorder)Active
Ineffective airway clearance (finding)Active
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Acute COVID-19", "reference": "Condition/0e346df7-8ea4-583f-5d3c-a4d15461437d"}, {"reference": "Condition/60c9e0a6-a64c-20bf-9b19-ed84b1260605"}, {"display": "Problem - Acute pulmonary embolism (disorder)", "reference": "Condition/43378e45-afc3-84b3-25a2-bc4414689967"}, {"display": "Problem - Ineffective airway clearance (finding)", "reference": "Condition/9a6bef6b-a68c-9efe-09f5-2a70b36878b2"}]}, {"id": "1a8d2a31-4447-e77f-e04c-c0d81c3afe2c", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
inpatient encounter20220522212400+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "a2b2297b-0a38-8cd3-cb66-b803d9a36233", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
Estimated Creatinine Clearance152.57|http://unitsofmeasure.org|mL/min
Art Hct43|http://unitsofmeasure.org|%
HCO3 Art25.2|http://unitsofmeasure.org|mmol/L
POC Pt Temp37.0|http://unitsofmeasure.org|DegC
POC FIO240|http://unitsofmeasure.org|%
POC Allen TestPOS
Art Base Excess1.0|http://unitsofmeasure.org|mmol/L
Art tHB14.0|http://unitsofmeasure.org|gm/dL
Art sO295|http://unitsofmeasure.org|%
Art pO273.0|http://unitsofmeasure.org|mmHg
pH ArterialUnknown
Art pCO239.1|http://unitsofmeasure.org|mmHg
eGFR PediatricNot Reported
Phosphorus3.8|http://unitsofmeasure.org|mg/dL
eGFR Non-African American121|http://unitsofmeasure.org|mL/min/1.73m2
eGFR African American140|http://unitsofmeasure.org|mL/min/1.73m2
Sodium138|http://unitsofmeasure.org|mmol/L
Potassium4.5|http://unitsofmeasure.org|mmol/L
Baso # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.5|http://unitsofmeasure.org|gm/dL
Mono # Auto0.99|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto10.23|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.3|http://unitsofmeasure.org|%
Eos % Auto0.0|http://unitsofmeasure.org|%
Lymph % Auto3.4|http://unitsofmeasure.org|%
Neut % Auto87.0|http://unitsofmeasure.org|%
Calcium8.7|http://unitsofmeasure.org|mg/dL
RDW-SD46.8|http://unitsofmeasure.org|Femtoliters
Immature Grans # Auto0.11|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto0.40|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.4|http://unitsofmeasure.org|%
RDW-CV14.6|http://unitsofmeasure.org|%
Immature Grans %0.9|http://unitsofmeasure.org|%
Eos # Auto0.00|http://unitsofmeasure.org|x10e3/mcL
Chloride107|http://unitsofmeasure.org|mmol/L
BUN8|http://unitsofmeasure.org|mg/dL
Plt264|http://unitsofmeasure.org|x10e3/mcL
WBC11.76|http://unitsofmeasure.org|x10e3/mcL
Uric Acid3.6|http://unitsofmeasure.org|mg/dL
RBC4.74|http://unitsofmeasure.org|x10e6/mcL
MPV11.8|http://unitsofmeasure.org|Femtoliters
MCV87.3|http://unitsofmeasure.org|Femtoliters
MCHC33.3|http://unitsofmeasure.org|gm/dL
MCH29.1|http://unitsofmeasure.org|pg
Mg Lvl2.0|http://unitsofmeasure.org|mg/dL
Hgb13.8|http://unitsofmeasure.org|gm/dL
Hct41.4|http://unitsofmeasure.org|%
Glucose Level134|http://unitsofmeasure.org|mg/dL
CO226|http://unitsofmeasure.org|mmol/L
BUN/Creat RatioUnknown
Anion Gap5|http://unitsofmeasure.org|mmol/L
Creatinine0.77|http://unitsofmeasure.org|mg/dL
Hgb13.8|http://unitsofmeasure.org|gm/dL
Hct42.9|http://unitsofmeasure.org|%
Procalcitonin0.04|http://unitsofmeasure.org|ng/mL
PTT28|http://unitsofmeasure.org|Seconds
PT11.6|http://unitsofmeasure.org|Seconds
Lactic Acid Lvl3.4|http://unitsofmeasure.org|mmol/L
CRP4.40|http://unitsofmeasure.org|mg/dL
INRUnknown
Troponin TNIH2.50|http://unitsofmeasure.org|ng/L
Art Hct44|http://unitsofmeasure.org|%
HCO3 Art22.3|http://unitsofmeasure.org|mmol/L
POC Pt Temp37.0|http://unitsofmeasure.org|DegC
POC Set RR14|http://unitsofmeasure.org|br/min
POC FIO260|http://unitsofmeasure.org|%
POC Allen TestPOS
Art Base Excess-2.2|http://unitsofmeasure.org|mmol/L
Art tHB14.3|http://unitsofmeasure.org|gm/dL
Art sO287|http://unitsofmeasure.org|%
Art pO256.1|http://unitsofmeasure.org|mmHg
pH ArterialUnknown
Art pCO237.5|http://unitsofmeasure.org|mmHg
Troponin TNIH2.50|http://unitsofmeasure.org|ng/L
Lactic Acid Lvl1.6|http://unitsofmeasure.org|mmol/L
Hgb13.7|http://unitsofmeasure.org|gm/dL
Hct43.8|http://unitsofmeasure.org|%
SARS-CoV-2Not Detected
Strep A PCRNot Detected
Influenza ANot Detected
Coronavirus OC43Not Detected
Coronavirus NL63Not Detected
Coronavirus HKU1Not Detected
Coronavirus 229ENot Detected
See CommentComment Charted
MRSA by PCRNot Detected
Ur pHUnknown
Ur Spec GravUnknown
Ur MethadoneNot Detected
Ur Urobilinogen<2.0 mg/dL
Ur BloodNegative
Ur BiliNegative
Ur Leuk EstNegative
Ur ColorYellow
Ur CannabinoidsNot Detected
Ur MucousOccasional /LPF
Ur Squam Epithelial1|http://unitsofmeasure.org|/HPF
Ur BarbituratesDetected
U Legionella AgNegative
Ur WBC1|http://unitsofmeasure.org|/HPF
Ur RBC1|http://unitsofmeasure.org|/HPF
Ur Protein1+
U PCPNot Detected
Ur OpiatesNot Detected
Ur NitriteNegative
Ur KetonesTrace
UR GlucoseNegative
Ur CocaineNot Detected
U Benzodiazepine ScreenNot Detected
Ur BacteriaNone Seen /HPF
Ur ClarityClear
Estimated Creatinine Clearance126.32|http://unitsofmeasure.org|mL/min
HCO3 Art24.7|http://unitsofmeasure.org|mmol/L
POC Pt Temp37.0|http://unitsofmeasure.org|DegC
POC FIO245|http://unitsofmeasure.org|%
POC Allen TestN/A
Art Base Excess0.5|http://unitsofmeasure.org|mmol/L
Art sO291|http://unitsofmeasure.org|%
Art pO262.9|http://unitsofmeasure.org|mmHg
pH ArterialUnknown
Art pCO237.4|http://unitsofmeasure.org|mmHg
Symptomatic as defined by CDC?YES
In ICU?NO
Group care resident?NO
Employed in healthcare?NO
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRNegative
Flu B PCRNegative
Flu A PCRNegative
Troponin TNIH2.50|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
A/G RatioUnknown
eGFR Non-African American109|http://unitsofmeasure.org|mL/min/1.73m2
eGFR African American126|http://unitsofmeasure.org|mL/min/1.73m2
Sodium141|http://unitsofmeasure.org|mmol/L
Potassium3.7|http://unitsofmeasure.org|mmol/L
Baso # Auto0.06|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.3|http://unitsofmeasure.org|gm/dL
Mono # Auto1.50|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto11.66|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.4|http://unitsofmeasure.org|%
Eos % Auto0.2|http://unitsofmeasure.org|%
Lymph % Auto3.4|http://unitsofmeasure.org|%
Neut % Auto84.4|http://unitsofmeasure.org|%
Calcium8.0|http://unitsofmeasure.org|mg/dL
RDW-SD47.7|http://unitsofmeasure.org|Femtoliters
Immature Grans # Auto0.09|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto0.47|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto10.9|http://unitsofmeasure.org|%
RDW-CV14.8|http://unitsofmeasure.org|%
Immature Grans %0.7|http://unitsofmeasure.org|%
Eos # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Chloride110|http://unitsofmeasure.org|mmol/L
BUN9|http://unitsofmeasure.org|mg/dL
Plt265|http://unitsofmeasure.org|x10e3/mcL
WBC13.81|http://unitsofmeasure.org|x10e3/mcL
TP5.0|http://unitsofmeasure.org|gm/dL
RBC4.86|http://unitsofmeasure.org|x10e6/mcL
MPV11.6|http://unitsofmeasure.org|Femtoliters
MCV88.3|http://unitsofmeasure.org|Femtoliters
MCHC31.7|http://unitsofmeasure.org|gm/dL
MCH28.0|http://unitsofmeasure.org|pg
Lactic Acid Lvl2.9|http://unitsofmeasure.org|mmol/L
Hgb13.6|http://unitsofmeasure.org|gm/dL
Hct42.9|http://unitsofmeasure.org|%
Glucose Level116|http://unitsofmeasure.org|mg/dL
CO225|http://unitsofmeasure.org|mmol/L
T Bili0.5|http://unitsofmeasure.org|mg/dL
AST30|http://unitsofmeasure.org|units/L
ALT23|http://unitsofmeasure.org|units/L
Alk Phos52|http://unitsofmeasure.org|units/L
BUN/Creat RatioUnknown
Anion Gap6|http://unitsofmeasure.org|mmol/L
Creatinine0.93|http://unitsofmeasure.org|mg/dL
Ionized Calcium1.14|http://unitsofmeasure.org|mmol/L
D Dimer1.77|http://unitsofmeasure.org|mcg/mL FEU
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Medication NameMedication Start Date
acetylcysteine (acetylcysteine 10% inhalation solution)20220523002700+0000
budesonide (budesonide 0.5 mg/2 mL inhalation suspension)20220523003000+0000
dabigatran (Pradaxa 150 mg oral capsule)20220523002600+0000
ipratropium (Atrovent HFA 17 mcg/inh inhalation aerosol)20220523002600+0000
guaiFENesin (Mucinex)20220523040000+0000
arformoterol20220523020000+0000
budesonide20220523020000+0000
levalbuterol (Xopenex)20220523020000+0000
acetaminophen20220522230700+0000
bisacodyl20220522230700+0000
hydrALAZINE20220522230700+0000
ipratropium-albuterol (DuoNeb)20220522230700+0000
labetalol20220522230700+0000
cefTRIAXone20220523210000+0000
azithromycin20220523220000+0000
methylPREDNISolone (SOLU-Medrol)20220523040000+0000
acetylcysteine (Mucomyst-20 (200mg/mL))20220523020000+0000
midazolam20220523182800+0000
midazolam20220523182700+0000
lidocaine20220523182400+0000
fentaNYL20220523171500+0000
midazolam20220523171500+0000
fentaNYL20220523155900+0000
fentaNYL20220523155900+0000
midazolam (midazolam PF)20220523155900+0000
midazolam (midazolam PF)20220523155900+0000
midazolam (midazolam PF)20220523155900+0000
Lactated Ringers (Lactated Ringers Bolus)20220523132100+0000
Sodium Chloride 0.9% intravenous solution (Sodium Chloride 0.9% Bolus (ADULT))20220522213200+0000
budesonide (Pulmicort Flexhaler 90 mcg/inh inhalation powder)20220523002800+0000
azithromycin20220522213200+0000
cefTRIAXone20220522213200+0000
butalbital/acetaminophen/caffeine (butalbital/acetaminophen/caffeine 50 mg-325 mg-40 mg oral tablet)20220522230000+0000
dexamethasone20220522220000+0000
Sodium Chloride 0.9% intravenous solution (Sodium Chloride 0.9% Bolus (ADULT SEPSIS))20220522213200+0000
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Social History ObservationSocial History Observation Result
Birth SexM
Travel HistoryCOVID-19 Resolved-Yes (qualifier value)
Travel HistoryCOVID-19 Test Date-
Travel HistoryCOVID-19 Previously tested-Yes, negative result
Travel HistoryInfluenza vaccination status (observable entity)-Received prior to admission, during current flu season
Travel HistoryCOVID-19 Previously tested-
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
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Drugs Of Abuse Comprehensive Screen, UrLabSTAT12/23/2022 11:13 AM PST
Scheduled Orders
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Drugs Of Abuse Comprehensive Screen, UrLabRoutineOne Time for 1 Occurrences starting 12/23/22 until 12/23/22
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Stephen NewtonCONSULTINGActive
Start: March 12th, 2022
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Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
anthraxMarch 15th, 2022 7:20am1PFIZER & OTHER CHARACTERSLOT9911Z
RIGRAPID HEART BEAT
anthraxMarch 24th, 2022 9:34am2JOHNSON AND JOHNSONLOT942X
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Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
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Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 24th, 2022 9:38am
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DR DEBRA A ALEXANDER JR, PHDFAMILYActive
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Active ProblemsNoted Date
Hashimoto''s encephalopathy10/11/22
Motion sickness10/11/22
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
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DateTypeDepartmentCare TeamDescription
10/11/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
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Reportability Response Information Section
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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
alum-mag hydroxide-simeth (MAALOX) 200-200-20 mg/5 mL oral suspension 15 mL15 mL, Oral, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 dose, Order WILL be automatically substituted with P&T Approved equivalent per protocol. SHAKE WELL prior to use.Given09/28/2022 8:37 PM PDT15 mL
aspirin tablet 325 mg325 mg, Oral, ONCE, On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT325 mg
lidocaine (XYLOCAINE) 2% viscous oral solution5 mL, Swish and Spit, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT5 mL
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Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "8cfa32e2-c143-2ba9-dc72-266a3ba673c6", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Close exposure to COVID-19 virusCoronavirus infection (Primary Dx);
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Reportability Response Information Section
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(ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.297.3.7.8.688883.480726', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.297.3.7.8.688883.480726", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.297.3.7.8.688883.480726", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "a0c14072-c71c-11ec-8119-c301d81100b2", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "10"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial 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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine04/28/2022 10:52 AM PDT
Clostridium difficile A and B EIAMicrobiologyRoutine04/28/2022 10:52 AM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/2f553a4b-e095-2570-dc87-859ddf3a796c"}]}, {"id": "A4FF424C-C71C-11EC-B490-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter (statuses as of 04/28/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "2cfa1813-6ae8-c2d9-e243-2a17fef007cb", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "A50468E4-C71C-11EC-B490-C301D81100B2", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Campylobacter, NAAT", "reference": "Observation/da616986-36ea-94b5-f370-600cad0019a6"}, {"display": "C. Diff Toxin A/B, NAAT", "reference": "Observation/ff4940ab-05a7-85b4-4658-b4a238d366e1"}, {"display": "Plesiomonas shigelloides, NAAT", "reference": "Observation/616d58c6-3f46-b471-bad2-9d528a6e4413"}, {"display": "Salmonella, NAAT", "reference": "Observation/0a607f92-acd1-eaee-f3d1-ac22682a6e3d"}, {"display": "Vibrio, NAAT", "reference": "Observation/f5270f18-c453-d71f-abb6-42498abeac84"}, {"display": "Vibrio cholerae, NAAT", "reference": "Observation/5a9876f0-68e4-28f7-730f-b221c467ffec"}, {"display": "Yersinia enterocolitica, NAAT", "reference": "Observation/591877c5-3b17-6a32-4f0f-7e8aca951dbd"}, {"display": "E. Coli O157, NAAT", "reference": "Observation/01bad959-06aa-9cbf-d309-b76cb75fe2f6"}, {"display": "E. Coli (EAEC), NAAT", "reference": "Observation/d014be01-1c5d-984c-1c51-03d3648d1d10"}, {"display": "E. Coli (EPEC), NAAT", "reference": "Observation/103350df-a471-6b82-d205-91d31468b518"}, {"display": "E. Coli (ETEC), NAAT", "reference": "Observation/83eaad2a-dd32-e186-44ee-ae03b2842e26"}, {"display": "Shiga-Like Toxin E. Coli (STEC), NAAT", "reference": "Observation/8464ea68-8c0c-6255-4926-1b260e4e6e2d"}, {"display": "Shigella/EIEC, NAAT", "reference": "Observation/c9afa4c1-95e3-edbc-66a4-ad56c99c8245"}, {"display": "Cryptosporidium, NAAT", "reference": "Observation/f9d4e57d-8c7e-c234-4661-7b51192dc4e8"}, {"display": "Cyclospora cayetanensis, NAAT", "reference": "Observation/fd40c643-5fb3-55cc-c746-7743406b0d8a"}, {"display": "E. histolytica, NAAT", "reference": "Observation/37fa05ba-347c-5df6-5bcd-230c81debf35"}, {"display": "Giardia lamblia, NAAT", "reference": "Observation/6632a00c-b284-df4f-d352-17c977477c7b"}, {"display": "Adenovirus F 40/41, NAAT", "reference": "Observation/247f6e32-8d9d-c6a5-6ea0-bfb28eccce1d"}, {"display": "Astrovirus, NAAT", "reference": "Observation/dddc8b1b-f199-e8d5-92f8-3f613fc28de7"}, {"display": "Norovirus, NAAT", "reference": "Observation/8534583a-c587-9ad3-cfa7-0d4d534d7c6d"}, {"display": "Rotavirus A, NAAT", "reference": "Observation/334bcdba-d189-02bb-eb08-7ca6b368ebc7"}, {"display": "Sapovirus, NAAT", "reference": "Observation/155151c3-bcfb-ac26-a050-dce07075c62a"}, {"display": "Lab Interpretation", "reference": "Observation/257f4503-edd7-8f59-dfd9-6f12915fec1e"}]}, {"id": "a24105bf-071e-dc7d-ce30-94ca6f2d040b", "title": "Social History", "text": {"status": "generated", "div": "
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Never Assessed
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Not on file
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DateTypeDepartmentCare TeamDescription
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NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
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Active ProblemsNoted Date
Bipolar I disorder11/19/20
Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
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Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Yes0 (1 standard drink = 0.6 oz pure alcohol)
Sex Assigned at BirthDate Recorded
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DateTypeDepartmentCare TeamDescription
9/28/22Lab RequisitionPROVIDENCE ST JOSEPH MED CTR LABORATORY501 S Buena Vista StBurbank, CA 91505-4809818-847-6060Test, Ambhp1, MD2001 LIND AVERENTON, WA 98059
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[{"display": "DTAP-HIB-IPV (PENTACEL)"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/7a4b0e4b-ca8a-a39b-1b44-19efe2c9ee5c"}}, {"fullUrl": "urn:uuid:b5d003f7-cfe2-56a4-6e91-07307f25aa83", "resource": {"resourceType": "Immunization", "id": "b5d003f7-cfe2-56a4-6e91-07307f25aa83", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "57643"}], "occurrenceDateTime": "2020-11-10", "note": {"text": "TDAP, (ADOL/ADULT)"}, "vaccineCode": {"coding": [{"code": "49281-400-10", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "369258741", "manufacturer": {"reference": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/9e9c2175-2960-491a-ab7a-d7e54bac3726"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/b5d003f7-cfe2-56a4-6e91-07307f25aa83"}}, {"fullUrl": 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Problem or DiagnosisProblem Status
Morbid obesity (disorder)Active
Bronchitis (disorder)Active
Hypertensive disorder, systemic arterial (disorder)Active
Disease caused by 2019-nCoVActive
Sleep apnea (finding)Active
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Encounter ReasonDate of Encounter
Outpatient20220407123000+0000
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Lab Test NameLab Test Result ValueLab Test Result Date
Hct43.2|http://unitsofmeasure.org|%
U Beta hCG QlNegative
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lisinopril (lisinopril 10 mg oral tablet)20220414172700+0000
acetaminophen (Ofirmev)20220419153100+0000
ceFAZolin (Ancef/Kefzol)20220419140000+0000
hydrocodone-acetaminophen (Norco 5 mg-325 mg oral tablet)20220419153100+0000
ondansetron (Zofran)20220419153100+0000
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prochlorperazine (Compazine)20220419153100+0000
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ondansetron20220419151900+0000
diphenhydrAMINE20220419151900+0000
fentaNYL20220419151900+0000
fentaNYL20220419151900+0000
morphine20220419151900+0000
morphine20220419151900+0000
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labetalol (labetalol (ANES))20220419155600+0000
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phenylephrine (phenylephrine (ANES))20220419153300+0000
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dexamethasone (dexAMETHasone 4 mg/mL injectable solution (ANES))20220419150700+0000
esmolol (esmolol (ANES))20220419150700+0000
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lidocaine (Xylocaine-MPF 1% injectable solution (ANES))20220419150200+0000
propofol (Diprivan 10 mg/mL intravenous emulsion (ANES))20220419150200+0000
rocuronium (rocuronium (ANES))20220419150200+0000
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morphine (morphine (ANES))20220419145700+0000
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enoxaparin (Lovenox)20220419140000+0000
azithromycin (azithromycin 250 mg oral tablet)20220414172800+0000
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predniSONE (predniSONE 5 mg oral tablet)20220414172600+0000
bupivacaine-epinephrine (bupivacaine-EPINEPHrine 0.25%)20220419133800+0000
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Vaccine NameVaccination Date
SARS-COV-2 (COVID-19 MODERNA) mRNA-1273Tue Mar 15 00:00:00 GMT 2022
SARS-COV-2 (COVID-19 MODERNA) mRNA-1273Tue Apr 27 00:00:00 GMT 2021
SARS-COV-2 (COVID-19 MODERNA) mRNA-1273Tue Mar 30 00:00:00 GMT 2021
"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "a68223e8-6948-25cc-882f-5eeca2c79f98", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Birth SexF
Travel HistoryCOVID-19 Test Date-
Travel HistoryCOVID-19 Previously tested-Yes, negative result
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryPregnancy Status-Negative HCG result
Travel HistoryCOVID-19 Test Date-
Travel HistoryCOVID-19 Previously tested-Yes, result pending
Travel HistoryExposure to severe acute respiratory syndrome coronavirus 2 (event)-Yes (qualifier value)
Travel HistoryMERS-CoV Travel History-Yes (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMERS-CoV Symptoms-Cough (finding)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryMRSA Sceen Dialysis or Venous Access-No (qualifier value)
Travel HistoryMRSA Screen Admit From Non-home Loc-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-Mexico (geographic location)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-Mexico (geographic location)
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Narrative Text
Unknown History of Present Illness
"}, "code": {"coding": [{"code": "10164-2", "display": "History of Present Illness", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "7afba9b9-e112-558e-a44c-72f2f0311885", "title": "Reason For Visit", "text": {"status": "generated", "div": "
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Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
CORONAVIRUS (COVID-19), PCRLabRoutineCoronavirus infectionClose exposure to COVID-19 virusOrdered: 9/28/22
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Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
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DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Close exposure to COVID-19 virusCoronavirus infection (Primary Dx);
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Active ProblemsNoted Date
Hashimoto''s encephalopathy10/11/22
Motion sickness10/11/22
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
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Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
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DateTypeDepartmentCare TeamDescription
10/11/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Hashimoto''s encephalopathyMotion sickness, sequela; Coronavirus infection; Close exposure to COVID-19 virus (Primary Dx);
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Kevin Lanzilloattending physicianActive
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MRS. PUMSEN R SOR SRprimary care physicianActive
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Sandra E Hoytadmitting physicianActive
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DR. LARDIEREFAMILYActive
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Brian Leary , MDREFERRINGActive
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DR. DAVID CONNOROTHERActive
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Author
CANTON MEDICAL CENTER OF MASSACHUSETTS-North Canton FacilitSandra Hoyt
AuthoredMarch 22nd, 2022 11:23am
Follow-up with PSOR referral and PCP.
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WHITE BLOOD COUNT
HEMOGLOBIN
HEMATOCRIT
MEAN CELL VOLUME
MEAN CORPUSCULAR HEMOGLOBIN
PLATELET COUNT
COVID19 OTHER VENDOR 94500-6March 18th, 2022 2:48pmMarch 18th, 2022
COVID-19 OV 94500-6March 17th, 2022 5:06pmMarch 31st, 2022
HIV Test: LOINC 10351-5March 22nd, 2022 11:26amMarch 28th, 2022
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Cardiac abnormalityPUMSEN''S PROVIDER GROUPWork Phone: +1(508)789-7891
BROCKTON MA 02301SUITE 1010110 MAIN ST
Medication NameStart DateInstructions
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Benazepril HCl (Benazepril) 40 MG TABLETMarch 22nd, 2022 8:32am
Cyclobenzaprine (CYCL10T) 10 MG TABMarch 21st, 2022 4:19pm
Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 21st, 2022 3:59pm
Rifampin - RXCUI C198201 (RIFAMPIN150 MG) 150 MG CAPMarch 17th, 2022 3:48pm
Severe Acute Respiratory Syndrome (SARS)

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["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}, {"fullUrl": "urn:uuid:dda633bd-cd7c-024d-a660-f8257661bd8b", "resource": {"resourceType": "Immunization", "id": "dda633bd-cd7c-024d-a660-f8257661bd8b", "identifier": [{"system": "urn:ietf:rfc:3986", "value": "urn:uuid:bab4bd75-ab7b-11ec-81e0-9e7eef92c510"}], "protocolApplied": [{"doseNumberPositiveInt": "1"}], "occurrenceDateTime": "2022-03-24T09:38:00-04:00", "note": {"text": "anthrax"}, "vaccineCode": {"coding": [{"code": "24", "display": "anthrax", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "LOT552Z", "manufacturer": {"reference": "Organization/1e2d10a1-e4d3-ac11-3b25-56396aee4ba2"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/c41c9554-989b-492a-be3d-dcb9037f1b3d"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": 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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Drugs Of Abuse Comprehensive Screen, UrLabSTAT12/23/2022 11:13 AM PST
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
Drugs Of Abuse Comprehensive Screen, UrLabRoutineOne Time for 1 Occurrences starting 12/23/22 until 12/23/22
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Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
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DateTypeDepartmentCare TeamDescription
10/11/22EmergencyHOAG MEMORIAL HOSPITAL NEWPORT EMERGENCY CENTER1 HOAG DRNEWPORT BEACH, CA 92663-4162949-764-8372
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Reportability Response Information Section
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remdesivirUnknown
remdesivirUnknown
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Vaccine NameVaccination Date
influenza virus vaccine, liveWed Nov 10 00:00:00 GMT 2021
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Social History ObservationSocial History Observation Result
Occupation HistoryStudent
Travel HistoryCovid Test Result-Negative (qualifier value)
Travel HistoryCovid Test Result-Negative (qualifier value)
Travel HistoryCongestion or Runny Nose-No (qualifier value)
Travel HistoryNausea-No (qualifier value)
Travel HistoryPositive COVID-19 Test-No (qualifier value)
Travel HistoryLoss of Taste or Smell-No (qualifier value)
Travel HistoryReported Fever-No (qualifier value)
Travel HistoryDry Cough-No (qualifier value)
Travel HistorySymptomatic Health Care Professional/SNF-No (qualifier value)
Travel HistorySymptomatic After Exposure to Contagion-No (qualifier value)
Travel HistoryDroplet, Contact Isolation Verification-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryUnexplained Hemorrhage, Bleed or Bruise-No (qualifier value)
Travel HistoryAbnormal Bleeding-No (qualifier value)
Travel HistoryAbdominal (Stomach Pain)-No (qualifier value)
Travel HistoryDifficulty breathing (finding)-No (qualifier value)
Travel HistoryChills Infectious Disease-No (qualifier value)
Travel HistoryBreastfeeding-Not applicable (qualifier value)
Travel HistoryDiarrhea (finding)-No (qualifier value)
Travel HistoryVomiting (disorder)-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryDyspnea (finding)-No (qualifier value)
Travel HistoryIllness With Generalized Rash-No (qualifier value)
Travel HistoryMuscle pain (finding)-No (qualifier value)
Travel HistoryHeadache (finding)-No (qualifier value)
Travel HistorySexual Orientation-Not applicable (qualifier value)
Travel HistorySexually active (finding)-Not applicable (qualifier value)
Travel HistoryCongestion or Runny Nose-No (qualifier value)
Travel HistoryNausea-No (qualifier value)
Travel HistoryPositive COVID-19 Test-No (qualifier value)
Travel HistoryLoss of Taste or Smell-No (qualifier value)
Travel HistoryReported Fever-No (qualifier value)
Travel HistoryDry Cough-No (qualifier value)
Travel HistorySymptomatic Health Care Professional/SNF-No (qualifier value)
Travel HistorySymptomatic After Exposure to Contagion-No (qualifier value)
Travel HistoryDroplet, Contact Isolation Verification-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryUnexplained Hemorrhage, Bleed or Bruise-No (qualifier value)
Travel HistoryAbnormal Bleeding-No (qualifier value)
Travel HistoryAbdominal (Stomach Pain)-No (qualifier value)
Travel HistoryDifficulty breathing (finding)-No (qualifier value)
Travel HistoryChills Infectious Disease-No (qualifier value)
Travel HistoryDiarrhea (finding)-No (qualifier value)
Travel HistoryVomiting (disorder)-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryDyspnea (finding)-No (qualifier value)
Travel HistoryIllness With Generalized Rash-No (qualifier value)
Travel HistoryMuscle pain (finding)-No (qualifier value)
Travel HistoryHeadache (finding)-No (qualifier value)
Travel HistoryInfectious Diseases Health History-None (qualifier value)
Travel HistorySexual Orientation-Not applicable (qualifier value)
Travel HistorySexually active (finding)-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
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Narrative Text
Other coronavirus as the cause of diseases classified elsewhere
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text
Resp Distress
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Reportability Response Information Section
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This panel is not to be used for legal drug cases. The presence of other compounds in the patient''s specimen may cause a false positive. Correlate the results with clinical evaluation and other diagnostic testing procedures.

.....DRUG...... \u00a0 \u00a0 \u00a0 \u00a0 THRESHOLD DETECTION LIMIT
AMPH/METHAMPHET \u00a0 \u00a0 \u00a0 \u00a0 >1000 ng/mL
BARBITUATES \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 200 ng/mL
BENZODIAZEPINES \u00a0 \u00a0 \u00a0 \u00a0 > 200 ng/mL
COCAINE \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 300 ng/mL
OPIATES \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 300 ng/mL
PCP \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a025 ng/mL
THC \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a050 ng/mL
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Team Status: Active
MemberRoleStatusDates
Adam Sheradmitting physicianActive
Start: March 12th, 2022
MCUTLERattending physicianActive
Start: March 12th, 2022
DR MEDITECHprimary care physicianActive
Start: March 12th, 2022
AMANDA NOELREFERRINGActive
Start: March 12th, 2022
AMANDA PARLATOFAMILYActive
Start: March 12th, 2022
Rickey RobertsOTHERActive
Start: March 12th, 2022
Stephen NewtonCONSULTINGActive
Start: March 12th, 2022
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Assigned Birth SexMale
Gender Identityunknown
Sexual OrientationDo not know
"}, "code": {"coding": [{"code": "29762-2", "display": "Social History", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/3d950365-4c94-05a3-0f30-ae741089137b"}]}, {"id": "be17251e-cbc0-688c-6388-eebd0f5fc0e7", "title": "Problems", "text": {"status": "generated", "div": "Active Problems
Medical ProblemOnset DateStatus
AnthraxActive
COVID-19Active
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Anthrax", "reference": "Condition/c172d574-fdc1-89f7-3278-005764c4e297"}, {"display": "Problem - Infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)", "reference": "Condition/f3f66c7c-b9ae-57ac-18e4-f6ff681f0e06"}]}, {"id": "d8361422-5b78-3451-1ceb-044df5fa4cbd", "title": "Immunizations", "text": {"status": "generated", "div": "
ImmunizationEvent DateNot Given ReasonDose NumberManufacturerLot NumberVaccine Information Statement (VIS) Detail
Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
anthraxMarch 15th, 2022 7:20am1PFIZER & OTHER CHARACTERSLOT9911Z
RIGRAPID HEART BEAT
anthraxMarch 24th, 2022 9:34am2JOHNSON AND JOHNSONLOT942X
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Vital ReadingResultReference RangeCollection Date/Time
Height65 [in_i]March 14th, 2022 1:48pm
Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
Weight68.039 kgMarch 14th, 2022 1:48pm
BMI (Body Mass Index)25.0 kg/m2March 14th, 2022 1:48pm
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MemberRoleStatusDates
Kevin Lanzilloattending physicianActive
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MRS. PUMSEN R SOR SRprimary care physicianActive
Start: March 17th, 2022
Sandra E Hoytadmitting physicianActive
Start: March 17th, 2022
DR. LARDIEREFAMILYActive
Start: March 17th, 2022
Brian Leary , MDREFERRINGActive
Start: March 17th, 2022
DR. DAVID CONNOROTHERActive
Start: March 17th, 2022
MCUTLERCONSULTINGActive
Start: March 17th, 2022
Samuel HoytNext of KinActive
Start: March 17th, 2022
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Never smoker (Never Smoked)March 17th, 2022 2:54pm
StatusDate of Observation
Not pregnantMarch 17th, 2022
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Gender Identityunknown
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January 18th, 2018 - February 18th, 2018
my family.Traveled to Singapore, Malaysia and Bali with
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HeadacheActive
Heart abnormalityActive
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RIFA150C15 (Rifampin ) 150 MG CAPSULE150MGORALBIDMarch 18th, 2022 3:30pmMarch 18th, 2022 3:30pm
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Admitted InpatientDot Facility (No ARM)March 17th, 2022 2:45pmKevin Lanzillo
Recent DiagnosisOnset Date
COVID-19March 14th, 2022
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NMI Testing UtilityMarch 23rd, 2022 4:51pm

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Author
CANTON MEDICAL CENTER OF MASSACHUSETTS-North Canton FacilitSandra Hoyt
AuthoredMarch 22nd, 2022 11:23am
Follow-up with PSOR referral and PCP.
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WHITE BLOOD COUNT
HEMOGLOBIN
HEMATOCRIT
MEAN CELL VOLUME
MEAN CORPUSCULAR HEMOGLOBIN
PLATELET COUNT
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HIV Test: LOINC 10351-5March 22nd, 2022 11:26amMarch 28th, 2022
Reason for ReferralReferral Start DateProviderProvider Contact InformationProvider Address
Cardiac abnormalityPUMSEN''S PROVIDER GROUPWork Phone: +1(508)789-7891
BROCKTON MA 02301SUITE 1010110 MAIN ST
Medication NameStart DateInstructions
Atorvastatin Calcium Tablet Dispense (LIPITOR - WITH DISPENSE) 40 MG TABMarch 17th, 2022 3:48pm
Benazepril HCl (Benazepril) 40 MG TABLETMarch 22nd, 2022 8:32am
Cyclobenzaprine (CYCL10T) 10 MG TABMarch 21st, 2022 4:19pm
Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 21st, 2022 3:59pm
Rifampin - RXCUI C198201 (RIFAMPIN150 MG) 150 MG CAPMarch 17th, 2022 3:48pm
Severe Acute Respiratory Syndrome (SARS)

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NameAdministration DatesNext Due
DTaP, 5 pertussis antigens vaccine (DAPTACEL)06/15/2021
Hep B, adult vaccine (Engerix/Recombivax)09/08/2020
SARS-COV-2 (COVID-19) Spikevax Vaccine, Moderna01/22/2021
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
PCR SARS-CoV-2 and Influenza A/BLabRoutine07/27/2022 3:49 PM CDT
PCR SARS-CoV-2 and Influenza A/BLabRoutine07/27/2022 3:49 PM CDT
PCR SARS-CoV-2 and Influenza A/BLabRoutine07/27/2022 3:49 PM CDT
PCR SARS-CoV-2 and Influenza A/BLabRoutine07/27/2022 3:49 PM CDT
PCR SARS-CoV-2 and Influenza A/BLabRoutine07/27/2022 3:49 PM CDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
PCR Hepatitis C Virus QtLabRoutineOrdered: 5/12/22
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Active ProblemsNoted Date
COVID toes7/13/22
Chest pain on breathing5/26/22
Type 1 diabetes2/28/22
Overview:Formatting of this note might be different from the original.
08/30/21 28.69 kg/m\u00b2BMI Readings from Last 1 Encounters:
Plague pneumonia6/16/21
Absence of menstruation6/12/18
Foot callus8/11/17
Overview:Formatting of this note might be different from the original.
Ouch.
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Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
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DateTypeDepartmentCare TeamDescription
2/18/22Transcribe OrdersVanderbilt University Adult Hospital1211 Medical Center DrNashville, TN 37232615-322-5000Tech, Lab, MLT
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Reportability Response Information Section
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"Observation/d3a8b35b-4563-2594-abd7-7d433ff0f7e8"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/6146a6d6-1b2c-26e8-82db-dab711b57aeb"}}, {"fullUrl": "urn:uuid:0c7d57dc-a961-8ffe-4593-540dba80b4b0", "resource": {"resourceType": "Observation", "id": "0c7d57dc-a961-8ffe-4593-540dba80b4b0", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.7.798268.1000", "value": "2061338"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2022-03-11T19:27:37Z", "valueString": "FISH REPORT

Request#:CG-22-0000003
Service date:3/11/2022 13:05


FISH IMPRESSION:

Abnormal for homozygous deletion of CDKN2A locus at 9p21 in __% of cells.

FISH KARYOTYPE:



nuc ish (DXZ1x1,DYZ3x1,D18Z1x2)[200]

\u00a0
\u00a0
\u00a0



COMMENTS:



Results of the FISH studies with the 21 DNA probes described above were analyzed in at least 200 cells per probe and no abnormal signal patterns were detected for the target regions of chromosomes 1, 4, 7, 9, 10, 11, 12, 14, 17, 19, 21, and 22.

Normal cut off values for probes:

1.0% for t(1;19) PBX1/TCF3
1.0% for t(9;22) BCR/ABL1
1.0% for KMT2A (11q23)
1.0% for t(12;21) ETV6/RUNX1
1.0% for IKZF1/CEP7
3.0% for CEP 4
2.0% for CEP 10
2.0% for CEP 17
1.0% for CDKN2A/CEP9 (9p21)
1.0% for IGH breakapart
1.0% for ABL2 breakapart
1.0% for ABL1 breakapart

These probes were developed by Vysis and their performance characteristics determined by VUMC as required by the CLIA ''88 regulations. \u00a0These probes have not been cleared or approved by the U.S. Food and Drug administration.


Ferrin Courtney Wheeler, PhD, FACMG
reviewed and approved

Electronically signed out by:
Mavrak, Geoffrey A

on 03/11/2022

Clinical History: \u00a0ALL
Specimen List: Blood
Date In Lab: 3/11/2022 13:09
Date Collected: 3/11/2022 13:05

Testing performed at Vanderbilt Cytogenetics One Hundred Oaks Laboratory, Suite 21100, 719 Thompson Ln,
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A detected result is positive and indicates the presence of the virus in the sample. A not detected result indicates that the test did not detect the virus in the sample."}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Nares"}, {"url": "specimen collection time", "valueDateTime": "2022-03-11T19:05:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-03-11T19:46:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.478.3.7.2.798268.2061339.Comp1"}]}, {"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "840539006", "system": "http://snomed.info/sct"}]}], "subject": {"reference": "Patient/7fa3a412-28d1-46d4-a4ef-5c3572b96649"}, "performer": [{"display": "VUMC CERNER LAB", "reference": "Organization/e3ece69c-0968-59c9-47dd-f16db731621a"}]}, "request": {"method": "PUT", "url": "Observation/b1ba1ccd-e2cd-3261-7460-be0abb6508cb"}}, {"fullUrl": "urn:uuid:b4965bf2-9a65-df39-676b-acc5151db64b", "resource": {"resourceType": "Observation", "id": "b4965bf2-9a65-df39-676b-acc5151db64b", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.6.798268.2000", "value": "2061339.2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "16535", "display": "SARS-CoV-2 Nucleic Acid Method (Comment)", "system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.768282"}]}, "effectiveDateTime": "2022-03-11T19:49:19Z", "valueString": "Nares
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VPLS clients: \u00a0 See separate report sent to client.", "note": [{"text": "This test was performed at: Quest Laboratory,Location Varies,,,,,,"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Oral"}, {"url": "specimen collection time", "valueDateTime": "2022-03-29T18:53:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-03-29T19:07:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.478.3.7.2.798268.2061344.Comp1"}]}], "subject": {"reference": "Patient/7fa3a412-28d1-46d4-a4ef-5c3572b96649"}, "performer": [{"display": "VUMC CERNER LAB", "reference": "Organization/e3ece69c-0968-59c9-47dd-f16db731621a"}]}, "request": {"method": "PUT", "url": "Observation/6fc06f11-d0f4-9553-2798-e8dd822678fe"}}, {"fullUrl": "urn:uuid:db8797cb-3129-eff4-9d78-a04b2326f0a2", "resource": {"resourceType": "Observation", "id": "db8797cb-3129-eff4-9d78-a04b2326f0a2", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.798268", "value": "2061344"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2022-03-29T20:10:54Z", "valueCodeableConcept": {"coding": [{"code": "16", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Oral"}, {"url": "specimen collection time", "valueDateTime": "2022-03-29T18:53:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-03-29T19:07:00Z"}]}], "subject": {"reference": "Patient/7fa3a412-28d1-46d4-a4ef-5c3572b96649"}}, "request": {"method": "PUT", "url": "Observation/db8797cb-3129-eff4-9d78-a04b2326f0a2"}}, {"fullUrl": "urn:uuid:c86958f4-4bd2-7450-15ff-4c490820f58f", "resource": {"resourceType": "DiagnosticReport", "id": "c86958f4-4bd2-7450-15ff-4c490820f58f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.798268", "value": "2061345"}], "status": "final", "code": {"coding": [{"code": "201700", "display": "Pharmacogenomics", "system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.696580"}]}, "effectivePeriod": {"start": "2022-03-31T22:36:00Z", "end": "2022-03-31T22:36:00Z"}, "subject": {"reference": "Patient/7fa3a412-28d1-46d4-a4ef-5c3572b96649"}, "performer": [{"reference": "Organization/22c6cdd0-bde1-e220-9ba4-2c2802f795ad"}], "result": [{"reference": "Observation/2e9477e8-412b-905c-270f-16ca12bff791"}, {"reference": "Observation/ed66ccf7-584a-1142-b9a4-8fe01b6f21fb"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/c86958f4-4bd2-7450-15ff-4c490820f58f"}}, {"fullUrl": "urn:uuid:2e9477e8-412b-905c-270f-16ca12bff791", "resource": {"resourceType": "Observation", "id": "2e9477e8-412b-905c-270f-16ca12bff791", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.7.798268.1000", "value": "2061345"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2022-03-31T22:51:17Z", "valueString": "Pharmacogenomics: Final Report

Request #: MD-22-0000041

Service Date: 3/31/2022 17:36

Reason for Request: Genotyping for Determination of Drug Efficacy, Dosage and Safety

Type of Specimen: DNA

Date Received: 3/31/2022 17:44

Date Reported: 3/31/2022 17:51

Interpretation:
Results from this assay may indicate dosage adjustments or medication alternatives that should be considered for this patient. Additional information regarding the implications of these results is available at www.mydruggenome.org.

For VUMC patients, clinical decision support regarding the management of this patient with respect to specific drugs based upon the patient''s genotype as listed below is available in the patient''s electronic medical record under Genomic Indicators. Clinical decision support may also be provided for some drugs through order entry and medication prescribing tools utilized within the VUMC system.



Comments:

Results:

CYP2C19 - \u00a0Cancelled

CYP2C9 - \u00a0 Cancelled

CYP2D6 - \u00a0 Cancelled \u00a0

CYP3A5 - \u00a0 Cancelled

CYP4F2 - \u00a0 Cancelled

DPYD - \u00a0 \u00a0 Cancelled

NUDT15 - \u00a0 Cancelled

SLCO1B1 - \u00a0Cancelled \u00a0 \u00a0 \u00a0

TPMT - \u00a0 \u00a0 Cancelled

VKORC1 - \u00a0 Cancelled \u00a0 \u00a0
\u00a0
These results should be correlated with other laboratory and clinical findings and additional testing should be considered if clinically indicated.
\u00a0 \u00a0

Methodology:

DNA was extracted from this specimen and screened for 37 variants in 10 genes that are associated with drug absorption, distribution, metabolism, excretion or response. The reported genotypes were determined using PCR amplification and oligonucleotide primers specific for each interrogated region of the genes listed within this panel. Fluorophore labeled probes were used to identify each variant.

Variants analyzed in this assay include: CYP2C19 *2, *3, *4, *6, *8, *17; CYP2C9 *2, *3, *6, *8; CYP3A5 *3, *6, *7; CYP4F2 *3; DPYD *2A, *13, c.557A>G, c.1236G>A (HapB3), c.2846A>T; \u00a0NUDT15 *2 or *3; SLCO1B1 *5; TPMT *2, *3B, *3C, *4; VKORC1 promoter variant c.-1639G>A; and CYP2D6 copy number and variants *2, *2A, *3, *4, *6, *7, *9, *10, *17, *29 and *41. A *1 allele is considered the reference (normal) sequence and is reported if none of the variants analyzed for a particular gene is detected. This assay is specific for the variants listed above and cannot exclude the presence of other variants within these genes that may affect the pharmacologic function of the protein product encoded by these genes. In most cases, variants for a particular gene exist on separate alleles; however, for individuals in which multiple variants in the same gene are detected, this assay cannot determine if the variants are on the same allele or on different alleles. Further, due to the highly polymorphic
nature of these regions, rare variants may exist that could affect the sensitivity or specificity of this assay and lead to a false-negative or a false-positive result.


Electronically signed out by:
Barba, Elizabeth

on 03/31/2022

This assay has not been cleared or approved by the US Food and Drug Administration. The performance of this assay was tested and validated prior to use for patient testing. This test is used for clinical purposes and should not be regarded as investigational or research. This laboratory is regulated by the Clinical Laboratory Improvement Act of 1988.", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "DNA"}, {"url": "specimen collection time", "valueDateTime": "2022-03-31T22:36:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-03-31T22:44:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.478.3.7.2.798268.2061345.Narrative"}]}], "subject": {"reference": "Patient/7fa3a412-28d1-46d4-a4ef-5c3572b96649"}, "performer": [{"display": "VUMC CERNER LAB", "reference": "Organization/e3ece69c-0968-59c9-47dd-f16db731621a"}]}, "request": {"method": "PUT", "url": "Observation/2e9477e8-412b-905c-270f-16ca12bff791"}}, {"fullUrl": "urn:uuid:ed66ccf7-584a-1142-b9a4-8fe01b6f21fb", "resource": {"resourceType": "Observation", "id": "ed66ccf7-584a-1142-b9a4-8fe01b6f21fb", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.798268", "value": "2061345"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2022-03-31T22:51:17Z", "valueCodeableConcept": {"coding": [{"code": "16", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "DNA"}, {"url": "specimen collection time", "valueDateTime": "2022-03-31T22:36:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-03-31T22:44:00Z"}]}], "subject": {"reference": "Patient/7fa3a412-28d1-46d4-a4ef-5c3572b96649"}}, "request": {"method": "PUT", "url": "Observation/ed66ccf7-584a-1142-b9a4-8fe01b6f21fb"}}, {"fullUrl": "urn:uuid:b0f590a6-4bf5-7add-9716-2bd3ba6defb2", "resource": {"resourceType": "DiagnosticReport", "id": "b0f590a6-4bf5-7add-9716-2bd3ba6defb2", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.798268", "value": "2061347"}], "status": "final", "code": {"coding": [{"code": "118330", "display": "Cytogenomic SNP microarray", "system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.696580"}]}, "effectivePeriod": {"start": "2022-04-04T16:55:00Z", "end": "2022-04-04T16:55:00Z"}, "subject": {"reference": "Patient/7fa3a412-28d1-46d4-a4ef-5c3572b96649"}, "performer": [{"reference": "Organization/22c6cdd0-bde1-e220-9ba4-2c2802f795ad"}], "result": [{"reference": "Observation/2a4f8fb5-f957-3c30-1353-a30aa441a12b"}, {"reference": "Observation/2e70be1d-fa6c-0256-cf67-f695f5bba1ac"}, {"reference": "Observation/97b316f7-bb96-051f-adba-72ddc4ae5825"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/b0f590a6-4bf5-7add-9716-2bd3ba6defb2"}}, {"fullUrl": "urn:uuid:2a4f8fb5-f957-3c30-1353-a30aa441a12b", "resource": {"resourceType": "Observation", "id": "2a4f8fb5-f957-3c30-1353-a30aa441a12b", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.7.798268.1000", "value": "2061347"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2022-04-18T19:57:02Z", "valueString": "MICROARRAY REPORT- Corrected

Request#: CG-22-0000006
Service date: 4/4/2022 11:55

Microarray Result:
Normal female

Microarray Interpretation:
SNP chromosomal microarray analysis (CMA) of a blood sample from this patient demonstrated no copy number changes of known clinical significance. No large regions of homozygosity (ROH) were detected. The ISCN nomenclature describing this result is: arr(X,1-22)x2.
Electronically signed out by:
Benfield, Luis A

on 04/18/2022
___________________________________________________________________

Clinical indication:
Specimen List: Blood
Date in Lab: 4/18/2022 14:46
Date Collected: 4/4/2022 11:55
___________________________________________________________________

Disclaimer:

Copy number gains less than 400 kb in size and copy number losses less than 200 kb in size will not be reported unless they represent a known or suspected clinically relevant imbalance. The reporting of copy number variants less than 100 kb in size is at the discretion of the laboratory and some clinically relevant copy number changes under 50 kb may not be reported due to limitations in probe coverage in certain genomic regions. Copy number changes of any size with no apparent clinical significance (likely benign or benign) have not been discussed in this report but may be available upon request. Regions of homozygosity (ROH) less than 10 Mb in size will not be reported unless the ROH is clinically relevant for potential uniparental disomy. Genome-wide ROH under 2% will not be reported. Copy number variants less than 200 kb associated with a carrier status for autosomal recessive conditions will not be reported unless specifically indicated in the reason for referral.

This microarray was designed and manufactured by Affymetrix for the sole purpose of identifying DNA copy number gains and losses associated with chromosomal imbalances and regions of homozygosity (ROH) associated with uniparental isodisomy (isoUPD).This microarray will detect aneuploidy, deletions and duplications of loci represented on the microarray. \u00a0It will not detect balanced alterations including: reciprocal translocations, inversions and balanced insertions. It will not detect point mutations and imbalances less than 10 kb. \u00a0Failure to detect an alteration at any locus does not exclude the diagnosis of any of the disorders represented on the microarray. This assay is not designed to detect mosaic gains and losses and its performance in detecting mosaicism has not been established. This test was developed and its performance characteristics determined by Affymetrix as required by CLIA \u00c2\u201988 regulations. This test is used for clinical purposes and the accuracy and precision has
been established and verified by this laboratory. This test has not been cleared or approved by the U.S. Food and Drug Administration.

Interpretation of copy number variants is performed using VUMC-laboratory maintained databases as well as the following resources:
Database of Genomic Variants (http://dgv.tcag.ca/dgv/app/home)
Online Mendelian Inheritance in Man (http://www.omim.org/)
UCSC Genome Bioinformatics (http://genome.ucsc.edu/cgi-bin/hgGateway)
ClinGen Clinical Genome Resource (http://www.ncbi.nlm.nih.gov/projects/dbvar/clingen)
DECIPHER Database (https://decipher.sanger.ac.uk/browser)
PubMed-NCBI (http://www.ncbi.nlm.nih.gov/pubmed)
Technical standards for the interpretation and reporting of constitutional copy-number variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics (ACMG) and the Clinical Genome Resource (ClinGen). PMID: 31690835

Method:
Microarray platform: ThermoFisher Scientific CytoScanTM HD Cytogenetics Solution
Version: 1.1 (Based on UCSC hg19 assembly)
Number of loci analyzed: 2,696,550
Mean probe spacing: <700 bp






Testing performed at Vanderbilt Cytogenetics One Hundred Oaks Laboratory, Suite 21100, 719 Thompson Ln,
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"Observation/a48c880c-f2bf-4f42-f1f2-9e04583a3617"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}, {"fullUrl": "urn:uuid:41331477-1d0d-2e1e-b53e-dbfd11b43f4b", "resource": {"resourceType": "Immunization", "id": "41331477-1d0d-2e1e-b53e-dbfd11b43f4b", "identifier": [{"system": "urn:ietf:rfc:3986", "value": "urn:uuid:bab4bd75-ab7b-11ec-81e0-9e7eef92c510"}], "protocolApplied": [{"doseNumberPositiveInt": "1"}], "occurrenceDateTime": "2022-03-24T09:38:00-04:00", "note": {"text": "anthrax"}, "vaccineCode": {"coding": [{"code": "24", "display": "anthrax", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "LOT552Z", "manufacturer": {"reference": "Organization/1e2d10a1-e4d3-ac11-3b25-56396aee4ba2"}, "status": "completed", "primarySource": true, "patient": {"reference": 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Problem or DiagnosisProblem Status
UnknownActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Condition/4669189e-043c-c7d9-d765-e40b1af670b0"}]}, {"id": "871e5d18-0533-1b1c-4a17-c49c5a86e461", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
Emergency20220426031700+0000
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Lab Test NameLab Test Result ValueLab Test Result Date
Estimated Creatinine Clearance98.48|http://unitsofmeasure.org|mL/min
Troponin TNIH7.9|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
Calc Osmo266|http://unitsofmeasure.org|mOsmol/L
ABO+Rh IO POS
A/G Ratio1.1|http://unitsofmeasure.org|Ratio
eGFR Non-African American119.74 mL/min/1.73m2
eGFR African American138.78 mL/min/1.73m2
Sodium135|http://unitsofmeasure.org|mmol/L
Potassium3.7|http://unitsofmeasure.org|mmol/L
HCG QT29556|http://unitsofmeasure.org|milli intl units/mL
Baso # Auto0.05|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level4.2|http://unitsofmeasure.org|gm/dL
Mono # Auto0.8|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto8.2|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.5|http://unitsofmeasure.org|%
Eos % Auto0.8|http://unitsofmeasure.org|%
Lymph % Auto5.4|http://unitsofmeasure.org|%
Neut % Auto84.0|http://unitsofmeasure.org|%
Calcium9.0|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.07|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto0.5|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.6|http://unitsofmeasure.org|%
RDW-CV12.3|http://unitsofmeasure.org|%
Immature Grans %0.7|http://unitsofmeasure.org|%
Eos # Auto0.1|http://unitsofmeasure.org|x10e3/mcL
Chloride104|http://unitsofmeasure.org|mmol/L
BUN3|http://unitsofmeasure.org|mg/dL
Plt326|http://unitsofmeasure.org|x10e3/mcL
WBC9.7|http://unitsofmeasure.org|x10e3/mcL
TP8.0|http://unitsofmeasure.org|gm/dL
RBC4.70|http://unitsofmeasure.org|x10e6/mcL
MPV8.6|http://unitsofmeasure.org|Femtoliters
MCV91.7|http://unitsofmeasure.org|Femtoliters
MCHC35.0|http://unitsofmeasure.org|gm/dL
MCH32.1|http://unitsofmeasure.org|pg
Lipase Lvl94|http://unitsofmeasure.org|Intl_units/L
Hgb15.1|http://unitsofmeasure.org|gm/dL
Hct43.1|http://unitsofmeasure.org|%
Glucose Level95|http://unitsofmeasure.org|mg/dL
CO2TNP mmol/L
T Bili0.6|http://unitsofmeasure.org|mg/dL
AST10|http://unitsofmeasure.org|Intl_units/L
ALT21|http://unitsofmeasure.org|Intl_units/L
Alk Phos78|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio5.0|http://unitsofmeasure.org|Ratio
Creatinine0.6|http://unitsofmeasure.org|mg/dL
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Medication NameMedication Start Date
acetaminophen (Tylenol)20220426042600+0000
"}, "code": {"coding": [{"code": "29549-3", "display": "Medications Administered", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "dd08df91-869b-46df-dd36-c5c0f2ad2eae", "title": "IMMUNIZATIONS", "text": {"status": "generated", "div": "No ImmunizationInformation"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "ef8f3d4a-dac9-1718-c5d1-d797134da774", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Birth SexF
Pregnancy ConditionPatient currently pregnant (finding)
Travel HistoryCOVID-19 Previously tested-Yes, positive result
Travel HistoryTB Risk Score-
Travel HistoryRisk Factors of TB-No risk factors identified
Travel HistorySymptoms of TB-
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryLast Menstrual Period-
Travel HistoryPregnancy Status-Confirmed positive
"}, "code": {"coding": [{"code": "29762-2", "display": "Social History", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/2b17f55d-bf9e-6fde-ce5f-deb519ec5eb7"}, {"reference": "Observation/b0c46db8-026e-942d-0aee-429acda37236"}, {"reference": "Observation/1d6ce605-8e6a-32b8-6039-b01dff4d41b7"}, {"reference": "Observation/37cd93a4-feea-78ec-e8ce-e32636284983"}, {"reference": "Observation/3f2df707-125d-bd5d-ae9a-000889695c8e"}, {"reference": "Observation/ce542281-8050-4d9a-58d6-752fed1816cc"}, {"reference": "Observation/219df162-1713-3cf7-a3bb-2e7a14365289"}, {"reference": "Observation/fd52fbad-6919-3aa7-f090-45e94ce90709"}, {"reference": "Observation/9c734782-f965-009c-5ba8-729f49eb1697"}, {"reference": "Observation/a336b749-aec3-d407-2cd1-f06d83bcc7ad"}]}, {"id": "7dbd51e8-1c15-8cfa-cbce-f6f4b9a1ed5d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "No Plan Of Treatment Information"}, "code": {"coding": [{"code": "18776-5", "display": "Treatment Plan", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/ec77d178-de8a-915a-311a-1f11f2838946"}]}, {"id": "07a28c1e-8321-7fa4-e654-66ae50374bc4", "title": "History of Present Illness", "text": {"status": "generated", "div": "
Narrative Text
COVID-19
Cough
Abdominal pain
Subchorionic hemorrhage
Encounter for medical screening examination
"}, "code": {"coding": [{"code": "10164-2", "display": "History of Present Illness", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "bc9bdaa4-198d-21a8-0f57-2071633fe649", "title": "Reason For Visit", "text": {"status": "generated", "div": "
text
COVID POS CP 5 WKS PREG
"}, "code": {"coding": [{"code": "29299-5", "display": "Reason For Visit", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "COVID POS CP 5 WKS PREG"}]}, {"id": "de7515e8-2c1a-1585-b19d-a8bee87913a0", "title": "Reportability Response Information Section", "text": {"status": "generated", "div": "
Reportability Response Information Section
"}, "extension": [{"url": "http://hl7.org/fhir/us/ecr/StructureDefinition/rr-composition", "valueIdentifier": {"use": "official", "type": {"coding": [{"code": "88085-6", "display": "Reportability response report Document Public health", "system": "http://loinc.org"}]}, "value": "0c3782a3-ab6d-4b8c-85fc-0a1433ffe3fc"}}, {"url": "http://hl7.org/fhir/us/ecr/StructureDefinition/rr-eicr-processing-status-extension", "valueCodeableConcept": {"coding": [{"code": "RRVS19", "display": "eICR processed", "system": "urn:oid:2.16.840.1.114222.4.5.274"}]}}], "code": {"coding": [{"code": "88085-6", "display": "Reportability response report Document Public health", "system": "http://loinc.org"}]}, "entry": [{"display": "Relevant Reportable Condition Observation - Disease caused by severe acute respiratory syndrome coronavirus 2 (disorder)", "reference": "Observation/557b3d07-1f75-458f-aaef-17b6b0a631bf"}]}], "subject": {"reference": "Patient/eff154e7-242d-487a-b464-3b193c9b4fdc"}, "encounter": 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MemberRoleStatusDates
Adam Sheradmitting physicianActive
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MCUTLERattending physicianActive
Start: March 12th, 2022
DR MEDITECHprimary care physicianActive
Start: March 12th, 2022
AMANDA NOELREFERRINGActive
Start: March 12th, 2022
AMANDA PARLATOFAMILYActive
Start: March 12th, 2022
Rickey RobertsOTHERActive
Start: March 12th, 2022
Stephen NewtonCONSULTINGActive
Start: March 12th, 2022
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Date patient received Moderna COVID-19 vaccine?
Date patient received Anthrax vaccine?
Date patient received Rabies vaccine?
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RIGRAPID HEART BEAT
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Height165.1 cmMarch 14th, 2022 1:48pm
Weight150.00 [lb_av]March 14th, 2022 1:48pm
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Anthrax

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Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 24th, 2022 9:38am
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This panel is not to be used for legal drug cases. The presence of other compounds in the patient''s specimen may cause a false positive. Correlate the results with clinical evaluation and other diagnostic testing procedures.

.....DRUG...... \u00a0 \u00a0 \u00a0 \u00a0 THRESHOLD DETECTION LIMIT
AMPH/METHAMPHET \u00a0 \u00a0 \u00a0 \u00a0 >1000 ng/mL
BARBITUATES \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 200 ng/mL
BENZODIAZEPINES \u00a0 \u00a0 \u00a0 \u00a0 > 200 ng/mL
COCAINE \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 300 ng/mL
OPIATES \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > 300 ng/mL
PCP \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a025 ng/mL
THC \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 > \u00a050 ng/mL
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NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Stool Pathogens, NAAT, 12 to 25 TargetsMicrobiologyRoutine11/01/2022 3:23 PM PDT
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ProblemNoted Date
Bipolar I disorder11/19/20
Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
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ProblemNoted Date
Malignant neoplasm of lower-inner quadrant of left breast in female, estrogen receptor positive12/14/22
Headache8/19/22
Backache8/19/22
Malignant neoplasm of urinary bladder neck11/5/21
Malignant neoplasm of overlapping sites of pancreas9/18/17
Cancer Staging:Stage IIB Stage III
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Cancer Staging:Stage IIA Stage IV
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DR. LARDIEREFAMILYActive
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Brian Leary , MDREFERRINGActive
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DR. DAVID CONNOROTHERActive
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Author
CANTON MEDICAL CENTER OF MASSACHUSETTS-North Canton FacilitSandra Hoyt
AuthoredMarch 22nd, 2022 11:23am
Follow-up with PSOR referral and PCP.
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WHITE BLOOD COUNT
HEMOGLOBIN
HEMATOCRIT
MEAN CELL VOLUME
MEAN CORPUSCULAR HEMOGLOBIN
PLATELET COUNT
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COVID-19 OV 94500-6March 17th, 2022 5:06pmMarch 31st, 2022
HIV Test: LOINC 10351-5March 22nd, 2022 11:26amMarch 28th, 2022
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Cardiac abnormalityPUMSEN''S PROVIDER GROUPWork Phone: +1(508)789-7891
BROCKTON MA 02301SUITE 1010110 MAIN ST
Medication NameStart DateInstructions
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Benazepril HCl (Benazepril) 40 MG TABLETMarch 22nd, 2022 8:32am
Cyclobenzaprine (CYCL10T) 10 MG TABMarch 21st, 2022 4:19pm
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Rifampin - RXCUI C198201 (RIFAMPIN150 MG) 150 MG CAPMarch 17th, 2022 3:48pm
Severe Acute Respiratory Syndrome (SARS)

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{"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/"}}, {"fullUrl": "urn:uuid:3f86f56d-09d1-99f9-d13d-19916791df4e", "resource": {"resourceType": "Condition", "id": "3f86f56d-09d1-99f9-d13d-19916791df4e", "identifier": [{"system": "urn:ietf:rfc:3986", "value": "urn:uuid:f848b453-fee9-4315-b782-56b81a94a4a5"}], "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "079.89", "display": "Infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)", "system": "urn:oid:2.16.840.1.113883.6.103"}]}, "onsetDateTime": "2022-03-14", "subject": {"reference": "Patient/a6371410-08da-41dd-92b7-8f9e4017168a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/3f86f56d-09d1-99f9-d13d-19916791df4e"}}, {"fullUrl": "urn:uuid:b6674044-78a3-fd5b-1818-c394a7efc76b", "resource": {"resourceType": "Condition", 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"77386006", "display": "pregnant", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/a6371410-08da-41dd-92b7-8f9e4017168a"}}, "request": {"method": "PUT", "url": "Observation/d1b616ae-8616-4a13-19f1-7ff2551ffe95"}}, {"fullUrl": "urn:uuid:506f9407-c9e8-6dda-0a67-98f18b9351d1", "resource": {"resourceType": "Observation", "id": "506f9407-c9e8-6dda-0a67-98f18b9351d1", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-sexual-orientation"], "source": "ecr"}, "code": {"coding": [{"system": "http://loinc.org", "code": "76690-7", "display": "Sexual orientation"}], "text": "Sexual orientation"}, "status": "final", "valueString": "Do not know", "subject": {"reference": "Patient/a6371410-08da-41dd-92b7-8f9e4017168a"}}, "request": {"method": "PUT", "url": "Observation/506f9407-c9e8-6dda-0a67-98f18b9351d1"}}, {"fullUrl": "urn:uuid:515a0d40-40f9-d455-e78c-50874ea66fbc", "resource": {"resourceType": "Observation", "id": 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(ecr_id, data) VALUES ('5ff34904-1cdd-45a9-bdae-69023b840c22', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:5ff34904-1cdd-45a9-bdae-69023b840c22", "resource": {"resourceType": "Composition", "id": "5ff34904-1cdd-45a9-bdae-69023b840c22", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "34682681|64851396"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "1"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-04-13T12:23:12Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "86eb9053-07e9-9b48-4906-a8b07a056d18", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Neoplasm of pituitary gland (disorder)Active
Strain of neckActive
HTN (hypertension)Active
Chronic male pelvic painActive
Motor vehicle crash, injuryActive
Closed injury of head (disorder)Active
Cerebrovascular accident (disorder)Active
Disease caused by 2019-nCoVActive
Low back strainActive
Cervicogenic headacheActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Neoplasm of pituitary gland (disorder)", "reference": "Condition/063ada0c-960f-8557-e828-76ea3ed99aba"}, {"display": "Problem - Strain of neck muscle (disorder)", "reference": "Condition/2c4295cc-bde8-63b2-7f48-081683140235"}, {"display": "Problem - Hypertensive disorder, systemic arterial (disorder)", "reference": "Condition/07559a5f-52d6-186f-25fd-123dd7950656"}, {"display": "Problem - Chronic pain in male pelvis (finding)", "reference": "Condition/65565a5f-5d97-9656-fc4f-c3fac1b55e3d"}, {"display": "Problem - Motor vehicle injury (disorder)", "reference": "Condition/8fabb65c-a7bc-d78a-ee66-87bc0f6f8f23"}, {"display": "Problem - Closed injury of head (disorder)", "reference": "Condition/47c4eafe-d230-03e3-a449-f3d4e8a570bb"}, {"display": "Problem - Cerebrovascular accident (disorder)", "reference": "Condition/2b0e32d9-1c75-b38e-c628-165e8fb18782"}, {"display": "Problem - Disease caused by 2019-nCoV", "reference": "Condition/7bcd701e-5d28-f178-a33f-64aa74239d54"}, {"reference": "Condition/bc63883a-ebd9-370f-0d9f-ad35c8fe7f52"}, {"display": "Problem - Low back strain (disorder)", "reference": "Condition/eef12569-0e57-b962-463d-8c74f3f211eb"}, {"display": "Problem - Cervicogenic headache (finding)", "reference": "Condition/6e0fec6b-8384-ad29-0f00-a6c9e11d0a29"}]}, {"id": "aeeada66-8e79-8d88-540c-1c05ea027505", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
observation encounter20220413083600+0000
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Lab Test NameLab Test Result ValueLab Test Result Date
Estimated Creatinine Clearance104.42|http://unitsofmeasure.org|mL/min
eGFR PediatricNot Reported
Calc Osmo277|http://unitsofmeasure.org|mOsmol/kg
A/G RatioUnknown
eGFR Non-African American88|http://unitsofmeasure.org|mL/min/1.73m2
eGFR African American102|http://unitsofmeasure.org|mL/min/1.73m2
NRBC #0.02|http://unitsofmeasure.org|x10e3/mcL
Sodium137|http://unitsofmeasure.org|mmol/L
Potassium4.1|http://unitsofmeasure.org|mmol/L
Baso # Auto0.05|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.6|http://unitsofmeasure.org|gm/dL
Mono # Auto1.15|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto7.67|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.4|http://unitsofmeasure.org|%
Eos % Auto0.8|http://unitsofmeasure.org|%
Lymph % Auto34.1|http://unitsofmeasure.org|%
Neut % Auto56.1|http://unitsofmeasure.org|%
Calcium9.6|http://unitsofmeasure.org|mg/dL
RDW-SD45.6|http://unitsofmeasure.org|Femtoliters
Immature Grans # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto4.67|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.4|http://unitsofmeasure.org|%
RDW-CV17.5|http://unitsofmeasure.org|%
Immature Grans %0.2|http://unitsofmeasure.org|%
Eos # Auto0.11|http://unitsofmeasure.org|x10e3/mcL
Chloride105|http://unitsofmeasure.org|mmol/L
BUN23|http://unitsofmeasure.org|mg/dL
Plt315|http://unitsofmeasure.org|x10e3/mcL
WBC13.68|http://unitsofmeasure.org|x10e3/mcL
TP7.5|http://unitsofmeasure.org|gm/dL
RBC5.41|http://unitsofmeasure.org|x10e6/mcL
PTT30|http://unitsofmeasure.org|Seconds
PT10.8|http://unitsofmeasure.org|Seconds
MPV8.3|http://unitsofmeasure.org|Femtoliters
MCV72.3|http://unitsofmeasure.org|Femtoliters
MCHC30.4|http://unitsofmeasure.org|gm/dL
MCH22.0|http://unitsofmeasure.org|pg
Hgb11.9|http://unitsofmeasure.org|gm/dL
Hct39.1|http://unitsofmeasure.org|%
Glucose Level95|http://unitsofmeasure.org|mg/dL
CO229|http://unitsofmeasure.org|mmol/L
T Bili0.2|http://unitsofmeasure.org|mg/dL
AST20|http://unitsofmeasure.org|units/L
ALT26|http://unitsofmeasure.org|units/L
Alk Phos74|http://unitsofmeasure.org|units/L
NRBC %0.1|http://unitsofmeasure.org|/100 WBC
BUN/Creat RatioUnknown
INRUnknown
Anion Gap3|http://unitsofmeasure.org|mmol/L
Creatinine1.010|http://unitsofmeasure.org|mg/dL
"}, "code": {"coding": [{"code": "30954-2", "display": "RESULTS", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/bef4ed94-75d6-0f59-94bf-c77032b1d617"}, {"reference": "Observation/2600299e-a371-f9d7-c127-43c19daf0129"}, {"reference": "Observation/a8f7b0cb-408c-07f3-d2d6-0530b7722f90"}, {"reference": "Observation/9364e788-cedb-9ac8-9829-394c197ea5e2"}, {"reference": "Observation/30b52e49-ba63-13f9-583a-205266bd325b"}, {"reference": "Observation/2dce3221-151a-c52b-46e4-28598769106f"}, {"reference": "Observation/e97632c6-00f5-1c20-fb4f-283420860772"}, {"reference": "Observation/1d3cb6ff-4b34-921a-5364-511a19e966cd"}, {"reference": "Observation/c3a47eaf-17cb-7f77-aabe-2009067d4db9"}, {"reference": "Observation/361e81b3-af06-110d-1ef2-cca8cdf46f5b"}, {"reference": "Observation/37970850-6632-1bd5-c592-d50a1c49beb5"}, {"reference": "Observation/6e3c6ee0-ec5e-4d2f-b83f-7746af2d1feb"}, {"reference": "Observation/e99cbca0-e606-71e0-2e7b-8edc9ba4e241"}, {"reference": "Observation/56eef5d7-788e-8d4e-9933-35a29418cfd5"}, {"reference": "Observation/efda5b60-be88-4e5a-53d4-e65933dd2253"}, {"reference": "Observation/41732919-97de-2987-c8ba-65147d09e31c"}, {"reference": "Observation/8ceebb8f-f17a-34d3-3563-c983cedf5cf2"}, {"reference": "Observation/e291b134-2484-3af0-cdd4-2b4b412e1e85"}, {"reference": "Observation/ff123f66-fc4d-6078-e4ec-9682e59e9621"}, {"reference": "Observation/201d329a-26c9-2583-32af-b044ab6e5702"}, {"reference": "Observation/e1506544-eb6a-89f2-d5c0-49e013f392bd"}, {"reference": "Observation/fedc1ccf-b364-50de-efd5-cfaa6b432dcc"}, {"reference": "Observation/8e251471-3559-7fee-5a80-b9e4d89e952f"}, {"reference": "Observation/b5aa5515-47fa-b975-c268-320262fdb294"}, {"reference": "Observation/b0b16712-3fe9-f939-e387-65da9e5cde42"}, {"reference": "Observation/a304b56c-db18-1942-4bb8-b8848f432343"}, {"reference": "Observation/9d262c4c-ff38-9831-87b7-dd06706b230d"}, {"reference": "Observation/2de6d76e-ab12-cf75-69cc-5522df8b471e"}, {"reference": "Observation/300414f6-21ed-767e-ecff-f368688a0ad5"}, {"reference": "Observation/08e89920-55a2-a8ab-4a4e-45403371d26f"}, {"reference": "Observation/71912eaa-8bdd-dab8-8784-d2078e50c832"}, {"reference": "Observation/9019681e-384f-9484-5a48-4a174e27c9e5"}, {"reference": "Observation/d7846ef8-c12c-da29-eac9-2ee948d2ae65"}, {"reference": "Observation/42547b50-9f44-363e-4175-886867ab7362"}, {"reference": "Observation/37edf291-f601-c897-ff7a-db53873275ce"}, {"reference": "Observation/68a2b0a5-0e86-6439-cd80-73d18a5266a8"}, {"reference": "Observation/e9ba5072-0842-2b5f-638c-4d4470477c68"}, {"reference": "Observation/34f2b1dc-2385-1e72-0070-641ed8bc362d"}, {"reference": "Observation/f2d8a614-d460-5830-415f-3ea45cd59437"}, {"reference": "Observation/f1e30de0-0e14-583d-7ce3-d89651fff143"}, {"reference": "Observation/1afe4393-93fc-6a86-c398-e0f85c98d8e7"}, {"reference": "Observation/605dec71-ba61-2e6f-b4e2-b79f74fd313a"}, {"reference": "Observation/bcb47f47-ca9f-a59d-9212-627b2dd8396f"}, {"reference": "Observation/c0e75f97-6108-f90f-0a8b-e25f0130cde6"}, {"reference": "Observation/122e8b3a-d601-3b94-c1ba-5ee2428dada4"}, {"reference": "Observation/fe7b3926-c039-128e-8bfe-862ba3ac64d0"}, {"reference": "Observation/95edcacc-0296-5fa5-1d6f-900de27637a6"}, {"reference": "Observation/18819b2c-48bf-203e-df11-9336b87aae54"}, {"reference": "Observation/96f503de-0766-2c08-c325-a241ac22cdee"}, {"reference": "Observation/38f02a5b-f81d-37f4-7dac-b6a14eb98149"}]}, {"id": "0ddb468b-5bca-f635-cc22-442d12b8fab4", "title": "Medications Administered", "text": {"status": "generated", "div": "
Medication NameMedication Start Date
famotidine (Pepcid)20220413170000+0000
heparin20220413130000+0000
meclizine20220413113800+0000
Sodium Chloride 0.9% intravenous solution 1,000 mL20220413110600+0000
acetaminophen (Tylenol)20220413110600+0000
ondansetron (Zofran)20220413110600+0000
morphine20220413113700+0000
morphine20220413105900+0000
prochlorperazine (Compazine)20220413120000+0000
diphenhydrAMINE (Benadryl)20220413105900+0000
ketorolac (Toradol)20220413105900+0000
"}, "code": {"coding": [{"code": "29549-3", "display": "Medications Administered", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/063f42b9-ec2a-c337-abc2-79465353a684"}, {"reference": "MedicationAdministration/1202713c-e31b-375a-feb0-c1825ef426ad"}, {"reference": "MedicationAdministration/6c3e2499-c536-d1dd-714a-7df34ebae992"}, {"reference": "MedicationAdministration/1c38d993-ef4b-0843-c004-f034c053743b"}, {"reference": "MedicationAdministration/6bd89508-7ee5-920b-0378-58b2b5688fca"}, {"reference": "MedicationAdministration/45bea8f0-6879-f811-f156-c7492e0f5963"}, {"reference": "MedicationAdministration/b1f87437-e50e-bdc1-cf1e-917e57e88521"}, {"reference": "MedicationAdministration/7ef50974-3a01-14c4-c8bd-fcd0a6984abb"}, {"reference": "MedicationAdministration/25c13c20-f35f-b9a6-772c-0f25ae50e215"}, {"reference": "MedicationAdministration/43150611-0371-84f8-e6c3-b5a906dbf9e3"}, {"reference": "MedicationAdministration/9297be23-425e-ccd9-46f8-045150362589"}]}, {"id": "dd08df91-869b-46df-dd36-c5c0f2ad2eae", "title": "IMMUNIZATIONS", "text": {"status": "generated", "div": "No ImmunizationInformation"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "3f42c9a8-e7bc-8936-142e-d6ae7f1deaa7", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Birth SexM
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryPregnancy Status-Not applicable (qualifier value)
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COVID-19Active
Hypertensive disorder, systemic arterial (disorder)Active
Neoplasm of pituitary gland (disorder)Active
Cerebrovascular accident (disorder)Active
Low back strainActive
Motor vehicle crash, injuryActive
Chronic male pelvic painActive
Strain of neckActive
Cervicogenic headacheActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Closed injury of head (disorder)", "reference": "Condition/47c4eafe-d230-03e3-a449-f3d4e8a570bb"}, {"display": "Problem - Disease caused by 2019-nCoV", "reference": "Condition/7bcd701e-5d28-f178-a33f-64aa74239d54"}, {"reference": "Condition/bc63883a-ebd9-370f-0d9f-ad35c8fe7f52"}, {"display": "Problem - Hypertensive disorder, systemic arterial (disorder)", "reference": "Condition/07559a5f-52d6-186f-25fd-123dd7950656"}, {"display": "Problem - Neoplasm of pituitary gland (disorder)", "reference": "Condition/063ada0c-960f-8557-e828-76ea3ed99aba"}, {"display": "Problem - Cerebrovascular accident (disorder)", "reference": "Condition/2b0e32d9-1c75-b38e-c628-165e8fb18782"}, {"display": "Problem - Low back strain (disorder)", "reference": "Condition/eef12569-0e57-b962-463d-8c74f3f211eb"}, {"display": "Problem - Motor vehicle injury (disorder)", "reference": "Condition/8fabb65c-a7bc-d78a-ee66-87bc0f6f8f23"}, {"display": "Problem - Chronic pain in male pelvis (finding)", "reference": "Condition/65565a5f-5d97-9656-fc4f-c3fac1b55e3d"}, {"display": "Problem - Strain of neck muscle (disorder)", "reference": "Condition/2c4295cc-bde8-63b2-7f48-081683140235"}, {"display": "Problem - Cervicogenic headache (finding)", "reference": "Condition/6e0fec6b-8384-ad29-0f00-a6c9e11d0a29"}]}, {"id": "c559c907-9f5c-028a-07d7-1fd82fc505e8", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
observation encounter20220413083600+0000
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Lab Test NameLab Test Result ValueLab Test Result Date
Chol/HDL RiskUnknown
Phosphorus4.1|http://unitsofmeasure.org|mg/dL
VLDL Chol Calc34.00|http://unitsofmeasure.org|mg/dL
LDL Direct81|http://unitsofmeasure.org|mg/dL
Trig168|http://unitsofmeasure.org|mg/dL
PTT31|http://unitsofmeasure.org|Seconds
PT10.6|http://unitsofmeasure.org|Seconds
Mg Lvl1.9|http://unitsofmeasure.org|mg/dL
HDL36|http://unitsofmeasure.org|mg/dL
Cholesterol129|http://unitsofmeasure.org|mg/dL
INRUnknown
Estimated Creatinine Clearance104.42|http://unitsofmeasure.org|mL/min
eGFR PediatricNot Reported
Calc Osmo277|http://unitsofmeasure.org|mOsmol/kg
A/G RatioUnknown
eGFR Non-African American88|http://unitsofmeasure.org|mL/min/1.73m2
eGFR African American102|http://unitsofmeasure.org|mL/min/1.73m2
NRBC #0.02|http://unitsofmeasure.org|x10e3/mcL
Sodium137|http://unitsofmeasure.org|mmol/L
Potassium4.1|http://unitsofmeasure.org|mmol/L
Baso # Auto0.05|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.6|http://unitsofmeasure.org|gm/dL
Mono # Auto1.15|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto7.67|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.4|http://unitsofmeasure.org|%
Eos % Auto0.8|http://unitsofmeasure.org|%
Lymph % Auto34.1|http://unitsofmeasure.org|%
Neut % Auto56.1|http://unitsofmeasure.org|%
Calcium9.6|http://unitsofmeasure.org|mg/dL
RDW-SD45.6|http://unitsofmeasure.org|Femtoliters
Immature Grans # Auto0.03|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto4.67|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.4|http://unitsofmeasure.org|%
RDW-CV17.5|http://unitsofmeasure.org|%
Immature Grans %0.2|http://unitsofmeasure.org|%
Eos # Auto0.11|http://unitsofmeasure.org|x10e3/mcL
Chloride105|http://unitsofmeasure.org|mmol/L
BUN23|http://unitsofmeasure.org|mg/dL
Plt315|http://unitsofmeasure.org|x10e3/mcL
WBC13.68|http://unitsofmeasure.org|x10e3/mcL
TP7.5|http://unitsofmeasure.org|gm/dL
RBC5.41|http://unitsofmeasure.org|x10e6/mcL
PTT30|http://unitsofmeasure.org|Seconds
PT10.8|http://unitsofmeasure.org|Seconds
MPV8.3|http://unitsofmeasure.org|Femtoliters
MCV72.3|http://unitsofmeasure.org|Femtoliters
MCHC30.4|http://unitsofmeasure.org|gm/dL
MCH22.0|http://unitsofmeasure.org|pg
Hgb11.9|http://unitsofmeasure.org|gm/dL
Hct39.1|http://unitsofmeasure.org|%
Glucose Level95|http://unitsofmeasure.org|mg/dL
CO229|http://unitsofmeasure.org|mmol/L
T Bili0.2|http://unitsofmeasure.org|mg/dL
AST20|http://unitsofmeasure.org|units/L
ALT26|http://unitsofmeasure.org|units/L
Alk Phos74|http://unitsofmeasure.org|units/L
NRBC %0.1|http://unitsofmeasure.org|/100 WBC
BUN/Creat RatioUnknown
INRUnknown
Anion Gap3|http://unitsofmeasure.org|mmol/L
Creatinine1.010|http://unitsofmeasure.org|mg/dL
"}, "code": {"coding": [{"code": "30954-2", "display": "RESULTS", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/669afe70-d46a-6c5a-bfaa-0462d90ba971"}, {"reference": "Observation/72cffbc2-4943-2898-0594-ee8d47b84782"}, {"reference": "Observation/25b26309-ce1b-541b-2ad0-b4037f1c2ed2"}, {"reference": "Observation/d500db57-e204-1544-45d3-5807c1f361da"}, {"reference": "Observation/24667cf4-bccd-7cb6-c513-1757c3d3df56"}, {"reference": "Observation/5659d25c-4bc9-f555-dea4-9d3b30666798"}, {"reference": "Observation/b7ef76fe-e4e3-198b-2f9a-d794724e2409"}, {"reference": "Observation/aec5ef09-b2e9-f0d2-6c16-a68dfce76c33"}, {"reference": "Observation/d6b3d327-931e-9310-be54-6e5c0ac9369c"}, {"reference": "Observation/a944fa13-5e3c-f119-b12e-f15d1c8ec410"}, {"reference": "Observation/9933511b-0922-5c70-fede-3fcb109c0b5d"}, {"reference": "Observation/e0aa51dc-77f9-41b2-e379-d0dd6d532e37"}, {"reference": "Observation/2995211e-b63a-04e0-291b-8b03d6e7209a"}, {"reference": "Observation/041d93a8-0ae4-7b9c-e1a6-15f8c7c6abdd"}, {"reference": "Observation/c8cd2349-1637-810c-2bb6-2a1997019295"}, {"reference": "Observation/264a6633-15a4-ffe9-a878-bfb37039c654"}, {"reference": "Observation/fcf12021-cb7c-e1d8-b42a-5bca54402469"}, {"reference": "Observation/3c2e98a4-fd49-f6db-d8d2-8aa7eb96ee5f"}, {"reference": "Observation/bb2380e8-f0e2-2280-ea12-5ff8ad038e59"}, {"reference": "Observation/505e9087-9721-c2a2-844d-99133b9fe974"}, {"reference": "Observation/2f178a8f-6e74-bb84-5619-0418924c6a7e"}, {"reference": "Observation/cfc53f36-abef-d177-e089-957c73c2fc07"}, {"reference": "Observation/f0d9b1a9-5706-8f53-b267-d05e692a19c6"}, {"reference": "Observation/ea70cb27-85f0-b205-d658-cf9ebdf40802"}, {"reference": "Observation/607685f7-0b3f-e484-0766-80dd6d4a5842"}, {"reference": "Observation/b35693d0-16d6-31d1-3fa9-e7691d7dc924"}, {"reference": "Observation/8c4061ab-74df-5093-6808-7ad07235e7e6"}, {"reference": "Observation/d2719f59-27ca-6226-f3bd-586ef734eef5"}, {"reference": "Observation/66a38bce-d5b3-fb1c-7e04-46069d2cdce4"}, {"reference": "Observation/3ca70793-400f-6caa-a25b-3a7ae07c5e39"}, {"reference": "Observation/7899eb53-1762-5452-2c01-1e89e87ecd75"}, {"reference": "Observation/e5978ea1-fec6-e6e8-5475-4c31c3c8abd7"}, {"reference": "Observation/eae839eb-9d6e-c9a8-1ac4-3dfbc3fac67d"}, {"reference": "Observation/7bbbf1a2-c4b2-c3ad-1832-788db7fa92fd"}, {"reference": "Observation/f17a85de-82fa-d809-2c99-6068baa126b4"}, {"reference": "Observation/d4b48186-6821-f30d-991d-1bd6f3b6691a"}, {"reference": "Observation/a1b7f8a7-7536-d96d-b436-74817230c55c"}, {"reference": "Observation/b242c5d7-74a7-6595-1783-7f6ee197f901"}, {"reference": "Observation/4ced71d6-ad9e-c3b4-9142-4ee295fc2e17"}, {"reference": "Observation/cd894b93-2504-2748-b955-f5ff523887ba"}, {"reference": "Observation/70d289aa-7f9b-bf1e-ecdf-c4d09e4a5093"}, {"reference": "Observation/05ba4e77-2ddf-8ab6-d92c-8e53fa1d55ed"}, {"reference": "Observation/a7d3def7-6bec-a8f8-d328-04c40aadecc9"}, {"reference": "Observation/244ddfa2-dd36-d911-97a9-7b3f8365b190"}, {"reference": "Observation/e5aa0a6b-9119-af83-bbc9-d4eca6c9b313"}, {"reference": "Observation/1850e9fa-7ef5-6507-e975-b99aa75a098f"}, {"reference": "Observation/7e081ec9-af06-a434-a0ca-f823aff8bae4"}, {"reference": "Observation/4fe4411e-4b85-1cf4-b1b2-5f53555963ed"}, {"reference": "Observation/858a2450-e45d-5df7-afb5-ac38115a7487"}, {"reference": "Observation/3b80b0f0-da03-a615-f69c-57b4591b96ea"}, {"reference": "Observation/dd63811b-60e3-605b-95b1-79b1305bd70e"}, {"reference": "Observation/7a4e1aac-b8b1-2179-a80c-e8c40934fff2"}, {"reference": "Observation/e86f39d7-4e90-9fca-677f-db58aeeca42e"}, {"reference": "Observation/539d5565-69b3-91fd-0744-f4e3c054e510"}, {"reference": "Observation/4605c412-3f46-1c67-e8d8-267f8974d192"}, {"reference": "Observation/ccb14b90-044c-fc57-6fc7-7cee67f06222"}, {"reference": "Observation/15b3d8a9-8ae7-0ab9-7ffe-57dff7a9cffd"}, {"reference": "Observation/7d9bc710-a31d-4047-df2f-2cafd97cb02e"}, {"reference": "Observation/aa0825c8-2cd8-f610-178b-16de6aafe423"}, {"reference": "Observation/e97c82cc-56f0-2980-85b1-e983dac30917"}, {"reference": "Observation/1c9600bc-b586-f001-25fc-13be72f7f296"}]}, {"id": "3bb3aac3-d469-3fba-d196-ba5e7a2c2801", "title": "Medications Administered", "text": {"status": "generated", "div": "
Medication NameMedication Start Date
docusate (Colace)20220413132200+0000
acetaminophen (Tylenol)20220413132200+0000
hydrocodone-acetaminophen (Norco 5 mg-325 mg oral tablet)20220413132200+0000
ipratropium-albuterol (DuoNeb)20220413132200+0000
hydrALAZINE20220413132200+0000
labetalol20220413132200+0000
levETIRAcetam (Keppra)Unknown
meclizine20220413113800+0000
melatonin (melatonin 3 mg oral tablet)20220413132200+0000
morphine20220413132200+0000
ondansetron (Zofran)20220413132200+0000
simethicone (Mylicon)20220413132200+0000
heparin20220413170000+0000
famotidine (Pepcid)Unknown
Sodium Chloride 0.9% intravenous solution 1,000 mL20220413110600+0000
acetaminophen (Tylenol)20220413110600+0000
heparin20220413130000+0000
morphine20220413113700+0000
ondansetron (Zofran)20220413110600+0000
morphine20220413105900+0000
prochlorperazine (Compazine)20220413120000+0000
diphenhydrAMINE (Benadryl)20220413105900+0000
ketorolac (Toradol)20220413105900+0000
"}, "code": {"coding": [{"code": "29549-3", "display": "Medications Administered", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/d79bfe31-f85f-4d2a-5eb9-6183842bd415"}, {"reference": "MedicationAdministration/a76d84ff-d244-13ff-54a1-b7da3861df8b"}, {"reference": "MedicationAdministration/978dd261-ced7-606c-94cb-d9a9ee079d69"}, {"reference": "MedicationAdministration/f8736fd2-4ec9-f119-f83d-dc5f902fbb39"}, {"reference": "MedicationAdministration/3fc944e1-612d-f09a-607a-2dcfdc31e067"}, {"reference": "MedicationAdministration/8a9c0b16-62f6-b3df-44ac-a4e3a3568025"}, {"reference": "MedicationAdministration/68ced031-e2b8-bb07-96df-263c4f62ee78"}, {"reference": "MedicationAdministration/09fe790a-08bb-15b5-ad51-b986c592c815"}, {"reference": "MedicationAdministration/680b158c-a138-eb05-a948-fc1b7a48fc95"}, {"reference": "MedicationAdministration/41947ef8-4fd7-3717-ccd7-59a5ed151bdb"}, {"reference": "MedicationAdministration/0af4fb75-7649-8b1e-3ac2-4ccf6ca8ddb5"}, {"reference": "MedicationAdministration/9256df52-4aae-21c8-0bdd-fd30f3d226ba"}, {"reference": "MedicationAdministration/0ef906a6-598a-f208-701f-407d7a89c539"}, {"reference": "MedicationAdministration/7ebdc457-3f17-7cfb-4976-fd2b2a353b39"}, {"reference": "MedicationAdministration/72f91cdf-07a2-b899-22b5-e838620e987b"}, {"reference": "MedicationAdministration/d0528813-3060-32f0-ef54-0cdd807e6b9c"}, {"reference": "MedicationAdministration/47489478-127e-2205-3016-77f4c552cb12"}, {"reference": "MedicationAdministration/b4b560b3-a232-865d-3dca-daac79ba0d40"}, {"reference": "MedicationAdministration/eec8a692-2b39-d7e7-a0d8-0a120c2b810b"}, {"reference": "MedicationAdministration/87241dd2-4d29-3445-74e9-361a3b263dd2"}, {"reference": "MedicationAdministration/1230d359-3d2b-b52a-3984-7a7dd860b2f0"}, {"reference": "MedicationAdministration/47a56c19-9de2-94ca-14c8-245c0f5bfa1e"}, {"reference": "MedicationAdministration/c6238475-81cb-a9ed-1535-aa716292a7d7"}]}, {"id": "dd08df91-869b-46df-dd36-c5c0f2ad2eae", "title": "IMMUNIZATIONS", "text": {"status": "generated", "div": "No ImmunizationInformation"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "c74504df-1bdc-137f-3790-44f6cea7fa89", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Birth SexM
Travel HistoryPregnancy Status-Not applicable (qualifier value)
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryPregnancy Status-Not applicable (qualifier value)
"}, "code": {"coding": [{"code": "29762-2", "display": "Social History", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/39fc6765-cae0-47b1-a804-7b1c6c7ebf10"}, {"reference": "Observation/cab882e1-ae87-073d-b589-f5330181b738"}, {"reference": "Observation/1258a4be-b52b-8064-23cb-54aff2543b55"}, {"reference": "Observation/b13e6f13-9f5e-714e-f96f-b446cf5058bd"}, {"reference": "Observation/930bcc29-63f3-183d-5bf3-411ee1901bf0"}, {"reference": "Observation/49e16c19-d8f8-ca01-2066-ba0f92f28886"}, {"reference": "Observation/ceba9aac-0792-15bf-7119-9c24f91e9cca"}, {"reference": "Observation/6b250e41-9ec3-b90e-be74-38babc748acf"}, {"reference": "Observation/4f434448-9204-4702-56c2-cad22e575809"}]}, {"id": "7dbd51e8-1c15-8cfa-cbce-f6f4b9a1ed5d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "No Plan Of Treatment Information"}, "code": {"coding": [{"code": "18776-5", "display": "Treatment Plan", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/ec77d178-de8a-915a-311a-1f11f2838946"}]}, {"id": "3bf22954-7e60-35a6-45d5-322ce2bae993", "title": "History of Present Illness", "text": {"status": "generated", "div": "
Narrative Text
Headache
Brain tumor
Headache
"}, "code": {"coding": [{"code": "10164-2", "display": "History of Present Illness", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "9f06fac1-cf69-4b39-ac51-fcf1e80aedf2", "title": "Reason For Visit", "text": {"status": "generated", "div": "
text
HEADACHE BRAIN TUMOR
"}, "code": {"coding": [{"code": "29299-5", "display": "Reason For Visit", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "HEADACHE BRAIN TUMOR"}]}, {"id": "edd6100d-fcef-07ce-10fb-2cc09042142a", "title": "Reportability Response Information Section", "text": {"status": "generated", "div": "
Reportability Response Information Section
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https://www.testmenu.com/Intermountain/Tests/1035258 See Syphilis Interpretative Guide in Laboratory Test DirectoryResult Comment: (NOTE)2 Result Comment: Nontreponemal antibodies detected. Treponema-specific testing to follow.
NameDate
RPR Titer (RPR TITER)8/16/22
Syphilis RPR: Only for Pregnant, Pediatric or Post-Treatment patients (SYPHILIS (RPR) PEDIATRIC, PREGNANCY OR POST TREATMENT)8/16/22
Treponema pallidum Ab by TP-PA (ARUP) (T.PALLIDUM AB BY TPPA)8/16/22
Most recent to oldest [Reference Range]:1
RPR Titer
(8/16/22 9:00 AM) 1:32
Syphilis Interpretation1
(8/16/22 9:00 AM) See Comments
RPR [Nonreactive]2
(8/16/22 9:00 AM) *ABN*Reactive
T.pallidum Ab by TP-PA (ARUP)
(8/16/22 9:00 AM) Reactive
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{"status": "generated", "div": "
NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "11194946-5A39-11ED-815F-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "576c9b22-b1f8-fc85-539e-f688ca7add3f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Stool Pathogens, NAAT, 12 to 25 TargetsMicrobiologyRoutine11/01/2022 3:23 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/f79f7fbc-cf8a-55d2-34b4-108ebff26173"}]}, {"id": "1136072A-5A39-11ED-815F-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "
ProblemNoted Date
Bipolar I disorder11/19/20
Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
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Pneumonia, unspecified organismResolved
HypertensionActive
Sleep apnea (finding)Active
Sleep apnea (finding)Active
Sleep apnea (finding)Active
At risk for injury due to fall (finding)Active
Bowel dysfunction (disorder)Active
Pneumonia due to COVID-19 virusResolved
At risk for falls (finding)Active
Vancomycin Resistant Enterococcus (organism)Resolved
Alcoholism /alcohol abuseActive
History of placement of stent for coronary artery disease (situation)Active
Chronic obstructive lung disease (disorder)Active
Other chest painResolved
Seizure disorderActive
Acute chest painResolved
Methicillin resistant Staphylococcus aureus (organism)Active
Methicillin resistant Staphylococcus aureus (organism)Resolved
Abdominal pain in maleResolved
DM (diabetes mellitus)Active
2019-nCoVResolved
Oxygen dependentActive
2019-nCoV acute respiratory diseaseActive
Acute pain (finding)Active
Myocardial infarction (disorder)Active
Anxiety (finding)Active
HomelessActive
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BUN/Creat RatioUnknown
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NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "1D6BC7D2-5A39-11ED-87E1-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "576c9b22-b1f8-fc85-539e-f688ca7add3f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Culture, Stool ResultMicrobiologyRoutine11/01/2022 3:23 PM PDT
Stool Pathogens, NAAT, 12 to 25 TargetsMicrobiologyRoutine11/01/2022 3:23 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/f79f7fbc-cf8a-55d2-34b4-108ebff26173"}]}, {"id": "1D882724-5A39-11ED-87E1-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "
ProblemNoted Date
Bipolar I disorder11/19/20
Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
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Smokes tobacco daily (finding)March 25th, 2021 4:57pm
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Full body hivesResolved
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DTaPJanuary 31st, 2019232323232
DTaPJanuary 31st, 2019+56+65464
Hepatitis B, Recombinant- EngerixFebruary 8th, 20196
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Pneumococcal Conjugate Vaccine, 13 valentJanuary 31st, 2019
Pneumococcal Conjugate Vaccine, 13 valentJanuary 31st, 20194564654
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PentacelFebruary 8th, 201935454364
Prevnar 13February 8th, 201964654654
RotaTeqFebruary 8th, 201953465464
Varicella Virus VaccineFebruary 6th, 20196545646564
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Height67.00 [in_i]January 29th, 2019 1:14pm
Weight160.00 [lb_av]January 29th, 2019 1:14pm
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Departed ClinicalMEDITECH General Hospital-Day Hospital - MTGHJanuary 29th, 2019 1:09pmJanuary 29th, 2019 1:10pmAnthony Brown
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AmmoniaJanuary 25th, 2021 9:39amJanuary 25th, 2021 9:38am
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Ur MucousNONE /LPF
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SARS-CoV-2 PCRNegative
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Ur BloodTrace-lysed
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Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Yes0 (1 standard drink = 0.6 oz pure alcohol)
Sex Assigned at BirthDate Recorded
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Job Start DateOccupationIndustry
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NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
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[{"display": "DTAP-HIB-IPV (PENTACEL)"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/7a4b0e4b-ca8a-a39b-1b44-19efe2c9ee5c"}}, {"fullUrl": "urn:uuid:b5d003f7-cfe2-56a4-6e91-07307f25aa83", "resource": {"resourceType": "Immunization", "id": "b5d003f7-cfe2-56a4-6e91-07307f25aa83", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "57643"}], "occurrenceDateTime": "2020-11-10", "note": {"text": "TDAP, (ADOL/ADULT)"}, "vaccineCode": {"coding": [{"code": "49281-400-10", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "369258741", "manufacturer": {"reference": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/68511808-c001-4571-b7e6-c09ae4dddd84"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/b5d003f7-cfe2-56a4-6e91-07307f25aa83"}}, {"fullUrl": "urn:uuid:b5c77b86-2764-79f9-10bf-5da5e63eb7c1", "resource": {"resourceType": "Organization", "id": "b5c77b86-2764-79f9-10bf-5da5e63eb7c1", "name": "Sanofi Pasteur", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}}, {"fullUrl": "urn:uuid:cffb2ab8-483c-a93e-56c3-5cc3d11e9168", "resource": {"resourceType": "Immunization", "id": "cffb2ab8-483c-a93e-56c3-5cc3d11e9168", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.297.3.7.2.768076", "value": "57644"}], "occurrenceDateTime": "2011-11-11", "note": {"text": "HEP A (ADULT) 2 DOSE"}, "vaccineCode": {"coding": [{"display": "HEP A (ADULT) 2 DOSE"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/cffb2ab8-483c-a93e-56c3-5cc3d11e9168"}}, {"fullUrl": "urn:uuid:35c0d7fc-0bc0-5a24-e65e-dc30321d7e2e", "resource": {"resourceType": "Immunization", "id": "35c0d7fc-0bc0-5a24-e65e-dc30321d7e2e", 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[{"display": "HEP B (PED,ADOLESCENT) 3 DOSE"}]}, "status": "completed", "primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/50fc36a0-b859-c4a4-de8f-53c149080081"}}]}') ON CONFLICT (ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.478.3.7.8.688883.252732', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.478.3.7.8.688883.252732", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.478.3.7.8.688883.252732", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "5e539dbe-8abe-11ed-847f-0050561597b4", "assigner": {"display": "EPC"}}], "extension": [{"url": 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NameAdministration DatesNext Due
DTaP, 5 pertussis antigens vaccine (DAPTACEL)06/15/2021
Hep B, adult vaccine (Engerix/Recombivax)09/08/2020
SARS-COV-2 (COVID-19) RED CAP +BLUE LABEL VACCINE, MODERNA 12+YO01/22/2021
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "651F5430-8ABE-11ED-8CA0-0050561597B4", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "eb08daad-1e00-4280-4846-4276acb00888", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
PCR SARS-CoV-2 and Influenza A/BLabRoutine12/07/2021 4:16 PM CST
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/581a29d4-5295-5382-5460-cf0582ee5bca"}]}, {"id": "656AD662-8ABE-11ED-8CA0-0050561597B4", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
COVID toes7/13/22
Chest pain on breathing5/26/22
Type 1 diabetes2/28/22
Overview:Formatting of this note might be different from the original.
08/30/21 28.69 kg/m\u00b2BMI Readings from Last 1 Encounters:
Plague pneumonia6/16/21
Absence of menstruation6/12/18
Foot callus8/11/17
Overview:Formatting of this note might be different from the original.
Ouch.
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
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DateTypeDepartmentCare TeamDescription
10/27/21Orders OnlyVanderbilt University Adult Hospital1211 Medical Center Dr6 Critical Care TowerNashville, TN 37232615-322-5000Inpatient, Nurse, RN
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Formatting of this note might be different from the original.

Ouch."}], "subject": {"reference": "Patient/d02ec36e-0084-4950-a3e9-a8bed3b05df7"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/74e3244b-afcc-1fd0-4cbb-864d85303dbc"}}, {"fullUrl": "urn:uuid:85d00c53-2448-939b-80ea-c251042ef350", "resource": {"resourceType": "Condition", "id": "85d00c53-2448-939b-80ea-c251042ef350", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.768076", "value": "66245"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N91.2", "display": "Absence of menstruation", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2018-06-12", "subject": {"reference": "Patient/d02ec36e-0084-4950-a3e9-a8bed3b05df7"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/85d00c53-2448-939b-80ea-c251042ef350"}}, {"fullUrl": "urn:uuid:c6bc07dc-6be8-ff50-ac51-e096139f444d", "resource": {"resourceType": "Condition", "id": "c6bc07dc-6be8-ff50-ac51-e096139f444d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.768076", "value": "90498"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "A20.2", "display": "Plague pneumonia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-06-16", "subject": {"reference": "Patient/d02ec36e-0084-4950-a3e9-a8bed3b05df7"}, "meta": {"source": "ecr"}, "extension": [{"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "58750007", "system": "http://snomed.info/sct"}]}]}, "request": {"method": "PUT", "url": "Condition/c6bc07dc-6be8-ff50-ac51-e096139f444d"}}, {"fullUrl": "urn:uuid:e47bddd9-8edd-ab04-1bc8-188ae3662beb", "resource": {"resourceType": "Condition", "id": "e47bddd9-8edd-ab04-1bc8-188ae3662beb", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.3.7.2.768076", "value": "95631"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.9", "display": "Type 1 diabetes", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-28", "note": [{"text": "Overview:
Formatting of this note might be different from the original.

BMI Readings from Last 1 Encounters:
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"display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "15182482|110500680"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "23"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-12-06T17:42:15Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "c9401c25-8529-73a2-3cd6-f917bb4da82c", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
Disease caused by 2019-nCoVActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Disease caused by 2019-nCoV", "reference": "Condition/298b03c4-a2cf-efdd-180a-ed000f4d630e"}, {"reference": "Condition/6d3200fa-8bce-062e-9960-6d2def58a7dc"}]}, {"id": "68f4ee02-1da0-3f83-bc12-9c376a7bf14e", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
inpatient encounter20220919145900+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "837f2f7c-ae50-4c56-a2ba-cb9518715887", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
SARS-CoV-2 BioFireNot Detected
Coronavirus HKU1Not Detected
Coronavirus NL63Not Detected
Coronavirus OC43Not Detected
Coronavirus 229ENot Detected
SARS-CoV-2 Xpert Xpress ResultsDetected
RSV PCRNot Detected
Influenza B, PCRNot Detected
Influenza A, PCRNot Detected
"}, "code": {"coding": [{"code": "30954-2", "display": "RESULTS", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/be844c85-b9f4-9392-e0df-9d9944be7751"}, {"reference": "Observation/b6d380ff-572b-4a79-9407-b2644db163ef"}, {"reference": "Observation/55c38733-4eb8-4a6a-7e23-44bff90a4fb0"}, {"reference": "Observation/f61f7d29-28a2-6a8c-ec17-2334d968a2bd"}, {"reference": "Observation/9fd36dae-6b24-b218-f901-dd19c3a7201e"}, {"reference": "Observation/d0f632a3-b0d2-08dc-1db4-25d6044592f1"}, {"reference": "Observation/521fbc78-9973-b07e-c493-3518fc548037"}, {"reference": "Observation/c312e4fe-6a56-ccc2-c2e0-840ee5ff893f"}, {"reference": "Observation/f503ba7e-9f4b-f5aa-47c6-0f84cf02bd15"}]}, {"id": "bb131d02-bf3c-d6bf-05ef-d55c8b1e9da9", "title": "Medications Administered", "text": {"status": "generated", "div": "
Medication NameMedication Start Date
remdesivir20221123010000+0000
remdesivirUnknown
remdesivirUnknown
"}, "code": {"coding": [{"code": "29549-3", "display": "Medications Administered", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/3fa0541c-348a-6c2e-3049-d778c54dddea"}, {"reference": "MedicationAdministration/0ffeca16-f0a5-3234-fca7-38851753a4db"}, {"reference": "MedicationAdministration/d09efaa1-c0f5-3b15-934e-3a6bd4367fb1"}]}, {"id": "9e063508-4ac0-9c4c-f41e-77ad22868a8d", "title": "IMMUNIZATIONS", "text": {"status": "generated", "div": "
Vaccine NameVaccination Date
influenza virus vaccine, liveWed Nov 10 00:00:00 GMT 2021
"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "d69703e2-5f33-f5f2-cba1-93d7574e262d", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Occupation HistoryStudent
Travel HistoryCovid Test Result-Negative (qualifier value)
Travel HistoryCovid Test Result-Negative (qualifier value)
Travel HistoryCongestion or Runny Nose-No (qualifier value)
Travel HistoryNausea-No (qualifier value)
Travel HistoryPositive COVID-19 Test-No (qualifier value)
Travel HistoryLoss of Taste or Smell-No (qualifier value)
Travel HistoryReported Fever-No (qualifier value)
Travel HistoryDry Cough-No (qualifier value)
Travel HistorySymptomatic Health Care Professional/SNF-No (qualifier value)
Travel HistorySymptomatic After Exposure to Contagion-No (qualifier value)
Travel HistoryDroplet, Contact Isolation Verification-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryUnexplained Hemorrhage, Bleed or Bruise-No (qualifier value)
Travel HistoryAbnormal Bleeding-No (qualifier value)
Travel HistoryAbdominal (Stomach Pain)-No (qualifier value)
Travel HistoryDifficulty breathing (finding)-No (qualifier value)
Travel HistoryChills Infectious Disease-No (qualifier value)
Travel HistoryBreastfeeding-Not applicable (qualifier value)
Travel HistoryDiarrhea (finding)-No (qualifier value)
Travel HistoryVomiting (disorder)-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryDyspnea (finding)-No (qualifier value)
Travel HistoryIllness With Generalized Rash-No (qualifier value)
Travel HistoryMuscle pain (finding)-No (qualifier value)
Travel HistoryHeadache (finding)-No (qualifier value)
Travel HistorySexual Orientation-Not applicable (qualifier value)
Travel HistorySexually active (finding)-Not applicable (qualifier value)
Travel HistoryCongestion or Runny Nose-No (qualifier value)
Travel HistoryNausea-No (qualifier value)
Travel HistoryPositive COVID-19 Test-No (qualifier value)
Travel HistoryLoss of Taste or Smell-No (qualifier value)
Travel HistoryReported Fever-No (qualifier value)
Travel HistoryDry Cough-No (qualifier value)
Travel HistorySymptomatic Health Care Professional/SNF-No (qualifier value)
Travel HistorySymptomatic After Exposure to Contagion-No (qualifier value)
Travel HistoryDroplet, Contact Isolation Verification-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryUnexplained Hemorrhage, Bleed or Bruise-No (qualifier value)
Travel HistoryAbnormal Bleeding-No (qualifier value)
Travel HistoryAbdominal (Stomach Pain)-No (qualifier value)
Travel HistoryDifficulty breathing (finding)-No (qualifier value)
Travel HistoryChills Infectious Disease-No (qualifier value)
Travel HistoryDiarrhea (finding)-No (qualifier value)
Travel HistoryVomiting (disorder)-No (qualifier value)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
Travel HistoryDyspnea (finding)-No (qualifier value)
Travel HistoryIllness With Generalized Rash-No (qualifier value)
Travel HistoryMuscle pain (finding)-No (qualifier value)
Travel HistoryHeadache (finding)-No (qualifier value)
Travel HistoryInfectious Diseases Health History-None (qualifier value)
Travel HistorySexual Orientation-Not applicable (qualifier value)
Travel HistorySexually active (finding)-Not applicable (qualifier value)
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryTravel Outside the US Within Last 1 Year-Yes, patient
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
Travel HistoryRecent countries visited (observable entity)-China (geographic location)
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Health Case Report", "system": "http://loinc.org"}]}, "value": "38381210|64871322"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "1"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-04-17T04:17:21Z", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "8387d52d-4149-8faf-9cf0-55a1d72748d5", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "
Problem or DiagnosisProblem Status
TTP (thrombotic thrombocytopenic purpura)Active
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Thrombotic thrombocytopenic purpura (disorder)", "reference": "Condition/3907477b-3eba-59c4-6622-d3c3a81a39f4"}]}, {"id": "58ebd6f7-9c63-dac4-1f3f-c4a55907bb39", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
observation encounter20220415161500+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "dc32a83b-bbcc-85fe-5240-91c405175be5", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
Troponin TNIH8.2|http://unitsofmeasure.org|ng/L
Troponin TNIH8.1|http://unitsofmeasure.org|ng/L
Troponin TNIH9.5|http://unitsofmeasure.org|ng/L
NT-ProBNP84|http://unitsofmeasure.org|pg/mL
Estimated Creatinine Clearance52.76|http://unitsofmeasure.org|mL/min
Symptomatic as defined by CDC?Yes
In ICU?No
Group care resident?No
Employed in healthcare?No
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRNegative
eGFR PediatricNot Reported
Flu B PCRNot Detected
Flu A PCRNot Detected
Calc Osmo270|http://unitsofmeasure.org|mOsmol/kg
A/G RatioUnknown
eGFR Non-African American70|http://unitsofmeasure.org|mL/min/1.73m2
eGFR African American81|http://unitsofmeasure.org|mL/min/1.73m2
Sodium135|http://unitsofmeasure.org|mmol/L
Potassium4.0|http://unitsofmeasure.org|mmol/L
Baso # Auto0.02|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level3.6|http://unitsofmeasure.org|gm/dL
Mono # Auto0.60|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto4.73|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.3|http://unitsofmeasure.org|%
Eos % Auto0.7|http://unitsofmeasure.org|%
Lymph % Auto21.3|http://unitsofmeasure.org|%
Neut % Auto68.9|http://unitsofmeasure.org|%
Calcium9.1|http://unitsofmeasure.org|mg/dL
RDW-SD49.7|http://unitsofmeasure.org|Femtoliters
Immature Grans # Auto0.01|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto1.46|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto8.7|http://unitsofmeasure.org|%
RDW-CV14.9|http://unitsofmeasure.org|%
Immature Grans %0.1|http://unitsofmeasure.org|%
Eos # Auto0.05|http://unitsofmeasure.org|x10e3/mcL
Chloride101|http://unitsofmeasure.org|mmol/L
BUN9|http://unitsofmeasure.org|mg/dL
Plt195|http://unitsofmeasure.org|x10e3/mcL
WBC6.87|http://unitsofmeasure.org|x10e3/mcL
TP8.9|http://unitsofmeasure.org|gm/dL
RBC4.92|http://unitsofmeasure.org|x10e6/mcL
MPV11.6|http://unitsofmeasure.org|Femtoliters
MCV90.7|http://unitsofmeasure.org|Femtoliters
MCHC33.0|http://unitsofmeasure.org|gm/dL
MCH29.9|http://unitsofmeasure.org|pg
Hgb14.7|http://unitsofmeasure.org|gm/dL
Hct44.6|http://unitsofmeasure.org|%
Glucose Level115|http://unitsofmeasure.org|mg/dL
D Dimer0.34|http://unitsofmeasure.org|mcg/mL FEU
CO228|http://unitsofmeasure.org|mmol/L
T Bili0.8|http://unitsofmeasure.org|mg/dL
AST25|http://unitsofmeasure.org|units/L
ALT19|http://unitsofmeasure.org|units/L
Alk Phos67|http://unitsofmeasure.org|units/L
BUN/Creat RatioUnknown
Anion Gap6|http://unitsofmeasure.org|mmol/L
Creatinine0.856|http://unitsofmeasure.org|mg/dL
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Medication NameMedication Start Date
albuterol (Ventolin HFA 90 mcg/inh inhalation aerosol)20220416050100+0000
doxycycline (doxycycline hyclate 100 mg oral tablet)20220416050100+0000
predniSONE (predniSONE 50 mg oral tablet)20220416050100+0000
Sodium Chloride 0.9% intravenous solution (NS Bolus (ADULT))20220415164100+0000
dexamethasone20220415164300+0000
ipratropium-albuterol (DuoNeb)20220415164300+0000
"}, "code": {"coding": [{"code": "29549-3", "display": "Medications Administered", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/cf9718b1-e622-e7af-3f57-7ccc11f47168"}, {"reference": "MedicationAdministration/660a34cf-6bb4-a0a0-70c1-2556ec6323f3"}, {"reference": "MedicationAdministration/4f0c772a-f2ae-e341-cf1a-7f2c778d8a53"}, {"reference": "MedicationAdministration/13d4231b-70e9-c943-f0e7-d149fdd14973"}, {"reference": "MedicationAdministration/7860e902-7286-abce-b085-f1ddf30bc76f"}, {"reference": "MedicationAdministration/c45ce1df-b3f0-999b-90a8-aa39fec61fa1"}]}, {"id": "dd08df91-869b-46df-dd36-c5c0f2ad2eae", "title": "IMMUNIZATIONS", "text": {"status": "generated", "div": "No ImmunizationInformation"}, "code": {"coding": [{"code": "11369-6", "display": "History of immunizations", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "1ee0e176-222f-864a-5b05-9a38d5189d31", "title": "SOCIAL HISTORY", "text": {"status": "generated", "div": "
Social History ObservationSocial History Observation Result
Birth SexF
Travel HistoryCOVID- 19 Testing Reason-Screening
Travel HistoryCOVID- 19 Testing Reason-Screening
Travel HistoryCOVID-19 Previously tested-No (qualifier value)
Travel HistoryExposure to severe acute respiratory syndrome coronavirus 2 (event)-No (qualifier value)
Travel HistoryMERS-CoV Travel History-No (qualifier value)
Travel HistoryTB Risk Score-
Travel HistorySymptoms of TB-No symptoms of TB
Travel HistoryHistory of tuberculosis (situation)-No known history of exposure to TB
Travel HistoryC.diff Screening-No (qualifier value)
Travel HistoryMERS-CoV Symptoms-
Travel HistoryMRSA Screen Hx MRSA-No (qualifier value)
Travel HistoryRecent Exposure to Communicable Disease-No (qualifier value)
"}, "code": {"coding": [{"code": "29762-2", "display": "Social History", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Observation/9389af18-d1a2-58ab-ee16-0681acd78c6f"}, {"reference": "Observation/51746276-2451-9932-9e58-4f21971c62ac"}, {"reference": "Observation/e3794f31-0b96-7d3f-69d5-7b944494e540"}, {"reference": "Observation/f21fadab-af58-b443-50c0-2201075d0c25"}, {"reference": "Observation/88ab5385-5cb5-0308-a58e-bc67b2f3b725"}, {"reference": "Observation/dbe310c6-9580-0fe6-11c8-4b8caa33a9fb"}, {"reference": "Observation/f4ed88e3-7742-2dea-1a58-8505caead382"}, {"reference": "Observation/68f1da74-94b9-7976-76f3-b5354cc0f35f"}, {"reference": "Observation/994278a6-ca17-8619-c789-19b8b6bf6f9c"}, {"reference": "Observation/1e6de63d-ea70-84d6-52d2-46429d031b57"}, {"reference": "Observation/3ca15288-a6ed-8ad3-77c9-eee0ba9275be"}, {"reference": "Observation/eedc882c-0f16-276c-3bd8-b677a1a6c600"}]}, {"id": "7dbd51e8-1c15-8cfa-cbce-f6f4b9a1ed5d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "No Plan Of Treatment Information"}, "code": {"coding": [{"code": "18776-5", "display": "Treatment Plan", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/ec77d178-de8a-915a-311a-1f11f2838946"}]}, {"id": "d9d29cc3-a276-3cb1-dfbf-e1c4ce391ff6", "title": "History of Present Illness", "text": {"status": "generated", "div": "
Narrative Text
Wheezing
Acute URI
Cough
Tachycardia
"}, "code": {"coding": [{"code": "10164-2", "display": "History of Present Illness", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "65225627-ffb0-e051-e796-fbbd26035fbc", "title": "Reason For Visit", "text": {"status": "generated", "div": "
text
ACUTE URI
"}, "code": {"coding": [{"code": "29299-5", "display": "Reason For Visit", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "ACUTE URI"}]}, {"id": "fe5ea6af-6ec5-edfd-fe9b-c6b07748e2dd", "title": "Reportability Response Information Section", "text": {"status": "generated", "div": "
Reportability Response Information Section
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('1.2.840.114350.1.13.202.3.7.8.688883.477', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.202.3.7.8.688883.477", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.202.3.7.8.688883.477", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "28beb5ae-3f68-11ed-8bdc-005056a7fb21", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "21"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": 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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
alum-mag hydroxide-simeth (MAALOX) 200-200-20 mg/5 mL oral suspension 15 mL15 mL, Oral, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 dose, Order WILL be automatically substituted with P&T Approved equivalent per protocol. SHAKE WELL prior to use.Given09/28/2022 8:37 PM PDT15 mL
aspirin tablet 325 mg325 mg, Oral, ONCE, On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT325 mg
lidocaine (XYLOCAINE) 2% viscous oral solution5 mL, Swish and Spit, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT5 mL
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/6dd25719-9ba8-9164-79fe-005e349bcb21"}, {"reference": "MedicationAdministration/3d9ad81e-9518-1b14-44a8-cc86725ed68c"}, {"reference": "MedicationAdministration/b3a81224-d404-4fd4-3134-5c54815acd0f"}]}, {"id": "ca51a58e-d5d5-8f6d-28be-f526ca11481f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/5ddcb7d6-d32c-e91c-f715-cf239eb4aee6"}]}, {"id": "BFF3AE86-4439-11ED-9D28-005056A7FB21", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
documented as of this encounter (statuses as of 10/04/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Seasonal allergies", "reference": "Condition/5c1d48d8-1b16-c482-65b0-874cdffb0325"}, {"display": "Problem - Coronavirus infection", "reference": "Condition/1e7e7161-de05-f41e-f064-c227e43edd3e"}, {"display": "Problem - Close exposure to COVID-19 virus", "reference": "Condition/6cb5bd36-5db9-68d4-ec94-afc3f96f6392"}]}, {"id": "578e38a5-2cc7-00e0-1769-ea74746c5fe8", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "BFF6E3A8-4439-11ED-9D28-005056A7FB21", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "SARS-CoV-2, RNA", "reference": "Observation/3a45daf2-6872-fd2a-6ede-606810d52bb2"}, {"display": "Lab Interpretation", "reference": "Observation/e9c8e4b3-3fec-4f29-a5c5-e45f96680a4c"}]}, {"id": "8a900c7f-2adf-c43c-4fde-16f9696944df", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "8cfa32e2-c143-2ba9-dc72-266a3ba673c6", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Close exposure to COVID-19 virusCoronavirus infection (Primary Dx);
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U.S.C. 360bbb-3(b)(1), unless the authorization is terminated or
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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
alum-mag hydroxide-simeth (MAALOX) 200-200-20 mg/5 mL oral suspension 15 mL15 mL, Oral, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 dose, Order WILL be automatically substituted with P&T Approved equivalent per protocol. SHAKE WELL prior to use.Given09/28/2022 8:37 PM PDT15 mL
aspirin tablet 325 mg325 mg, Oral, ONCE, On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT325 mg
lidocaine (XYLOCAINE) 2% viscous oral solution5 mL, Swish and Spit, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT5 mL
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Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
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DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Close exposure to COVID-19 virusCoronavirus infection (Primary Dx);
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Reportability Response Information Section
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MemberRoleStatusDates
TESTPHYS AAAprimary care physicianActive
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Ed Bakeradmitting physicianActive
Start: March 31st, 2022
GAIL SILVAattending physicianActive
Start: March 31st, 2022
DR DEBRA A ALEXANDER JR, PHDFAMILYActive
Start: March 31st, 2022
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Is patient pregnant?NMarch 31st, 2022 12:06pm
Assigned Birth SexFemale
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Problem or DiagnosisProblem Status
Disease caused by 2019-nCoVActive
Abdominal pain (finding)Active
Abdominal pain (finding)Active
Patient encounter status (finding)Active
Patient encounter status (finding)Active
Lupus erythematosus (disorder)Active
Abdominal painActive
Lupus erythematosusActive
Malaise (finding)Active
Low back painActive
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Encounter ReasonDate of Encounter
Emergency20220428011000+0000
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Lab Test NameLab Test Result ValueLab Test Result Date
Ur pHUnknown
Ur Spec GravUnknown
Ur Urobilinogen<2.0 mg/dL
Ur Blood1+ mg/dL
Ur BiliNegative mg/dL
Ur Leuk Est1+
Ur ColorYellow
Ur MucousRare /LPF
Ur Squam Epithelial5|http://unitsofmeasure.org|/HPF
Ur WBC18|http://unitsofmeasure.org|/HPF
Ur RBC2|http://unitsofmeasure.org|/HPF
Ur ProteinNegative mg/dL
Ur NitriteNegative
Ur KetonesNegative mg/dL
UR GlucoseNegative mg/dL
Ur BacteriaNone Seen /HPF
Ur ClarityClear
U Beta hCG QlNegative
Ur pH5.5
Ur Spec Grav1.020 mg/dL
Ur Urobilinogen0.2 EU/dL
Ur BloodTrace-lysed
Ur BiliNegative
Ur Leuk EstTrace
Ur ProteinNegative mg/dL
Ur NitriteNegative
Ur KetonesNegative mg/dL
UR GlucoseNegative mg/dL
Estimated Creatinine Clearance55.01|http://unitsofmeasure.org|mL/min
Troponin TNIH4.2|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
Calc Osmo284|http://unitsofmeasure.org|mOsmol/L
A/G Ratio1.1|http://unitsofmeasure.org|Ratio
eGFR Non-African American64.68 mL/min/1.73m2
eGFR African American74.97 mL/min/1.73m2
Sodium141|http://unitsofmeasure.org|mmol/L
Potassium3.6|http://unitsofmeasure.org|mmol/L
NT-ProBNP44|http://unitsofmeasure.org|pg/mL
Baso # Auto0.05|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level4.1|http://unitsofmeasure.org|gm/dL
Mono # Auto0.6|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto3.3|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.8|http://unitsofmeasure.org|%
Eos % Auto1.9|http://unitsofmeasure.org|%
Lymph % Auto32.3|http://unitsofmeasure.org|%
Neut % Auto55.5|http://unitsofmeasure.org|%
Calcium8.8|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.01|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto1.9|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto9.3|http://unitsofmeasure.org|%
RDW-CV13.9|http://unitsofmeasure.org|%
Immature Grans %0.2|http://unitsofmeasure.org|%
Eos # Auto0.1|http://unitsofmeasure.org|x10e3/mcL
Chloride106|http://unitsofmeasure.org|mmol/L
BUN20|http://unitsofmeasure.org|mg/dL
Plt231|http://unitsofmeasure.org|x10e3/mcL
WBC5.9|http://unitsofmeasure.org|x10e3/mcL
TP7.8|http://unitsofmeasure.org|gm/dL
RBC4.01|http://unitsofmeasure.org|x10e6/mcL
PT11.3|http://unitsofmeasure.org|Seconds
MPV11.7|http://unitsofmeasure.org|Femtoliters
MCV93.8|http://unitsofmeasure.org|Femtoliters
MCHC31.9|http://unitsofmeasure.org|gm/dL
MCH29.9|http://unitsofmeasure.org|pg
Hgb12.0|http://unitsofmeasure.org|gm/dL
Hct37.6|http://unitsofmeasure.org|%
Glucose Level97|http://unitsofmeasure.org|mg/dL
CO224.8|http://unitsofmeasure.org|mmol/L
T BiliTNP see comment mg/dL
AST22|http://unitsofmeasure.org|Intl_units/L
ALT27|http://unitsofmeasure.org|Intl_units/L
Alk Phos72|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio20.0|http://unitsofmeasure.org|Ratio
INRUnknown
Anion GapUnknown
HCG Bld QLNegative
Creatinine1.0|http://unitsofmeasure.org|mg/dL
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NameAdministration DatesNext Due
COVID-19, mRNA, Moderna, Preservative Free06/12/202111/12/2022
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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
albuterol (VENTOLIN) 2.5 mg /3 mL (0.083 %) nebulizer solution 2.5 mg2.5 mg, Nebulization, ONCE (IN CLINIC), On Tue 8/2/22 at 1200, For 1 dose, Order MAY be automatically substituted with P&T Approved equivalent per protocol. Dilute before use with normal saline if needed. , Delivery Mode: HHNGiven08/02/2022 11:39 AM PDT2.5 mg
aspirin tablet 650 mg650 mg, Oral, ONCE (IN CLINIC), On Tue 8/2/22 at 1200, For 1 doseGiven08/02/2022 11:40 AM PDT650 mg
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Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
CREATININE, SERUMLabRoutineCOVID-19 virus detectedPregnancy test positiveOrdered: 8/2/22
THYROID-STIMULATING HORMONE (TSH)LabRoutineCOVID-19 virus detectedPregnancy test positiveOrdered: 8/2/22
THYROXINE (T4), FREELabRoutineCOVID-19 virus detectedPregnancy test positiveOrdered: 8/2/22
GLUCOSE, BLOODLabRoutineCOVID-19 virus detectedPregnancy test positiveOrdered: 8/2/22
HELICOBACTER PYLORI ANTIBODY, IGALabRoutineCOVID-19 virus detectedPregnancy test positiveOrdered: 8/2/22
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Active ProblemsNoted Date
2019 novel coronavirus disease (COVID-19)8/2/22
Generalized abdominal pain8/2/22
Eclampsia, antepartum8/2/22
Pregnancy related exhaustion and fatigue, antepartum8/2/22
Pregnancy test positive8/2/22
Pain, upper back7/22/22
Mild to moderate pre-eclampsia7/21/22
Depression, recurrent7/21/22
PregnantComments
Yes
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Every DayCigarettes330
Smokeless Tobacco: Never
Tobacco Cessation:
Ready to Quit: No; Counseling Given: Yes
Alcohol UseStandard Drinks/WeekComments
Yes0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Doctorate07/25/2022
Sex Assigned at BirthDate Recorded
Female07/21/2022 4:09 PM PDT
Job Start DateOccupationIndustry
1/1/14Not on fileNot on file
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DateTypeDepartmentCare TeamDescription
8/2/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031So, Naomi
Pregnancy test positiveCOVID-19 virus detected (Primary Dx);
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NameAdministration DatesNext Due
DTAP-HIB-IPV (PENTACEL)04/16/2010
HEP A (ADULT) 2 DOSE11/11/2011
HEP B (PED,ADOLESCENT) 3 DOSE03/21/1974
MENINGOCOCCAL CONJUGATE,MENACTRA (PED/ADOL/ADULT)11/16/2020
TDAP, (ADOL/ADULT)11/10/2020
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "A643FC02-3F70-11ED-9549-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "af896ab0-09ae-234e-c3ec-12823ba33230", "title": "Plan of Treatment", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/bc17dacd-4cfa-7ecf-f264-423f87ef2461"}]}, {"id": "A654AFCA-3F70-11ED-9549-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
Bipolar I disorder11/19/20
Reactive depression11/19/20
Rheumatoid arthritis with negative rheumatoid factor11/16/20
Arthralgia of both ankles11/16/20
Anxiety11/10/20
Asthma11/10/20
Knee pain4/29/19
Sprain of calcaneofibular ligament of right ankle4/16/19
Last Assessment & Plan:Formatting of this note might be different from the original.
This is my note about this problem.
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture bloodMicrobiologyRoutineRoutine general medical examination at a health care facility06/16/2022 4:12 PM EDT
Blood culture pathogens molecular studyMicrobiologyRoutineRoutine general medical examination at a health care facility06/16/2022 4:12 PM EDT
Culture bloodMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 2:19 PM EDT
Blood culture pathogens molecular studyMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 2:19 PM EDT
Culture body fluid with gram stainMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 2:27 PM EDT
Legionella antigen urine, EIALabRoutineRoutine general medical examination at a health care facility06/17/2022 2:48 PM EDT
Culture throatMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 2:58 PM EDT
Culture throatMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 3:37 PM EDT
Culture woundMicrobiologyRoutineRoutine general medical examination at a health care facility06/17/2022 3:49 PM EDT
Occult blood screen, guaiacLabRoutineRoutine general medical examination at a health care facility06/17/2022 4:05 PM EDT
Rapid influenza A and B, molecularMicrobiologyRoutineRoutine general medical examination at a health care facility06/20/2022 7:58 AM EDT
SARS-COV2-RNA, qualitative RT-PCR, internal labMicrobiologyRoutineRoutine general medical examination at a health care facility06/20/2022 7:58 AM EDT
SARS-COV2-RNA, RSV, Influenza A and B qualitative RT-PCRMicrobiologyRoutineRoutine general medical examination at a health care facility06/20/2022 7:58 AM EDT
MRSA molecular studyMicrobiologyRoutineRoutine general medical examination at a health care facility06/20/2022 8:11 AM EDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
SARS-COV2-RNA, qualitative RT-PCRMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Culture bloodMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Culture body fluid with gram stainMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Legionella antigen urine, EIALabRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Culture throatMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Culture throatMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Culture woundMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Occult blood screen, guaiacLabRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/17/22 until 6/17/23
Rapid influenza A and B, molecularMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/20/22 until 6/20/23
SARS-COV2-RNA, qualitative RT-PCR, internal labMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/20/22 until 6/20/23
SARS-COV2-RNA, RSV, Influenza A and B qualitative RT-PCRMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/20/22 until 6/20/23
Rapid influenza A and B, molecularMicrobiologyRoutineRoutine general medical examination at a health care facilityOnce for 1 Occurrences starting 6/20/22 until 6/20/22
SARS-COV2-RNA, qualitative RT-PCR, internal labMicrobiologyRoutineRoutine general medical examination at a health care facilityOnce for 1 Occurrences starting 6/20/22 until 6/20/22
SARS-COV2-RNA, RSV, Influenza A and B qualitative RT-PCRMicrobiologyRoutineRoutine general medical examination at a health care facilityOnce for 1 Occurrences starting 6/20/22 until 6/20/22
MRSA molecular studyMicrobiologyRoutineRoutine general medical examination at a health care facility1 Occurrences starting 6/20/22 until 6/20/23
MRSA molecular studyMicrobiologyRoutineRoutine general medical examination at a health care facilityOnce for 1 Occurrences starting 6/20/22 until 6/20/22, 1 completed
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Tobacco UseTypesPacks/DayYears UsedDate
Never Assessed
Sex Assigned at BirthDate Recorded
Not on file
Job Start DateOccupationIndustry
Not on fileNot on fileNot on file
COVID-19 ExposureResponseDate Recorded
In the last 10 days, have you been in contact with someone who was confirmed or suspected to have Coronavirus/COVID-19?No / Unsure6/13/2022 10:25 AM EDT
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DateTypeDepartmentCare TeamDescription
6/16/22Hospital EncounterTrinity Health Lab - Muskegon Hospital1500 E Sherman BlvdMuskegon, MI 49444-1849231-672-6259
Routine general medical examination at a health care facilityInfertility male (Primary Dx);
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Diagnosis
Infertility male - PrimaryUnspecified male infertility
Routine general medical examination at a health care facility
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Procedure NamePriorityDate/TimeAssociated DiagnosisComments
SARS-COV2-RNA, RSV, FLU A AND B QUALITATIVE RT-PCR, INTERNAL LABRoutine06/20/2022 7:58 AM EDTRoutine general medical examination at a health care facilityresults section .Results for this procedure are in the
LEGIONELLA ANTIGEN URINE, EIARoutine06/16/2022 4:22 PM EDTRoutine general medical examination at a health care facilityresults section .Results for this procedure are in the
CULTURE BLOODRoutine06/16/2022 4:12 PM EDTRoutine general medical examination at a health care facility
SEMEN ANALYSIS, POST VASECTOMYRoutine06/16/2022 3:18 PM EDTInfertility maleresults section .Results for this procedure are in the
MONONUCLEOSIS SCREENRoutine06/16/2022 1:53 PM EDTRoutine general medical examination at a health care facilityresults section .Results for this procedure are in the
THROMBOELASTOGRAPH 6 GLOBAL HEMOSTASIS PANELRoutine06/16/2022 1:44 PM EDTRoutine general medical examination at a health care facilityresults section .Results for this procedure are in the
THROMBOELASTOGRAPH WITH PLATELET MAPPING ADPRoutine06/16/2022 1:31 PM EDTRoutine general medical examination at a health care facilityresults section .Results for this procedure are in the
SEMEN ANALYSISRoutine06/16/2022 12:48 PM EDTInfertility maleresults section .Results for this procedure are in the
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InfectionOnset DateLast IndicatedResolved Time
COVID-1906/13/202206/13/2022
Respiratory Rule-Out06/20/202206/20/202206/20/2022 8:22 AM EDT
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Reportability Response Information Section
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('1.2.840.114350.1.13.202.3.7.8.688883.487', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.202.3.7.8.688883.487", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.202.3.7.8.688883.487", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "28beb5ae-3f68-11ed-8bdc-005056a7fb21", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "31"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-10-04T17:05:47-07:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "c80f67bb-6876-6ad5-ea57-46aea1afa973", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "76F20BE4-4441-11ED-91C1-005056A7FB21", "title": "Immunizations", "text": {"status": "generated", "div": "Not on file documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "76F66F4A-4441-11ED-91C1-005056A7FB21", "title": "Administered Medications", "text": {"status": "generated", "div": "
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
alum-mag hydroxide-simeth (MAALOX) 200-200-20 mg/5 mL oral suspension 15 mL15 mL, Oral, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 dose, Order WILL be automatically substituted with P&T Approved equivalent per protocol. SHAKE WELL prior to use.Given09/28/2022 8:37 PM PDT15 mL
aspirin tablet 325 mg325 mg, Oral, ONCE, On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT325 mg
lidocaine (XYLOCAINE) 2% viscous oral solution5 mL, Swish and Spit, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT5 mL
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/6dd25719-9ba8-9164-79fe-005e349bcb21"}, {"reference": "MedicationAdministration/3d9ad81e-9518-1b14-44a8-cc86725ed68c"}, {"reference": "MedicationAdministration/b3a81224-d404-4fd4-3134-5c54815acd0f"}]}, {"id": "ca51a58e-d5d5-8f6d-28be-f526ca11481f", "title": "Plan of Treatment", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/5ddcb7d6-d32c-e91c-f715-cf239eb4aee6"}]}, {"id": "76F9D87E-4441-11ED-91C1-005056A7FB21", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
documented as of this encounter (statuses as of 10/04/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Seasonal allergies", "reference": "Condition/5c1d48d8-1b16-c482-65b0-874cdffb0325"}, {"display": "Problem - Coronavirus infection", "reference": "Condition/1e7e7161-de05-f41e-f064-c227e43edd3e"}, {"display": "Problem - Close exposure to COVID-19 virus", "reference": "Condition/6cb5bd36-5db9-68d4-ec94-afc3f96f6392"}]}, {"id": "578e38a5-2cc7-00e0-1769-ea74746c5fe8", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "76FCD222-4441-11ED-91C1-005056A7FB21", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "SARS-CoV-2, RNA", "reference": "Observation/3a45daf2-6872-fd2a-6ede-606810d52bb2"}, {"display": "Lab Interpretation", "reference": "Observation/e9c8e4b3-3fec-4f29-a5c5-e45f96680a4c"}]}, {"id": "8a900c7f-2adf-c43c-4fde-16f9696944df", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "8cfa32e2-c143-2ba9-dc72-266a3ba673c6", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Close exposure to COVID-19 virusCoronavirus infection (Primary Dx);
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Reportability Response Information Section
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Problem or DiagnosisProblem Status
UnknownActive
"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "Condition/0a66854a-5643-4338-2b22-4564d9958ed8"}]}, {"id": "119142ea-0976-3fbf-8f73-0f955476c21d", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter ReasonDate of Encounter
Emergency20220515223400+0000
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "bd144f2f-358f-c7a7-7e31-b27478de2c48", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueLab Test Result Date
Symptomatic as defined by CDC?Yes
In ICU?No
Group care resident?No
Employed in healthcare?No
SARS-CoV-2 Interp:Unknown
SARS-CoV-2 PCRNegative
Flu B PCRNot Detected
Flu A PCRNot Detected
Troponin TNIH46.4|http://unitsofmeasure.org|ng/L
Estimated Creatinine Clearance108.17|http://unitsofmeasure.org|mL/min
Troponin TNIH54.2|http://unitsofmeasure.org|ng/L
eGFR PediatricNot Reported
Calc Osmo271|http://unitsofmeasure.org|mOsmol/L
A/G Ratio0.9|http://unitsofmeasure.org|Ratio
eGFR Non-African American108.66 mL/min/1.73m2
eGFR African American125.94 mL/min/1.73m2
Sodium136|http://unitsofmeasure.org|mmol/L
Potassium4.1|http://unitsofmeasure.org|mmol/L
NT-ProBNP25|http://unitsofmeasure.org|pg/mL
Baso # Auto0.06|http://unitsofmeasure.org|x10e3/mcL
Albumin. Level4.0|http://unitsofmeasure.org|gm/dL
Mono # Auto0.9|http://unitsofmeasure.org|x10e3/mcL
Neut # Auto13.1|http://unitsofmeasure.org|x10e3/mcL
Baso % Auto0.4|http://unitsofmeasure.org|%
Eos % Auto2.9|http://unitsofmeasure.org|%
Lymph % Auto13.7|http://unitsofmeasure.org|%
Neut % Auto77.1|http://unitsofmeasure.org|%
Calcium10.0|http://unitsofmeasure.org|mg/dL
Immature Grans # Auto0.08|http://unitsofmeasure.org|x10e3/mcL
Lymph # Auto2.3|http://unitsofmeasure.org|x10e3/mcL
Mono % Auto5.4|http://unitsofmeasure.org|%
RDW-CV13.2|http://unitsofmeasure.org|%
Immature Grans %0.5|http://unitsofmeasure.org|%
Eos # Auto0.5|http://unitsofmeasure.org|x10e3/mcL
Chloride105|http://unitsofmeasure.org|mmol/L
BUN8|http://unitsofmeasure.org|mg/dL
Plt326|http://unitsofmeasure.org|x10e3/mcL
WBC17.0|http://unitsofmeasure.org|x10e3/mcL
TP8.4|http://unitsofmeasure.org|gm/dL
RBC5.10|http://unitsofmeasure.org|x10e6/mcL
PT10.7|http://unitsofmeasure.org|Seconds
MPV9.3|http://unitsofmeasure.org|Femtoliters
MCV86.7|http://unitsofmeasure.org|Femtoliters
MCHC34.2|http://unitsofmeasure.org|gm/dL
MCH29.6|http://unitsofmeasure.org|pg
Mg Lvl2.2|http://unitsofmeasure.org|mg/dL
Hgb15.1|http://unitsofmeasure.org|gm/dL
Hct44.2|http://unitsofmeasure.org|%
Glucose Level110|http://unitsofmeasure.org|mg/dL
D Dimer0.58|http://unitsofmeasure.org|mg/L
CO221.2|http://unitsofmeasure.org|mmol/L
T Bili0.5|http://unitsofmeasure.org|mg/dL
AST18|http://unitsofmeasure.org|Intl_units/L
ALT31|http://unitsofmeasure.org|Intl_units/L
Alk Phos88|http://unitsofmeasure.org|Intl_units/L
BUN/Creat Ratio10.0|http://unitsofmeasure.org|Ratio
INRUnknown
Anion GapUnknown
HCG Bld QLNegative
Creatinine0.8|http://unitsofmeasure.org|mg/dL
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Travel HistoryCOVID- 19 Testing Reason-Diagnostic
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Travel HistoryTB Risk Score-
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Pneumonia due to COVID-19 virus
Encounter for medical screening examination
Shortness of breath
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Drugs Of Abuse Comprehensive Screen, UrLabSTAT12/23/2022 11:13 AM PST
Scheduled Orders
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Drugs Of Abuse Comprehensive Screen, UrLabRoutineOne Time for 1 Occurrences starting 12/23/22 until 12/23/22
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Unconfirmed screening results must not be used for non-medical purposes (e.g., employment testing).
Only positive maternal and neonatal screening results reflex for confirmation and are reported separately.
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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
alum-mag hydroxide-simeth (MAALOX) 200-200-20 mg/5 mL oral suspension 15 mL15 mL, Oral, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 dose, Order WILL be automatically substituted with P&T Approved equivalent per protocol. SHAKE WELL prior to use.Given09/28/2022 8:37 PM PDT15 mL
aspirin tablet 325 mg325 mg, Oral, ONCE, On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT325 mg
lidocaine (XYLOCAINE) 2% viscous oral solution5 mL, Swish and Spit, ONCE (IN CLINIC), On Wed 9/28/22 at 2100, For 1 doseGiven09/28/2022 8:37 PM PDT5 mL
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Active ProblemsNoted Date
Coronavirus infection9/28/22
Close exposure to COVID-19 virus9/28/22
Seasonal allergies9/24/22
PregnantEstimated Date of DeliveryComments
Yes5/6/23Based on Est. Date of Conception
documented as of this encounter (statuses as of 10/04/2022)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Seasonal allergies", "reference": "Condition/2b90aed1-911f-1ddf-44d8-fd13c5477a61"}, {"display": "Problem - Coronavirus infection", "reference": "Condition/1e7e7161-de05-f41e-f064-c227e43edd3e"}, {"display": "Problem - Close exposure to COVID-19 virus", "reference": "Condition/6cb5bd36-5db9-68d4-ec94-afc3f96f6392"}]}, {"id": "578e38a5-2cc7-00e0-1769-ea74746c5fe8", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "E8789A36-4440-11ED-B2C1-005056A7FB21", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "SARS-CoV-2, RNA", "reference": "Observation/3a45daf2-6872-fd2a-6ede-606810d52bb2"}, {"display": "Lab Interpretation", "reference": "Observation/e9c8e4b3-3fec-4f29-a5c5-e45f96680a4c"}]}, {"id": "8a900c7f-2adf-c43c-4fde-16f9696944df", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
EducationAnswerDate Recorded
What is the highest level of school you have completed or the highest degree you have received?Bachelor''s degree (e.g., BA, AB, BS)09/24/2022
Sex Assigned at BirthDate Recorded
Female09/24/2022 12:34 PM PDT
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "8cfa32e2-c143-2ba9-dc72-266a3ba673c6", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare TeamDescription
9/28/22Office VisitCSMG Internal Medicine8767 Wilshire Blvd2nd FloorBEVERLY HILLS, CA 90211310-385-6031Canavan, Allison H, MD8631 W. THIRD STREETSTE 510ELOS ANGELES, CA 90048310-385-3380 (Work)310-385-3224 (Fax)allison.canavan@cshs.org
Close exposure to COVID-19 virusCoronavirus infection (Primary Dx);
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Reportability Response Information Section
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[{"code": "Z20.822", "display": "Close exposure to COVID-19 virus", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-09-28", "subject": {"reference": "Patient/2f08e8b7-6d02-43a8-8413-e6d0a87548f1"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/6cb5bd36-5db9-68d4-ec94-afc3f96f6392"}}, {"fullUrl": "urn:uuid:8439b6e2-73dc-f8ce-a363-101ef19fca53", "resource": {"resourceType": "DiagnosticReport", "id": "8439b6e2-73dc-f8ce-a363-101ef19fca53", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.202.3.7.2.798268", "value": "476858944"}], "status": "final", "code": {"coding": [{"code": "10251656", "display": "CORONAVIRUS (COVID-19), PCR", "system": "urn:oid:1.2.840.114350.1.13.202.3.7.2.696580"}]}, "effectivePeriod": {"start": "2002-09-29T15:01:00Z", "end": "2002-09-29T15:01:00Z"}, "subject": {"reference": "Patient/2f08e8b7-6d02-43a8-8413-e6d0a87548f1"}, "performer": [{"reference": "Organization/cdc68856-765f-f4d3-0ddc-ab56ee90eb35"}], 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U.S.C. 360bbb-3(b)(1), unless the authorization is terminated or
diagnosis of COVID-19 infection under section 564(b)(1) of the Act, 21
of in vitro diagnostic tests for detection of SARS-CoV-2 virus and/or
circumstances exist justifying the authorization of the emergency use
only authorized for the duration of time the declaration that
FDA independent review of this validation is pending. This test is
during the Public Health Emergency) issued on February 29th, 2020.
prior to Emergency Use Authorization for Coronavirus Disease-2019
Laboratories Certified to Perform High Complexity Testing under CLIA
the FDA''s Guidance Document (Policy for Diagnostics Testing in
Authorization (EUA). This test has been validated in accordance with
approved. This test has been authorized by FDA under an Emergency Use
by LabCorp Laboratories. This test has not been FDA cleared or
This test was developed and its performance characteristics determined"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2002-09-29T15:01:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-09-29T07:00:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.202.3.7.2.798268.476858944.Comp1"}]}, {"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "840539006", "system": "http://snomed.info/sct"}]}], "subject": {"reference": "Patient/2f08e8b7-6d02-43a8-8413-e6d0a87548f1"}, "performer": [{"display": "LABCORP", "reference": "Organization/cdcee673-8d7c-d7f5-79f8-09ecfc30200c"}]}, "request": {"method": "PUT", "url": "Observation/3a45daf2-6872-fd2a-6ede-606810d52bb2"}}, {"fullUrl": "urn:uuid:cdcee673-8d7c-d7f5-79f8-09ecfc30200c", "resource": {"resourceType": "Organization", "id": "cdcee673-8d7c-d7f5-79f8-09ecfc30200c", "name": "LABCORP", "address": [{"line": ["13112 Evening Creek Dr, Ste 200"], "city": "San Diego", "state": "CA", "postalCode": "92128"}], "telecom": [{"system": "phone", "value": "+1-858-668-3700"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/cdcee673-8d7c-d7f5-79f8-09ecfc30200c"}}, {"fullUrl": "urn:uuid:31568b13-cf9d-3d66-9d07-513e6d3fad9b", "resource": {"resourceType": "Observation", "id": "31568b13-cf9d-3d66-9d07-513e6d3fad9b", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.202.3.7.7.798268.1000", "value": "476858944"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2022-09-29T21:13:00Z", "valueString": "Performed at: \u00a001 - Labcorp Burlington
1447 York Court, Burlington, NC \u00a0272153361
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["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.202.3.7.2.798268", "value": "476858944"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2022-09-29T21:13:00Z", "valueCodeableConcept": {"coding": [{"code": "16", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2002-09-29T15:01:00Z"}, {"url": "specimen receive time", "valueDateTime": "2022-09-29T07:00:00Z"}]}], "subject": {"reference": "Patient/2f08e8b7-6d02-43a8-8413-e6d0a87548f1"}}, "request": {"method": "PUT", "url": "Observation/bcac2d24-eb7d-0ead-70db-f17f34e2ac92"}}, {"fullUrl": "urn:uuid:a25b5d68-4093-c72c-7657-75e82624305d", "resource": {"resourceType": "Observation", "id": "a25b5d68-4093-c72c-7657-75e82624305d", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.202.3.7.1.1040.1", "value": "Z264^^72166-2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "72166-2", "display": "Tobacco smoking status NHIS", "system": "http://loinc.org"}]}, "effectiveDateTime": "2022-09-24", "valueCodeableConcept": {"coding": [{"code": "266919005", "display": "Never smoked tobacco", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/2f08e8b7-6d02-43a8-8413-e6d0a87548f1"}}, "request": {"method": "PUT", "url": "Observation/a25b5d68-4093-c72c-7657-75e82624305d"}}, {"fullUrl": "urn:uuid:f9b1e556-f475-d9fb-619f-78f50c714bfd", "resource": {"resourceType": "Observation", "id": 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"14ffb63a-2610-1814-6651-9aa1c8d5bb07", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.202.3.7.1.1040.12", "value": "Z264^55154.99^160573003"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "160573003", "display": "Alcohol intake", "system": "http://snomed.info/sct"}]}, "effectiveDateTime": "2022-09-24", "valueCodeableConcept": {"coding": [{"code": "228274009", "display": "Lifetime non-drinker (finding)", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/2f08e8b7-6d02-43a8-8413-e6d0a87548f1"}}, "request": {"method": "PUT", "url": "Observation/14ffb63a-2610-1814-6651-9aa1c8d5bb07"}}, {"fullUrl": "urn:uuid:7a48c55f-79c6-cb43-232b-da9f52f27846", "resource": {"resourceType": "Observation", "id": "7a48c55f-79c6-cb43-232b-da9f52f27846", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.202.3.7.7.698084.19928", "value": "Z264"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "X-SDOH-19928", "display": "Education", "system": "urn:oid:1.2.840.114350.1.72.1.8"}]}, "effectiveDateTime": "2022-09-24", "valueString": "17", "subject": {"reference": "Patient/2f08e8b7-6d02-43a8-8413-e6d0a87548f1"}}, "request": {"method": "PUT", "url": "Observation/7a48c55f-79c6-cb43-232b-da9f52f27846"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}]}') ON CONFLICT (ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.297.3.7.8.688883.518869', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.297.3.7.8.688883.518869", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.297.3.7.8.688883.518869", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "54482604-1a8a-11ed-b217-c301d81100b2", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "4"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2022-08-16T16:25:06-07:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "85fc8a49-7528-b342-07a4-d7fbf380bd2f", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "A9BB042A-1DBA-11ED-AEA0-C301D81100B2", "title": "Immunizations", "text": {"status": "generated", "div": "Not on file documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "A9F62348-1DBA-11ED-AEA0-C301D81100B2", "title": "Administered Medications", "text": {"status": "generated", "div": "
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
albuterol 90 mcg/puff inhaler 2 puff2 puff, Inhalation, ONCE PRN, Bronchospasm or hypoxemia, Starting on Fri 8/12/22 at 1503, Shake well. May repeat x 1. Shake well.Given08/12/2022 3:12 PM PDT2 puffs
diphenhydrAMINE (BENADRYL) injection 25 mg25 mg, Intravenous, EVERY 15 MIN PRN, infusion reaction, may repeat x1, Starting on Fri 8/12/22 at 1503, For 2 dosesGiven08/12/2022 3:11 PM PDT25 mg
EPINEPHrine 1 mg/mL injection 0.3 mg0.3 mg, Intramuscular, EVERY 5 MIN PRN, Anaphylaxis, Starting on Fri 8/12/22 at 1503, For 3 doses, Administer in the anterior lateral thigh using 1 - 1.5 inch needle for airway obstruction symptoms and/or hypotension.Given08/12/2022 3:10 PM PDT0.3 mgDeltoid-Left
famotidine (PF) (PEPCID) injection 20 mg20 mg, Intravenous, ONCE PRN, Moderate reaction or anaphylaxis., Starting on Fri 8/12/22 at 1503, Dilute 2 mL of famotidine with 8 mL of normal saline to a final concentration of 2 mg/mL. Administer ordered dose over a period of at least 2 minutes.Given08/12/2022 3:12 PM PDT20 mg
heparin 100 units/mL flush injection 500 Units500 Units (5 mL), Intracatheter, PRN, Line Care, Starting on Fri 8/12/22 at 1503Given08/12/2022 3:10 PM PDT500 Units
methylPREDNISolone sodium succinate (solu-MEDROL) 62.5 mg/mL injection 125 mg125 mg, Intravenous, ONCE PRN, Infusion reaction, Starting on Fri 8/12/22 at 1503, For 1 dose, Mix with 2 mL provided diluent to make 62.5 mg/mL.Given08/12/2022 3:11 PM PDT125 mg
sodium chloride 0.9% (NS) bolus 250 mL250 mL, Intravenous, PRN, Flush before and after IV medication(s) and as needed with NS, Starting on Fri 8/12/22 at 1503New Bag08/12/2022 3:09 PM PDT250 mLs250 mL/hr
sodium chloride 0.9% (NS) infusion 500 mLat 500 mL/hr, Intravenous, PRN, Moderate reacton or anaphylaxis., Starting on Fri 8/12/22 at 1503, Run wide open to gravity.New Bag08/12/2022 3:10 PM PDT500 mLs500 mL/hr
sodium chloride 0.9% flush 10 mL10 mL, Intracatheter, PRN, Line Care, Starting on Fri 8/12/22 at 1503Given08/12/2022 3:10 PM PDT10 mLs
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/c2b754b8-f67e-2f12-b52d-6cbf7b1f8aee"}, {"reference": "MedicationAdministration/70cb3e2b-13ba-e755-31a2-e7cb7e4597e8"}, {"reference": "MedicationAdministration/f68ce018-403c-b976-6cc3-26dd1b4fd625"}, {"reference": "MedicationAdministration/771d3d37-8fa2-7bfa-ab4f-72b60aae4bab"}, {"reference": "MedicationAdministration/aa3a6323-e4c1-0b26-93f9-0389c7c32227"}, {"reference": "MedicationAdministration/76883e63-529a-e134-729b-63fccbd9db76"}, {"reference": "MedicationAdministration/401566d8-f50f-7a24-b9c9-da94040c32d3"}, {"reference": "MedicationAdministration/43e8ffea-cba6-c5ba-1c3c-2465c016e048"}, {"reference": "MedicationAdministration/c2b901e1-13c0-57e3-8dc6-4508ac1fc4c2"}]}, {"id": "eb66d618-8ad1-0a61-7aef-29738cbad56d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/dbb4df9f-6c1f-ea78-b404-09d9474816ca"}]}, {"id": "AA0C8F20-1DBA-11ED-AEA0-C301D81100B2", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted Date
Malignant neoplasm of overlapping sites of left lung8/12/22
Osteoporosis5/9/22
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Kevin Lanzilloattending physicianActive
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MRS. PUMSEN R SOR SRprimary care physicianActive
Start: March 17th, 2022
Sandra E Hoytadmitting physicianActive
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DR. LARDIEREFAMILYActive
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Brian Leary , MDREFERRINGActive
Start: March 17th, 2022
DR. DAVID CONNOROTHERActive
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MCUTLERCONSULTINGActive
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Samuel HoytNext of KinActive
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Never smoker (Never Smoked)March 17th, 2022 2:54pm
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Not pregnantMarch 17th, 2022
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Gender Identityunknown
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HeadacheActive
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Admitted InpatientDot Facility (No ARM)March 17th, 2022 2:45pmKevin Lanzillo
Recent DiagnosisOnset Date
COVID-19March 14th, 2022

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Author
CANTON MEDICAL CENTER OF MASSACHUSETTS-North Canton FacilitSandra Hoyt
AuthoredMarch 22nd, 2022 11:23am
Follow-up with PSOR referral and PCP.
Test NameOrdered DateScheduled Date
WHITE BLOOD COUNT
HEMOGLOBIN
HEMATOCRIT
MEAN CELL VOLUME
MEAN CORPUSCULAR HEMOGLOBIN
PLATELET COUNT
COVID19 OTHER VENDOR 94500-6March 18th, 2022 2:48pmMarch 18th, 2022
COVID-19 OV 94500-6March 17th, 2022 5:06pmMarch 31st, 2022
HIV Test: LOINC 10351-5March 22nd, 2022 11:26amMarch 28th, 2022
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Cardiac abnormalityPUMSEN''S PROVIDER GROUPWork Phone: +1(508)789-7891
BROCKTON MA 02301SUITE 1010110 MAIN ST
Medication NameStart DateInstructions
Atorvastatin Calcium Tablet Dispense (LIPITOR - WITH DISPENSE) 40 MG TABMarch 17th, 2022 3:48pm
Benazepril HCl (Benazepril) 40 MG TABLETMarch 22nd, 2022 8:32am
Cyclobenzaprine (CYCL10T) 10 MG TABMarch 21st, 2022 4:19pm
Dapsone (Topical) - RXCUI C1741905 (DAPSONE7.5 %) 7.5 % GEL OINTMENTMarch 21st, 2022 3:59pm
Rifampin - RXCUI C198201 (RIFAMPIN150 MG) 150 MG CAPMarch 17th, 2022 3:48pm
Severe Acute Respiratory Syndrome (SARS)

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Providers-Please access the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV and the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV plus FDA FACT Sheet at the following web \u00a0address: www.providence.org/covidtesting
Patients-Please access the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV and the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSVplus FDA FACT sheet at the following \u00a0address: www.providence.org/covidtesting
Testing performed using the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV or the Cepheid Xpert Xpress SARS-CoV-2/Flu/RSVplus, PCR Testing
\u00a0
This laboratory is certified under the Clinical Laboratory Improvement Amendments (CLIA) Act, to perform, at minimum, Waived Testing.\u00a0 This test''s performance characteristics have been verified. These results are not intended to be used as the sole means for clinical diagnosis or patient management decisions.
\u00a0
This test has not been FDA cleared or approved. This test has been authorized by the FDA under an EUA for use by authorized laboratories. This test is only authorized for the duration of time the declaration that circumstances exist justifying the authorization of the emergency use of in vitro diagnostic tests for detection of SARS-CoV-2 virus and/or diagnosis of COVID-19 infection under section 564(b)(1) of the Act, 21 U.S.C. 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.
If only one viral target is positive but coinfection with multiple targets is suspected, the sample should be re-tested with another FDA cleared, approved, or authorized test, if coinfection would change clinical management.
Positive (Detected) results are indicative of the presence of SARS-CoV-2 RNA, clinical correlation with patient history and other diagnostic information is necessary to determine patient infection status. Positive results do not rule out bacterial infection or co-infection with other viruses.
\u00a0
This is a PCR performed test.
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NameAdministration DatesNext Due
Hepatitis B Pediatric/Adolescent07/27/2024 Deferred: Patient Refused ) (
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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
erythromycin (ROMYCIN) 5 mg/gram (0.5 %) eye ointment 1 Application1 Application, Both Eyes, Once, On Thu 7/25/24 at 1245, 1 dose, Administer within one hour of birth.Given07/25/2024 8:09 PM CDT1 Application
phytonadione-vitamin K (AQUA-MEPHYTON) injection 0.5-1 mg0.5-1 mg, Intramuscular, Once, On Thu 7/25/24 at 1245, 1 dose, Give 0.5 mg for newborns with birthweight less than 1000 g; give 1 mg for newborns with birthweight over 1000 g. Administer within one hour of birth.Given07/25/2024 8:09 PM CDT1 mgLeft Anterior Thigh
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ProblemNoted DateDiagnosed Date
Term newborn delivered vaginally, current hospitalization07/26/2024
Term birth of newborn female07/25/2024
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Smoking Tobacco: Never Assessed
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
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DateTypeDepartmentCare Team (Latest Contact Info)Description
07/25/2024 8:08 PM CDT - 07/27/2024 3:52 PM CDTHospital EncounterWOM NURSERY6225 Humphreys BlvdMemphis, TN 38120901-227-9000Sevier, Georgette Rochelle, MD5366 Mendenhall MallMemphis, TN 38115901-842-3163 (Work)901-842-2368 (Fax)Discharge Disposition: Home
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Reportability Response Information Section
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"url": "Observation/acb6ee01-5c68-e61f-5fcf-2017e2bc8f77"}}, {"fullUrl": "urn:uuid:a2c99f41-b345-4911-094e-700c874d94a5", "resource": {"resourceType": "DiagnosticReport", "id": "a2c99f41-b345-4911-094e-700c874d94a5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.798268", "value": "658949276"}], "status": "final", "code": {"coding": [{"code": "100938", "display": "Newborn screen TN panel", "system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-07-27T01:56:00Z", "end": "2024-07-27T01:56:00Z"}, "subject": {"reference": "Patient/fb81b4af-8055-4c23-98d9-76f216b9c3da"}, "performer": [{"reference": "Organization/ec4c2416-6376-04e0-1dd1-5d97a2adb382"}], "result": [{"reference": "Observation/b784e337-1e5e-21f9-d0f9-d516f002bf98"}, {"reference": "Observation/811d072d-e28a-c361-00b3-95761a591d06"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/a2c99f41-b345-4911-094e-700c874d94a5"}}, {"fullUrl": "urn:uuid:ec4c2416-6376-04e0-1dd1-5d97a2adb382", "resource": {"resourceType": "Organization", "id": "ec4c2416-6376-04e0-1dd1-5d97a2adb382", "name": "NONINTERFACED REFERENCE LAB", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/ec4c2416-6376-04e0-1dd1-5d97a2adb382"}}, {"fullUrl": "urn:uuid:b784e337-1e5e-21f9-d0f9-d516f002bf98", "resource": {"resourceType": "Observation", "id": "b784e337-1e5e-21f9-d0f9-d516f002bf98", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.6.798268.2000", "value": "658949276.1"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "6353", "display": "Newborn TN Screen", "system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.768282"}]}, "effectiveDateTime": "2024-07-28T16:01:16Z", "valueString": "See comment", "note": [{"text": "Newborn screen specimens are sent to the Tennessee Department of Health for analysis and require approximately 14 days to be completed. Results are forwarded to the attending physician''s office and to the collecting facility."}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-27T01:56:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-27T21:41:48Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.363.2.7.2.798268.658949276.Comp1"}]}], "subject": {"reference": "Patient/fb81b4af-8055-4c23-98d9-76f216b9c3da"}, "performer": [{"display": "NONINTERFACED REFERENCE LAB", "reference": "Organization/7f276f0a-9aa8-ef2a-b09d-e26a6a9ad802"}]}, "request": {"method": "PUT", "url": "Observation/b784e337-1e5e-21f9-d0f9-d516f002bf98"}}, {"fullUrl": "urn:uuid:7f276f0a-9aa8-ef2a-b09d-e26a6a9ad802", "resource": {"resourceType": "Organization", "id": "7f276f0a-9aa8-ef2a-b09d-e26a6a9ad802", "name": "NONINTERFACED REFERENCE LAB", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/7f276f0a-9aa8-ef2a-b09d-e26a6a9ad802"}}, {"fullUrl": "urn:uuid:811d072d-e28a-c361-00b3-95761a591d06", "resource": {"resourceType": "Observation", "id": "811d072d-e28a-c361-00b3-95761a591d06", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.798268", "value": "658949276"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2024-07-28T16:01:16Z", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-27T01:56:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-27T21:41:48Z"}]}], "subject": {"reference": "Patient/fb81b4af-8055-4c23-98d9-76f216b9c3da"}}, "request": {"method": "PUT", "url": "Observation/811d072d-e28a-c361-00b3-95761a591d06"}}, {"fullUrl": "urn:uuid:6bc1ecde-357b-dcab-906a-b54721cd4e0e", "resource": {"resourceType": "Observation", "id": "6bc1ecde-357b-dcab-906a-b54721cd4e0e", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.1.1040.1", "value": "Z4551826^^72166-2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "72166-2", "display": "Tobacco smoking status NHIS", "system": "http://loinc.org"}]}, "valueCodeableConcept": {"coding": [{"code": "266927001", "display": "Tobacco smoking consumption unknown", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/fb81b4af-8055-4c23-98d9-76f216b9c3da"}}, "request": {"method": "PUT", "url": "Observation/6bc1ecde-357b-dcab-906a-b54721cd4e0e"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}, {"fullUrl": "urn:uuid:c0351834-b345-8e94-17bc-eb2c69fae80e", "resource": {"resourceType": "Immunization", "id": "c0351834-b345-8e94-17bc-eb2c69fae80e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.768076", "value": "39428338"}], "occurrenceDateTime": "2024-07-27", "note": {"text": "Hepatitis B Pediatric/Adolescent"}, "vaccineCode": {"coding": [{"code": "0006-4093-02", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/fb81b4af-8055-4c23-98d9-76f216b9c3da"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/c0351834-b345-8e94-17bc-eb2c69fae80e"}}]}') ON CONFLICT (ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.638.2.7.8.688883.36629971', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.638.2.7.8.688883.36629971", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.638.2.7.8.688883.36629971", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-0888-84a1-9a9c-8e5c677bb9df", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "1"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-07-29T14:33:41-05:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "b7a7ed08-af88-4a31-cc4e-8dddd58b7fc8", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-010B-6AE4-8B6D-9DF4AB7CEB82", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
Anthrax07/01/2007 06/17/2007 06/02/2007 , ,
FLU VACCINE (IIV4) EQUAL TO 6MONTHS-35MONTHS OLD WITH PRESERVATIVE (VFC)10/19/2021 11/04/2019 ,
Flu vaccine (IIV4) 6months and older, preservative free11/03/2023 12/07/2022 12/09/2020 10/17/2018 11/03/2017 , , , ,
Flu vaccine, quadrivalent, intranasal 2years-49 years (VFC)10/15/2013
Hep A / Hep B09/01/2005 06/23/2004 05/25/2004 05/23/2004 , , ,
Hep A, Adult09/01/2005
IPV11/15/2004 05/25/2004 ,
Influenza, Split (incl. purified surface antigen)11/30/2010 02/25/2009 11/30/2007 10/27/2006 11/09/2005 05/25/2004 , , , , ,
Influenza, Unspecified10/24/2017
Influenza, injectable, MDCK, quadrivalent10/24/2017
Influenza, live, intranasal10/09/2012 10/19/2011 11/19/2010 09/22/2009 , , ,
Influenza, seasonal, injectable, preservative free03/07/2017 10/05/2015 09/29/2014 , ,
MMR10/26/2017 05/25/2004 ,
Meningococcal MPSV405/25/2004
Novel influenza-H1N1-0902/11/2010
OPV01/10/2006
PPD Test09/22/2008
Pneumococcal Polysaccharide PPV2309/01/2021
TD (adult), 2 Lf tetanus toxoid, preservative free, adsorbed06/23/2004 05/25/2004 ,
Tdap05/12/2023 08/17/2012 ,
Tetanus toxoid, adsorbed06/12/2006
Typhoid, ViCPs08/17/2012 12/06/2006 11/16/2006 11/15/2004 , , ,
Yellow Fever06/23/2004
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-010B-6AE5-8B6D-9DF4AB7CEB82", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "2f9a48f2-d7fe-2c68-f260-152a5836c902", "title": "Plan of Treatment", "text": {"status": "generated", "div": "Not on filedocumented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/b2c66834-765a-abc7-50d7-b70310498762"}]}, {"id": "00000000-010B-6AE6-8B6D-9DF4AB7CEB82", "title": "Problems", "text": {"status": "generated", "div": "
ProblemNoted DateDiagnosed Date
BMI 29.0-29.9,adult11/03/2023
Type 2 diabetes mellitus with hyperosmolarity without coma, without long-term current use of insulin06/23/2023
Hyperlipidemia06/23/2023
Hypertension06/23/2023
Assessment & Plan (06/23/2023 12:39 PM CDT):Formatting of this note might be different from the original.
stable
Viral infection, unspecified06/23/2023
Edema06/08/2023
COVID-1901/21/2022
Plantar fasciitis06/22/2019
Assessment & Plan (06/23/2023 12:40 PM CDT):Formatting of this note might be different from the original.
Uses inserts--podiatry referral
Baker''s cyst of knee, right06/05/2019
Carpal tunnel syndrome06/22/2018
Cubital tunnel syndrome of both upper extremities06/22/2018
Type 2 diabetes mellitus06/01/2017
Fusion of spine, cervical region06/01/2016
Arthritis06/01/2015
Diverticulitis02/01/2009
documented as of this encounter (statuses as of 07/29/2024)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Type 2 diabetes mellitus with hyperosmolarity without coma, without long-term current use of insulin", "reference": "Condition/cbf5ec25-b066-bb06-63e8-02f62976aa22"}, {"display": "Problem - Arthritis", "reference": "Condition/7ac38eec-073d-2cd9-32c7-8e93bab99ef7"}, {"display": "Problem - Plantar fasciitis", "reference": "Condition/30c861ed-e2fd-1b14-4819-6855a869305f"}, {"display": "Problem - Baker''s cyst of knee, right", "reference": "Condition/61b4aa09-f43a-07b3-b617-cb64c3ecb239"}, {"display": "Problem - Carpal tunnel syndrome", "reference": "Condition/805abf56-1314-73bc-811f-90f0aaf23665"}, {"display": "Problem - Cubital tunnel syndrome of both upper extremities", "reference": "Condition/7b01cd67-b162-a52d-fe2f-e7f49dd8aa08"}, {"display": "Problem - Diverticulitis", "reference": "Condition/a35f515c-1028-e41e-0b7e-4c167fc0b1c5"}, {"display": "Problem - Edema", "reference": "Condition/a92758d4-41d9-885a-6381-7386899815d4"}, {"display": "Problem - Fusion of spine, cervical region", "reference": "Condition/56c0d3f1-b56f-249a-7e07-5967929c1e2a"}, {"display": "Problem - Hyperlipidemia", "reference": "Condition/6d046942-f33a-04f5-4f02-cfcdca81e30d"}, {"display": "Problem - Hypertension", "reference": "Condition/86857c4a-e988-a30b-1710-381aa1144609"}, {"display": "Problem - Viral infection, unspecified", "reference": "Condition/21645922-1ee9-d207-7dd0-1ec82067acd2"}, {"display": "Problem - COVID-19", "reference": "Condition/8d73a4bc-ca56-33c7-c91d-e025b35405d6"}, {"display": "Problem - Type 2 diabetes mellitus", "reference": "Condition/3bf53746-727c-758a-2f13-0dfe10105a7e"}, {"display": "Problem - BMI 29.0-29.9,adult", "reference": "Condition/7a4e0659-8e44-f40d-b316-8063ad426f02"}]}, {"id": "f40a22d7-23dc-cf63-8c19-c55a1ed03d2b", "title": "Reason for Visit", "text": {"status": "generated", "div": "Not on file"}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Not on file"}]}, {"id": "00000000-010B-6AE7-8B6D-9DF4AB7CEB82", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "POCT Covid Rapid Test - PCR", "reference": "Observation/21458942-e225-89eb-59fc-1c257862d745"}, {"display": "Lab Interpretation", "reference": "Observation/cee4c18f-a5a5-8322-ad9a-ad81e3ac7ee0"}]}, {"id": "1af939c5-d9ab-8ed4-d28c-78b3fc9e3ef1", "title": "Social History", "text": {"status": "generated", "div": "
Smoking Status as of 07/12/2024
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Every DayCigarettes0.515
Smokeless Tobacco: Never
Tobacco Cessation:
Ready to Quit: Not Asked; Counseling Given: Not Answered
Smoking Status as of 10/02/2023
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Every DayCigarettes0.515
Smokeless Tobacco: Never
Alcohol Use as of 07/12/2024
Alcohol UseStandard Drinks/WeekComments
Yes2 (1 standard drink = 0.6 oz pure alcohol)OCCASIONAL
Humiliation, Afraid, Rape, and Kick questionnaireAnswerDate Recorded
Within the last year, have you been afraid of your partner or ex-partner?No06/22/2023
Within the last year, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?Patient declined06/22/2023
Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?No06/22/2023
Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?No06/22/2023
Social Connection and Isolation Panel [NHANES]AnswerDate Recorded
In a typical week, how many times do you talk on the phone with family, friends, or neighbors?More than three times a week06/22/2023
How often do you get together with friends or relatives?Three times a week06/22/2023
How often do you attend church or religious services?1 to 4 times per year06/22/2023
Do you belong to any clubs or organizations such as church groups, unions, fraternal or athletic groups, or school groups?Yes06/22/2023
How often do you attend meetings of the clubs or organizations you belong to?1 to 4 times per year06/22/2023
Are you married, widowed, divorced, separated, never married, or living with a partner?Married06/22/2023
AUDIT-CAnswerDate Recorded
Q1: How often do you have a drink containing alcohol?2-4 times a month06/22/2023
Q2: How many drinks containing alcohol do you have on a typical day when you are drinking?1 or 206/22/2023
Q3: How often do you have six or more drinks on one occasion?Never06/22/2023
Overall Financial Resource Strain (CARDIA)AnswerDate Recorded
How hard is it for you to pay for the very basics like food, housing, medical care, and heating?Not hard at all06/22/2023
PHQ-2AnswerDate Recorded
Patient Health Questionnaire-2 Score404/25/2024
Finnish Institute of Occupational Health - Occupational Stress QuestionnaireAnswerDate Recorded
Do you feel stress - tense, restless, nervous, or anxious, or unable to sleep at night because your mind is troubled all the time - these days?Rather much06/22/2023
Exercise Vital SignAnswerDate Recorded
On average, how many days per week do you engage in moderate to strenuous exercise (like a brisk walk)?2 days06/22/2023
On average, how many minutes do you engage in exercise at this level?30 min06/22/2023
Hunger Vital SignAnswerDate Recorded
Within the past 12 months, you worried that your food would run out before you got the money to buy more.Never true06/22/2023
Within the past 12 months, the food you bought just didn''t last and you didn''t have money to get more.Never true06/22/2023
PRAPARE - TransportationAnswerDate Recorded
In the past 12 months, has lack of transportation kept you from medical appointments or from getting medications?No06/22/2023
In the past 12 months, has lack of transportation kept you from meetings, work, or from getting things needed for daily living?No06/22/2023
Housing StabilityAnswerDate Recorded
In the last 12 months, was there a time when you were not able to pay the mortgage or rent on time?No06/22/2023
In the last 12 months, how many places have you lived?306/22/2023
In the last 12 months, was there a time when you did not have a steady place to sleep or slept in a shelter (including now)?No06/22/2023
Health LiteracyAnswerDate Recorded
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Child CareAnswerDate Recorded
Child Care: Difficult to Study or WorkNot on file07/08/2024
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthMale06/22/2023 12:50 PM CDT
Gender IdentityMale06/22/2023 12:50 PM CDT
Sexual OrientationStraight06/22/2023 12:50 PM CDT
Job Start DateOccupationIndustry
Not on fileNot on fileNot on file
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"value": "3460495"}], "occurrenceDateTime": "2012-08-17", "note": {"text": "Typhoid, ViCPs"}, "vaccineCode": {"coding": [{"code": "101", "display": "Typhoid, ViCPs", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "G1541-1", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/419f61be-357d-4bcc-a0bb-159bd254fd6c"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/35293781-d68e-59e5-8dcb-395f0174693f"}}, {"fullUrl": "urn:uuid:a564e91e-1697-a13d-9da0-89191ec294fd", "resource": {"resourceType": "Immunization", "id": "a564e91e-1697-a13d-9da0-89191ec294fd", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460496"}], "occurrenceDateTime": "2006-11-16", "note": {"text": "Typhoid, ViCPs"}, "vaccineCode": {"coding": [{"code": "101", "display": "Typhoid, ViCPs", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "UNK", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/419f61be-357d-4bcc-a0bb-159bd254fd6c"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/a564e91e-1697-a13d-9da0-89191ec294fd"}}, {"fullUrl": "urn:uuid:63a8e21d-48e2-4523-3fd8-e6dcd11d5799", "resource": {"resourceType": "Immunization", "id": "63a8e21d-48e2-4523-3fd8-e6dcd11d5799", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460497"}], "occurrenceDateTime": "2006-12-06", "note": {"text": "Typhoid, ViCPs"}, "vaccineCode": {"coding": [{"code": "101", "display": "Typhoid, ViCPs", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "Z0663", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/419f61be-357d-4bcc-a0bb-159bd254fd6c"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/63a8e21d-48e2-4523-3fd8-e6dcd11d5799"}}, {"fullUrl": "urn:uuid:accebbab-2bca-b7a4-6c62-c8434fb06677", "resource": {"resourceType": "Immunization", "id": "accebbab-2bca-b7a4-6c62-c8434fb06677", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460498"}], "occurrenceDateTime": "2004-11-15", "note": {"text": "Typhoid, ViCPs"}, "vaccineCode": {"coding": [{"code": "101", "display": "Typhoid, ViCPs", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "UNKNOWN", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/419f61be-357d-4bcc-a0bb-159bd254fd6c"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/accebbab-2bca-b7a4-6c62-c8434fb06677"}}, {"fullUrl": "urn:uuid:77e08339-011e-600e-1ff9-8d79e8a4abfb", "resource": {"resourceType": "Immunization", "id": "77e08339-011e-600e-1ff9-8d79e8a4abfb", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3460499"}], "occurrenceDateTime": "2004-06-23", "note": {"text": "Yellow Fever"}, "vaccineCode": {"coding": [{"code": "37", "display": "Yellow Fever", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "UE014AA", "status": "completed", "primarySource": true, "patient": {"reference": "Patient/419f61be-357d-4bcc-a0bb-159bd254fd6c"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/77e08339-011e-600e-1ff9-8d79e8a4abfb"}}, {"fullUrl": "urn:uuid:286a4b61-e56e-1996-3461-01f290ac9729", "resource": {"resourceType": "Immunization", "id": "286a4b61-e56e-1996-3461-01f290ac9729", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "3610956"}], "occurrenceDateTime": "2023-11-03", "note": {"text": "Flu vaccine (IIV4) 6months and older, preservative free"}, "vaccineCode": {"coding": [{"code": "58160-909-41", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "FJ4X5", "manufacturer": {"reference": "Organization/a1439865-b6cb-7b35-67e3-cc00011c9f1c"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/419f61be-357d-4bcc-a0bb-159bd254fd6c"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/286a4b61-e56e-1996-3461-01f290ac9729"}}, {"fullUrl": "urn:uuid:a1439865-b6cb-7b35-67e3-cc00011c9f1c", "resource": {"resourceType": "Organization", "id": "a1439865-b6cb-7b35-67e3-cc00011c9f1c", "name": "GlaxoSmithKline", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/a1439865-b6cb-7b35-67e3-cc00011c9f1c"}}, {"fullUrl": "urn:uuid:fcf0aad4-b6f1-f11c-c9fb-3e5095310810", "resource": {"resourceType": "Immunization", "id": "fcf0aad4-b6f1-f11c-c9fb-3e5095310810", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.638.2.7.2.768076", "value": "4361173"}], "occurrenceDateTime": "2017-10-24", "note": {"text": "Influenza, Unspecified"}, "vaccineCode": {"coding": [{"code": "88", "display": "Influenza, Unspecified", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "lotNumber": "L95248", "status": "completed", "primarySource": true, "patient": {"reference": 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{"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-07-29T05:28:19-07:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "abf8106a-2b40-0578-d253-08a75fbbdf9d", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-0B5E-F190-C213-F6543E4A3F7B", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
DTP08/19/1986 06/25/1982 07/15/1981 04/08/1981 12/12/1980 , , , ,
Flu, Preservative Free11/08/2022 10/04/2021 09/16/2020 , ,
HEP A-HEP B04/09/2018 09/26/2016 08/26/2016 , ,
HIB, HISTORICAL08/19/1982
Hib (HbOC)08/19/1986
MMR (MMR II/Priorix)03/19/1982
Moderna COVID-19 Vaccine, red cap blue label, 12+ Primary Series08/31/2021 01/29/2021 12/29/2020 , ,
OPV, Trivalent08/19/1986 06/25/1982 07/15/1981 04/08/1981 12/12/1980 , , , ,
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-0B5E-F191-C213-F6543E4A3F7B", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "93d6a0b5-34fa-8d23-19f5-729b79cb0d33", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
07/30/2024 10:00 AM PDTTelemedicine VisitCempa Community Care Clinic1000 East Third St Suite 300Chattanooga, TN 37403-2153423-265-2273Campbell, Zachary, NP-C1000 EAST THIRD STSUITE 300CHATTANOOGA, TN 37403423-265-2273 (Work)423-648-9935 (Fax)
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/20ba7b1c-caa5-5e98-ecfc-93e28bb0cfd8"}]}, {"id": "00000000-0B5E-F192-C213-F6543E4A3F7B", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
Acute left flank pain08/03/2023
Overview:Formatting of this note might be different from the original.
Pt c/o mild left sided back/flank pain w/o the presence of hematuria or dysuria. Pt states he has been exercising and working out more and believes this coincides with his new exercise routine. No CVA tenderness, site is not tender or acutely painful. Discomfort improves when not slouching, likely muscle strain. Recommended ice and heat therapy and if site pain does not improve in 4 weeks to call clinic for additional support.
Need for vaccination11/08/2022
Erectile dysfunction11/08/2022
Overview:Formatting of this note might be different from the original.
Pt states sildenafil works well and has had no adrs or se related to medication administration. Requires refill today.
Anxiety disorder09/30/2020
Obesity09/30/2020
Human immunodeficiency virus (HIV) disease (HCC-CMS)01/01/2014
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Long-term well-controlled HIV. His primary health concerns are primary care in naturePt denies barriers to care or medication administration at this time. Denies ADRs and s/e to medication administration and denies any missed doses. Formatting of this note might be different from the original.
Follow up in clinic in 6 months for lab results with labs drawn one week before.Encouraged overall health behavior modifications to improve health including diet and exercise.Encouraged ongoing adherence to this regimen and discussed side effects, risks and benefits of antiretroviral therapy.Continue current HAART.
Blood chemistry abnormal
Controlled type 2 diabetes mellitus without complication, without long-term current use of insulin (HCC-CMS)
Overview:Formatting of this note might be different from the original.
Pt has only been taking Synjardy d/t being out of his Trulicity and unable to find time to refill medication. Pt''s A1C has only shown a mild increase of 4/10 of a point. Educated pt on the importance of medication administration but his A1C is still well controlled at this time. Pt voiced understanding. Denies any ADRs to medication admin.
Mixed hyperlipidemia
Insomnia disorder related to another mental disorder
Benign essential hypertension
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Pt''s BP is mildly elevated today but he states he was rushed to get to Hub location, didn''t know which office was ours and mildly irritated by experience. Feels fine now and denies HA. Has no barriers to taking his antihypertensives at this time. Will continue to refill and recheck at next visit. Formatting of this note might be different from the original.
Discussed sodium restriction, maintaining ideal body weight and regular exercise program as physiologic means to achieve blood pressure control. The patient will strive towards this. Meanwhile, it is appropriate to lower BP with medications, while observing for therapeutic effect and if appropriate later, can discontinue medications if physiologic methods appear to be effective. The patient indicates understanding of these issues and agrees to the plan. The various types of antihypertensives are discussed fully. See medication orders in EpicCare. Side effects explained in detail. Continue home readings and see me for follow-up as scheduled.
Impotence of organic origin
Obese class II
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Yes2 (1 standard drink = 0.6 oz pure alcohol)1-2 DRINKS 2 TO 4 TIMES A MONTH
Social ConnectionsAnswerDate Recorded
Social Connections and Isolation009/02/2022
Financial Resource StrainAnswerDate Recorded
Financial Resource Strain009/02/2022
StressAnswerDate Recorded
Stress009/02/2022
Physical ActivityAnswerDate Recorded
Physical Activity009/02/2022
Food InsecurityAnswerDate Recorded
Food009/02/2022
Transportation NeedsAnswerDate Recorded
Transportation009/02/2022
Housing StabilityAnswerDate Recorded
Housing009/02/2022
Safety and EnvironmentAnswerDate Recorded
Safety009/02/2022
UtilitiesAnswerDate Recorded
Utilities009/02/2022
EmploymentAnswerDate Recorded
Employment009/02/2022
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthMale11/08/2022 11:08 AM PST
Gender IdentityMale09/12/2022 7:42 PM PDT
Sexual OrientationLesbian or Gay09/12/2022 7:42 PM PDT
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DateTypeDepartmentCare Team (Latest Contact Info)Description
07/24/2024 8:30 AM PDTErroneous EncounterCempa Community Care Clinic1000 East Third St Suite 300Chattanooga, TN 37403-2153423-265-2273Campbell, Zachary, NP-C1000 EAST THIRD STSUITE 300CHATTANOOGA, TN 37403423-265-2273 (Work)423-648-9935 (Fax)
ERRONEOUS ENCOUNTER--DISREGARDAnxiety disorder, unspecified type; Blood chemistry abnormal; Other problems related to lifestyle; Encounter for screening for infections with predominantly sexual mode of transmission; Other long term (current) drug therapy; Human immunodeficiency virus (HIV) disease (HCC-CMS) (Primary Dx);
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"Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "CareTeam", "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}}, {"fullUrl": "urn:uuid:20ba7b1c-caa5-5e98-ecfc-93e28bb0cfd8", "resource": {"resourceType": "CarePlan", "id": "20ba7b1c-caa5-5e98-ecfc-93e28bb0cfd8", "status": "unknown", "intent": "proposal", "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "CarePlan/20ba7b1c-caa5-5e98-ecfc-93e28bb0cfd8"}}, {"fullUrl": "urn:uuid:fafbd077-661e-b35b-ea24-dd63a8462b1b", "resource": {"resourceType": "Condition", "id": "fafbd077-661e-b35b-ea24-dd63a8462b1b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687221"}], "clinicalStatus": {"coding": [{"code": "246455001", "display": "Recurrence", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "B20", "display": "Human immunodeficiency virus (HIV) disease (HCC-CMS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2014-01-01", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote34
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System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote35
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}, "extension": [{"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "86406008", "system": "http://snomed.info/sct"}]}]}, "request": {"method": "PUT", "url": "Condition/fafbd077-661e-b35b-ea24-dd63a8462b1b"}}, {"fullUrl": "urn:uuid:2d171402-d536-5802-8c2e-9a26718e377c", "resource": {"resourceType": "Condition", "id": "2d171402-d536-5802-8c2e-9a26718e377c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687224"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R79.9", "display": "Abnormal blood chemistry level", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-09-07T10:37:26-07:00", "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/2d171402-d536-5802-8c2e-9a26718e377c"}}, {"fullUrl": "urn:uuid:169ad249-aac7-e6a7-aa55-5e17876e5d91", "resource": {"resourceType": "Condition", "id": "169ad249-aac7-e6a7-aa55-5e17876e5d91", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687226"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "F41.9", "display": "Anxiety disorder", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2020-09-30", "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/169ad249-aac7-e6a7-aa55-5e17876e5d91"}}, {"fullUrl": "urn:uuid:759aac4d-1e78-cda4-e581-51ffa5628b38", "resource": {"resourceType": "Condition", "id": "759aac4d-1e78-cda4-e581-51ffa5628b38", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687229"}], "clinicalStatus": {"coding": [{"code": "246455001", "display": "Recurrence", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.9", "display": "Controlled type 2 diabetes mellitus without complication, without long-term current use of insulin (HCC-CMS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-08-03T15:11:31-07:00", "note": [{"text": "Overview:
problemNote40
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Pt has only been taking Synjardy d/t being out of his Trulicity and unable to find time to refill medication. Pt''s A1C has only shown a mild increase of 4/10 of a point. Educated pt on the importance of medication administration but his A1C is still well controlled at this time. Pt voiced understanding. Denies any ADRs to medication admin. "}], "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/759aac4d-1e78-cda4-e581-51ffa5628b38"}}, {"fullUrl": "urn:uuid:b9c369fb-95cc-02ab-d326-5957784ef703", "resource": {"resourceType": "Condition", "id": "b9c369fb-95cc-02ab-d326-5957784ef703", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687231"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E78.2", "display": "Mixed hyperlipidemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-09-07T10:37:26-07:00", "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/b9c369fb-95cc-02ab-d326-5957784ef703"}}, {"fullUrl": "urn:uuid:6476b8da-a197-94a5-99a5-298b2df82320", "resource": {"resourceType": "Condition", "id": "6476b8da-a197-94a5-99a5-298b2df82320", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687234"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E66.9", "display": "Obesity", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2020-09-30", "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/6476b8da-a197-94a5-99a5-298b2df82320"}}, {"fullUrl": "urn:uuid:d54bb5b7-c31a-0cc9-3f83-7c4300565059", "resource": {"resourceType": "Condition", "id": "d54bb5b7-c31a-0cc9-3f83-7c4300565059", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687237"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "F51.05", "display": "Insomnia related to another mental disorder", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-09-07T10:37:26-07:00", "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/d54bb5b7-c31a-0cc9-3f83-7c4300565059"}}, {"fullUrl": "urn:uuid:ae076694-18bc-1321-3f6b-ff56f881ff3e", "resource": {"resourceType": "Condition", "id": "ae076694-18bc-1321-3f6b-ff56f881ff3e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687240"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I10", "display": "Benign essential hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-08-03T15:12:38-07:00", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote45
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Pt''s BP is mildly elevated today but he states he was rushed to get to Hub location, didn''t know which office was ours and mildly irritated by experience. Feels fine now and denies HA. Has no barriers to taking his antihypertensives at this time. Will continue to refill and recheck at next visit.
problemNote46
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Discussed sodium restriction, maintaining ideal body weight and regular exercise program as physiologic means to achieve blood pressure control. The patient will strive towards this. Meanwhile, it is appropriate to lower BP with medications, while observing for therapeutic effect and if appropriate later, can discontinue medications if physiologic methods appear to be effective. The patient indicates understanding of these issues and agrees to the plan. The various types of antihypertensives are discussed fully. See medication orders in EpicCare. Side effects explained in detail. Continue home readings and see me for follow-up as scheduled."}], "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ae076694-18bc-1321-3f6b-ff56f881ff3e"}}, {"fullUrl": "urn:uuid:5bd75093-1f4b-df91-1a3c-a34449937280", "resource": {"resourceType": "Condition", "id": "5bd75093-1f4b-df91-1a3c-a34449937280", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687242"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N52.9", "display": "Impotence of organic origin", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-09-07T10:37:26-07:00", "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5bd75093-1f4b-df91-1a3c-a34449937280"}}, {"fullUrl": "urn:uuid:75a3275b-0cf8-5865-2489-f106add93964", "resource": {"resourceType": "Condition", "id": "75a3275b-0cf8-5865-2489-f106add93964", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "158687245"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z68.39", "display": "Body mass index (BMI) 39.0-39.9, adult", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-09-07T10:37:26-07:00", "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/75a3275b-0cf8-5865-2489-f106add93964"}}, {"fullUrl": "urn:uuid:28002d98-3a28-b579-9deb-530e0ad889e5", "resource": {"resourceType": "Condition", "id": "28002d98-3a28-b579-9deb-530e0ad889e5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "169262051"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z23", "display": "Need for vaccination", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-11-08", "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/28002d98-3a28-b579-9deb-530e0ad889e5"}}, {"fullUrl": "urn:uuid:f29ecf9e-1bd7-0364-3881-ecd275509c6e", "resource": {"resourceType": "Condition", "id": "f29ecf9e-1bd7-0364-3881-ecd275509c6e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "169287254"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N52.9", "display": "Erectile dysfunction", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-11-08", "note": [{"text": "Overview:
problemNote51
Formatting of this note might be different from the original.

Pt states sildenafil works well and has had no adrs or se related to medication administration. Requires refill today. "}], "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/f29ecf9e-1bd7-0364-3881-ecd275509c6e"}}, {"fullUrl": "urn:uuid:e9ae6a11-aea2-0afc-d08e-7f0edc3eff83", "resource": {"resourceType": "Condition", "id": "e9ae6a11-aea2-0afc-d08e-7f0edc3eff83", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.2.768076", "value": "193635834"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R10.9", "display": "Acute left flank pain", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-08-03", "note": [{"text": "Overview:
problemNote53
Formatting of this note might be different from the original.

Pt c/o mild left sided back/flank pain w/o the presence of hematuria or dysuria. Pt states he has been exercising and working out more and believes this coincides with his new exercise routine. No CVA tenderness, site is not tender or acutely painful. Discomfort improves when not slouching, likely muscle strain. Recommended ice and heat therapy and if site pain does not improve in 4 weeks to call clinic for additional support. 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Laboratory Director: Jonathan R. Genzen, MD, PhD
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500 Chipeta Way
Performed By: ARUP Laboratories
clinical purposes.
performed in a CLIA certified laboratory and is intended for
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\u00a0100 to 129 mg/dL \u00a0 \u00a0 \u00a0 \u00a0Near Optimal/ Above Optimal
\u00a0Less than 100 mg/dL \u00a0 \u00a0 Optimal
\u00a0LDL Cholesterol Levels*"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T11:27:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T20:53:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780417444.Comp6"}]}], "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/4743a33c-da23-d66e-307a-095a16b29fd9"}}, {"fullUrl": "urn:uuid:caccd32c-c9c5-5aa4-d1a0-4e0165b717d9", "resource": {"resourceType": "Observation", "id": "caccd32c-c9c5-5aa4-d1a0-4e0165b717d9", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.6.798268.2000", "value": "780417444.7"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "11054-4", "display": "LDL/HDL Ratio", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-26T22:01:00Z", "valueQuantity": {"value": 1.6}, "referenceRange": [{"text": "<3.3 Ratio", "high": {"value": "3.3", "unit": "Ratio"}}], "note": [{"text": "_________________________________________________________________________
% Change: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0-20%
Units: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 mg/dL
LDL Results: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 60
Test Date: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 07/24/2024
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% Change: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0+33%
Units: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 mg/dL
LDL Results: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 75
Test Date: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 01/24/2024
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% Change: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0-18%
Units: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 mg/dL
LDL Results: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 56
Test Date: \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 07/21/2023
_________________________________________________________________________
LDL Cholesterol Patient History
_________________________________________________________________________"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T11:27:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T20:53:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780417444.Comp7"}]}], "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/caccd32c-c9c5-5aa4-d1a0-4e0165b717d9"}}, {"fullUrl": "urn:uuid:e88ff567-64c7-d714-7847-6ddddc5bbbdd", "resource": {"resourceType": "Observation", "id": "e88ff567-64c7-d714-7847-6ddddc5bbbdd", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.7.798268.1000", "value": "780417444"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-07-26T22:01:00Z", "valueString": "Test performed by PathGroup Labs, LLC
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\u00a0 \u00a0 \u00a0 \u00a0> 100 ng/mL - Super-therapeutic- toxicity may occur above this level.
\u00a0 \u00a0 30 - 100 ng/mL - Sufficiency
\u00a0 \u00a0 \u00a020 - 29 ng/mL - Insufficiency
\u00a0 \u00a0 \u00a0 \u00a0 < 20 ng/mL - Deficiency
Interpretation of Vitamin D 25 OH:"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T11:27:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T20:53:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780419470.Comp1"}]}], "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/84bfeae2-2a69-b5e7-8c1f-d34d8c081506"}}, {"fullUrl": "urn:uuid:496858d1-19f0-3653-e21f-107539b1a684", "resource": {"resourceType": "Observation", "id": "496858d1-19f0-3653-e21f-107539b1a684", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.6.798268.2000", "value": "780419470.2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "1649-3", "display": "Vitamin D, 1, 25 Dihydroxy", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-26T22:01:00Z", "valueQuantity": {"value": 32.5, "unit": "pg/mL"}, "referenceRange": [{"text": "19.9 pg/mL - 79.3 pg/mL", "low": {"value": 19.9, "unit": "pg/mL"}, "high": {"value": 79.3, "unit": "pg/mL"}}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T11:27:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T20:53:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780419470.Comp2"}]}], "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/496858d1-19f0-3653-e21f-107539b1a684"}}, {"fullUrl": "urn:uuid:4afa3eee-4f51-a887-ac54-2bb4d44090f2", "resource": {"resourceType": "Observation", "id": "4afa3eee-4f51-a887-ac54-2bb4d44090f2", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.7.798268.1000", "value": "780419470"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-07-26T22:01:00Z", "valueString": "Test performed by PathGroup Labs, LLC
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\u00a0 \u00a0 \u00a0 >=6.5% \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Diabetic
\u00a0 \u00a0 \u00a0 \u00a0HA1c \u00a0 \u00a0 \u00a0 \u00a0 Suggested Diagnosis
\u00a0(ADA) may be used as an aid in the diagnosis of diabetes mellitus.
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Benton R. Middleman, MD, Laboratory Director
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or sampling error. Test performed by Associated Pathologists, LLC
does not preclude a possible infection due to a specimen inadequacy
prevalence populations may require re-evaluation. A negative result
positive and negative results may occur. Positive results in low
clinical presentation. This assay is highly accurate, but rare false
Results should be interpreted in conjunction with patient history and
DNA testing performed by Transcription Mediated Amplification (TMA)."}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Urine"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T12:36:49Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T05:00:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780424744.Comp1"}]}], "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/1a5a946f-3485-5955-81e9-de8878ef3b48"}}, {"fullUrl": "urn:uuid:271443bb-810e-5f55-cc4e-a9a9e8603508", "resource": {"resourceType": "Observation", "id": "271443bb-810e-5f55-cc4e-a9a9e8603508", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.6.798268.2000", "value": "780424744.2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "43403-5", "display": "Neisseria gonorrhoeae", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-25T12:09:00Z", "valueString": "NOT DETECTED", "note": [{"text": "37217, Pranil K. Chandra, DO, Laboratory Director, CLIA# 44D2062928
d/b/a PathGroup, 1010 Airpark Center Dr., Suite M, Nashville, TN
or sampling error. Test performed by Associated Pathologists, LLC
does not preclude a possible infection due to a specimen inadequacy
prevalence populations may require re-evaluation. A negative result
positive and negative results may occur. Positive results in low
clinical presentation. This assay is highly accurate, but rare false
Results should be interpreted in conjunction with patient history and
DNA testing performed by Transcription Mediated Amplification (TMA)."}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Urine"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T12:36:49Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T05:00:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780424744.Comp2"}]}], "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/271443bb-810e-5f55-cc4e-a9a9e8603508"}}, {"fullUrl": "urn:uuid:103e4385-7bcd-ce33-5ed7-6c401105ad01", "resource": {"resourceType": "Observation", "id": "103e4385-7bcd-ce33-5ed7-6c401105ad01", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.66.2.7.6.798268.2000", "value": "780424744.3"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "43404-3", "display": "Chlamydia trachomatis", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-25T12:09:00Z", "valueString": "NOT DETECTED", "note": [{"text": "37217, Pranil K. Chandra, DO, Laboratory Director, CLIA# 44D2062928
d/b/a PathGroup, 1010 Airpark Center Dr., Suite M, Nashville, TN
or sampling error. Test performed by Associated Pathologists, LLC
does not preclude a possible infection due to a specimen inadequacy
prevalence populations may require re-evaluation. A negative result
positive and negative results may occur. Positive results in low
clinical presentation. This assay is highly accurate, but rare false
Results should be interpreted in conjunction with patient history and
DNA testing performed by Transcription Mediated Amplification (TMA)."}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Urine"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T12:36:49Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T05:00:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.66.2.7.2.798268.780424744.Comp3"}]}], "subject": {"reference": "Patient/d8964bed-874e-4e70-a67d-01b96033fbdd"}, "performer": [{"display": "PATHGROUP LABS LLC", "reference": "Organization/cb28a994-671e-46be-3b26-9469305f6a40"}]}, "request": {"method": "PUT", "url": "Observation/103e4385-7bcd-ce33-5ed7-6c401105ad01"}}, {"fullUrl": "urn:uuid:14f0ae72-14d0-5657-bccd-bfe5bc10eb45", "resource": {"resourceType": "Observation", "id": "14f0ae72-14d0-5657-bccd-bfe5bc10eb45", "meta": {"profile": 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NameAdministration DatesNext Due
DTaP01/22/2020
DTaP / Hep B / IPV02/14/2019 12/03/2018 08/30/2018 , ,
DTaP / IPV08/09/2022
Hep A, 2 Dose Pediatric01/22/2020 07/03/2019 ,
Hep B, Adolescent or Pediatric06/22/2018
Hib (PRP-OMP)01/22/2020 12/03/2018 08/30/2018 , ,
Influenza, Quadrivalent, Ped Pres Free IM10/09/2019 04/18/2019 02/14/2019 , ,
Influenza, Quadrivalent, Pres Free (FLUARIX,FLULAVEL,FLUZONE)02/08/2021
Influenza, Quadrivalent, Pres Free (FLUCELVAX)09/20/2023
MMR07/03/2019
MMRV08/09/2022
Pneumococcal Conjugate 13-Valent01/22/2020 02/14/2019 12/03/2018 08/30/2018 , , ,
Rotavirus Pentavalent02/14/2019 12/03/2018 08/30/2018 , ,
Varicella07/03/2019
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Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
sodium chloride 0.9 % bolus 356 mL356 mL (20 mL/kg \u00d7 17.8 kg), intravenous, at 356 mL/hr, Administer over 1 Hours, Once, On Fri 7/26/24 at 2226, For 1 doseNew Bag07/26/2024 10:33 PM EDT356 mL356 mL/hr
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "49c8af06-d6a1-6bd0-44fa-92482bedd01e", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
11/11/2024 1:10 PM ESTOffice VisitEMG CHE General Pediatrics900 East Third Street2nd floorCHATTANOOGA, TN 37403423-778-5437Cox, Victoria S, DO910 Blackford StreetDepartment of PediatricsChattanooga, TN 37403423-778-5437 (Work)423-778-6958 (Fax)
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
POCT Occult Blood Stool, SinglePoint of Care TestingSTAT07/26/2024 9:20 PM EDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
Urinalysis Reflex To CultureLabSTATSTAT for 1 Occurrences starting 7/26/24 until 7/26/24
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ProblemNoted DateDiagnosed Date
Dental caries12/04/2023
Failed vision screen10/03/2022
Overview:Formatting of this note might be different from the original.
Anisometropia, myopia, astimatism and amblyopia. Seen on 8/11/22 and rx for glasses updated
Myopia07/08/2021
Overview:Formatting of this note might be different from the original.
Wears glasses
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never
Smokeless Tobacco: Never
Hunger Vital SignAnswerDate Recorded
Within the past 12 months, you worried that your food would run out before you got the money to buy more.Never true02/08/2021
Within the past 12 months, the food you bought just didn''t last and you didn''t have money to get more.Never true02/08/2021
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
Job Start DateOccupationIndustry
Not on fileNot on fileNot on file
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"identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "8706612"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "H52.10", "display": "Myopia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-07-08", "note": [{"text": "Overview:
problemNote42
Formatting of this note might be different from the original.

Wears glasses"}], "subject": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4d4c1cb7-7b26-51c3-b709-086eacfd35a8"}}, {"fullUrl": "urn:uuid:1ae9b4d2-1e00-722f-0752-05dedb50f785", "resource": {"resourceType": "Condition", "id": "1ae9b4d2-1e00-722f-0752-05dedb50f785", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "11155452"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z01.01", "display": "Failed vision screen", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-03", "note": [{"text": "Overview:
problemNote44
Formatting of this note might be different from the original.

Anisometropia, myopia, astimatism and amblyopia. Seen on 8/11/22 and rx for glasses updated "}], "subject": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1ae9b4d2-1e00-722f-0752-05dedb50f785"}}, {"fullUrl": "urn:uuid:2bcc3936-af37-e8d9-1353-7ff7572eecb1", "resource": {"resourceType": "Condition", "id": "2bcc3936-af37-e8d9-1353-7ff7572eecb1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "13270335"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K02.9", "display": "Dental caries", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-12-04", "subject": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/2bcc3936-af37-e8d9-1353-7ff7572eecb1"}}, {"fullUrl": "urn:uuid:e8c6f57a-ada7-212f-41af-dce167731172", "resource": {"resourceType": "DiagnosticReport", "id": "e8c6f57a-ada7-212f-41af-dce167731172", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.798268", "value": "197645960"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.461.2.798268.2.197645960.1"}], "status": "final", "code": {"coding": [{"code": "33720", "display": "X-ray abdomen 2 views AP supine and erect", "system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-07-27T02:46:39Z", "end": "2024-07-27T02:46:39Z"}, "subject": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "performer": [{"reference": "Organization/1388e08a-fcdc-4f35-d1c5-633c7fce2dae"}], "result": [{"reference": "Observation/3b15800b-8e8c-c49a-67c6-3fd1dbf02a3f"}, {"reference": "Observation/1d07b454-774a-b40b-dd20-222505bbd8c7"}, {"reference": "Observation/923fff36-b661-527a-b14a-6e9b66244a28"}, {"reference": "Observation/22d8b48a-0863-e629-232c-56b2c14905ae"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/e8c6f57a-ada7-212f-41af-dce167731172"}}, {"fullUrl": "urn:uuid:1388e08a-fcdc-4f35-d1c5-633c7fce2dae", "resource": {"resourceType": "Organization", "id": "1388e08a-fcdc-4f35-d1c5-633c7fce2dae", "name": "CARESTREAM PACS/PS360", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/1388e08a-fcdc-4f35-d1c5-633c7fce2dae"}}, {"fullUrl": "urn:uuid:3b15800b-8e8c-c49a-67c6-3fd1dbf02a3f", "resource": {"resourceType": "Observation", "id": "3b15800b-8e8c-c49a-67c6-3fd1dbf02a3f", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.3.696580.52175", "value": "33720"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-07-27T01:33:19Z", "end": "2024-07-27T01:37:38Z"}, "bodySite": {"coding": [{"code": "123", "display": "Body", "system": "urn:oid:1.2.840.114350.1.13.461.2.7.10.696580.52010"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-07-27T02:46:39Z"}]}], "subject": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}}, "request": {"method": "PUT", "url": "Observation/3b15800b-8e8c-c49a-67c6-3fd1dbf02a3f"}}, {"fullUrl": "urn:uuid:1d07b454-774a-b40b-dd20-222505bbd8c7", "resource": {"resourceType": "Observation", "id": "1d07b454-774a-b40b-dd20-222505bbd8c7", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.7.798268.1000", "value": "197645960"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-07-27T02:48:19Z", "valueString": "XR ABDOMEN SUPINE ERECT

HISTORY: abdominal pain, rectal bleeding

TECHNIQUE: Two views of the abdomen.

COMPARISON: None

FINDINGS/IMPRESSION:
There is a paucity of bowel gas at the right abdomen including the right lower quadrant which is nonspecific but could raise concern for intussusception in the appropriate clinical setting. If there is clinical concern, consider an abdominal ultrasound for further evaluation.

Mildly distended colon projects over the left abdomen. No definite dilated air filled loops of small bowel.

No suspicious calcifications.

Osseous structures appear normal.

The imaged lung bases appear clear






Dictated By: \u00a0 \u00a0- 7/26/2024 10:46 PM EDT

Electronically Signed By: \u00a0Kevin Crawford, MD - 7/26/2024 10:48 PM EDT

", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-07-27T02:46:39Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.461.2.7.2.798268.197645960.Narrative"}]}], "subject": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "performer": [{"display": "CARESTREAM PACS/PS360", "reference": "Organization/0b5c71c1-fdf4-2661-6d26-6c10fab9d415"}]}, "request": {"method": "PUT", "url": "Observation/1d07b454-774a-b40b-dd20-222505bbd8c7"}}, {"fullUrl": "urn:uuid:0b5c71c1-fdf4-2661-6d26-6c10fab9d415", "resource": {"resourceType": "Organization", "id": "0b5c71c1-fdf4-2661-6d26-6c10fab9d415", "name": "CARESTREAM PACS/PS360", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/0b5c71c1-fdf4-2661-6d26-6c10fab9d415"}}, {"fullUrl": "urn:uuid:923fff36-b661-527a-b14a-6e9b66244a28", "resource": {"resourceType": "Observation", "id": "923fff36-b661-527a-b14a-6e9b66244a28", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.727879", "value": "670766436"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-07-27T02:48:19Z", "valueString": "

Electronically Signed By: Kevin Crawford, MD - 7/26/2024 10:48 PM EDT

Dictated By: - 7/26/2024 10:46 PM EDT






The imaged lung bases appear clear

Osseous structures appear normal.

No suspicious calcifications.

air filled loops of small bowel.
Mildly distended colon projects over the left abdomen. No definite dilated

concern, consider an abdominal ultrasound for further evaluation.
intussusception in the appropriate clinical setting. If there is clinical
lower quadrant which is nonspecific but could raise concern for
There is a paucity of bowel gas at the right abdomen including the right
FINDINGS/IMPRESSION:

COMPARISON: None

TECHNIQUE: Two views of the abdomen.

HISTORY: abdominal pain, rectal bleeding

XR ABDOMEN SUPINE ERECT
Formatting of this note might be different from the original.
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Dictated By: \u00a0 \u00a0- 7/26/2024 11:41 PM EDT

Electronically Signed By: \u00a0Justin Buchanan, MD - 7/26/2024 11:41 PM EDT

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HISTORY: bloody diarrhea

COMPARISON: None

TECHNIQUE:
Multiplanar gray-scale and color Doppler images of the abdomen were obtained.

FINDINGS:
No evidence of target sign or pseudokidney sign or other findings to suggest ileocolic intussusception. No other significant incidental findings are identified.
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Electronically Signed By: Justin Buchanan, MD - 7/26/2024 11:41 PM EDT

Dictated By: - 7/26/2024 11:41 PM EDT

persistent pain, close follow-up ultrasound is recommended.
No sonographic evidence of ileocolic intussusception. If clinically
IMPRESSION:

findings are identified.
suggest ileocolic intussusception. No other significant incidental
No evidence of target sign or pseudokidney sign or other findings to
FINDINGS:

obtained.
Multiplanar gray-scale and color Doppler images of the abdomen were
TECHNIQUE:

COMPARISON: None

HISTORY: bloody diarrhea

EXAMINATION: US ABDOMEN FOR INTUSSUSCEPTION
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"Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/2b2730f3-8c0a-b7ae-908f-f97e1914465a"}}, {"fullUrl": "urn:uuid:7f2ae584-73ea-c5e6-87bc-ce20cf26d5cb", "resource": {"resourceType": "Immunization", "id": "7f2ae584-73ea-c5e6-87bc-ce20cf26d5cb", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "6170332"}], "occurrenceDateTime": "2020-01-22", "note": {"text": "Hep A, 2 Dose Pediatric"}, "vaccineCode": {"coding": [{"code": "58160-825-43", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "4KJ79", "manufacturer": {"reference": "Organization/a1439865-b6cb-7b35-67e3-cc00011c9f1c"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/7f2ae584-73ea-c5e6-87bc-ce20cf26d5cb"}}, {"fullUrl": "urn:uuid:b43337a6-d447-bcc4-f264-55c4cd4d4ad8", "resource": {"resourceType": "Immunization", "id": "b43337a6-d447-bcc4-f264-55c4cd4d4ad8", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "6170333"}], "occurrenceDateTime": "2020-01-22", "note": {"text": "Hib (PRP-OMP)"}, "vaccineCode": {"coding": [{"code": "0006-4897-01", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "S008730", "manufacturer": {"reference": "Organization/6cf87e59-f4c2-a044-88fa-94a2bff77460"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/b43337a6-d447-bcc4-f264-55c4cd4d4ad8"}}, {"fullUrl": "urn:uuid:072b3205-97ba-d63e-7efa-09bf4286e69e", "resource": {"resourceType": "Immunization", "id": "072b3205-97ba-d63e-7efa-09bf4286e69e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "6170334"}], "occurrenceDateTime": "2020-01-22", "note": {"text": "Pneumococcal Conjugate 13-Valent"}, "vaccineCode": {"coding": [{"code": "0005-1971-01", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "AT5497", "manufacturer": {"reference": "Organization/cfa17dcb-937a-460e-6cdf-d2d46a4daa93"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/072b3205-97ba-d63e-7efa-09bf4286e69e"}}, {"fullUrl": "urn:uuid:c23d64ce-b902-3ddf-9cde-925e88511b41", "resource": {"resourceType": "Immunization", "id": "c23d64ce-b902-3ddf-9cde-925e88511b41", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "7799104"}], "occurrenceDateTime": "2021-02-08", "note": {"text": "Influenza, Quadrivalent, Pres Free (FLUARIX,FLULAVEL,FLUZONE)"}, "vaccineCode": {"coding": [{"code": "49281-420-50", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "UT7011MA", "manufacturer": {"reference": "Organization/b5c77b86-2764-79f9-10bf-5da5e63eb7c1"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/c23d64ce-b902-3ddf-9cde-925e88511b41"}}, {"fullUrl": "urn:uuid:f8a155a3-86be-0d98-6597-4b455c3fe1ec", "resource": {"resourceType": "Immunization", "id": "f8a155a3-86be-0d98-6597-4b455c3fe1ec", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "10869088"}], "occurrenceDateTime": "2022-08-09", "note": {"text": "DTaP / IPV"}, "vaccineCode": {"coding": [{"code": "58160-812-52", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "E2L54", "manufacturer": {"reference": "Organization/a1439865-b6cb-7b35-67e3-cc00011c9f1c"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/f8a155a3-86be-0d98-6597-4b455c3fe1ec"}}, {"fullUrl": "urn:uuid:05444f7a-c69a-cf27-f3d8-27b2aece95c8", "resource": {"resourceType": "Immunization", "id": "05444f7a-c69a-cf27-f3d8-27b2aece95c8", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "10869089"}], "occurrenceDateTime": "2022-08-09", "note": {"text": "MMRV"}, "vaccineCode": {"coding": [{"code": "0006-4171-01", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "W006587", "manufacturer": {"reference": "Organization/6cf87e59-f4c2-a044-88fa-94a2bff77460"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/05444f7a-c69a-cf27-f3d8-27b2aece95c8"}}, {"fullUrl": "urn:uuid:91782aeb-e3d4-24c8-6a1a-96e6a6804d85", "resource": {"resourceType": "Immunization", "id": "91782aeb-e3d4-24c8-6a1a-96e6a6804d85", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.461.2.7.2.768076", "value": "12905244"}], "occurrenceDateTime": "2023-09-20", "note": {"text": "Influenza, Quadrivalent, Pres Free (FLUCELVAX)"}, "vaccineCode": {"coding": [{"code": "70461-323-04", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "370647", "manufacturer": {"reference": "Organization/c70da4f4-1209-2a5c-b813-121a21c6ad42"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/d6e2ccef-ff4b-4ca6-b23b-bf5ebf1607ff"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/91782aeb-e3d4-24c8-6a1a-96e6a6804d85"}}, {"fullUrl": "urn:uuid:c70da4f4-1209-2a5c-b813-121a21c6ad42", "resource": {"resourceType": "Organization", "id": "c70da4f4-1209-2a5c-b813-121a21c6ad42", "name": "Seqirus", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/c70da4f4-1209-2a5c-b813-121a21c6ad42"}}]}') ON CONFLICT (ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.363.2.7.8.688883.859361050', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.363.2.7.8.688883.859361050", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.363.2.7.8.688883.859361050", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-17eb-cab7-0c68-e9e7bf945115", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "2"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-07-26T22:00:06-05:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "b7a7ed08-af88-4a31-cc4e-8dddd58b7fc8", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-1C06-B153-0C68-E9E7BF945115", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
Hepatitis A04/28/2022 07/26/2021 ,
Influenza (Historical)10/01/2020
Influenza Inj. Cell Derived Quadrivalent 4 years+ (PF)12/03/2018
Influenza Inj. QIV (PF)09/29/2023 11/29/2022 Deferred: Other - pt recived bfore admission ) ( 11/09/2022 11/05/2022 Deferred: Other ) ( 11/01/2021 10/07/2021 09/16/2020 , , , , , ,
Influenza Nasal (Historical)09/29/2023
Influenza TIV (IM)09/18/2013 11/05/2012 03/03/2012 , ,
Pfizer-BioNTech COVID-19 Vaccine11/29/2021 03/29/2021 03/04/2021 , ,
Pfizer-BioNTech COVID-19 Vaccine 12Y+ Bivalent11/14/2022
Pneumo Polysaccharide 23-valent01/19/2022 10/26/2020 03/11/2012 , ,
Pneumococcal Conjugate 13-Valent04/01/2021
Tdap07/02/2021
Zoster Vaccine Recombinant02/23/2024 09/29/2023 ,
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-1C06-B165-0C68-E9E7BF945115", "title": "Administered Medications", "text": {"status": "generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "8adbae3c-970d-4aba-3e93-c981803eb02d", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
08/01/2024 1:15 PM CDTPost-Op VisitUT Podiatry1068 Cresthaven RdSuite 110MEMPHIS, TN 38119901-767-5620Moinester, David M, DPM6575 Stage RDMemphis, TN 38134-3809901-382-0393 (Work)901-381-1177 (Fax)
08/08/2024 1:15 PM CDTPost-Op VisitUT Podiatry1068 Cresthaven RdSuite 110MEMPHIS, TN 38119901-767-5620Moinester, David M, DPM6575 Stage RDMemphis, TN 38134-3809901-382-0393 (Work)901-381-1177 (Fax)
08/21/2024 9:00 AM CDTLabBaptist Memorial Hospital - Memphis6019 Walnut Grove Rd.Memphis, TN 38120901-226-5000Discharge Disposition: Home
08/21/2024 9:30 AM CDTOffice VisitMemphis Transplant Clinic6025 WALNUT GROVE, STE 111MEMPHIS, TN 38120901-226-2000Discharge Disposition: Home
08/21/2024 10:00 AM CDTAppointmentBaptist Memorial Hospital - Memphis6019 Walnut Grove Rd.Memphis, TN 38120901-226-5000Discharge Disposition: Home
08/21/2024 10:15 AM CDTAppointmentBaptist Memorial Hospital - Memphis6029 Walnut Grove RdMemphis, TN 38120901-226-5000Discharge Disposition: Home
11/12/2024 9:30 AM CSTOffice VisitBMG Family Physicians Group Winchester7685 Winchester RoadMemphis, TN 38125901-752-6963Venegas, Julian Lucas, DO400 Market BLVDSTE 101Collierville, TN 38017901-752-6963 (Work)901-737-3640 (Fax)
06/03/2025 10:15 AM CDTOffice VisitBMG The Endocrine Clinic5659 South Rex RdMEMPHIS, TN 38119-3821901-763-3636Cohen, Alan Jay, MD5659 S Rex RDMemphis, TN 38119901-763-3636 (Work)901-763-3694 (Fax)
Scheduled Procedures
NamePriorityAssociated DiagnosesDate/Time
COLONOSCOPYEncounter for screening colonoscopyIschemic cardiomyopathy
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/7fd3552e-5b1b-9616-5ae2-d6dab71f509c"}]}, {"id": "00000000-1C06-B1BE-0C68-E9E7BF945115", "title": "Problems", "text": {"status": "generated", "div": "
ProblemNoted DateDiagnosed Date
History of heart transplant05/31/2024
History of arterial ischemic stroke05/31/2024
Dilated cardiomyopathy04/18/2024
Overview (04/18/2024):Formatting of this note might be different from the original.
Noted by THRELKELD STEPHEN C MD last documented on 20230106
Chronic viral hepatitis B without delta-agent10/17/2023
Overview (10/17/2023):Formatting of this note might be different from the original.
Noted by CENSEO HEALTH LLC last documented on 20230629
Chronic kidney disease, stage 3a09/05/2023
Overview (09/05/2023):Formatting of this note might be different from the original.
Noted by SWEAT BONNIE J NP last documented on 20230316
Portal hypertension09/05/2023
Overview (09/05/2023):Formatting of this note might be different from the original.
Noted by BAPTIST MEMORIAL HOSPITAL last documented on 20220428
Uncontrolled type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin09/05/2023
Overview (09/05/2023):Formatting of this note might be different from the original.
Noted by VENEGAS JULIAN L DO last documented on 20230606
Localization-related epilepsy08/28/2023
Chronic hepatitis, unspecified08/28/2023
Paroxysmal atrial fibrillation08/28/2023
Encounter for aftercare following heart transplant04/28/2023
Blood pressure check04/28/2023
Hypomagnesemia04/28/2023
Steroid-induced hyperglycemia04/28/2023
Seizure-like activity03/27/2023
Decreased diffusion capacity of lung03/21/2023
Encounter for therapeutic drug level monitoring02/22/2023
Hepatitis B core antibody positive02/22/2023
Hypertensive cardiovascular-renal disease, stage 1-4 or unspecified chronic kidney disease, without heart failure02/22/2023
Heart transplanted01/28/2023
Stroke01/17/2023
Donor, organ: CMV D (+) / R (+) ; EBV D (+) / R (+); Toxo D (-) / R (-) Hep B core D (+) / Hep B core (+) R12/28/2022
CKD (chronic kidney disease)04/29/2022
Ulcerative colitis03/24/2022
Hyperlipidemia03/24/2022
Mixed restrictive and obstructive lung disease03/24/2022
Pulmonary emphysema03/24/2022
Mixed hyperlipidemia03/11/2021
PAH (pulmonary arterial hypertension) with portal hypertension12/09/2020
Stage 1 mild COPD by GOLD classification08/03/2020
documented as of this encounter (statuses as of 07/26/2024)"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Stage 1 mild COPD by GOLD classification", "reference": "Condition/9373a0f7-c7e8-5542-7d78-397bea62f10e"}, {"display": "Problem - PAH (pulmonary arterial hypertension) with portal hypertension", "reference": "Condition/faae7256-730b-b13c-00d4-058022a75778"}, {"display": "Problem - Mixed hyperlipidemia", "reference": "Condition/21604e63-8df5-a386-ce32-6d01933a7a7c"}, {"display": "Problem - Ulcerative colitis", "reference": "Condition/c5e64b1b-a7d0-c50a-7917-89f8b18aff2a"}, {"display": "Problem - Hyperlipidemia", "reference": "Condition/8e9a0e84-86f9-fddb-8370-4feda03632c2"}, {"display": "Problem - Mixed restrictive and obstructive lung disease", "reference": "Condition/2b7519c3-f7bb-9f23-4ed1-d9e78d50f706"}, {"display": "Problem - Pulmonary emphysema", "reference": "Condition/c109107c-22ea-f4ec-6546-bc2a15421502"}, {"display": "Problem - CKD (chronic kidney disease)", "reference": "Condition/8caceaba-d6a7-f33e-3855-0bcbb64b1715"}, {"display": "Problem - Donor, organ", "reference": "Condition/f707ddcf-34dd-f756-b148-e07a8c99fba6"}, {"display": "Problem - Stroke", "reference": "Condition/4a5b532a-6bc8-cd73-7d92-0fb56dbbbb86"}, {"display": "Problem - Heart transplanted", "reference": "Condition/34a075ed-c48b-3078-3c8b-a56f399a6dfe"}, {"display": "Problem - Encounter for therapeutic drug level monitoring", "reference": "Condition/eadafe80-54bb-c64e-9139-2542f44790ff"}, {"display": "Problem - Hepatitis B core antibody positive", "reference": "Condition/9a588f18-07de-85e6-2721-48a950c496dc"}, {"display": "Problem - Hypertensive cardiovascular-renal disease, stage 1-4 or unspecified chronic kidney disease, without heart failure", "reference": "Condition/461c5d1f-1632-91a9-deaa-9b66ec29f286"}, {"display": "Problem - Decreased diffusion capacity of lung", "reference": "Condition/852be5af-65f9-fe76-f3dc-46d2cc89c8c5"}, {"display": "Problem - Seizure-like activity", "reference": "Condition/3701bd5e-ccf5-a1ea-7bec-9c70fad26a68"}, {"display": "Problem - Encounter for aftercare following heart transplant", "reference": "Condition/0a489258-334b-a0bf-410b-919ee6a4f587"}, {"display": "Problem - Blood pressure check", "reference": "Condition/c623e67f-a29d-7d12-f560-9745bf52ac27"}, {"display": "Problem - Hypomagnesemia", "reference": "Condition/524df5bd-7625-28b6-e367-8f87dab7ba59"}, {"display": "Problem - Steroid-induced hyperglycemia", "reference": "Condition/56d4666c-8218-798b-ed33-d6299cb7cc31"}, {"display": "Problem - Localization-related epilepsy", "reference": "Condition/30626279-34d6-7ab1-46d9-b028a8f45d48"}, {"display": "Problem - Chronic hepatitis, unspecified", "reference": "Condition/2e35acd9-247c-b392-b712-3bba7b83c22a"}, {"display": "Problem - Paroxysmal atrial fibrillation", "reference": 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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: FormerCigarettes147.801/01/1973 - 10/08/2020
Smokeless Tobacco: Never
Comments:
pt states he stopped 2 weeks ago
Alcohol UseStandard Drinks/WeekComments
Not Currently0 (1 standard drink = 0.6 oz pure alcohol)
PHQ-2AnswerDate Recorded
PHQ-2 Score005/03/2024
BOC Food InsecurityAnswerDate Recorded
Food Insecurity103/24/2024
BOC Transportation NeedsAnswerDate Recorded
Transportation Needs103/24/2024
BOC Housing Stability SourceAnswerDate Recorded
Housing Insecurity103/24/2024
BOC Utility Needs SourceAnswerDate Recorded
Utility Needs102/28/2024
BOC Financial Resource NeedsAnswerDate Recorded
Financial Resource Strain103/24/2024
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthMale01/23/2021 7:27 AM CST
Gender IdentityMale01/23/2021 7:27 AM CST
Sexual OrientationStraight01/23/2021 7:27 AM CST
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DateTypeDepartmentCare Team (Latest Contact Info)Description
07/24/2024 10:00 AM CDTLabBaptist Memorial Hospital - Memphis6019 Walnut Grove Rd.Memphis, TN 38120901-226-5000
Shortness of breathMixed hyperlipidemia; Magnesium deficiency; Steroid-induced diabetes mellitus (HCC); Screening PSA (prostate specific antigen); Thyroid disorder screening; Vitamin D deficiency; Immunosuppression due to chronic steroid use (HCC); Current chronic use of systemic steroids; Steroid-induced osteopenia; Encounter for therapeutic drug level monitoring; Hypomagnesemia; Immunosuppressed status (HCC); Encounter for aftercare following heart transplant (HCC); Immunosuppression (HCC); Immunocompromised (HCC); At high risk for infection; S/P orthotopic heart transplant (HCC);
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Pierce, M.D.
\u00a01701 Century Center Cove, Memphis, TN 38134-8975
MEM - American Esoteric Laboratories - Memphis CLIA# 44D0889744
for blood or blood products.
This CMV assay is not intended for use as a screening tool
can be used to assess viral response to treatment.
receiving anti-CMV therapy, serial DNA measurements
hematopoietic stem cell transplant patients. \u00a0In patients
of CMV in solid organ transplant patients and in
This test is intended for use as an aid in the management
Reference Range: \u00a0None Detected
Comment for CMV VIRAL LOAD"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T16:35:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T17:52:19Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.363.2.7.2.798268.658526038.Comp2"}]}], "subject": {"reference": "Patient/17262ced-5b28-4ce8-b23c-dda6653cf10a"}, "performer": [{"display": "AEL", "reference": "Organization/baf1a81f-fd90-674d-c1ed-40d724c1d83b"}]}, "request": {"method": "PUT", "url": "Observation/6df750e5-c83a-34d0-e4bf-d06b902d9732"}}, {"fullUrl": "urn:uuid:8694917f-a83a-e42e-1f4c-6d96fd5cd305", "resource": {"resourceType": "Observation", "id": "8694917f-a83a-e42e-1f4c-6d96fd5cd305", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.798268", "value": "658526038"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "56850-1", "display": "Lab Interpretation", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-27T02:59:00Z", "valueString": "Abnormal", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T16:35:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T17:52:19Z"}]}], "subject": {"reference": "Patient/17262ced-5b28-4ce8-b23c-dda6653cf10a"}}, "request": {"method": "PUT", "url": "Observation/8694917f-a83a-e42e-1f4c-6d96fd5cd305"}}, {"fullUrl": "urn:uuid:c242f6aa-7965-d92f-d7cc-e3f096eba2dd", "resource": {"resourceType": "Observation", "id": "c242f6aa-7965-d92f-d7cc-e3f096eba2dd", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.798268", "value": "658526038"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2024-07-27T02:59:00Z", "valueCodeableConcept": {"coding": [{"code": "17", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-24T16:35:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-24T17:52:19Z"}]}], "subject": {"reference": "Patient/17262ced-5b28-4ce8-b23c-dda6653cf10a"}}, "request": {"method": "PUT", "url": "Observation/c242f6aa-7965-d92f-d7cc-e3f096eba2dd"}}, {"fullUrl": "urn:uuid:c1a7e37a-78ba-8647-dece-58e62b24293b", "resource": {"resourceType": "DiagnosticReport", "id": "c1a7e37a-78ba-8647-dece-58e62b24293b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.798268", "value": "658526039"}], "status": "final", "code": {"coding": [{"code": "211539", "display": "ImmuKnow", "system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-07-24T16:35:00Z", "end": "2024-07-24T16:35:00Z"}, "subject": {"reference": "Patient/17262ced-5b28-4ce8-b23c-dda6653cf10a"}, "performer": [{"reference": "Organization/5183447d-912b-edd3-271d-c6e9d2a1425d"}], "result": [{"reference": "Observation/ae5b6e82-f4e9-4080-b4a9-5a33f516b2f0"}, {"reference": "Observation/b6d1c1b7-e26b-2405-ffd2-a324cdc2f0b5"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/c1a7e37a-78ba-8647-dece-58e62b24293b"}}, {"fullUrl": "urn:uuid:ae5b6e82-f4e9-4080-b4a9-5a33f516b2f0", "resource": {"resourceType": "Observation", "id": "ae5b6e82-f4e9-4080-b4a9-5a33f516b2f0", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.6.798268.2000", "value": "658526039.1"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "53939-5", "display": "ImmuKnow", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-26T12:12:00Z", "valueQuantity": {"value": 163}, "referenceRange": [{"text": "ATP ng/mL"}], "note": [{"text": "Laboratory Director: Holly H. Pierce, M.D. CLIA# 44D0889744
1701 Century Center Cove Memphis, TN 38134
American Esoteric Laboratories
Unless otherwise indicated, all testing performed at:
FLAG Interpretation: A = Abnormal, H = High, L = Low
CLIA # 26D-0983643
Lab Director: Brock Neil, PhD BCLD (ABB)
Lenexa, KS 66219
18000 W. 99th Street, Suite 10
Eurofins Viracor, LLC
Testing Performed At:
____________________________________________________________
Administration. ImmuKnow (R) is a registered trademark.
cleared or approved for diagnostic use by the U.S. Food and Drug
establishing the immune status of a patient. This test has been
presentation, medical history, and other clinical indicators when
These results should be used in conjunction with clinical
directly quantify the level of immunosuppression.
NOTE: This is a qualitative assay. Therefore the result does not
Strong Immune Cell Response >=525 ATP Level ng/mL
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QIV (PF)"}, "vaccineCode": {"coding": [{"code": "19515-814-41", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "MC355", "manufacturer": {"reference": "Organization/d71f8943-b3e0-07cf-5ccb-7cba5505cd15"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/17262ced-5b28-4ce8-b23c-dda6653cf10a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/9339316b-caf7-a61c-d016-2be792a9755f"}}, {"fullUrl": "urn:uuid:e7bf36d6-9f77-0f38-f70c-d50a626299bc", "resource": {"resourceType": "Immunization", "id": "e7bf36d6-9f77-0f38-f70c-d50a626299bc", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.768076", "value": "35779715"}], "occurrenceDateTime": "2023-09-29", "note": {"text": "Zoster Vaccine Recombinant"}, "vaccineCode": {"coding": [{"code": "58160-823-11", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "manufacturer": {"reference": "Organization/a1439865-b6cb-7b35-67e3-cc00011c9f1c"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/17262ced-5b28-4ce8-b23c-dda6653cf10a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/e7bf36d6-9f77-0f38-f70c-d50a626299bc"}}, {"fullUrl": "urn:uuid:68013aab-1b76-44de-4a08-a34b325289e2", "resource": {"resourceType": "Immunization", "id": "68013aab-1b76-44de-4a08-a34b325289e2", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.768076", "value": "36375026"}], "occurrenceDateTime": "2023-09-29", "note": {"text": "Influenza Nasal (Historical)"}, "vaccineCode": {"coding": [{"code": "151", "display": "Influenza Nasal (Historical)", "system": "urn:oid:2.16.840.1.113883.12.292"}]}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/17262ced-5b28-4ce8-b23c-dda6653cf10a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/68013aab-1b76-44de-4a08-a34b325289e2"}}, {"fullUrl": "urn:uuid:65438b2f-7f06-9786-d148-b094e18fd563", "resource": {"resourceType": "Immunization", "id": "65438b2f-7f06-9786-d148-b094e18fd563", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.363.2.7.2.768076", "value": "37597645"}], "occurrenceDateTime": "2024-02-23", "note": {"text": "Zoster Vaccine Recombinant"}, "vaccineCode": {"coding": [{"code": "58160-828-03", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "lotNumber": "47LF3", "manufacturer": {"reference": "Organization/a1439865-b6cb-7b35-67e3-cc00011c9f1c"}, "status": "completed", "primarySource": true, "patient": {"reference": "Patient/17262ced-5b28-4ce8-b23c-dda6653cf10a"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/65438b2f-7f06-9786-d148-b094e18fd563"}}]}') ON CONFLICT (ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('0a094680-9a5d-45b5-bdda-197f79df2d03', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:0a094680-9a5d-45b5-bdda-197f79df2d03", "resource": {"resourceType": "Composition", "id": "0a094680-9a5d-45b5-bdda-197f79df2d03", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "1013-156287716|298594141"}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "3"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-07-28T11:56:45-04:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "1c6b60d4-0f98-67b9-6078-ccbc8cee7ce5", "title": "PROBLEMS - DIAGNOSES", "text": {"status": "generated", "div": "No Problem Information"}, "code": {"coding": [{"code": "11450-4", "display": "PROBLEM LIST", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "bdea0a78-bfa2-fe93-ab37-ab7bb9b3fe19", "title": "ENCOUNTERS", "text": {"status": "generated", "div": "
Encounter CodeDate of Encounter
inpatient encounter07/23/24 11:27 EDT
"}, "code": {"coding": [{"code": "46240-8", "display": "History of Encounters", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "214592e7-735b-ea93-528d-ae3b0a059003", "title": "RESULTS", "text": {"status": "generated", "div": "
Lab Test NameLab Test Result ValueCollection DateResult DateLab Result InterpretationLab Result Reference RangeLab Result Note
Glucose:MCnc:Pt:Ser/Plas:Qn:124.007/23/24 12:10 EDT07/23/24 13:01 EDTHigh40-114None
Erythrocyte mean corpuscular hemoglobin concentration:MCnc:Pt:RBC:Qn:36.1 g/dL07/23/24 12:10 EDT07/23/24 13:44 EDTHigh32-36None
Erythrocyte mean corpuscular hemoglobin:EntMass:Pt:RBC:Qn:34.9 pg07/23/24 12:10 EDT07/23/24 13:44 EDTHigh25-34None
Platelets:PrThr:Pt:Bld:Ord:Microscopy.lightADEQUATE07/23/24 12:10 EDT07/23/24 13:44 EDTUnknownUnknownNone
Platelets:NCnc:Pt:Bld:Qn:193.0 k/uL07/23/24 12:10 EDT07/23/24 13:44 EDTNormal145-483None
Platelet morphology finding:Prid:Pt:Bld:Nom:NORMAL07/23/24 12:10 EDT07/23/24 13:44 EDTUnknownUnknownNone
Erythrocyte mean corpuscular volume:EntVol:Pt:RBC:Qn:96.8 fl07/23/24 12:10 EDT07/23/24 13:44 EDTNormal96.2-131.8None
Sodium:SCnc:Pt:Ser/Plas:Qn:140.0 mmo/L07/23/24 12:10 EDT07/23/24 13:01 EDTNormal131-143None
Creatinine:MCnc:Pt:Ser/Plas:Qn:0.32 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTLow0.90-1.30None
Potassium:SCnc:Pt:Ser/Plas:Qn:5.1 mmol/L07/23/24 12:10 EDT07/23/24 13:01 EDTNormal3.9-5.9None
Chloride:SCnc:Pt:Ser/Plas:Qn:109.0 mmol/L07/23/24 12:10 EDT07/23/24 13:01 EDTHigh98-107None
Carbon dioxide:SCnc:Pt:Ser/Plas:Qn:22.0 mmol/l07/23/24 12:10 EDT07/23/24 13:01 EDTNormal16-28None
Bilirubin:MCnc:Pt:Ser/Plas:Qn:18.1 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTHigh0.1-11.7CALLED TO AND RESULTS VERBALLY REPEATED BACK BY MALIA VARNER; BY SM.LB.LF 07/23/241157;
Leukocytes:NCnc:Pt:Bld:Qn:10.4 k/ul07/23/24 12:10 EDT07/23/24 13:44 EDTNormal9.0-30.0None
Hematocrit:VFr:Pt:Bld:Qn:52.1 %07/23/24 12:10 EDT07/23/24 13:44 EDTNormal42.4-71.6None
C reactive protein:MCnc:Pt:Ser/Plas:Qn:< 0.29 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTNormal0.0-0.29None
Bilirubin.glucuronidated+Bilirubin.albumin bound:MCnc:Pt:Ser/Plas:Qn:0.3 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTHigh0.0-0.2None
Urea nitrogen:MCnc:Pt:Ser/Plas:Qn:9.0 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTNormal6-20None
Hemoglobin:MCnc:Pt:Bld:Qn:18.8 g/dL07/23/24 12:10 EDT07/23/24 13:44 EDTNormal15.4-19.8None
Glucose:MCnc:Pt:Bld:Qn:71.0 mg/dL07/23/24 12:03 EDT07/23/24 12:03 EDTNormal33-144None
Anion gap:SCnc:Pt:Ser/Plas:Qn:9.0 mmol/L07/23/24 12:10 EDT07/23/24 13:01 EDTNormal4-14None
Calcium:MCnc:Pt:Ser/Plas:Qn:9.3 mg/dL07/23/24 12:10 EDT07/23/24 13:01 EDTNormal8.6-10.0None
Eosinophils/100 leukocytes:NFr:Pt:Bld:Qn:Automated count1.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTNormal0-4None
Lymphocytes/100 leukocytes:NFr:Pt:Bld:Qn:50.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTHigh20-40None
Erythrocytes:NCnc:Pt:Bld:Qn:5.38 m/uL07/23/24 12:10 EDT07/23/24 13:44 EDTNormal4.17-5.77None
Neutrophils.segmented/100 leukocytes:NFr:Pt:Bld:Qn:25.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTLow53-61None
Monocytes/100 leukocytes:NFr:Pt:Bld:Qn:12.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTHigh0-8None
Granulocytes.immature/100 leukocytes:NFr:Pt:Bld:Qn:0.5 %07/23/24 12:10 EDT07/23/24 13:44 EDTNormal0-0.5None
Erythrocytes.nucleated:NCnc:Pt:Bld:Qn:0.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTNormal0-1None
Erythrocytes.nucleated:NCnc:Pt:Bld:Qn:0.0 k/uL07/23/24 12:10 EDT07/23/24 13:44 EDTUnknownUnknownNone
Lymphocytes.variant/100 leukocytes:NFr:Pt:Bld:Qn:12.0 %07/23/24 12:10 EDT07/23/24 13:44 EDTUnknownUnknownNone
Glucose:MCnc:Pt:Ser/Plas:Qn:84.007/24/24 03:43 EDT07/24/24 04:52 EDTNormal40-114None
Erythrocyte mean corpuscular hemoglobin concentration:MCnc:Pt:RBC:Qn:36.4 g/dL07/24/24 03:43 EDT07/24/24 04:47 EDTHigh32-36None
Erythrocyte mean corpuscular hemoglobin:EntMass:Pt:RBC:Qn:35.1 pg07/24/24 03:43 EDT07/24/24 04:47 EDTHigh25-34None
Platelets:PrThr:Pt:Bld:Ord:Microscopy.lightADEQUATE07/24/24 03:43 EDT07/24/24 04:47 EDTUnknownUnknownNone
Platelets:NCnc:Pt:Bld:Qn:147.0 k/uL07/24/24 03:43 EDT07/24/24 04:47 EDTNormal145-483None
Platelet morphology finding:Prid:Pt:Bld:Nom:NORMAL07/24/24 03:43 EDT07/24/24 04:47 EDTUnknownUnknownfew plts clumps seen . plts count may not be accurate`;
Erythrocyte mean corpuscular volume:EntVol:Pt:RBC:Qn:96.4 fl07/24/24 03:43 EDT07/24/24 04:47 EDTNormal96.2-131.8None
Sodium:SCnc:Pt:Ser/Plas:Qn:138.0 mmo/L07/24/24 03:43 EDT07/24/24 04:52 EDTNormal131-143None
Creatinine:MCnc:Pt:Ser/Plas:Qn:0.32 mg/dL07/24/24 03:43 EDT07/24/24 04:52 EDTLow0.90-1.30None
Potassium:SCnc:Pt:Ser/Plas:Qn:5.7 mmol/L07/24/24 03:43 EDT07/24/24 04:52 EDTNormal3.9-5.9None
Chloride:SCnc:Pt:Ser/Plas:Qn:106.0 mmol/L07/24/24 03:43 EDT07/24/24 04:52 EDTNormal98-107None
Carbon dioxide:SCnc:Pt:Ser/Plas:Qn:24.0 mmol/l07/24/24 03:43 EDT07/24/24 04:52 EDTNormal16-28None
Bilirubin:MCnc:Pt:Ser/Plas:Qn:16.2 mg/dL07/24/24 03:43 EDT07/24/24 04:52 EDTHigh0.1-11.7None
Leukocytes:NCnc:Pt:Bld:Qn:11.9 k/ul07/24/24 03:43 EDT07/24/24 04:47 EDTNormal9.0-30.0None
Hematocrit:VFr:Pt:Bld:Qn:51.1 %07/24/24 03:43 EDT07/24/24 04:47 EDTNormal42.4-71.6None
Neutrophils.band form/100 leukocytes:NFr:Pt:Bld:Qn:0.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTNormal0-5None
C reactive protein:MCnc:Pt:Ser/Plas:Qn:< 0.29 mg/dL07/24/24 03:43 EDT07/24/24 04:52 EDTNormal0.0-0.29None
C reactive protein:MCnc:Pt:Ser/Plas:Qn:C-REACTIVE PROTEIN Ordered07/24/24 07:00 EDT07/24/24 01:02 EDTUnknownUnknownNone
Glucose:MCnc:Pt:CSF:Qn:68.007/23/24 16:19 EDT07/23/24 17:34 EDTNormal40-70None
Protein:MCnc:Pt:CSF:Qn:55.0 MG/DL07/23/24 16:19 EDT07/23/24 17:34 EDTHigh15-45None
Leukocytes:NCnc:Pt:CSF:Qn:Manual count1.0 /cmm07/23/24 16:19 EDT07/23/24 17:34 EDTNormal0-5None
Urea nitrogen:MCnc:Pt:Ser/Plas:Qn:<6 mg/dL07/24/24 03:43 EDT07/24/24 04:52 EDTLow6-20None
Hemoglobin:MCnc:Pt:Bld:Qn:18.6 g/dL07/24/24 03:43 EDT07/24/24 04:47 EDTNormal15.4-19.8None
Glucose:MCnc:Pt:Bld:Qn:110.0 mg/dL07/23/24 15:58 EDT07/23/24 16:17 EDTNormal33-144None
Glucose:MCnc:Pt:Bld:Qn:101.0 mg/dL07/23/24 23:05 EDT07/23/24 23:07 EDTNormal33-144None
Glucose:MCnc:Pt:Bld:Qn:99.0 mg/dL07/24/24 03:48 EDT07/24/24 03:53 EDTNormal33-144None
Anion gap:SCnc:Pt:Ser/Plas:Qn:8.0 mmol/L07/24/24 03:43 EDT07/24/24 04:52 EDTNormal4-14None
Calcium:MCnc:Pt:Ser/Plas:Qn:9.7 mg/dL07/24/24 03:43 EDT07/24/24 04:52 EDTNormal8.6-10.0None
Glomerular filtration rate/1.73 sq M.predicted:ArVRat:Pt:Ser/Plas:Qn:Creatinine-based formula (MDRD)GFR not calculated if age <18 yrs.07/24/24 03:43 EDT07/24/24 04:52 EDTUnknownUnknownThe Glomerular Filtration Rate is a calculated parameter; based on serum Creatinine levels, patient age, and sex. GFR; values less than 60 mL/min/1.73 square meters are indicative; of Chronic Kidney Disease. Values less than 15 mL/min/1.73; square meters indicate Kidney failure.; The calculation for GFR is based on the CKD-EPI(2021); calculation. This formula is race indifferent and is the; recommended formula for GFR by the National Kidney; Foundation for adults.; The GFR will not calculate if the sex is Unknown or if the; patient''s age is <18 years.;
Eosinophils/100 leukocytes:NFr:Pt:Bld:Qn:Automated count2.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTNormal0-4None
Lymphocytes/100 leukocytes:NFr:Pt:Bld:Qn:25.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTNormal20-40None
Erythrocytes:NCnc:Pt:Bld:Qn:5.3 m/uL07/24/24 03:43 EDT07/24/24 04:47 EDTNormal4.17-5.77None
Neutrophils.segmented/100 leukocytes:NFr:Pt:Bld:Qn:21.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTLow53-61None
Monocytes/100 leukocytes:NFr:Pt:Bld:Qn:9.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTHigh0-8None
Color:Type:Pt:CSF:Nom:YELLOW07/23/24 16:19 EDT07/23/24 17:34 EDTAbnormalCOLORLESSNone
Appearance:Aper:Pt:CSF:Nom:CLEAR07/23/24 16:19 EDT07/23/24 17:34 EDTUnknownCLEARNone
Erythrocytes:NCnc:Pt:CSF:Qn:33.0 /cmm07/23/24 16:19 EDT07/23/24 17:34 EDTHigh0-0None
Granulocytes.immature/100 leukocytes:NFr:Pt:Bld:Qn:0.7 %07/24/24 03:43 EDT07/24/24 04:47 EDTHigh0-0.5None
Erythrocytes.nucleated:NCnc:Pt:Bld:Qn:0.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTNormal0-1None
Erythrocytes.nucleated:NCnc:Pt:Bld:Qn:0.0 k/uL07/24/24 03:43 EDT07/24/24 04:47 EDTUnknownUnknownNone
Lymphocytes.variant/100 leukocytes:NFr:Pt:Bld:Qn:43.0 %07/24/24 03:43 EDT07/24/24 04:47 EDTUnknownUnknownNone
Glucose:MCnc:Pt:Bld:Qn:95.0 mg/dL07/24/24 12:45 EDT07/24/24 12:46 EDTNormal33-144None
Glucose:MCnc:Pt:Bld:Qn:84.0 mg/dL07/24/24 18:37 EDT07/24/24 19:00 EDTNormal33-144None
Staphylococcus aureus.methicillin resistant isolate:PrThr:Pt:XXX:Ord:Organism specific cultureMethicillin resistant Staphylococcus aureus07/23/24 12:10 EDT07/24/24 15:15 EDTAbnormalUnknownNone
Bacteria identified:Prid:Pt:Bld:Nom:CultureStaphylococcus epidermidis07/23/24 12:10 EDT07/26/24 12:34 EDTAbnormalUnknownNone
Bacteria identified:Prid:Pt:Bld:Nom:CultureNeisseria flavescens07/23/24 12:10 EDT07/26/24 12:34 EDTAbnormalUnknownNone
Bacteria identified:Prid:Pt:Bld:Nom:CultureStreptococcus parasanguinis07/23/24 12:10 EDT07/26/24 12:34 EDTAbnormalUnknownNone
Microscopic observation:Prid:Pt:CSF:Nom:Gram stainNo WBC(s) Present07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Bacteria identified:Prid:Pt:CSF:Nom:CultureNO GROWTH AFTER 4 DAYS INCUBATION07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Streptococcus agalactiae DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Streptococcus pneumoniae DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Cytomegalovirus DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Enterovirus RNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Herpes simplex virus 1 DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Herpes simplex virus 2 DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Herpes virus 6 DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Parechovirus RNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Varicella zoster virus DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Cryptococcus neoformans rRNA:PrThr:Pt:XXX:Ord:ProbeNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Microscopic observation:Prid:Pt:CSF:Nom:Gram stainNo Organism Seen07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Escherichia coli K1 Ag:PrThr:Pt:Ser:Ord:NOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Haemophilus influenzae DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarHaemophilus influenzae07/23/24 16:19 EDT07/27/24 16:30 EDTAbnormalUnknownNone
Listeria monocytogenes DNA:PrThr:Pt:XXX:Ord:Probe.amp.tarNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Neisseria meningitidis rRNA:PrThr:Pt:XXX:Ord:ProbeNOT DETECTED07/23/24 16:19 EDT07/27/24 16:30 EDTNormalUnknownNone
Bacteria identified:Prid:Pt:Bld:Nom:CultureNo growth in 3 days07/24/24 12:59 EDT07/27/24 13:46 EDTNormalUnknownNone
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Narrative Text
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ILLNESS, UNSPECIFIED
HYPOTHERMIA OF NEWBORN, UNSPECIFIED
BACTERIAL SEPSIS OF NEWBORN, UNSPECIFIED
MENINGITIS, UNSPECIFIED
UNSPECIFIED APNEA OF NEWBORN
OTHER SPECIFIED INFECTIONS SPECIFIC TO THE PERINAT
OTHER RESPIRATORY DISTRESS OF NEWBORN
NEONATAL JAUNDICE, UNSPECIFIED
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rRNA:PrThr:Pt:XXX:Ord:Probe (LOINC concept)", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-23T15:19:00-05:00", "valueString": "NOT DETECTED", "interpretation": [{"coding": [{"code": "N", "display": "Normal", "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"}]}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-07-23T15:19:00-05:00"}]}], "subject": {"reference": "Patient/1d11ae5c-a3f5-4d25-9a24-3693fce76514"}}, "request": {"method": "PUT", "url": "Observation/24ae302f-8f8e-f787-19de-5082c1a696e6"}}, {"fullUrl": "urn:uuid:202cf0d2-c217-3e00-689e-e22275b23ca9", "resource": {"resourceType": "DiagnosticReport", "id": "202cf0d2-c217-3e00-689e-e22275b23ca9", "identifier": [{"system": "urn:ietf:rfc:3986", "value": "urn:uuid:bd9905b7-a80d-41d5-bd4f-4acad173a7f6"}], "status": "final", "code": {"coding": [{"code": "600-7", "display": "Bacteria identified:Prid:Pt:Bld:Nom:Culture (LOINC concept)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-07-24T11:59:00-05:00", "end": "2024-07-27T12:46:00-05:00"}, "subject": {"reference": "Patient/1d11ae5c-a3f5-4d25-9a24-3693fce76514"}, "performer": [{"reference": "Organization/2a08cae2-6abf-ee1d-14a0-1be051a26c79"}], "result": [{"reference": "Observation/4118565f-039a-f65d-3187-458c89c07848"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/202cf0d2-c217-3e00-689e-e22275b23ca9"}}, {"fullUrl": "urn:uuid:4118565f-039a-f65d-3187-458c89c07848", "resource": {"resourceType": "Observation", "id": "4118565f-039a-f65d-3187-458c89c07848", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.0.1.7.777.555.222", "value": "https://ips-tdapi-prod2.app.medcity.net/tdapi/tdfhir/api/fhir/Observation/M4348415"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "600-7", "display": "Bacteria identified:Prid:Pt:Bld:Nom:Culture (LOINC concept)", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-07-24T11:59:00-05:00", "valueString": "No growth in 3 days", "interpretation": [{"coding": [{"code": "N", "display": "Normal", "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation"}]}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-07-24T11:59:00-05:00"}]}], "subject": {"reference": "Patient/1d11ae5c-a3f5-4d25-9a24-3693fce76514"}}, "request": {"method": "PUT", "url": "Observation/4118565f-039a-f65d-3187-458c89c07848"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}]}') ON CONFLICT (ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.478.2.7.8.688883.331587038', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.478.2.7.8.688883.331587038", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.478.2.7.8.688883.331587038", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-0447-49a7-0ad9-73e39bea24fa", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "4"}, {"url": 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NameAdministration DatesNext Due
Rho (D) Immune Globulin05/23/2024
Tdap vaccine (Adacel/Boostrix)05/23/2024
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-04DD-D9EA-32B4-FF9C6A46DBA2", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (TYLENOL) tablet 650 mg650 mg, oral, Every 6 hours PRN, headaches, PRN headache/ pain score 1-4, or if pt declines opioids, Starting on Sat 7/27/24 at 2312, Postpartum, Do not exceed 4000mg acetaminophen in 24hrs.Given07/28/2024 8:34 PM CDT650 mg
benzocaine-menthoL (DERMOPLAST) 20-0.5 % topical sprayPostpartumGiven07/27/2024 11:17 PM CDT
ibuprofen (ADVIL,MOTRIN) tablet 600 mg600 mg, oral, Every 6 hours scheduled, First dose on Sat 7/27/24 at 2315, Postpartum, Don''t give within 6 hours of patient receiving ketorolac (TORADOL) Tier One pain medicationGiven07/28/2024 5:46 PM CDT600 mg
Given07/28/2024 12:21 PM CDT600 mg
Given07/28/2024 5:56 AM CDT600 mg
LR infusion125 mL/hr, intraVENOUS, Continuous, Starting on Fri 7/26/24 at 1330New Bag07/27/2024 6:46 PM CDT125 mL/hr125 mL/hr
Rate/Dose Verify07/27/2024 2:56 PM CDT125 mL/hr125 mL/hr
New Bag07/27/2024 12:45 PM CDT125 mL/hr125 mL/hr
ondansetron (ZOFRAN) injection 4 mg4 mg, intraVENOUS, Every 6 hours PRN, nausea, vomiting, 1st line treatment for patients with IV access, Starting on Sat 7/27/24 at 2312, For 48 hours, Postpartum, Doses up to 4 mg may be administered undiluted. Inject over at least 30 seconds, but preferably over 2-5 minutes.
ondansetron (ZOFRAN) tablet 4 mg4 mg, oral, Every 6 hours PRN, nausea, vomiting, 1st line treatment for patients without IV access, Starting on Sat 7/27/24 at 2312, For 48 hours, Postpartum
Prenatal multivitamin tablet 1 tablet1 tablet, oral, Daily, First dose on Sun 7/28/24 at 1000, PostpartumGiven07/28/2024 10:47 AM CDT1 tablet
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
ampicillin (OMNIPEN) 2,000 mg in NS 100 mL IVPB (ADD-Vantage)2,000 mg, intraVENOUS, at 200 mL/hr, Administer over 30 Minutes, Once, On Fri 7/26/24 at 1630, For 1 dose, Scheduling/ADT, Indication: Prophylaxis, Pharmacist may adjust the dose according to the patient\u2019s renal function per the Pharmacist Antimicrobial Renal Dose Adjustment Protocol: YesGiven07/27/2024 7:15 PM CDT2,000 mg200 mL/hr
fentaNYL 2 mcg/mL-bupivacaine 0.0625 % in NS 250 mL OB epiduralInitial Prep Volume: 250 mL, epidural, Continuous, Starting on Fri 7/26/24 at 2345, L&D Pre-Delivery, Priming volume = 3 mL CONTROLLED SUBSTANCE - MUST ALWAYS BE SECURED - DO NOT TUBE, OB Epidural PCEA : See Anesthesia Record for dosing detailsAnesthesia - IntraOp Start Epidural Infusion07/27/2024 5:48 PM CDT
Rate/Dose Verify07/27/2024 1:10 PM CDT
Rate/Dose Verify07/27/2024 4:18 AM CDT
lactated Ringer''s bolus 500 mL500 mL, intraVENOUS, at 1,000 mL/hr, Administer over 30 Minutes, Once, On Fri 7/26/24 at 2345, For 1 dose, L&D Pre-Delivery, Administer immediately prior to epidural placement.New Bag07/26/2024 11:38 PM CDT500 mL1000 mL/hr
miSOPROStol (CYTOTEC) tablet (for vaginal or buccal use) 50 mcg50 mcg, buccal, Every 4 hours, First dose on Fri 7/26/24 at 1900, For 2 doses, L&D Pre-Delivery, FOR USE IN OB/GYN PROCEDURES ONLYGiven07/26/2024 7:03 PM CDT50 mcg
nalbuphine (NUBAIN) 10 mg/mL 2.5 mg injection 0.25 mL2.5 mg, intraVENOUS, Every 3 hours PRN, pruritus, Starting on Fri 7/26/24 at 2339, For 2 doses, L&D Pre-Delivery, 1st line therapy for pruritusGiven07/27/2024 4:06 AM CDT2.5 mg
nicotine (NICODERM CQ) 7 mg/24 hr 1 patch1 patch, transdermal, Administer over 24 Hours, Daily, First dose on Fri 7/26/24 at 1545, L&D Pre-Delivery, EPA WASTE CATEGORY *P* Apply to hairless, clean, dry skin on the upper body or upper outer arm.Medication Applied07/27/2024 12:07 PM CDT1 patchLeft Upper Back
Medication Applied07/26/2024 5:26 PM CDT1 patchLeft Upper Arm
ondansetron (ZOFRAN) injection 4 mg4 mg, intraVENOUS, Every 8 hours PRN, nausea, vomiting, Starting on Fri 7/26/24 at 1323, L&D Pre-Delivery, Slow IV Push Doses up to 4 mg may be administered undiluted. Inject over at least 30 seconds, but preferably over 2-5 minutes.Self Administered Via Pump07/27/2024 1:17 PM CDT4 mg
oxytocin (PITOCIN) 30 unit/500 mL (0.06 units/mL) in NS infusion2-20 milli-units/min (2-20 mL/hr), intraVENOUS, Titrated, Starting on Fri 7/26/24 at 1330, L&D Pre-Delivery, Start at 2 milli-units/min and increase by 2 milli-units/min every 30 minutes until adequate labor, (uterine contractions are 2-3 minutes apart and are of moderate quality by palpation, or 50-60 mmHg above baseline with IUPC. \u00a0Labor progress may be 0.5 to 1 cm of cervical dilation per hour during induction, particularly for nulliparous women). Max dose 20 milli-units/min. Notify house officer if more than 20 milli-units/min required. Refer to SOP for Care of the Patient Admitted with Intended Labor and Vaginal Birth.Rate/Dose Verify07/27/2024 6:30 PM CDT18 milli-units/min18 mL/hr
Rate/Dose Change07/27/2024 2:27 PM CDT18 milli-units/min18 mL/hr
Rate/Dose Change07/27/2024 1:12 PM CDT16 milli-units/min16 mL/hr
oxytocin (PITOCIN) 30 unit/500 mL (0.06 units/mL) in NS infusion0.5-20 milli-units/min (0.5-20 mL/hr), intraVENOUS, Titrated, Starting on Fri 7/26/24 at 1615, L&D Pre-Delivery, Begin infusion at 2 milli-units/min; increase infusion by 2 milli-units every 30 minutes until adequate uterine activity is established (3 contractions at least 40 seconds duration within a continuous 10 minute window). Max rate 20 milli-units/min. NHO if adequate uterine activity is not established. Limit to one 500 mL bag.Rate/Dose Change07/26/2024 6:08 PM CDT4 milli-units/min4 mL/hr
New Bag07/26/2024 5:38 PM CDT2 milli-units/min2 mL/hr
penicillin G potassium 5 million units in 100 mL NS IVPB5 Million Units, intraVENOUS, Administer over 30 Minutes, Once, On Fri 7/26/24 at 1330, For 1 dose, L&D Pre-Delivery, Over 30 minutes Infiltration/Extravasation Risk = Yellow (Irritant), Indication: ProphylaxisNew Bag07/26/2024 9:27 PM CDT5 Million Units
penicillin G potassium IVPB 2.5 million units in NS 100 mL2.5 Million Units (2,500,000 Units), intraVENOUS, Administer over 30 Minutes, Every 4 hours, First dose on Fri 7/26/24 at 1730, L&D Pre-Delivery, For GBS prophylaxis, discontinue after baby is born. Infiltration/Extravasation Risk = Yellow (Irritant), Indication: ProphylaxisNew Bag07/27/2024 4:54 PM CDT2,500,000 Units
New Bag07/27/2024 1:11 PM CDT2,500,000 Units
New Bag07/27/2024 9:00 AM CDT2,500,000 Units
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Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
08/08/2024 9:00 AM CDTClinical SupportVanderbilt Center for Women''s Health719 Thompson LnSuite 27100Nashville, TN 37204615-343-5700
08/08/2024 9:30 AM CDTRoutine PrenatalVanderbilt Center for Women''s Health719 Thompson LnSuite 27100Nashville, TN 37204Eshelman, Anne Ward, APRN719 THOMPSON LANESUITE 27100NASHVILLE, TN 37204615-875-0425 (Work)615-936-1106 (Fax)
08/08/2024 10:00 AM CDTOffice VisitVanderbilt Center for Women''s Health719 Thompson LnSuite 27100Nashville, TN 37204Generic, Attending
08/15/2024 9:00 AM CDTClinical SupportVanderbilt Center for Women''s Health719 Thompson LnSuite 27100Nashville, TN 37204615-343-5700
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
PCR Hepatitis C Virus QtLabSTAT07/26/2024 2:18 PM CDT
RPR TiterLabRoutine07/26/2024 1:43 PM CDT
UR Drug Scrn 9 Pnl w/Rfx Conf-ARUPLabSTAT07/28/2024 3:41 PM CDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
PCR Hepatitis C Virus QtLabSTATOnce for 1 Occurrences starting 7/26/24 until 7/26/24
RPR TiterLabRoutineOnce for 1 Occurrences starting 7/26/24 until 7/26/24
UR Drug Scrn 9 Pnl w/Rfx Conf-ARUPLabSTATSTAT for 1 Occurrences starting 7/28/24 until 7/28/24
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/d600f29a-aa2e-3b97-4d6c-1328ac6e073e"}]}, {"id": "00000000-04DD-D9EC-32B4-FF9C6A46DBA2", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
Postpartum state07/28/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
BCM: TBD.F/U 3 and 6 wks Eshelman/ OHO.B neg/ RI/ Tdap UTD. (No need for Rhogam/ baby B neg).Plans D/C tomorrow. EPDS pending.Pumping.Baby in NICU transitioning w/ poss TTN. VSS.Minimal rubra. No clots this am. No dizziness. EBL300.Now PPD #1 after SVD. Intact. EBL 300.- GBS positive - First child in foster care - Nicotine use -Hx of septic PE - Rh negative - received rhogam 5/23/2024 -Chronic hepatitis C - Polysubstance use- reports last used methamphetamines 2/2024; hx heroine use, + for MDMA in pregnancy - Syphilis, treated in 6/2024 - cHTN, no meds -FGR, EFW 7%tile; AC 17%tilePregnancy c/b: 26 y.o G2P2002 at 37.2 admitted for IOL iso FGR
Encounter for induction of labor07/26/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
- 10/100/+1, pt starting to push- Amp completed before delivery as prophylaxis for hx of septic PE in last delivery- Close BP surveillance. - Nsy aware of HCV/ latent Syphilis- Continuous fetal surveillance. - Labs Q 12 hrs to trend LFTs. - RN to continue to titrate pit.- Plan: recheck in 4hrs or as clinically indicated.- SVE 7/C/0 AROM''d w/pt agreement for clear non odorous fluid.- GBS + on PCN.- Epidural in situ and comfortable.- UCS: 2-3/10 lasting 40 seconds. Pit at 18- Cat 1 FHR tracing -Elevated LFTs upon admit. Labs Q 12. Downtrending. #BMI 45/ # cHTN no meds/ # HCV VL pending/ # poly substance abuse UDS pending/ Hx of Septic - PE (Needs amp before delivery).Latent Syphilis treated in June.IOL in setting of FGR / elevated UADs. Neg OCT upon admit.
Nicotine use07/26/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Nicotine patch ordered 6 cigarettes day
Custody issue07/26/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Social work PP 1st child in foster care
Septic pulmonary embolism07/26/2024
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Hx of septic PE in 2017 and 2020 Formatting of this note might be different from the original.
See MFM note PCN to be admin within 1 hr of delivery Echocardiogram ordered
Encounter for triage in pregnant patient07/24/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
- Discharged to home with scheduled IOL tomorrow 7/25 @ 2200- Discharged to home with strict return precautions- NST appropriate for GA
Positive GBS test07/22/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
PCN for GBS prophylaxis
Fetal growth restriction antepartum07/18/2024
Overview:Formatting of this note might be different from the original.
TWT. Repeat growth at 38 weeks.Dx at 36 weeks
Pregnancy03/22/2024
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
NIPT low risk female EDD 8/15/24 by LMP Formatting of this note might be different from the original.
GBS next visit Start weekly visits next week Discussed IOL at 39-40wks, will continue to discuss Precautions reviewed
Polysubstance use disorder03/22/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Utox collected on admission 7/25 Presumptive + MDMA
Chronic hypertension affecting pregnancy03/22/2024
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Multiple mild range BPs in outside records Formatting of this note might be different from the original.
HELLP labs collected Denies S&S of pre-e Normotensive
Short interval between pregnancies affecting pregnancy, antepartum03/22/2024
Syphilis03/19/2024
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Reports treatment in 2022 Formatting of this note might be different from the original.
Titers ordered Retreated in June 2024
Chronic hepatitis C virus infection03/19/2024
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
AST/ALT mildly elevated on NOB labs Formatting of this note might be different from the original.
Viral load and HIV collected
Rh negative state in antepartum period03/19/2024
PregnantComments
Yes
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Every DayCigarettes0.56.1Started: 01/01/2018; Last attempted to quit: 02/24/2024
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Not Currently0 (1 standard drink = 0.6 oz pure alcohol)
PHQ-2AnswerDate Recorded
PHQ-9 Score003/18/2024
PregnantComments
Yes
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityFemale02/12/2024 10:53 AM CST
Sexual OrientationNot on file
COVID-19 ExposureResponseDate Recorded
In the last 10 days, have you been in contact with someone who was confirmed or suspected to have Coronavirus/COVID-19?No / Unsure7/26/2024 2:10 PM CDT
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DateTypeDepartmentCare Team (Latest Contact Info)Description
07/26/2024 12:59 PM CDT - PresentHospital EncounterVanderbilt University Adult Hospital1211 Medical Center Dr4E Post PartumNashville, TN 37232615-322-5000Detzel, Patricia, CNM, APRN719 THOMPSON LANESUITE 27100NASHVILLE, TN 37204615-343-5700 (Work)615-936-1106 (Fax)Stec, Melissa Ann, CNM719 THOMPSON LANESUITE 27100NASHVILLE, TN 37204615-875-0425 (Work)615-936-1106 (Fax)Perry, Amanda Paige, CNM719 THOMPSON LANESUITE 27100NASHVILLE, TN 37204615-875-0425 (Work)615-936-1106 (Fax)
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Overview:
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Last Assessment & Plan:
problemNote93
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Overview:
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Last Assessment & Plan:
problemNote96
System.Collections.Generic.Dictionary`2[System.String,System.Object]

AST/ALT mildly elevated on NOB labs
problemNote97
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Viral load and HIV collected "}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}, "extension": [{"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "50711007", "system": "http://snomed.info/sct"}]}]}, "request": {"method": "PUT", "url": "Condition/6a7ae801-4e63-52f2-a79c-dbbd952050e7"}}, {"fullUrl": "urn:uuid:1ee8afed-b25d-8fc0-745d-222375799527", "resource": {"resourceType": "Condition", "id": "1ee8afed-b25d-8fc0-745d-222375799527", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "47035953"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "O26.899", "display": "Rh negative state in antepartum period", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-03-19", "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1ee8afed-b25d-8fc0-745d-222375799527"}}, {"fullUrl": "urn:uuid:26594aa5-1a38-415d-21f3-f8b6606ebdc1", "resource": {"resourceType": "Condition", "id": "26594aa5-1a38-415d-21f3-f8b6606ebdc1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "47108535"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z34.90", "display": "Pregnancy", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-03-22", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote100
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote101
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/26594aa5-1a38-415d-21f3-f8b6606ebdc1"}}, {"fullUrl": "urn:uuid:46e23328-ecd5-9889-b3cc-e31c6f54b7c6", "resource": {"resourceType": "Condition", "id": "46e23328-ecd5-9889-b3cc-e31c6f54b7c6", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "47108540"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "F19.90", "display": "Polysubstance use disorder", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-03-22", "note": [{"text": "Last Assessment & Plan:
problemNote104
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7/25 Presumptive + MDMA
Utox collected on admission "}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/46e23328-ecd5-9889-b3cc-e31c6f54b7c6"}}, {"fullUrl": "urn:uuid:f7c6d0fe-d098-184d-1fa1-04a56a02a0b3", "resource": {"resourceType": "Condition", "id": "f7c6d0fe-d098-184d-1fa1-04a56a02a0b3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "47108942"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "O10.919", "display": "Chronic hypertension affecting pregnancy", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-03-22", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote108
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Multiple mild range BPs in outside records
problemNote109
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/f7c6d0fe-d098-184d-1fa1-04a56a02a0b3"}}, {"fullUrl": "urn:uuid:0d9ed265-b00b-6690-fa6a-8db14e762a39", "resource": {"resourceType": "Condition", "id": "0d9ed265-b00b-6690-fa6a-8db14e762a39", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "47108946"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "O09.899", "display": "Short interval between pregnancies affecting pregnancy, antepartum", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-03-22", "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/0d9ed265-b00b-6690-fa6a-8db14e762a39"}}, {"fullUrl": "urn:uuid:726334d9-50fd-7b33-2e35-b09df09a9a8b", "resource": {"resourceType": "Condition", "id": "726334d9-50fd-7b33-2e35-b09df09a9a8b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49247360"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "O36.5990", "display": "Fetal growth restriction antepartum", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-18", "note": [{"text": "Overview:
problemNote114
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Dx at 36 weeks
TWT. Repeat growth at 38 weeks."}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/726334d9-50fd-7b33-2e35-b09df09a9a8b"}}, {"fullUrl": "urn:uuid:42fe7b21-cd3c-5048-912b-3d0585001876", "resource": {"resourceType": "Condition", "id": "42fe7b21-cd3c-5048-912b-3d0585001876", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49298327"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "B95.1", "display": "Positive GBS test", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-22", "note": [{"text": "Last Assessment & Plan:
problemNote116
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PCN for GBS prophylaxis "}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/42fe7b21-cd3c-5048-912b-3d0585001876"}}, {"fullUrl": "urn:uuid:cd842186-f62f-a72c-ae0f-bfcd516651dd", "resource": {"resourceType": "Condition", "id": "cd842186-f62f-a72c-ae0f-bfcd516651dd", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49372393"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z36.89", "display": "Encounter for triage in pregnant patient", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-24", "note": [{"text": "Last Assessment & Plan:
problemNote119
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- NST appropriate for GA
- Discharged to home with strict return precautions
- Discharged to home with scheduled IOL tomorrow 7/25 @ 2200"}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/cd842186-f62f-a72c-ae0f-bfcd516651dd"}}, {"fullUrl": "urn:uuid:27791555-4fa0-6f54-5371-489443b6fcf6", "resource": {"resourceType": "Condition", "id": "27791555-4fa0-6f54-5371-489443b6fcf6", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49410838"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z34.90", "display": "Encounter for induction of labor", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-26", "note": [{"text": "Last Assessment & Plan:
problemNote121
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IOL in setting of FGR / elevated UADs. Neg OCT upon admit.
#BMI 45/ # cHTN no meds/ # HCV VL pending/ # poly substance abuse UDS pending/ Hx of Septic - PE (Needs amp before delivery).Latent Syphilis treated in June.
-Elevated LFTs upon admit. Labs Q 12. Downtrending.
- Cat 1 FHR tracing
- UCS: 2-3/10 lasting 40 seconds. Pit at 18
- Epidural in situ and comfortable.
- GBS + on PCN.
- SVE 7/C/0 AROM''d w/pt agreement for clear non odorous fluid.
- Plan: recheck in 4hrs or as clinically indicated.
- RN to continue to titrate pit.
- Labs Q 12 hrs to trend LFTs.
- Continuous fetal surveillance.
- Nsy aware of HCV/ latent Syphilis
- Close BP surveillance.
- Amp completed before delivery as prophylaxis for hx of septic PE in last delivery
- 10/100/+1, pt starting to push"}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/27791555-4fa0-6f54-5371-489443b6fcf6"}}, {"fullUrl": "urn:uuid:6522dfd1-cd59-b5db-a38e-c9dc05331d25", "resource": {"resourceType": "Condition", "id": "6522dfd1-cd59-b5db-a38e-c9dc05331d25", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49415018"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z72.0", "display": "Nicotine use", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-26", "note": [{"text": "Last Assessment & Plan:
problemNote127
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6 cigarettes day
Nicotine patch ordered "}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/6522dfd1-cd59-b5db-a38e-c9dc05331d25"}}, {"fullUrl": "urn:uuid:eff42d34-a063-4259-624c-8342c8e10043", "resource": {"resourceType": "Condition", "id": "eff42d34-a063-4259-624c-8342c8e10043", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49415114"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z65.3", "display": "Custody issue", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-26", "note": [{"text": "Last Assessment & Plan:
problemNote129
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1st child in foster care
Social work PP "}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/eff42d34-a063-4259-624c-8342c8e10043"}}, {"fullUrl": "urn:uuid:f2450258-e9c2-654b-7fec-e9555ec96542", "resource": {"resourceType": "Condition", "id": "f2450258-e9c2-654b-7fec-e9555ec96542", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49415658"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I26.90", "display": "Septic pulmonary embolism", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-26", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote131
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Hx of septic PE in 2017 and 2020
problemNote132
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/f2450258-e9c2-654b-7fec-e9555ec96542"}}, {"fullUrl": "urn:uuid:25680984-f769-6d2c-999d-3b476c528e66", "resource": {"resourceType": "Condition", "id": "25680984-f769-6d2c-999d-3b476c528e66", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.768076", "value": "49423379"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z39.2", "display": "Postpartum state", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-07-28", "note": [{"text": "Last Assessment & Plan:
problemNote134
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26 y.o G2P2002 at 37.2 admitted for IOL iso FGR
Pregnancy c/b:
-FGR, EFW 7%tile; AC 17%tile
- cHTN, no meds
- Syphilis, treated in 6/2024
- Polysubstance use- reports last used methamphetamines 2/2024; hx heroine use, + for MDMA in pregnancy
-Chronic hepatitis C
- Rh negative - received rhogam 5/23/2024
-Hx of septic PE
- Nicotine use
- First child in foster care
- GBS positive
Now PPD #1 after SVD. Intact. EBL 300.
Minimal rubra. No clots this am. No dizziness. EBL300.
VSS.
Baby in NICU transitioning w/ poss TTN.
Pumping.
Plans D/C tomorrow. EPDS pending.
B neg/ RI/ Tdap UTD. (No need for Rhogam/ baby B neg).
F/U 3 and 6 wks Eshelman/ OHO.
BCM: TBD."}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/25680984-f769-6d2c-999d-3b476c528e66"}}, {"fullUrl": "urn:uuid:f59af6da-6dec-e72c-74a5-d912730df734", "resource": {"resourceType": "DiagnosticReport", "id": "f59af6da-6dec-e72c-74a5-d912730df734", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.798268", "value": "462386203"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.478.2.798268.2.462386203.1"}], "status": "final", "code": {"coding": [{"code": "104443", "display": "Transthoracic echo (TTE) complete with or without contrast per protocol", "system": "urn:oid:1.2.840.114350.1.13.478.2.7.2.696580"}]}, "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "performer": [{"reference": "Organization/d61d56a8-7cff-d6de-4938-7162d5353ea6"}], "result": [{"reference": "Observation/7ff54a1a-0407-7c16-0708-a6dd6bbed56e"}, {"reference": "Observation/18af0182-67bc-47c2-e9b3-89acd792afc5"}, {"reference": "Observation/1f639d21-ac21-0eac-ff77-809a7d11ce48"}, {"reference": "Observation/ca539092-a60d-cdaa-94da-b59920d6d061"}, {"reference": "Observation/c22d45e5-8d6b-9549-d4c8-01c4b38a581a"}, {"reference": "Observation/e8bace46-0fb7-d0a0-6bd5-e96baeb32667"}, {"reference": "Observation/00ec2adb-3089-d510-6092-0423573b3805"}, {"reference": "Observation/145fd351-2b25-631b-0847-13ea0ce3d49e"}, {"reference": "Observation/75fb5f7e-7ed6-7f68-7617-c42eacf34e55"}, {"reference": "Observation/e487019f-d253-983c-51fa-ba2513d99ca9"}, {"reference": "Observation/58be3cdc-d302-88fd-e9af-c3edb5df4aa8"}, {"reference": "Observation/5b5b7074-348f-f56e-7311-d1cf852e510b"}, {"reference": "Observation/ed0d3494-370e-55f5-8e23-bffcd97fd089"}, {"reference": "Observation/6e4b08b9-1edc-ba27-9b6e-2b65323aecd6"}, {"reference": "Observation/34a3352d-aad1-ec72-e00e-b11110bf3955"}, 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"Observation/19b5a50b-8032-14a8-d9a8-add4f4bd6687"}}, {"fullUrl": "urn:uuid:3c5780b2-f18e-177c-97ff-03078bb87b58", "resource": {"resourceType": "Observation", "id": "3c5780b2-f18e-177c-97ff-03078bb87b58", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.478.2.7.7.798268.1000", "value": "462386203"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-07-26T22:09:31Z", "valueString": "\u2022 \u00a0Left\u00a0Ventricle: The left ventricle is normal in size. (LVIDd 4.40 cm)
Left ventricular ejection fraction is normal. The visually estimated
ejection fraction is 55-65%.
\u2022 \u00a0Right\u00a0Ventricle: RV systolic function is normal. The TAPSE is 1.84 cm.
\u2022 \u00a0Tricuspid\u00a0Valve: The right ventricular systolic pressure is normal. \u00a0
RVSP ~ 20 mmHg
\u2022 \u00a0IVC/SVC: The inferior vena cava demonstrates a diameter of <=21 mm and
collapses >50%; therefore, the right atrial pressure is estimated at 0-5
mmHg.
\u2022 \u00a0Pericardium: There is a very small pericardial effusion. There is no
echocardiographic evidence of tamponade. The pericardium is thickened.
\u2022 \u00a0No significant valvular lesions
\u2022 \u00a0No prior echocardiogram here

Left Ventricle
The left ventricle is normal in size. (LVIDd 4.40 cm) Left ventricular wall thickness is normal. Left ventricular ejection fraction is normal. The visually estimated ejection fraction is 55-65%. Left ventricular wall motion is normal. Left ventricular diastolic function appears normal.
Right Ventricle
Right ventricular size normal. RV systolic function is normal. The TAPSE is 1.84 cm. RV wall thickness is normal.
Left Atrium
Left atrium size is normal.
Right Atrium
Right atrium is normal.
IVC/SVC
The inferior vena cava demonstrates a diameter of <=21 mm and collapses >50%; therefore, the right atrial pressure is estimated at 0-5 mmHg.
Mitral Valve
Mitral valve structure is normal. There is no regurgitation or stenosis.
Tricuspid Valve
Tricuspid valve structure is normal. There is trace regurgitation. The right ventricular systolic pressure is normal. RVSP ~ 20 mmHg
Aortic Valve
The aortic valve was not well visualized. There is no regurgitation or stenosis.
Pulmonic Valve
Pulmonic valve structure is normal. There is no regurgitation.
Ascending Aorta
The aorta appears normal in size.
Pericardium
There is a very small pericardial effusion. There is no echocardiographic evidence of tamponade. The pericardium is thickened.
Study Details
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Laboratory Director: Jonathan R. Genzen, MD, PhD
Salt Lake City, UT 84108
500 Chipeta Way
Performed By: ARUP Laboratories
For medical purposes only; not valid for forensic use.
can be ordered. Refer to aruplab.com for test information.
includes these opioids is available or individual opioid testing
meperidine, tramadol, and tapentadol. A comprehensive panel that
opioids are not detected in this test: fentanyl, buprenorphine,
results are reported with the amphetamines results. The following
Oxycodone results are reported with the opiates results. MDMA
to the laboratory.
be reported as positive. Interpretive questions should be directed
concentration value must be greater than or equal to the cutoff to
second, more specific technology (GC/MS and/or LC-MS/MS). The
or drug classes are detected by the screen are reflexed to a
metabolite varies within a drug class. Specimens for which drugs
concentration at which the screening test can detect a drug or
diluted/adulterated urine, or limitations of testing. The
collection relative to drug administration, poor drug absorption,
indicate non-compliance, inappropriate timing of specimen
The absence of expected drug(s) and/or drug metabolite(s) may
INTERPRETIVE INFORMATION: Drug Panel 9, Urn, Scrn w/Rflx to Conf"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Urine"}, {"url": "specimen collection time", "valueDateTime": "2024-07-26T20:23:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-27T00:50:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.478.2.7.2.798268.462385362.Comp11"}]}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "performer": [{"display": "VUMC CERNER LAB", "reference": "Organization/e3ece69c-0968-59c9-47dd-f16db731621a"}]}, "request": {"method": "PUT", "url": "Observation/73be09cd-bca8-ac47-cda5-e26e830cd448"}}, {"fullUrl": "urn:uuid:8c1be472-0a45-0669-926c-cd40e26ab27b", "resource": {"resourceType": "Observation", "id": "8c1be472-0a45-0669-926c-cd40e26ab27b", "meta": {"profile": 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*In the absence of evidence of kidney damage, neither GFR category G1 nor G2 fulfill the criteria for CKD (Kidney Int Suppl 2013;3:1-150)
G5 14 or less \u00a0 \u00a0Kidney failure
G4 15-29 \u00a0 \u00a0Severe decrease
G3b 30-44 \u00a0 \u00a0Moderate to severe decrease
G3a 45-59 \u00a0 \u00a0Mild to moderate decrease
G2 60-89 \u00a0 \u00a0Mild decrease*
G1 90 or greater \u00a0 \u00a0Normal or high*
GFR GFR (mL/min/1.73 Category: square meters) Interpretation:
GFR Categories in Chronic Kidney Disease (CKD)
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American Journal of Kidney Diseases (2021)"}], "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen collection time", "valueDateTime": "2024-07-27T17:21:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-07-27T18:12:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.478.2.7.2.798268.462499688.Comp1"}]}], "subject": {"reference": "Patient/3ddafbca-0194-4ff5-b733-9bf6ddfccde3"}, "performer": [{"display": "VUMC CERNER LAB", "reference": "Organization/e3ece69c-0968-59c9-47dd-f16db731621a"}]}, "request": {"method": "PUT", "url": "Observation/27d80412-5b55-ace8-85bf-bcd91d06bc6a"}}, {"fullUrl": "urn:uuid:fccf7df0-ff04-02de-bc2d-969599d858d1", "resource": {"resourceType": "Observation", "id": "fccf7df0-ff04-02de-bc2d-969599d858d1", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": 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"identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-484b-2a8d-3ed3-d4617497f7f5", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "2"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-08-05T12:45:31-04:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "6015a440-5fd2-0c40-3ac4-f019b96880b3", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E7-DD0F-D69B-FFA4C7D55C45", "title": "Immunizations", "text": {"status": "generated", "div": "Not on file documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E7-DD16-D69B-FFA4C7D55C45", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (TYLENOL) 32 mg/ml oral suspension (80 mg syringe) 23.04 mg23.04 mg (rounded from 22.97 mg = 10 mg/kg \u00d7 2.297 kg), Oral, Every 6 hours PRN, Moderate Pain (4-6), NPASS >3, Starting on Sun 8/4/24 at 0305, Maximum neonatal dose: GA 28-32 weeks: 40 mg/kg/day; 33-37 weeks or term neonates < 10 days: 60 mg/kg/day; term neonates >/= 10 days: 75 mg/kg/day from all sources in 24 hoursGiven08/04/2024 4:14 AM EDT23.04 mg
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
ampicillin 100 mg/mL IV Push (Omnipen) 115 mg115 mg (rounded from 114.85 mg = 50 mg/kg \u00d7 2.297 kg), Intravenous, Every 12 hours, First dose on Sat 8/3/24 at 1930, For 2 doses, First dose given at CMMC prior to transfer Dilute 500 milligram vial of ampicillin with 5 mL of Sterile Water for injection for a final concentration of 100mg/ml. Do not exceed 100 mg/min.Given08/04/2024 6:40 AM EDT115 mg
Given08/03/2024 7:08 PM EDT115 mg
dextrose 10% infusion7.7 mL/hr, Intravenous, Continuous, Starting on Sat 8/3/24 at 1445Rate/Dose Verify08/04/2024 5:00 PM EDT1.1 mL/hr1.1 mL/hr
Rate/Dose Verify08/04/2024 4:00 PM EDT1.1 mL/hr1.1 mL/hr
Rate/Dose Verify08/04/2024 3:00 PM EDT1.1 mL/hr1.1 mL/hr
morphine (neonatal) injection 0.116 mg0.116 mg (rounded from 0.1153 mg = 0.05 mg/kg \u00d7 2.305 kg Dosing weight), Intravenous, Once, On Sat 8/3/24 at 1100, For 1 dose, NICU/CCN: Do not dilute. Otherwise for IV Administration: Add to 1 ml 0.9% sodium chloride and administer over 5 minutesGiven08/03/2024 10:57 AM EDT0.116 mg
morphine (neonatal) injection 0.116 mg0.116 mg (rounded from 0.1153 mg = 0.05 mg/kg \u00d7 2.305 kg Dosing weight), Intravenous, Once, On Sat 8/3/24 at 1215, For 1 dose, NICU/CCN: Do not dilute. Otherwise for IV Administration: Add to 1 ml 0.9% sodium chloride and administer over 5 minutesGiven08/03/2024 12:12 PM EDT0.116 mg
poractant alfa suspension 5.8 mL5.8 mL (rounded from 5.7625 mL = 2.5 mL/kg \u00d7 2.305 kg Dosing weight), Tracheal Tube, Once, On Sat 8/3/24 at 1130, For 1 doseGiven08/03/2024 3:08 PM EDT5.8 mL
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/bc04c4f9-e389-8d47-3d6e-e36f49703b26"}, {"reference": "MedicationAdministration/7158c313-04a8-144f-c203-4574b061bac3"}, {"reference": "MedicationAdministration/03920702-56bd-a866-ea79-c3a02d610d6e"}, {"reference": "MedicationAdministration/aab10817-4d22-17ce-f9b9-35a2e516e79d"}, {"reference": "MedicationAdministration/575aa120-ae09-93b1-37d3-6e2743a65675"}, {"reference": "MedicationAdministration/95d294ee-8fcd-0067-97d4-67c88b301517"}]}, {"id": "30323353-e3c7-29f3-2936-2440a0adcb06", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
NICU Monitoring Continuous Pulse OxRespiratory CareRoutineUntil Discontinued until discontinued starting 8/3/24
POC Bedside Glucose TestPoint of Care TestingRoutineAs Needed until discontinued starting 8/3/24
NICU Oxygen ProtocolRespiratory CareRoutineUntil Discontinued until discontinued starting 8/3/24
Glucose RandomLabTimedprn until discontinued starting 8/3/24, 3 completed
NICU BUBBLE/CPAPRespiratory CareRoutineContinuous until discontinued starting 8/4/24
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/631e40a0-b38e-8414-b9a3-51b8ba1d9b8d"}]}, {"id": "00000000-25E7-DD19-D69B-FFA4C7D55C45", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
High risk social situation08/04/2024
Overview:Formatting of this note might be different from the original.
Prenatal lab results from CMMC recorded in admission problem. Trep to be done of the babyParents will be giving guardianship to Jeff and Dottie Bernier. Jeff should be notified of problems and ay make medical decisions.Mom Sabrina and Dad John. Sabrina had no prenatal care and delivered at CMMC at an estimated 34 weeks. DHHS open case, Case worker Candace Gomez 740-7143
Respiratory distress08/03/2024
Overview:Formatting of this note might be different from the original.
-Obtain CXR and/or blood gas prn-Consider extubation to CPAP if remains stable-Titrate FiO2 to maintain oxygen saturations within target for age-Continue SIMV-VG with TV 12 ml (5.2 ml/kg), Rate 25, PEEP 7, PS 8Plan:SVD at CMMC, developed respiratory distress at ~3 minutes of age and placed on CPAP 6. Subsequently required increase to CPAP 7 cm with FiO2 60-100% at CMMC nursery. MMC transport team arrived to find infant on CPAP 7/FiO2 60%. Infant tachypneic with moderate retractions and intermittent grunting. Infant intubated at CMMC with curosurf administered (8/3). Transferred back to MMC NICU intubated on conventional vent. Chest film on arrival shows ~9 ribs expanded with few ground glass opacities consistent with RDS. CBG on arrival 7.38/39/23/-2.
Healthcare maintenance08/03/2024
Overview:Formatting of this note is different from the original.
PCP: No primary care provider on file. % Difference between R hand and foot: Post-ductal (Right Food): Pre-ductal (Right Hand): Congenital Heart Screening Prior to discharge [] Completed [] Results: Car Seat Angle Tolerance Test Prior to discharge [x] Completed [] Results: Hearing Screen Prior to discharge [x] Completed [] Results: 8/3/24 Hepatitis B vaccine Date Given: 2 wks age [] 24-72 hours 8/5/24 [x] State Metabolic Screen Date Ordered Completed Notes Vitamin K Date Given: 8/3/24 Notes: Erythromycin Ointment Date Given: 8/3/24 Notes: Health Maintenance: >32 wks GA Male
FEN08/03/2024
Overview:Formatting of this note might be different from the original.
- - Follow for feeding toleranceMark was started on Similac Sensitive 20 cal and has been advancing without any issues so far. Blood sugars have been appropriate as IV fluids wean. BMP appropriateAssessment/plan:NPO. Started on 80 mL/kg/day of D10W at CMMC. Mother has consented to formula.
r/o sepsis08/03/2024
Overview:Formatting of this note might be different from the original.
- If antibiotics continued beyond 36 hours, will obtain gentamicin levels and order pharmacokinetics consult. - Will consider continuing antibiotics beyond 36 hours for positive blood culture or clinical concerns for infection. - Continue ampicillin and gentamicin for an anticipated 36 hour sepsis evaluation (ampicillin X 3 doses and the gentamicin X 1 dose). - Follow-up on blood culture drawn at CMMCAssessment/plan: Infant delivered at CMMC and developed respiratory distress at ~6 minutes of life. Maternal GBS unknown with no PNC. Rupture of membranes for 2 hours prior to delivery. Blood culture obtained at CMMC on 8/3/24. Antibiotics of ampicillin and gentamicin started at CMMC for r/o sepsis pending laboratory and culture results.
Preterm infant estimated 34 weeks gestation08/03/2024
Overview:Formatting of this note might be different from the original.
PCP: No primary care provider on file.Sabrina resides in Buckfield, ME. She has 2 older child that live with MGM who has custody.Social History Mark was born estimated 34 weeks gestation with a birth weight of 2305g delivered by SVD following placental abruption. His mother is Sabrina who is a 28yo G3P3 with a pregnancy complicated by no prenatal care and polysubstance use during pregnancy. Prenatal labs, Blood type/Rh A- antibody screen unknown, GBS unknown, HIV negative, Hep C positive, Hep B negative. Rubella unknown Maternal medications included, unknown. Delivery was complicated by abruption. The APGAR score was & at 1 and 5 minutes, respectively.
Newborn affected by maternal use of other drugs of addiction (CMS-HCC V28)08/03/2024
Overview:Formatting of this note might be different from the original.
-Consider bolus and/or maintenance morphine if indicated for withdrawal symptoms-Follow-up with CMMC regarding cord toxicology results-Monitor for signs/symptoms of withdrawalPlan:Mark is irritable and jittery on exam. Very tachypnic at times but he also has respiratory distress. He received a dose of tylenol over night as he has significant facial brusing Maternal urine tox +fentanyl and cocaine, methamphetamines Cord toxicology sent at CMMC with results pending. Infant given IV morphine (0.05 mg/kg) x2 by transport team prior to arrival at MMC NICU.
Incomplete foreskin with concern for hypospadias08/03/2024
Overview:Formatting of this note might be different from the original.
-Consider Urology consult week of 8/5Plan:Infant with incomplete foreskin and apparent hypospadias.
At risk for hyperbilirubinemia08/03/2024
Overview:Formatting of this note might be different from the original.
-Trend bilirubin at 24 hours of agePlan:Infant with significant facial bruising following delivery. Bilirubin 5.1 mg/dL at ~12 hours of age.
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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
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DateTypeDepartmentCare Team (Latest Contact Info)Description
08/03/2024 1:31 PM EDT - PresentHospital EncounterMaineHealth Maine Medical Center Portland Barbara Bush Childrens Hospital Neonatal Intensive Care Unit 122 Bramhall StPortland, ME 04102-3134207-662-2246Frehm, Eric J, MD22 Bramhall St, 4th Flr, Ste 4809Portland, ME 04102207-662-2553 (Work)207-662-6063 (Fax)
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Reportability Response Information Section
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"urn:uuid:575aa120-ae09-93b1-37d3-6e2743a65675", "resource": {"resourceType": "MedicationAdministration", "id": "575aa120-ae09-93b1-37d3-6e2743a65675", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355077725"}], "status": "completed", "effectivePeriod": {"start": "2024-08-03T23:30:00Z", "end": "2024-08-04T10:40:00Z"}, "dosage": {"route": {"coding": [{"code": "C38276", "display": "Intravenous", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 50, "unit": "mg/kg"}}, "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "medicationReference": {"reference": "Medication/bd03efdf-85f0-e6c6-991b-3431d5f41af7"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/575aa120-ae09-93b1-37d3-6e2743a65675"}}, {"fullUrl": "urn:uuid:bd03efdf-85f0-e6c6-991b-3431d5f41af7", "resource": {"resourceType": "Medication", "id": "bd03efdf-85f0-e6c6-991b-3431d5f41af7", "code": {"coding": [{"code": "0781-3407-95", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/bd03efdf-85f0-e6c6-991b-3431d5f41af7"}}, {"fullUrl": "urn:uuid:95d294ee-8fcd-0067-97d4-67c88b301517", "resource": {"resourceType": "MedicationAdministration", "id": "95d294ee-8fcd-0067-97d4-67c88b301517", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355077542"}], "status": "stopped", "effectivePeriod": {"start": "2024-08-03T18:45:00Z", "end": "2024-08-05T02:10:04Z"}, "dosage": {"route": {"coding": [{"code": "C38276", "display": "Intravenous", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 7.7, "unit": "mL/h"}}, "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "medicationReference": {"reference": "Medication/37f1eac0-a30b-a71b-c82c-6789f339ba73"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/95d294ee-8fcd-0067-97d4-67c88b301517"}}, {"fullUrl": "urn:uuid:37f1eac0-a30b-a71b-c82c-6789f339ba73", "resource": {"resourceType": "Medication", "id": "37f1eac0-a30b-a71b-c82c-6789f339ba73", "code": {"coding": [{"code": "0264-7520-00", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/37f1eac0-a30b-a71b-c82c-6789f339ba73"}}, {"fullUrl": "urn:uuid:ed4f86fd-7c05-1439-ba50-577e24fad0b9", "resource": {"resourceType": "RelatedPerson", "id": "ed4f86fd-7c05-1439-ba50-577e24fad0b9", "relationship": [{"coding": [{"display": "Mother"}]}], "telecom": [{"system": "phone", "value": "+1-207-500-6905", "use": "mobile"}], "patient": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "RelatedPerson/ed4f86fd-7c05-1439-ba50-577e24fad0b9"}}, {"fullUrl": "urn:uuid:1559feda-2408-5aaf-6a69-59aa691fc4ba", "resource": {"resourceType": "Condition", "id": "1559feda-2408-5aaf-6a69-59aa691fc4ba", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924242"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R06.03", "display": "Respiratory distress", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote46
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SVD at CMMC, developed respiratory distress at ~3 minutes of age and placed on CPAP 6. Subsequently required increase to CPAP 7 cm with FiO2 60-100% at CMMC nursery. MMC transport team arrived to find infant on CPAP 7/FiO2 60%. Infant tachypneic with moderate retractions and intermittent grunting. Infant intubated at CMMC with curosurf administered (8/3). Transferred back to MMC NICU intubated on conventional vent. Chest film on arrival shows ~9 ribs expanded with few ground glass opacities consistent with RDS. CBG on arrival 7.38/39/23/-2.
Plan:
-Continue SIMV-VG with TV 12 ml (5.2 ml/kg), Rate 25, PEEP 7, PS 8
-Titrate FiO2 to maintain oxygen saturations within target for age
-Consider extubation to CPAP if remains stable
-Obtain CXR and/or blood gas prn"}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1559feda-2408-5aaf-6a69-59aa691fc4ba"}}, {"fullUrl": "urn:uuid:f776a8a1-c412-9e8d-90d4-57337564b4f1", "resource": {"resourceType": "Condition", "id": "f776a8a1-c412-9e8d-90d4-57337564b4f1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924267"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z00.00", "display": "Healthcare maintenance", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote48
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Health Maintenance: >32 wks GA Male
Erythromycin Ointment Date Given: 8/3/24 Notes:
Vitamin K Date Given: 8/3/24 Notes:
State Metabolic Screen Date Ordered Completed Notes
24-72 hours 8/5/24 [x]
2 wks age []
Hepatitis B vaccine Date Given:
8/3/24
Hearing Screen Prior to discharge [x] Completed [] Results:
Car Seat Angle Tolerance Test Prior to discharge [x] Completed [] Results:
Congenital Heart Screening Prior to discharge [] Completed [] Results:
Pre-ductal (Right Hand):
Post-ductal (Right Food):
% Difference between R hand and foot:
PCP: No primary care provider on file. "}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/f776a8a1-c412-9e8d-90d4-57337564b4f1"}}, {"fullUrl": "urn:uuid:44f8a7bc-be67-4fec-b099-e5be487a799b", "resource": {"resourceType": "Condition", "id": "44f8a7bc-be67-4fec-b099-e5be487a799b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924268"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "P92.8", "display": "Other feeding problems of newborn", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote50
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NPO. Started on 80 mL/kg/day of D10W at CMMC. Mother has consented to formula.
Assessment/plan:
Mark was started on Similac Sensitive 20 cal and has been advancing without any issues so far. Blood sugars have been appropriate as IV fluids wean. BMP appropriate
- Follow for feeding tolerance
- "}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/44f8a7bc-be67-4fec-b099-e5be487a799b"}}, {"fullUrl": "urn:uuid:d55a3694-a729-fb27-aaf5-a23b3c52f3c1", "resource": {"resourceType": "Condition", "id": "d55a3694-a729-fb27-aaf5-a23b3c52f3c1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924269"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z05.1", "display": "Observation and evaluation of newborn for suspected infectious condition", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote52
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Infant delivered at CMMC and developed respiratory distress at ~6 minutes of life. Maternal GBS unknown with no PNC. Rupture of membranes for 2 hours prior to delivery. Blood culture obtained at CMMC on 8/3/24. Antibiotics of ampicillin and gentamicin started at CMMC for r/o sepsis pending laboratory and culture results.
Assessment/plan:
- Follow-up on blood culture drawn at CMMC
- Continue ampicillin and gentamicin for an anticipated 36 hour sepsis evaluation (ampicillin X 3 doses and the gentamicin X 1 dose).
- Will consider continuing antibiotics beyond 36 hours for positive blood culture or clinical concerns for infection.
- If antibiotics continued beyond 36 hours, will obtain gentamicin levels and order pharmacokinetics consult. "}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/d55a3694-a729-fb27-aaf5-a23b3c52f3c1"}}, {"fullUrl": "urn:uuid:9d306df9-cb19-7fc5-26c1-7c35ae66ffc3", "resource": {"resourceType": "Condition", "id": "9d306df9-cb19-7fc5-26c1-7c35ae66ffc3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924273"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "P07.30", "display": "Preterm newborn of unknown gestational age", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote54
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Mark was born estimated 34 weeks gestation with a birth weight of 2305g delivered by SVD following placental abruption. His mother is Sabrina who is a 28yo G3P3 with a pregnancy complicated by no prenatal care and polysubstance use during pregnancy. Prenatal labs, Blood type/Rh A- antibody screen unknown, GBS unknown, HIV negative, Hep C positive, Hep B negative. Rubella unknown Maternal medications included, unknown. Delivery was complicated by abruption. The APGAR score was & at 1 and 5 minutes, respectively.
Social History
Sabrina resides in Buckfield, ME. She has 2 older child that live with MGM who has custody.
PCP: No primary care provider on file."}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/9d306df9-cb19-7fc5-26c1-7c35ae66ffc3"}}, {"fullUrl": "urn:uuid:fc64c211-6e43-5ae1-699e-a88179f3627c", "resource": {"resourceType": "Condition", "id": "fc64c211-6e43-5ae1-699e-a88179f3627c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924279"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "P04.49", "display": "Newborn affected by maternal use of other drugs of addiction (CMS-HCC V28)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote56
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Maternal urine tox +fentanyl and cocaine, methamphetamines Cord toxicology sent at CMMC with results pending. Infant given IV morphine (0.05 mg/kg) x2 by transport team prior to arrival at MMC NICU.
Mark is irritable and jittery on exam. Very tachypnic at times but he also has respiratory distress. He received a dose of tylenol over night as he has significant facial brusing
Plan:
-Monitor for signs/symptoms of withdrawal
-Follow-up with CMMC regarding cord toxicology results
-Consider bolus and/or maintenance morphine if indicated for withdrawal symptoms"}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/fc64c211-6e43-5ae1-699e-a88179f3627c"}}, {"fullUrl": "urn:uuid:fa6a2c0a-fd3f-f537-4230-ebd6371913e7", "resource": {"resourceType": "Condition", "id": "fa6a2c0a-fd3f-f537-4230-ebd6371913e7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924419"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R89.9", "display": "Abnormal findings on examination of genitourinary organs", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote58
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Infant with incomplete foreskin and apparent hypospadias.
Plan:
-Consider Urology consult week of 8/5"}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/fa6a2c0a-fd3f-f537-4230-ebd6371913e7"}}, {"fullUrl": "urn:uuid:e767a5cf-9518-1a72-3ad6-56209f931427", "resource": {"resourceType": "Condition", "id": "e767a5cf-9518-1a72-3ad6-56209f931427", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924437"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z91.89", "display": "At risk for hyperbilirubinemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Overview:
problemNote60
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Infant with significant facial bruising following delivery. Bilirubin 5.1 mg/dL at ~12 hours of age.
Plan:
-Trend bilirubin at 24 hours of age"}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e767a5cf-9518-1a72-3ad6-56209f931427"}}, {"fullUrl": "urn:uuid:64b7c99f-e106-2380-70c7-e6781d42e2dd", "resource": {"resourceType": "Condition", "id": "64b7c99f-e106-2380-70c7-e6781d42e2dd", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50927093"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z60.9", "display": "High risk social situation", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-04", "note": [{"text": "Overview:
problemNote62
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Mom Sabrina and Dad John. Sabrina had no prenatal care and delivered at CMMC at an estimated 34 weeks. DHHS open case, Case worker Candace Gomez 740-7143
Parents will be giving guardianship to Jeff and Dottie Bernier. Jeff should be notified of problems and ay make medical decisions.
Prenatal lab results from CMMC recorded in admission problem. Trep to be done of the baby"}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/64b7c99f-e106-2380-70c7-e6781d42e2dd"}}, {"fullUrl": "urn:uuid:0e026883-717c-3079-413e-b1659b9936f6", "resource": {"resourceType": "DiagnosticReport", "id": "0e026883-717c-3079-413e-b1659b9936f6", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355077723"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.206.2.798268.2.355077723.1"}], "status": "final", "code": {"coding": [{"code": "61611", "display": "XR Chest Portable", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-08-03T17:55:00Z", "end": "2024-08-03T17:55:00Z"}, "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "performer": [{"reference": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}], "result": [{"reference": "Observation/ed91d633-c896-74fe-3697-7bcf7f584f30"}, {"reference": "Observation/0d6b822e-0aac-ef44-f1a9-22f57369544e"}, {"reference": "Observation/9c7c0fea-1cc3-b69c-103b-3b9f44c83832"}, {"reference": "Observation/ff754c1d-9f3d-933a-cda3-33b3a71140b0"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/0e026883-717c-3079-413e-b1659b9936f6"}}, {"fullUrl": "urn:uuid:6785067f-cee7-c612-c204-069a2bb67949", "resource": {"resourceType": "Organization", "id": "6785067f-cee7-c612-c204-069a2bb67949", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}}, {"fullUrl": "urn:uuid:ed91d633-c896-74fe-3697-7bcf7f584f30", "resource": {"resourceType": "Observation", "id": "ed91d633-c896-74fe-3697-7bcf7f584f30", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.3.696580.52175", "value": "61611"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-08-03T17:53:53Z", "end": "2024-08-03T18:06:38Z"}, "bodySite": {"coding": [{"code": "101", "display": "Chest", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.10.696580.52010"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T17:55:00Z"}]}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}}, "request": {"method": "PUT", "url": "Observation/ed91d633-c896-74fe-3697-7bcf7f584f30"}}, {"fullUrl": "urn:uuid:0d6b822e-0aac-ef44-f1a9-22f57369544e", "resource": {"resourceType": "Observation", "id": "0d6b822e-0aac-ef44-f1a9-22f57369544e", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.7.798268.1000", "value": "355077723"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-03T19:14:36Z", "valueString": "EXAM: XR CHEST PORTABLE 1VW
INDICATION: \u00a0respiratory distress
COMPARISON: None.
TECHNIQUE: Single portable view of the chest was obtained.
FINDINGS:
Lungs/Pleura: No infiltrate or pleural fluid .
Cardiac Silhouette: Within normal limits.
Hila/Mediastinum: The endotracheal tube and nasogastric tube are in satisfactory position.
Bones: Unremarkable.
Soft Tissues: Unremarkable.
IMPRESSION: No acute process is identified. The endotracheal tube and nasogastric tube are in satisfactory position.
WORKSTATION: MILES-MG-DS1
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/3/2024 3:12 PM \u00a0Charles Mullen, MD", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T17:55:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355077723.Narrative"}]}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/0d6b822e-0aac-ef44-f1a9-22f57369544e"}}, {"fullUrl": "urn:uuid:cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "resource": {"resourceType": "Organization", "id": "cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}}, {"fullUrl": "urn:uuid:9c7c0fea-1cc3-b69c-103b-3b9f44c83832", "resource": {"resourceType": "Observation", "id": "9c7c0fea-1cc3-b69c-103b-3b9f44c83832", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051864226"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-03T19:14:36Z", "valueString": "RECOGNITION * * 8/3/2024 3:12 PM Charles Mullen, MD
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: MILES-MG-DS1
nasogastric tube are in satisfactory position.
IMPRESSION: No acute process is identified. The endotracheal tube and
Soft Tissues: Unremarkable.
Bones: Unremarkable.
satisfactory position.
Hila/Mediastinum: The endotracheal tube and nasogastric tube are in
Cardiac Silhouette: Within normal limits.
Lungs/Pleura: No infiltrate or pleural fluid .
FINDINGS:
TECHNIQUE: Single portable view of the chest was obtained.
COMPARISON: None.
INDICATION: respiratory distress
EXAM: XR CHEST PORTABLE 1VW
Formatting of this note might be different from the original.
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MH IP INTUBATION
Date/Time: 8/3/2024 11:05 AM
Performed by: Cotton, Katherine A, NP
Authorized by: Cotton, Katherine A, NP \u00a0
Consent:
\u00a0Consent obtained: \u00a0Verbal
\u00a0Consent given by: \u00a0Parent
\u00a0Risks, benefits, and alternatives were discussed: yes \u00a0
\u00a0Risks discussed: \u00a0Laryngeal injury, hypoxia and bleeding
\u00a0Alternatives discussed: \u00a0No treatment
Universal protocol:
\u00a0Procedure explained and questions answered to patient or proxy''s
satisfaction: yes \u00a0
\u00a0Imaging studies available: yes \u00a0
\u00a0Immediately prior to procedure, a time out was called: yes \u00a0
\u00a0Patient identity confirmed: \u00a0Arm band and provided demographic data
Pre-procedure details:
\u00a0Indication: failure to ventilate and predicted clinical deterioration \u00a0
\u00a0Patient status: \u00a0Awake
\u00a0Look externally: no concerns \u00a0
\u00a0Obstruction: none \u00a0
\u00a0Neck mobility: normal \u00a0
\u00a0Pharmacologic strategy comment: \u00a0Given morphine (0.05 mg/kg) x1
pre-procedure
\u00a0Preatreatment Medications: \u00a0None
\u00a0Sedation: morphine (0.05 mg/kg) x1 pre-procedure.
\u00a0Paralytics: \u00a0None
Procedure details:
\u00a0Preoxygenation: CPAP prongs.
\u00a0CPR in progress: no \u00a0
\u00a0Intubation method: \u00a0Oral
\u00a0Intubation technique: direct \u00a0
\u00a0Laryngoscope blade: \u00a0Miller 0
\u00a0Bougie used: no \u00a0
\u00a0Tube size (mm): \u00a03.0
\u00a0Tube type: \u00a0Uncuffed
\u00a0Number of attempts: \u00a03 or more
\u00a0Ventilation between attempts comment: \u00a0Yes, CPAP prongs
\u00a0Tube visualized through cords: yes \u00a0
Placement assessment:
\u00a0ETT at teeth/gumline (cm): \u00a08.5
\u00a0Tube secured with: \u00a0Adhesive tape
\u00a0Breath sounds: \u00a0Equal
\u00a0Placement verification: CXR verification, direct visualization, equal
breath sounds, ETCO2 detector and tube exhalation \u00a0
\u00a0CXR findings: \u00a0Appropriate position
Post-procedure details:
\u00a0Procedure completion: \u00a0Tolerated
Comments:
\u00a0 Timeout performed. CMMC MD (Dr. Wood) attempted intubation x1 but
unsuccessful. Moderate bloody secretions observed to oral mucosa following
attempt. NNP inserts #3.0 ETT to 8.5 cm at gum with copious bloody
secretions coming up ETT following insertion (?r/t trauma vs. Early
pulmonary hemorrhage). Placement confirmed by mist in tube, equal breath
sounds, and color change on ETCO2 detector. Infant transitioned to
conventional vent via transporter and PEEP increased to 7 with improvement
of bloody drainage. Discussed with Dr. Frehm. CXR confirms ETT in
appropriate placement with tip terminating at ~T3 above carina. Curosurf
administered via ETT in 1 aliquot. Hematocrit (post-intubation) stable at
54.1%. Infant tolerated procedure fairly well with no immediate
complications. ", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen receive time", "valueDateTime": "2024-08-05T07:07:53Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355077734.Narrative"}]}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}, "performer": [{"display": ".MANUAL ENTRY (EXTERNAL LAB)", "reference": "Organization/5f797041-fb55-9a9d-4c39-674033c3def6"}]}, "request": {"method": "PUT", "url": "Observation/cccdf2e4-b04e-544f-32f5-410cdad2efd4"}}, {"fullUrl": "urn:uuid:5f797041-fb55-9a9d-4c39-674033c3def6", "resource": {"resourceType": "Organization", "id": "5f797041-fb55-9a9d-4c39-674033c3def6", "name": ".MANUAL ENTRY (EXTERNAL LAB)", "address": [{"line": ["Please Refer to Scanned Lab Report"]}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/5f797041-fb55-9a9d-4c39-674033c3def6"}}, {"fullUrl": "urn:uuid:2c99386b-ba1b-fc79-743c-87ca477ca67f", "resource": {"resourceType": "Observation", "id": "2c99386b-ba1b-fc79-743c-87ca477ca67f", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355077734"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2024-08-03T15:05:00Z", "valueCodeableConcept": {"coding": [{"code": "12", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen source", "valueString": "Blood"}, {"url": "specimen receive time", "valueDateTime": "2024-08-05T07:07:53Z"}]}], "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}}, "request": {"method": "PUT", "url": "Observation/2c99386b-ba1b-fc79-743c-87ca477ca67f"}}, {"fullUrl": "urn:uuid:e05b992d-e4eb-db01-5861-b126cd2b18a3", "resource": {"resourceType": "Observation", "id": "e05b992d-e4eb-db01-5861-b126cd2b18a3", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.1.1040.1", "value": "Z4402796^^72166-2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "72166-2", "display": "Tobacco smoking status NHIS", "system": "http://loinc.org"}]}, "valueCodeableConcept": {"coding": [{"code": "266927001", "display": "Tobacco smoking consumption unknown", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/0d64a551-a408-4074-aeef-86f38bd7d730"}}, "request": {"method": "PUT", "url": "Observation/e05b992d-e4eb-db01-5861-b126cd2b18a3"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}]}') ON CONFLICT (ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('1.2.840.114350.1.13.206.2.7.8.688883.470000397', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:1.2.840.114350.1.13.206.2.7.8.688883.470000397", "resource": {"resourceType": "Composition", "id": "1.2.840.114350.1.13.206.2.7.8.688883.470000397", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-4848-224b-3ed3-d4617497f7f5", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "6"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-08-05T12:33:11-04:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "6330ab6c-b294-e349-de60-412f496fe94a", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E7-74A9-D69B-FFA4C7D55C45", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
Hepatitis B Vaccine09/24/2011 04/06/2011 ,
Influenza A H1N1 200912/01/2009
Influenza Vaccine10/10/2023 10/13/2010 10/21/2008 , ,
Influenza Vaccine 0.5mL IM High Dose Age 65+ (IMM90)10/10/2018
Influenza Vaccine 0.7mL IM High Dose Age 65+ (IMM10220)10/06/2021
Influenza Vaccine Age 3+ PF10/12/2011
MMR Vaccine04/27/2011
Moderna Red Cap(12+)Covid-19,Monovalent,mrna,lnp-s,pf,.5mL (IMM10222)08/24/2021 01/26/2021 12/28/2020 , ,
PREVNAR 20,(PCV-20),Pneumococcal Conjugate Vaccine (IMM21058)11/09/2023
Pfizer Bivalent (12+)Gray Cap,Tris-Sucrose,Covid-19,PF,30mcg/0.3mL(IMM10252)09/26/2022
Pfizer Comirnaty (12+)covid-19,mrna,lnp-s,pf,tris-sucrose,30mcg/0.3mL(IMM10263)10/20/2023
Tdap Vaccine Age 7+11/09/2023 04/06/2011 ,
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E7-74B5-D69B-FFA4C7D55C45", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (Tylenol) tablet 650 mg650 mg, Oral, Every 8 hours PRN, Mild Pain (1-3), Fever, Starting on Sun 8/4/24 at 0645, Maximum dose of acetaminophen is 4000 mg from all sources in 24 hours. Possible side effects: upset stomach, rash
amLODIPine (Norvasc) tablet 10 mg10 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900, Possible side effects: leg swelling, fatigue, flushingGiven08/05/2024 8:24 AM EDT10 mg
Given08/04/2024 9:28 AM EDT10 mg
aspirin chewable tablet 81 mg81 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900, Possible side effects: easy bruising and bleeding, heartburn, ulcerGiven08/05/2024 8:24 AM EDT81 mg
Given08/04/2024 9:25 AM EDT81 mg
atorvastatin (Lipitor) tablet 40 mg40 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900, Possible side effects: muscle pain and weakness, diarrhea, nauseaGiven08/05/2024 8:24 AM EDT40 mg
Given08/04/2024 9:25 AM EDT40 mg
azaTHIOprine (Imuran) tablet 100 mg100 mg, Oral, Daily, First dose on Sat 8/3/24 at 1530, **Hazardous Drug - Moderate Risk - Handle with double ASTM6978 rated gloves. For liquids or suspensions: wear non-permeable gown and face/eye protection if risk for spills or splashes.**Given08/05/2024 8:26 AM EDT100 mg
Given08/04/2024 9:25 AM EDT100 mg
Given08/03/2024 8:18 PM EDT100 mg
azithromycin (Zithromax) 500 mg in 0.9% NaCl 250 mL500 mg, Intravenous, at 250 mL/hr, Every 24 hours, First dose on Sun 8/4/24 at 1645, Possible side effects: nausea/vomiting, diarrhea, rashRestarted08/04/2024 9:29 PM EDT250 mL/hr
New Bag08/04/2024 4:28 PM EDT500 mg250 mL/hr
bisacodyl (Dulcolax) rectal suppository 10 mg10 mg, Rectal, Daily PRN, Constipation, Starting on Mon 8/5/24 at 0000, 2nd line therapy (Adult Bowel Management - No Risk Factors): Only initiate if no BM by 48 hours after using 1st line therapy per Bowel Management orders. Notify Provider/Team if no response to 2nd line agents (no BM) in 3 days.
carvedilol (Coreg) tablet 25 mg25 mg, Oral, 2 times daily, First dose on Sun 8/4/24 at 0900, take with food to slow absorption and reduce orthostatic effects. Possible side effects: tiredness, weakness, dizzinessGiven08/05/2024 8:25 AM EDT25 mg
Given08/04/2024 9:30 PM EDT25 mg
Given08/04/2024 9:24 AM EDT25 mg
ceFAZolin (Ancef) syringe infusion 1 gm1 gm, Intravenous, Daily, First dose on Sun 8/4/24 at 1045, Possible side effects: Nausea, diarrhea, rash Administer after dialysis on dialysis days Reconstitute\u00a01 gm vial of cefazolin in 20 mL of SWFI or 0.9% NaCl. For locations with access to Plum360 pump: Connect syringe to Plum360 Pump and infuse over 5 minutes (4 mL/min). Upon completion of infusion, flush with 20 mL at the same rate to ensure all antibiotic in tubing has been administered. In locations where Plum360 pump is unavailable: push syringe over 2 minutes. Upon completion of IV push, flush with 20 mL of NS or maintenance fluid to ensure all antibiotic in tubing has been administered.Given08/04/2024 10:53 AM EDT1 gm
cholecalciferol (VITAMIN D3) tablet 1,000 Units1,000 Units, Oral, Daily, First dose on Sun 8/4/24 at 0900, Possible side effects: nausea/vomiting, constipationGiven08/05/2024 8:24 AM EDT1,000 Units
Given08/04/2024 9:35 AM EDT1,000 Units
darbepoetin alfa 40mcg/0.4mL (Aranesp) injection 40 mcg40 mcg, Subcutaneous, Every 7 days scheduled, First dose on Sat 8/3/24 at 1800, If Hgb greater than 11, hold darbepoetin and check Hgb daily. When Hgb < 11, restart dosing as follows: decrease to next lower dose. Do not shake., Indications: Anemia assoc. with ESRD (End Stage Renal Disease)Given08/04/2024 6:40 AM EDT40 mcgLeft Lower Abdomen
famotidine (Pepcid) tablet 10 mg10 mg, Oral, Daily, First dose (after last reorder) on Sun 8/4/24 at 0900, Possible side effects: headache, dizzinessGiven08/05/2024 8:25 AM EDT10 mg
Given08/04/2024 9:25 AM EDT10 mg
gabapentin (Neurontin) capsule 100 mg100 mg, Oral, Daily with breakfast, First dose (after last modification) on Tue 8/6/24 at 0800, Possible side effects: drowsiness, dizziness, swelling in hands or feet
losartan (Cozaar) tablet 100 mg100 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900Given08/05/2024 8:24 AM EDT100 mg
Given08/04/2024 9:25 AM EDT100 mg
niacin (VITAMIN B3) tablet 50 mg50 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900, Immediate release tabletGiven08/05/2024 10:48 AM EDT50 mg
ondansetron (Zofran) injection 4 mg4 mg, Intravenous, Every 6 hours PRN, Nausea, Vomiting, Starting on Sat 8/3/24 at 1309, For doses 8mg or less, may administer undiluted IV push over 2 minutes. Otherwise, dilute in 0.9% NS (sterile water not recommended) and infuse via infusion pump. Possible side effects: headache, fatigue, constipation
polyethylene glycol (Miralax) packet 17 gm17 gm, Oral, Daily PRN, Constipation, Starting on Sat 8/3/24 at 1624, 1st line therapy (Adult Bowel Management - No Risk Factors): If no BM in 24 hours, administer one of 1st line therapy options per patient preference, switch to 2nd line therapy if no BM by 48 hours after using 1st line therapy. For 8.5g: Mix with 2 oz (60mL) non-carbonated liquid. For 17g: Mix with 4oz (120mL) non-carbonated liquid. For 119g: Mix with 32oz (~1 liter) non-carbonated, clear liquid (not blue, red, or purple). For 238g: Mix with 64oz (~2 liters) non-carbonated, clear liquid(not blue, red, or purple). Possible side effects: diarrhea, bloating, cramps
polyethylene glycol (Miralax) packet 34 gm34 gm, Oral, Daily PRN, Constipation, Starting on Mon 8/5/24 at 0000, 2nd line therapy (Adult Bowel Management - No Risk Factors): Only initiate if no BM by 48 hours after using 1st line therapy per Bowel Management orders. Do NOT administer if 1st line polyethylene glycol powder (17 gm dose) has already been administered today. Notify Provider/Team if no response to 2nd line agents (no BM) in 3 days. For 8.5g: Mix with 2 oz (60mL) non-carbonated liquid. For 17g: Mix with 4oz (120mL) non-carbonated liquid. For 119g: Mix with 32oz (~1 liter) non-carbonated, clear liquid (not blue, red, or purple). For 238g: Mix with 64oz (~2 liters) non-carbonated, clear liquid(not blue, red, or purple). Possible side effects: diarrhea, bloating, cramps
predniSONE (Deltasone) tablet 5 mg5 mg, Oral, Daily with breakfast, First dose on Sun 8/4/24 at 0800, Possible side effects: high blood sugar, change in mood, fluid retentionGiven08/05/2024 8:24 AM EDT5 mg
Given08/04/2024 9:24 AM EDT5 mg
renal multivitamin capsule 1 Capsule1 Capsule, Oral, Daily, First dose on Sun 8/4/24 at 0900Given08/05/2024 8:24 AM EDT1 Capsule
Given08/04/2024 9:23 AM EDT1 Capsule
senna (Senokot) tablet 2 Tablet2 Tablet, Oral, Daily PRN, Constipation, Starting on Sat 8/3/24 at 1624, 1st line therapy (Adult Bowel Management - No Risk Factors): If no BM in 24 hours, administer one of 1st line therapy options per patient preference, switch to 2nd line therapy if no BM by 48 hours after using 1st line therapy.
sevelamer (Renvela) tablet 1,600 mg1,600 mg, Oral, 3 times daily with meals, First dose on Sat 8/3/24 at 1730, Possible side effects: nausea/vomiting, indigestion, diarrhea. Do not crush, chew, or break. Broken/crushed tablets rapidly expand in water/saliva and may be a choking hazardGiven08/05/2024 8:23 AM EDT1,600 mg
Given08/04/2024 6:34 PM EDT1,600 mg
Given08/04/2024 2:10 PM EDT1,600 mg
sodium bicarbonate tablet 1,300 mg1,300 mg, Oral, Daily, First dose on Sun 8/4/24 at 0900Given08/05/2024 8:23 AM EDT1,300 mg
Given08/04/2024 9:25 AM EDT1,300 mg
sodium chloride (NS) 0.9 % flush 5 mL5 mL, Intravenous, As needed, Line Care, Starting on Sat 8/3/24 at 1227
tacrolimus (Prograf) capsule 1 mg1 mg, Oral, Over 24 hours, First dose on Sat 8/3/24 at 1800, If ordered sublingually, open cap and place contents under patient''s tongue. Possible side effects: headache, insomnia, tremor **Hazardous Drug - Low Risk - Handle with single gloves. For liquids or suspensions: wear non-permeable gown and face/eye protection if risk for spills or splashes.**Given08/04/2024 6:34 PM EDT1 mg
Given08/03/2024 8:10 PM EDT1 mg
tacrolimus (Prograf) capsule 2 mg2 mg, Oral, Over 24 hours, First dose on Sun 8/4/24 at 0600, If ordered sublingually, open cap and place contents under patient''s tongue. Possible side effects: headache, insomnia, tremor **Hazardous Drug - Low Risk - Handle with single gloves. For liquids or suspensions: wear non-permeable gown and face/eye protection if risk for spills or splashes.**Given08/05/2024 5:28 AM EDT2 mg
Given08/04/2024 6:39 AM EDT2 mg
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (Tylenol) tablet 1,000 mg1,000 mg, Oral, Once, On Sun 8/4/24 at 0245, For 1 dose, Maximum dose of acetaminophen is 4000 mg from all sources in 24 hours. Possible side effects: upset stomach, rashGiven08/04/2024 2:07 AM EDT1,000 mg
azithromycin (Zithromax) 500 mg in 0.9% NaCl 250 mL500 mg, Intravenous, at 250 mL/hr, Every 24 hours, First dose on Sat 8/3/24 at 1315, Possible side effects: nausea/vomiting, diarrhea, rashNew Bag08/03/2024 2:05 PM EDT500 mg250 mL/hr
ceFEPIme 2 gm in 0.9% NaCl 50 mL2 gm, Intravenous, at 100 mL/hr, Once, On Sat 8/3/24 at 1230, For 1 dose, Possible side effects: Nausea, diarrhea, rashNew Bag08/03/2024 1:13 PM EDT2 gm100 mL/hr
gabapentin (Neurontin) capsule 100 mg100 mg, Oral, 3 times daily, First dose on Sat 8/3/24 at 1645, Possible side effects: drowsiness, dizziness, swelling in hands or feetGiven08/05/2024 8:26 AM EDT100 mg
Given08/04/2024 9:30 PM EDT100 mg
Given08/04/2024 4:37 PM EDT100 mg
lactated ringers infusion bolus 1,000 mL1,000 mL, Intravenous, Administer over 1 Hours, Every hour, First dose on Sat 8/3/24 at 1300, For 1 dose, Alternate fluids volume ordered due to: Concern for fluid overloadNew Bag08/03/2024 1:18 PM EDT1,000 mL1000 mL/hr
vancomycin 1,500 mg in 0.9% NaCl 500 mL1,500 mg, Intravenous, at 333.3 mL/hr, Once, On Sat 8/3/24 at 1245, For 1 dose, Possible side effects: rash, redness & itching. Caution: bag may contain overfill. Please ensure entire volume is infused.New Bag08/03/2024 1:18 PM EDT1,500 mg333.3 mL/hr
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/be450b99-9e2c-143d-662b-fb4c2b10293b"}, {"reference": "MedicationAdministration/ba844e59-104f-414d-e483-6ba507dd2045"}, {"reference": "MedicationAdministration/ebe7a5fd-4eb4-593a-90b4-8136915ff716"}, {"reference": "MedicationAdministration/c8016c8d-d69e-22b1-16c8-f321d5d75b83"}, {"reference": "MedicationAdministration/a2fba765-d382-6ed0-09a0-46e528d8111c"}, {"reference": "MedicationAdministration/74ad6d11-c904-f665-1ebe-d3fbf054002f"}, {"reference": "MedicationAdministration/9d535c5d-4554-4abb-2252-9edc5d81b24e"}, {"reference": "MedicationAdministration/16fba715-48c7-2d76-7a53-f6742acdfb1e"}, {"reference": "MedicationAdministration/33878db5-f630-702b-c13d-3fa4e9fea203"}, {"reference": "MedicationAdministration/7eb6f133-fa81-ff96-7bda-a978ef480149"}, {"reference": "MedicationAdministration/4fafd277-54eb-e1b6-8d69-487a4a5b6eaf"}, {"reference": "MedicationAdministration/4f6fb180-3f97-33ff-d9cb-e2f591006ac9"}, {"reference": "MedicationAdministration/f014a5a9-e659-8bec-dc05-a0037a06c428"}, {"reference": "MedicationAdministration/ed16acbe-6efe-a907-5b6d-c97201457fe9"}, {"reference": "MedicationAdministration/620ca199-3d7c-cf89-2a43-fbbb474bbb47"}, {"reference": "MedicationAdministration/d7231e5a-a031-4831-d2c3-7b6e911957f5"}, {"reference": "MedicationAdministration/ef0dae54-0017-5210-f07d-cc611750f888"}, {"reference": "MedicationAdministration/be27c90b-c58d-e67b-b2b3-35e40eed0895"}, {"reference": "MedicationAdministration/2bc53212-7db8-77ec-bbca-e8c839057179"}, {"reference": "MedicationAdministration/a2b92530-cc90-f097-9d66-cd0671c3374c"}, {"reference": "MedicationAdministration/c2813503-f062-cac0-d78f-f280f80ff9c7"}, {"reference": "MedicationAdministration/1ae002e0-9d8f-9ddd-09e4-33ce0a139b09"}, {"reference": "MedicationAdministration/a1dbd8fa-a1ba-7b57-5e40-8b4a6e52cc50"}, {"reference": "MedicationAdministration/a6a746a1-b3d3-3a91-cfe4-49bcfb6aa6b8"}, {"reference": "MedicationAdministration/86ffca5e-e7c0-d43b-ca7c-9badab35e0cc"}, {"reference": "MedicationAdministration/352faa93-2f54-236a-83ec-cc345423f009"}, {"reference": "MedicationAdministration/2a70d19e-7263-b04a-5142-f576c6de25a2"}, {"reference": "MedicationAdministration/fa92a93f-15f7-ed9e-a25b-56cfce2d9121"}, {"reference": "MedicationAdministration/69e8e59e-5f9d-4694-20f9-d92281b07b6d"}, {"reference": "MedicationAdministration/f1b9c6b0-19b6-3bf9-140c-a85500fe5e81"}, {"reference": "MedicationAdministration/6a038284-f170-fb82-b2ba-f7de37896225"}, {"reference": "MedicationAdministration/43ba9182-6997-0926-510a-f1de01242a25"}, {"reference": "MedicationAdministration/ce68e61c-a510-e8c1-c8d8-7786043253aa"}]}, {"id": "2e102c8d-b676-abd2-efae-1715a8604c8e", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
08/08/2024 3:30 PM EDTAppointmentMaineHealth Vascular Surgery Radiology Ultrasound Scarborough92 Campus DrSte DScarborough, ME 04074-7229207-662-8900
08/09/2024 8:00 AM EDTOffice VisitMaineHealth Wound Care Brighton Ave Portland335 Brighton AvePortland, ME 04102-2363207-662-4325Hughes, Holland M, NP335 Brighton AvePortland, ME 04102207-662-4325 (Work)207-662-8068 (Fax)
09/18/2024 2:00 PM EDTOffice VisitMaineHealth Cancer Care and IV Therapy South Portland265 Western AveSte 2South Portland, ME 04106-2458207-661-0200Rogers, Andrew M, MD265 Western AveSte 2South Portland, ME 04106-2458207-661-0200 (Work)207-661-0299 (Fax)
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture Blood - #1 of 1MicrobiologySTAT08/03/2024 12:51 PM EDT
RED BLOOD CELL, LEUKOREDUCED 1 Unit; IRRADIATEDBlood BankTimed08/04/2024 9:45 AM EDT
Red Blood Cell Transfusion OrderNursing TransfusionSTAT08/04/2024 11:49 AM EDT
FerritinLabAdd-On08/04/2024 7:47 AM EDT
HaptoglobinLabAdd-On08/04/2024 7:47 AM EDT
Iron + Iron Binding CapacityLabAdd-On08/04/2024 7:47 AM EDT
Red Blood Cell Transfusion OrderNursing TransfusionSTAT08/04/2024 11:44 AM EDT
Mycoplasma Pneumoniae Ab IgG IgMLabRoutine08/05/2024 12:03 AM EDT
US Vascular Upper Extremities Arteries LeftVascular ImagingRoutine08/05/2024 11:31 AM EDT
CBC + DifferentialLabRoutine08/05/2024 5:17 AM EDT
CBC and DifferentialLabRoutine08/05/2024 5:17 AM EDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
POC Bedside Glucose TestPoint of Care TestingSTATAs Needed until discontinued starting 8/3/24
FerritinLabAdd-OnRoutine Today Routine Today for 1 Occurrences starting 8/4/24 until 8/4/24
HaptoglobinLabAdd-OnRoutine Today Routine Today for 1 Occurrences starting 8/4/24 until 8/4/24
Iron + Iron Binding CapacityLabAdd-OnRoutine Today Routine Today for 1 Occurrences starting 8/4/24 until 8/4/24, 1 completed
CBC + DifferentialLabRoutineOrders placed after 4am will default to tomorr for 1 Occurrences starting 8/5/24 until 8/5/24
Mycoplasma Pneumoniae Ab IgG IgMLabAdd-OnRoutine Today Routine Today for 1 Occurrences starting 8/4/24 until 8/4/24
US Vascular Upper Extremities Arteries LeftVascular ImagingRoutineOne time imaging One time imaging for 1 Occurrences starting 8/5/24 until 8/5/24
Culture Blood - single specimenMicrobiologyRoutineOrders placed after 4am will default to tomorr for 1 Occurrences starting 8/6/24 until 8/6/24
Culture Anaerobic + Aerobic w/ Gram StainMicrobiologySTATSTAT for 1 Occurrences starting 8/5/24 until 8/5/24
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/c3ab7650-aec6-2d85-5a17-4c82ee0071d9"}]}, {"id": "00000000-25E7-74D1-D69B-FFA4C7D55C45", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
Fever in adult08/04/2024
ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS)08/04/2024
Immunosuppressed status (CMS-HCC V24)08/03/2024
Transplant recipient08/03/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Pancreas stable, lipase 11Now ESRD with some urine productionS/p kidney and pancreas transplant at MGH
MSSA bacteremia08/03/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
-Repeat blood culture to evaluate for clearance of bacteremia tomorrow (8/5) -Narrow antibiotics to cefazolin (will review with ID whether any additional coverage is needed for question of pneumonia)-F/u TTE and fistula US Cefazolin 2g q8h for 6 weeks for osteo-Appreciate ID recs:-Treat osteomyelitis (below)Source likely R ankle osteomyelitis seen on MRI. Warrants workup for valvular involvement via TTE and involvement of fistula via US.Blood culture resulted positive for methicillin-susceptible S. aureus.Presented with high fevers (first fever reported 7/30/24), malaise, dry cough.
Osteomyelitis of right ankle (CMS/HHS)08/03/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Mesalt gauze tucked into the depth of the wound followed by ABD pad, rolled gauze, Ace wrap for higher level of compression than he is achieving currently with his own compression stocking. Change dressing daily. -Wound care per prior outpatient recommendations:-Wound care nursing consult with low threshold for burn and soft tissue surgery consult-Consult ortho re: drainage for septic jointOsteomyelitis seen on 8/3 MRI. Likely related to medial malleolar ulcer present for 3 months, which started as a burn. The patient is followed by the wound care clinic. Per MRI, cannot exclude septic joint.
Urethral polyp06/21/2024
Condyloma acuminatum06/21/2024
Diabetic ulcer of right ankle (CMS/HHS)06/21/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Return to see us next Friday.Patient to begin taking doxycycline, prescribed 10-day course to be completed on 8/12/24Mesalt gauze tucked into the depth of the wound followed by ABD pad, rolled gauze, Ace wrap for higher level of compression than he is achieving currently with his own compression stocking. Change dressing daily.Until he sees us back next Friday I would like him to dress the wounds with the following:Ryan states that he would be agreeable to this at this time.I did discuss with Ryan today that I believe he would benefit from negative pressure wound therapy assuming that the MRI was negative for any underlying infection in the bone.He will return to see us next Friday.He has arterial studies next Thursday.Patient does have an MRI coming up next Wednesday.Was not able to express any wispy thick yellow fluid as I was last week.Heavy amount of drainage continues to flow from the open area of the wound, lower leg is significantly edematous 3+ pitting to foot ankle and lower leg.Right ankle ulceration with increased depth, noted 2.5 cm straight and. Was not able to palpate any bone at the base but I anticipate this is very close.
Type 2 diabetes mellitus without complication, without long-term current use of insulin (CMS-HCC) (CMS/HHS)11/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
Continue to track yearly A1c Discussed fructosamine declines at this time Well controlled
Primary hypertension11/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
Continue current regiment amlodipine and lisinopril Well controlled at home and during dialysis 147/70 today On amlodipine and lisinoril
Diabetic autonomic neuropathy associated with type 2 diabetes mellitus (CMS/HHS)11/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
Bilateral neuropathy, well controlled on low-dose gabapentin, uses 100 to 300 mg nightly. Foot exam done today. No open wounds. No concerning findings.On gabapentin In the bilateral feet
Healthcare maintenance11/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
- His fasting glucose has always been within normal limits.- Discussed using fructosamine instead; however, he declines at this time.- Up to date with all blood work. We will do a lipid panel, hemoglobin A1c yearly. UTD COVID booster Got flu shot through MaineHealth PCV 20 TDAP today
COVID-1906/05/2023
History of amputation of right great toe (CMS-HCC) (CMS-HCC V24)01/29/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
Stable no concern for infection
Other specified coagulation defects (CMS-HCC V24)01/29/2023
Type 2 diabetes mellitus with foot ulcer (CMS/HHS)10/11/2022
AV fistula (CMS-HCC) (CMS-HCC V24)10/11/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- Obtain US Soft Tissue left upper extremityR/o active infection/abscess along fistula.
Anemia in other chronic diseases classified elsewhere10/11/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Check LDH, haptoglobin, fibrinogen, INR, iron studies, ferritin-Epogen per nephrology recommendations-Transfuse RBCs for hemoglobin less than 7 - he wants to be notified before additional RBC units are ordered, as he is on a kidney transplant listHemoglobin below goal. Likely superimposed acute and chronic anemias. Differential diagnosis includes DIC/hemolysis, anemia of chronic inflammation, ESRD. Schistocytes seen on blood smear, raising concern for DIC/hemolysis, but high fibrinogen is reassuring that this is not DIC. No evidence of acute blood loss.
Open toe wound04/28/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
Unfortunately today Ryan has a extensive wound over the great toe on the left foot. This is malodorous. The wound beds are actively leaking a purulent material and there is gas production. The toe overall is very soft. This is very concerning for extensive necrotic tissue and also gangrene. I spoke with the wound care center to see if we can get him in urgently, the physician on-call they reviewed the pictures and expected extensive soft tissue infection and possible osteomyelitis and recommended an emergency department assessment. I discussed this with Ryan. The final recommendation is to present to the emergency department given the concern for this wound which is certainly toe threatening if not foot threatening. He states today that he is not sure if he will present to the emergency room. I was very frank with Ryan, I told him that I can certainly understand the stress he has been through recently and the fact the last place he wants to be is back in the hospital but the formal medical advice is to present urgently as I suspect he needs IV antibiotics and urgent imaging. He asked if this could be coordinated as an outpatient, this is virtually impossible at this time given delays in our imaging capabilities and the fact there is an active infection at this time. I asked Ryan again if he will present and he states he is not sure. I encouraged he and his wife who are each capable adults to have this conversation but again reemphasized the formal medical advice to present urgently to the emergency room. I did provide handoff to the emergency department providers so they are aware of his potential arrival.
Osteomyelitis of great toe of right foot (CMS-HCC) (CMS/HHS)04/28/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
He will continue vancomycin and cefepime through infectious diseases. Estimated completion date in Mid June. I wrote a letter to his place of employment to reflect this restriction.He should remain nonweightbearing or at least have his foot upright when he is sitting down until he is off his antibiotics.Followed by vascular now.
Copper deficiency02/17/2022
Chronic diastolic congestive heart failure (CMS-HCC) (CMS/HHS)01/25/2022
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Clapp DO agreed with CDI query for Acute on chronic diastolic (congestive) heart failure on 01/24/22 1620 Formatting of this note might be different from the original.
On asa and statin Euvolemic on exam Had a 80% blockage with PCI and stent placed Stable no recent exacerbations
Status post simultaneous kidney and pancreas transplant 5/31/201801/21/2022
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
WIT: 25 mins, CIT 3 hours, 44minsKDPI%: 29%Kidney: Donor ID: AFE2322CMV D-/R -Day of DC creatinine: 7.236Pre-operative creatinine: 8.36Initiation date:4/10/2015 Dialysis pre-transplant? yesFunctional Status: 80%DSA: noClass I PRA: 0% Class II PRA0 % HLA A2 B50 B62 Bw6 Cw4 Cw6 DR7 DR9 DR53 DQ2 DQ9Type of kidney transplant: DBDComplicated by Delayed graft function in the early postoperative periodCMV D-R- Standard Criteria Donor . KDPI 29% Transplant Surgery: MGH 5/31/2018 Formatting of this note might be different from the original.
I have asked him to address whether or not he would be a candidate for Evusheld with his transplant docs.
Nephrotic syndrome01/20/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- Nutrition consult placed for hypoalbuminemia - Low salt diet, 2L fluid restriction diet- Daily standing weights- Strict in/outs (with urinary retention protocol)- consider renal biopsy if 24 hr UPC is elevated- 24 hr urine protein, creatinine- Telemetry to assess for tachy mediated cause of CHF, patient has been refusing- Change Bumex 2 mg IV BID to Bumex 4 mg PO BID Plan:Transplant US demonstrated minimal pelvicaliectasis with small amount of adjacent fluid with elevated resistive indices and urinary bladder distention to 459 mL. Spot urine protein to creatinine ratio 7.5.Currently diuresing with Bumex with good output. Had been prescribed Bumex 1 mg prn in outpatient setting due to nephrotic syndrome after receiving rituxin last year but has not been taking recentlyPatient has a history of nephrotic syndrome managed by MGH with asa 325 mg and lisinopril. Patient with notable proteinuria and hypoalbuminemia on admission. Of note he was seen at BWH in March 2020 with 3+ nephrotic range proteinuria, dx with Antibody Mediated Rejection and was given rituxin. Considered protal vein thrombosis with elevated liver enzymes on admission but resolved so less likely. CHF less likely given TTE demonstrating normal LV size with moderately increased wall thickness, EF 65%, normal right ventricular size and systolic function. Hypervolemia noted on admission. Pro-BNP 6K. Received Bumex 2 mg IV in ED, put out 500cc independently. CXR with bilateral pleural effusions.
Decreased libido10/08/2021
Last Assessment & Plan:Formatting of this note might be different from the original.
Discussed with endocrine, they do not suspect hypogonadismThis is been a relatively new finding for Ryan, we review his prior testosterone readings which were in the lower ranges of normal. We discussed that there is some variability with testosterone readings depending on the time of day this is done. Would also want to consider upstream signaling. We discussed that decreased libido can be multifaceted in etiology, overall he is in a very strong relationship and can identify no additional stressors. We will go ahead and work this up and screen for low testosterone again.
PVD (peripheral vascular disease) (CMS-HCC V24)10/06/2021
Immunosuppression (CMS-HCC)01/16/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
-Follow-up tacrolimus level ordered for 8/5/2024-Continue tacrolimus 2 mg in the morning and 1 mg in the evening-Continue prednisone 5 mg daily-Continue azathioprine 100 mg daily-Appreciate nephrology/transplant consultation
Coronary artery disease involving native coronary artery11/24/2017
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PTCA of LAD and diag1 Dec 2017DES to mid LAD April 2015 Formatting of this note might be different from the original.
Continues on asa and plavixHx of PCI to LAD 5/2015 and POBA to LAD/diagonal bifurcation with POBA to existing LAD stent 12/2017
Acute respiratory failure with hypoxia with question of pneumonia09/25/2017
Last Assessment & Plan:Formatting of this note might be different from the original.
-Appreciate nephrology assistance with volume management via dialysis-Continue supplemental oxygen as needed with goal SpO2 greater than 92%-Will discuss antibiotic regimen with ID today Azithromycin 3 days 500mg in case this is CAP Consider CrAg, bdglucan, asp ag, silver stain for PJP F/u legionella, mycoplasma, MRSA nares-Appreciate ID recs:Has had a dry cough for ~1 month. The patient was started on 2 L of oxygen in the emergency department. Chest CT shows calcified nodules, ground glass, and lymphadenopathy. Differential diagnosis for hypoxemia includes pneumonia versus pulmonary edema. Potential exposures to mold in his workplace.
Hypertension09/25/2017
Last Assessment & Plan:Formatting of this note might be different from the original.
-Continue outpatient doses of losartan, amlodipine, carvedilol-Continue to monitor blood pressure closely
Hypertension secondary to other renal disorders05/18/2016
Last Assessment & Plan:Formatting of this note might be different from the original.
Monitor daily serum magnesium Labetalol 10 mg IV q 6 hr prn for systolic > 160 Hydralazine 50 mg po TID Carvedilol 25 mg po BID Aim for net negative 1 liter/24 hrs Bumetanide 4 mg po am and Bumetanide tablet 2 mg po daily before dinner. Rx:- lisinopril 2.5- carvedilol 25 bid- bumex 2&1 ( am & pm)Home meds:B/P 145/72 - 129/73 AP 80 + Anasarca. He is ~ 8 kg above his pre hospital weight Hx of HTN
Secondary hyperparathyroidism, renal (CMS-HCC)05/06/2016
Last Assessment & Plan:Formatting of this note might be different from the original.
-Continue cholecalciferol -Continue calcitriol 0.75 mcg 3 times weekly
Urinary retention01/22/2015
Last Assessment & Plan:Formatting of this note is different from the original.
- PVR Bladder scans 1-2x a day- Monitor for constipation - Acute urinary retention protocol- Hold desipramine\u00a0Able to urinate independently nowRequired straight cath on admission, traumatic with obstruction met per RN documentationUA non-infectious appearingEpisode of urinary retention on admission. Uncertain etiology. Potentially secondary to desipramine (which patient reports is a new diagnosis) vs autonomic dysfunction
Hyperlipidemia09/22/2010
Last Assessment & Plan:Formatting of this note might be different from the original.
- Well controlled on atorvastatin, LDL at goal.
ED (erectile dysfunction)01/15/2009
Last Assessment & Plan:Formatting of this note might be different from the original.
Using TRIMIX as prescribed through urology, he uses this PRN prior to sexual activity.
Chronic anemia with concern for possible GIB
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Stool occult blood negative and capsule study did not show any GI bleedingBone marrow suppression/MDS is possible though would likely see all cell lines decreased vs isolated anemiaLDH, haptoglobin, and bili are normal so less likely to be consumption/hemolysis, though tacro can cause MTA. Fe 96, TIBC low at 133, % sat 72, not c/w iron deficiency.Anemia is likely chronic in the setting of his CKD however MCV elevated 103, though B12 elevated to ~2000 and folate normalHemoglobin 7 on admission which may be contributing to his weakness and fatigue. Wbc and plt normal on admission. Baseline hemoglobin around 10 (December 2021) Formatting of this note might be different from the original.
- restarted oral iron- ldh and haptoglobin for evidence of hemolysis were not c/w that- monitor for overt GI bleeding- cont to monitor hgb/hct- GI not to scope this admission, however if continues to require transfusion would re-engage; outpatient EGD and colonoscopy with propofol with Dr. Stefan (his outpatient gastroenterologist)- transfuse for Hgb < 5 -(irradiated, cmv negative); or symptomatic- PO PPIS/p 5 units of blood. Patient denies black/bloody stools, hematemesisSemi- recent EGD and colonoscopy 10/2021, both of which grossly normal at that time as well as pathology results -- follow-up capsule study 1/2022 --also grossly normal.Labs on 4/27 showing hemoglobin of 5.6 --> he presented to the emergency department to receive 2 units of bloodPatient has anemia of chronic disease as well as iron deficiency
ESRD on hemodialysis (CMS-HCC) (CMS/HHS)
Last Assessment & Plan:Formatting of this note might be different from the original.
-Left arm precautions-Renal diet-Appreciate nephrology consultation-HD T/T/S while in patient
Resolved ProblemsNoted DateDiagnosed DateResolved Date
Protein-calorie malnutrition, unspecified severity (CMS-HCC) (CMS-HCC V24)01/29/202311/09/2023
Bacteremia10/11/202211/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
-US fistula pending-Continue with IV antibiotics: cefepime for now. Bactrim at dischargemri thoracic and lumbar spine negativeNow blood cultures with serratiaSource not obvious, however chronic wounds - DM foot ulcer (though look good), home dialysis line
Pancytopenia (CMS/HHS)10/11/202211/09/2023
Pancytopenia (CMS/HHS)10/11/202211/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
- consider DIC if worsening TCP with AM labs- HIV, chronic hep panel- trendPlan:Now WBC rapidly transitioned to leukocytosis, 19 today.Suspect related to acute illness. Macrocytic anemia (not new and HgB improved from previously)New thrombocytopenia, mild at 124WBC 1.5, lymphopenia, mild absolute neutropenia
Unresponsive episode10/11/202211/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
-tele x24 hours, uneventful. Removing. Plan:Suspect his syncope was secondary to a low flow state with hypotension. Additionally he reports restarting his lisinopril today for the first time in 2 weeks.Reportedly EMS found him unresponsive with low systolic? Wife reports he became unresponsive w BP 94/60 and tachycardic
Inadequate flow of dialysis arteriovenous fistula, initial encounter (CMS-HCC) (CMS-HCC V24)05/05/202211/09/2023
Last Assessment & Plan:Formatting of this note might be different from the original.
- has a stitch in place that will need to be removed 5/9 at dialysisFistulogram and angioplasty 5/6.
Leukopenia05/04/202205/13/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- continue current abx regimen pending specificitiesWondering if cefepime is causing marrow suppression and if he needs other antibiotic however multiple other causes. Patient with leukopenia.
Tenosynovitis of right foot05/03/202205/13/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
Immunosuppressed status does push the duration of treatment to longer (4 vs 3 weeks), but would be considered effectively treated at 3 week mark, at which point he would from an infectious perspective be able to okay for transplantation. Initially presenting with diabetic foot wound that progressed to osteomyelitis and tracked into the tendon. No growth on culture of tendon specifically, but right toe amputation growing 4+ alpha strep (likely culprit for purulent material found in tendon), 1+ corynebacterium, and 4+ gram positive organism that by gross appearance looks like Actinomyces. Additional organism have identified including campylobacter ureolyticus, finegoldia (pepto strep) magna. Path shows residual inflammation at margins on right toe but not from right toe tendon.
Sepsis (CMS/HHS)04/29/202205/02/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-blood culture?-UA?- monitor inflammatory labs- continue vancomycin + cefepime
Hemoperitoneum02/07/202202/09/2022
Last Assessment & Plan:Formatting of this note is different from the original.
- pain well controlled not requiring PRNs overnight- Wound:\u00a0midline incision closed with staples, dressed with gauze and tape, change prn for soiling; wicks to be removed POD 3 (?by surg)- Monitor abdominal exam closely, low threshold to re-engage surgery if needed- Transfuse for <6 given immunocompromised- Trend HgB - 1500 check. Access: LIJHgB this AM slightly lower than priors (7.3 from 7.9 )Overnight HDSKidney biopsy on c/b hemoperitoneum and hemorrhagic shock requiring pressors, intubation for ex-lap on 2/3, and fascial closure on 2/3
Hemorrhagic shock (CMS-HCC) (CMS/HHS)02/03/202202/07/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-plan for hemodialysis for hyperkalemia-patient will be transferred to surgery ICU primary after OR procedure-OR with surgery for control of bleedingPlan:Noted to be hypotensive to 70 systolic with dropping hemoglobin in the setting of post procedure for renal biopsy to evaluate for nephrotic syndrome. CT of abdomen/pelvis demonstrated left rectus sheath hematoma. CT was done without contrast due to poor renal function, creatinine 2.6. Patient was initially admitted to transplant service. Given that patient remained hypotensive with altered mental status with further driving hemoglobin to 5.3 status post 3 L of IV fluids, general surgery consulted for control of bleed and went to the OR. Critical care was involved at this time. Patient received three units of packed red blood cells. Transfusion complicated by patient having co-current refractory hyperkalemia with with peaked T waves on stat EKG.
Anemia, unspecified01/21/202202/04/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- Vitamin with minerals given low copper- Monitor for nowHgb 8.2 on admission was down to 6.9 with improvement to 8.2 on repeat. Zinc slightly low at 36. Appreciate work-up at last admission and given darbopoeitin at that time.
Elevated troponin level01/20/202201/23/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- STAT EKG for chest pain- Monitor closely for ACS- Telemetry, patient refusingDelta troponin 0.04Refused telemetry, risks awknowledgedSuspect elevated troponin is secondary to myocardial injury due to hypervolemia, in addition to elevation in the setting of ESRD.Troponin 0.05 on admission with EKG that appears similar to previous without convincing signs of active ischemia and without symptoms concerning for ACS (though with history of type 1 diabetes could present with silent ischemia)
Elevated liver enzymes01/20/202201/21/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- Consider abdominal ultrasound of portal venous system if further work-up of hypervolemia is unrevealing.- Will need further assessment if not improved with diuresis- Continue to monitor for nowR factor of 1 suggestive of cholestatic injury, suspect from hepatic congestion in light of hypervolemia. Less likely infiltrative disease (Ferritin last checked 1/13/22 and was 391, no elevated calcium to suspect granulomatous disease). Lipase last checked and was 82 (1/12/2022). CMV PCR 1/13/22 not detected.
Metabolic acidosis, normal anion gap (NAG)01/12/202201/16/2022
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Serum ketones negative, Elevated serum osm 308 with a calculated osm of 316, serum osm gap is 6, less than 8 so less likely to be a toxic ingestion Formatting of this note might be different from the original.
- Compression stockings for LE edema- Discontinue bicarb ggtPresented with anion gap of less than 7 on initial CMP, corrected to 12 when accounting for albumin; Likely 2/2 GI losses of bicarb; less likely to be RTA or ingestion, and no pancreatic diverticula or ureteral fistula seen on CTAP
Electrolyte disturbance01/12/202201/17/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Replace Mag prn, will try magnesium gluconnate to see if this is a better option than mag oxide for outpatient use-Replet prn-Monitor with daily BMP, mag-Hold home lokelmaPlan:K now low as wellK normal on presentation but mag low likely 2/2 diarrhea vs tacroHas h/o of hyperkalemia, on lokelma every 2 to 3 days at home
Weakness01/12/202201/17/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Consider PT/OT consults pending functional status-Encourage p.o. intake as toleratedLikely due to dehydration and non-anion gap metabolic acidosis as well as anemia versus infection versus electrolyte abnormalities
AKI (acute kidney injury) (CMS-HCC V24)01/12/202201/17/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Monitor daily BMPPlan:Creatinine now nearly at baseline Creatinine on admission 2.63 likely iso volume depletion/hypotensionBaseline creatinine ~1.9-2.1 as of December 2021, however was at a baseline of approximately 1.5 in the summer 2021
Vaccine counseling10/08/202101/21/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
Pleasant 43-year-old who who request the high-dose flu vaccination, we discussed that the indication for this is age over 65 not for underlying immunosuppression. He discusses that he has received a high-dose flu vaccine as the recommendation of his transplant team for numerous years. There shared decision making we do administer this vaccine today. He is fully vaccinated against COVID-19.
Skin ulcer of left foot, limited to breakdown of skin (CMS/HHS)10/06/202110/06/2021
Diarrhea, unspecified10/06/202102/04/2022
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
CTAP w/ fluid in distal colon suggestive of diarrhea, no calcification or diverticula of pancreas seen Etiology remains unclear however differential includes infectious (C. difficile versus CMV versus norovirus versus other bacterial or viral gastroenteritis versus influenza versus COVID) versus, medication side effects with the most likely culprit being microscopic colitis secondary to mycophenolate versus PPI versus magnesium oxide. Less likely to be pancreatic insufficiency as synthetic function of the pancreas remains intact. Also less likely to be IBD or other autoimmune colitis as he has been on immunosuppressionIn October he had an endoscopy and colonoscopy which unfortunately was limited by poor prep but visualized mucosa appeared normal. Random biopsies obtained showed some chronic gastritis, otherwise unrevealing for cause. Per outpatient GI notes a capsule endoscopy was planned.Records from Portland Gastroenterology show patient has a history of C. difficile in 2016, as well as norovirus in 2019. Initial Portland GI consult note indicates that the patient has been having intermittent bouts of severe diarrhea for roughly 1 year, despite high amounts of Imodium. Has also tried cholestyramine without much effect. Has been on desipramine nightly. Formatting of this note might be different from the original.
-Continue to hold mycophenolate; may need to switch to Myfortic or azathioprine, so far unsuccessful at contacting transplant team at MGH to discuss due to weekend/holiday hours-Follow-up Fecal elastase-Stool leukocyte ordered-GI consulted, appreciate recommendations-Imodium 2 mg q2h prn w/ max of 16 mg dailyPlanNorovirus G2 detected. Of note, he was positive for Norovirus G2 in December 2019, ~1 year prior to this episode of prolonged diarrhea. In an immunocompromise patient, norovirus can cause protracted diarrhea after initial exposure but unlikely to be causing this long of a course. Although he was positive in 2019, it is unclear if his PCR would remain positive for 2+ years but very unlikely that that initial exposure in 2019 is causing his current diarrhea. Regardless, treatment is typically supportive care.Fecal calprotectin normalCapsule endoscopy unrevealingC. Diff negative, CMV negative, Giardia negativeEtiology remains unclear however differential includes medication side effects with the most likely culprit being microscopic colitis secondary to mycophenolate (versus PPI versus magnesium oxide. Vs infectious~10-12 months of diarrhea
Family hx of prostate cancer08/05/202102/04/2022
Weak urine stream08/05/202102/04/2022
Nausea vomiting and diarrhea12/19/201912/21/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
- Will check in around noon, if nausea/vomiting continues to improve - will restart oral home meds. May hold myfortic for one more day given side effect of GI upset. Received 8 mg methylprednisone this AM (higher dose than home prednisone as may need to hold myfortic today).- Replete Mg IV, hold oral magnesium given diarrhea- PRN compazine- IVF LR maintanence fluid- Will progress diet to clear liquidsTx:- Follow-up C Diff- Follow-up blood cultures x2, Stool cultures (bacterial and viral), CMV Serum PCRDx:Improving with conservative treatment (anti-emetics, bowel rest, IV fluids). Leading differential: viral gastroenteritis. Though given transplant status, need to consider CMV, C Diff, bacterial infections.
Renal transplant recipient11/11/201901/21/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Immunosuppression as elsewhere Plan:CTAP without obvious concern in the kidneys though transplanted kidney not able to be fully evaluated without contrastBaseline creatinine from last labs done in December 2021 appears to be ~1.9-2.1Followed by Dr. GilliganRenal transplant MGH in May 2018
Osteomyelitis of ankle or foot, acute, left (CMS/HHS)04/16/201910/06/2021
Last Assessment & Plan:Formatting of this note might be different from the original.
- Consult to PICC team placed- Blood cultures, wound cultures pending- Vascular consulted, wound culture sent, follow-up with wound center and Dr. Aranson set up- Will follow-up ID re: antibiotics after culture returns- Continue IV vancomycin and cefepimePlan:Patient presenting with left foot wound after stepping on stone 5 weeks prior to admission 4/5, found to have osteomyelitis by MRI, poor pulse with associated loss of waveform in left foot on US doppler 4/7. Refused surgical intervention at prior admission and left AMA on 4/8. Representing today as planned admission. Interval drainage of left foot wound since 4/15
History of orthostatic hypotension04/06/201902/04/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
-Maintenance fluids, clear liquid diet, monitor BP-Restarting fludrocortisone when able to tolerate PO.History of orthostatic hypotension and has been taking fludrocortisone for this.
Diabetic foot infection (CMS-HCC) (CMS/HCC) (CMS/HHS)04/05/201910/06/2021
Last Assessment & Plan:Formatting of this note might be different from the original.
- Dressings: betadine paint to the ulcer with dry guaze.- F/u with primary team and ID reguarding optimal PO abx and plan for IV abx initiation after return from trip. - Continue vancomycin, cefepime- MR: Positive for left TM head/phalanx osteomyelitis.Left plantar foot ulcer, ?probed to 5th TMA head. No wet gangrene or drainage. Erythema improving.
Pancreas transplant status (CMS/HHS)01/16/201902/04/2022
Overview:Last Assessment & Plan:Formatting of this note is different from the original.
Received on ice, stayed on iceWIT: 25 mins, CIT 3 hours, 44minsKDPI%: 29%\u00a0Kidney: Donor ID: AFE2322CMV D-/R -Day of DC creatinine: 7.236Pre-operative creatinine: 8.36Initiation date:4/10/2015 Dialysis pre-transplant? yesFunctional Status: 80%DSA: noClass I PRA: 0% Class II PRA0 % HLA A2 B50 B62 Bw6 Cw4 Cw6 DR7 DR9 DR53 DQ2 DQ9Type of kidney transplant: DBDOriginal kidney disease: DiabetesTransplant date:5/31/2018 Formatting of this note might be different from the original.
- Immunosuppression as elsewhereSynthetic function of pancreas evaluated on last admission and was wnlReceived islet cell transplant in 2018 at MGH
Preop cardiovascular exam12/05/201701/16/2019
Diabetes type I09/25/201701/16/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
- hypoglycemia protocol in place. - diabetic diet.- continue correctional short acting. - reduce his am dose to 28 units and his night dose to 24 units.Reportedly last A1c 7.4.Takes detemir 35 units in am and 30 units at night along with correctional insulin. Apparently well controlled but with complications as above.
End-stage renal disease on hemodialysis09/25/201701/16/2019
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Casco Bay dialysis - MWF; Dr. Cantlin Formatting of this note might be different from the original.
I talked to the nurse and arranged for that So the decision was done to dc him to do his hd session at Cascobay center today as scheduledCardio team will dc pt today before doing cathPotassium 6, would like to do HD prior to the cardiac cathPlan on next dialysis: todayCurrent Situation: StablePrimary outpatient nephrologist: CantlinDialysis Duration 5 hrsDialysis Days Mon/Wed/Fri Arm Precautions NAccess Function: NormalLocation: Left Access: AVF fistulaAttends renal replacement therapy at Casco Bay Dialysis Facility Patient has ESRD due to DM1Nephrology Assessment and Plan
Fatigue11/02/201601/16/2019
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Worsened anemia probably playing a partial role, but he has tolerated as bad previously - see anemia plan aboveReceiving empiric antibiotics for pneumoniaHas tolerated volume removal wellNo clear single etiologySignificantly improved
Hypertensive urgency09/09/201601/16/2019
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- Will hold on addition more antihypertensives this AM, to avoid hypotension/reletive hypotension in HD. Will reconsider after HD today. - dialysis this AM- labetalol 10 mg IV prn SBP > 160- continue home oral anti-hypertensives including labetalol 400 mg TID, hydralazine 50 mg TID, lisinopril 40 mg, amlodipine 10 mgNo clear end organ dysfunction (troponin at baseline, creatinine elevated in setting of ESRD, no chest pain, no changes in mentation). Unclear etiology, patient reports he was compliant with all of his home meds and does not appearing significantly fluid overloaded on exam. Has had similar hypertensive episodes in the past that have been unprovoked.
Near syncope05/18/201601/16/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
-no indication to broaden antibiotics or reculture at this time. -hold antihypertensives-500cc fluid bolus-hold on dialysis todayPresyncope event in dialysis with SBP in 90''s which increased to 120''s once patient was laying flat. Likely due to volume depletion from aggressive dialysis for pericardial effusion and now with diarrhea. No new signs to suggest respiratory process. Echo from yesterday was improved so doubt any enlargement of pericardial effusion or tamponade physiology. WBC is improving with treatment of C.diff
Clostridium difficile diarrhea05/16/201601/16/2019
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-Enteric precautions-cont Metronidazole day 2/10Acute onset of frequent liquid stools 5/16 without abdominal pain - C.diff +
Acute hypoxemic respiratory failure05/12/201602/08/2022
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-O2 protocol, wean as tolerated-HD per Nephrology-ABX as aboveLikely multifactorial, due to pleural effusions R >> L, new opacity of RLL
Pericardial effusion05/11/201601/16/2019
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Repeat echo with cardiology follow up arranged
Uremic pericarditis05/11/201601/16/2019
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Short course of steroids completed todayWill monitor on regular hemodialysis Very much improved clinically
End-stage renal disease on hemodialysis05/11/201601/16/2019
Renovascular hypertension05/11/201605/15/2016
Last Assessment & Plan:Formatting of this note might be different from the original.
-Continue amlodipineBPs elevated, likely some aspect of volume overload contributing
Type 1 diabetes mellitus complicated by ESRD now s/p kidney and pancreaus transplant 201805/11/201602/04/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
- See immunosuppressionAlso c/b autonomic dysfunction w/ known gastroparesis. History of type 1 diabetes mellitus now s/p kidney and pancreatic transplant 2018 followed by Dr. Gilligan (Massachusetts General Hospital).
Coronary artery disease involving native coronary artery of native heart without angina pectoris05/11/201601/16/2019
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Labetalol and high intensity statinDual antiplatelet therapy (DAPT) with Aspirin (ASA) 81 mg daily and Clopidogrel (Plavix) 75 mg daily History of coronary stents
Volume overload05/11/201602/04/2022
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-Fluid restriction, low Na diet-Continue daily HD (except Sundays)HD again today for further volume overload, will continue to challenge EDW as tolerated
Hyponatremia05/11/201601/16/2019
Pneumonia05/11/201605/17/2016
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- O2 support PRN- stop vancomycin and cefepime (pt s/p a 10 day treatment course)Blood cultures negative at 48 hoursRecently discharged on PO treatment of RML PNA on levofloxacin, now presenting with profound weakness, increased O2 requirement.
Hypoxia05/09/201601/16/2019
Esophagitis05/08/201601/16/2019
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- Also takes TUMS for renal indications - Omeprazole 40 mg PO daily - F/up biopsies PPI started per GI recs; as discussed with the patient by Dr. Buzanoski today, this is not for relief of symptoms (he denies any) but for prevention of long-term damage and Barrett''s Esophagus. Found on EGD; likely caused by his chronic vomiting 2/2 gastroparesis.
Colon polyps05/07/201601/16/2019
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- Will need a follow-up colonoscopy in 1 year with better prep - F/up biopsy results - Monitor for further GI bleeding Unusual finding in a young patient. New finding on colonoscopy today. Prep quality was poor, therefore possibly not all polyps were visualized.
Coronary artery disease05/07/201601/21/2022
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-Continue home meds: ASA, statin, plavix, blockerDiffuse ST elevations on admission due to pericarditis. Flat troponins x3 likely elevated due to ESRDHistory of DES to LAD in 2015 following MI.
Murmur, cardiac05/06/201601/16/2019
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- Monitor clinically - Further dialysis per Nephrology Unable to follow through with prior plan of obtaining fluid sample from pleural effusion, as the effusion is reduced today.Given also pleural effusion and profound anemia, this is suspicious for an additional systemic inflammatory process e.g lupus. Infections (viral) pericarditis with effusion also possible. However, as the rub appears to improve after he received extra HD yesterday, uremic etiology is supported. Discussed with Nephrology, their impression is that this is possibly uremic pericarditis. TTE showed mild MR and mild TR and a small circumferential pericardial effusion.Most likely transmitted noise from fistula vs flow murmur vs pericardial rub.
Healthcare-associated pneumonia05/05/201601/16/2019
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- Blood cultures reported sent from Casco HD on 5/2 -- no results of this found at NorDx Microbiology - we will follow up with the dialysis center prior to discharge. - Supplemental O2- Incentive spirometry- D/c IV antibiotics and will complete treatment with PO levofloxacin dosed for dialysis - 250 mg Q 48 hrs Plan:Not likely this is a MRSA pneumonia given his rapid improvement, relative stability from a pulmonary point of view, and no dramatic findings on lung exam or imaging. Antibiotics narrowed to vancomycin + cefepime on 5/8. This effusion appears reduced in side on repeat CXR today and on bedside ultrasound by Pulmonology fellow Dr. Ranganath. Therefore thoracentesis was not attempted. Upright and lateral CXRs showed sizeable, mobile pleural effusion on the right -- likely infectious vs inflammatory in origin. Sputum culture with polymicrobial mix (GPC, GPR, GNR). Flu swab negative in ED.Treated for HCAP with cefepime + vancomycin given HD exposure, with ciprofloxacin added initially for GI coverage. Hemodynamically stable, on 2L O2 (none at baseline), does not meet SIRS criteria. Pattern appears most consistent with a bacterial infection given loculation on CXR. Primary complaint of dyspnea on exertion and weakness on presentation.
Complication of AV dialysis fistula03/01/201611/09/2023
Vitreous hemorrhage of right eye12/10/201501/16/2019
Type 1 diabetes mellitus with nephropathy (CMS/HHS)12/10/201505/13/2022
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
IMO Dx Update Formatting of this note might be different from the original.
Remote history of diabetes type 1 insulin-dependent, since his islet cell transplantation he no longer has insulin dependency and is making his own endogenous insulin.
Encounter for removal of vascular catheter10/09/201501/16/2019
Syncope09/16/201505/05/2016
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- f/u with cards next week, consideration for loop recorder if arrhythmia is felt as likely cause of syncope, although anemia is first on DDx- teleAtraumatic/non LOC syncopal event x 1 yesterday with preceding dizziness. Sugar wnl, found to be orthostatic upon standing. With Hgb 6.3, first concern is for anemia induced syncope. Does have CAD with recent elective stent placement, but denies palpitations during the event. No neuro deficits to suggest central process
NSTEMI (non-ST elevated myocardial infarction) (CMS-HCC) (CMS/HHS)09/15/201505/05/2016
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- f/u with outpatient cardiologist next week- no more tropTrop > 0.3, now trending down. No baseline trop. Given anemia, difficult to convince myself this is not a type 2. Has underlying atherosclerosis d/t years of IDDM
Intracranial hypertension09/03/201501/16/2019
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Ryan has a complex ophthalmologic history given multiple pathology in the eye related to his diabetes. From review of his ophthalmologists records, it seems pretty clear that he had an acute change a week ago. Prior eye exams did not demonstrate papilledema in contrast to his ophthalmologic exam from September 1, 2015. His neuro imaging suggests that this is idiopathic intracranial hypertension at least in so much as there is no structural problem and no venous sinus thrombosis. This condition has been known to develop in the setting of hypertensive crisis and profound hypotension such as cardiogenic shock. I find nothing in the literature to suggest it could be a delayed complication of profound hypoglycemia although he was hospitalized 2 weeks or earlier with severe hypoglycemia. This is not a condition typically associated with end-stage renal disease and dialysis. The kidney problem complicates management of ICP following today''s lumbar puncture. It is my opinion that Diamox would not be effective although I will discuss it tomorrow with his nephrologist. Because this is such an unusual presentation in a patient with severe chronic conditions, there is no way of predicting whether the ICP will rise again and over what period of time. It will be hard to monitor her vision complaints because of coexisting diabetic retinopathy, vitreal hemorrhages and cataracts. I think the better part of valor is to refer him for a neuro-ophthalmology to evaluation at Tufts University with Dr. Hedges. I spoke to the patient''s ophthalmologist who will arrange to see him and repeat his funduscopic and visual assessment tomorrow and arrange for subsequent periodic visits in conjunction with a neuro-ophthalmologist.
Hyperkalemia08/07/201502/04/2022
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-sodium bicarb 150 mEq at 100 cc/h-plan for hemodialysis for hyperkalemia-remain on telemetryPlan:Potassium elevated to 7 post procedure of renal bx. Peaked T waves noted on EKG. potassium remained elevated despite sodium bicarb, insulin, calcium gluconate,lokelma.
Severe diabetic hypoglycemia (CMS-HCC) (CMS/HHS)08/07/201508/08/2015
Type 1 diabetes mellitus (CMS/HHS)08/07/201509/16/2015
ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS)08/07/201509/15/2015
Renovascular hypertension08/07/201509/16/2015
CKD (chronic kidney disease), stage V (CMS-HCC) (CMS/HHS)08/04/201509/15/2015
Last Assessment & Plan:Formatting of this note might be different from the original.
I will need to discuss with his nephrologist whether there could be any relationship between his kidney failure and This otherwise idiopathic intracranial hypertension. I am also uncertain whether it would be safe or even effective to use Diamox.
Renovascular hypertension06/19/201509/15/2015
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Now with hypertensive urgency. Plan and medications as above.
Hypertensive urgency06/19/201505/05/2016
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The patient had a hospitalization in June with hypertensive crisis with symptoms of headache. Interestingly with his intracranial hypertension he did not have headache, only vision loss. I do not believe that his episode of hypertensive crisis in June was the proximate cause to be intracranial hypertension since he did not have papilledema on funduscopic exam until his most recent visit on September 1..
Shortness of breath06/19/201509/15/2015
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Shortness of breath at rest without oxygen requirement, cough/sputum, or chest pain. Also without increased work of breathing. Previously pulmonary edema seen on CXR about 10 days ago. Patient associates with HA and elevated BP, so there may be some pain or anxiety component. CXR with increased institial markings
CAD (coronary artery disease)04/14/201501/21/2022
Last Assessment & Plan:Formatting of this note might be different from the original.
Follows with Dr. Vasiwalla @ MMP Cardiology, history of PCI with stenting in 2015.
ESRD (end stage renal disease) on dialysis (CMS/HHS)04/10/201501/16/2019
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Reason for dialysis: solute clearance, volume removalReceives dialysis MWF at Casco Bay. Fistula functioning well. EDW 70.2 kg. Formatting of this note is different from the original.
Special Instructions 2.5 Ca, low dose heparin \u00a0 Bicarb 30 mEq \u00a0 Na+ 137 mEq \u00a0 K+ 2 mEq \u00a0 Dialysate type Bicarbonate \u00a0 Dialysate Flow Rate (ml/min) 800 ml/min \u00a0 Blood Flow Rate (cc/min) 400 cc/min \u00a0 Dialyzer Optiflux 160 \u00a0 Duration of Treatment 5 Hours \u00a0 Fluid removal goal To be determined \u00a0 Target Dry Weight Other (please specify) 72 kg Ultrafiltration only No Dialysis today and resume his normal scheduleHome prescription 5 hrs, Optiflux 160, BFR 400, EDW 72 kg, 2K, 2.5Ca, 1 Mg - we are using bigger dialyzer and doing 4 hoursAccess right AV fistulaMWF at Casco Bay, last dialysis Monday
Uremia04/09/201509/15/2015
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- Nephrology followingFollowing. Improving with dialysis.
Hypoglycemia01/22/201506/19/2015
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-if trends up and stabilizes, may be ok to discharge later this afternoon- prandial dosing if needed- regular diet for now until BS stabilize- basal insulin decreased from 54 units BID to 15 units BID- have dose his meds according to home schedule- has ordered breakfast- 1/2 amp dextrose given with BS 128Plan:BS 27 this am- patient has not eaten since 7pm last night (finally got to floor and fell asleep)Felt to be secondary to decreased oral intake prior and post surgery. Confusion multifactorial with hypoglycemia and oxycodone playing roles. Clear now. Assessment:
Intervertebral lumbar disc disorder with myelopathy, lumbar region01/20/201501/16/2019
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-Recheck CK pending-scheduled tylenol and lower oxycodone 5-10 mg prn to 2.5 prn. -Follow up as previously directed.Plan:CK elevated to 632-1398.Procedure performed 1/20. Wound appears stable.Assessment:
Anemia of chronic renal failure, stage 5 (CMS/HCC) (CMS/HHS)06/04/201201/16/2019
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-Convert to Aranesp 25 mcg q7 days while here-Hold IV iron until infection ruled outOutpatient regimen - Epogen 1300 mg TIW, Venofer 50 mg q4 weeks with last dose 9/18Hgb 8.7 today, stable
Hyperphosphatemia08/03/201101/16/2019
HTN (hypertension)08/18/200901/16/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
Would continue home meds amlodipine, labetalol, and lisinoprilHypertension improved as expected with volume removalHas struggled with high intradialytic weight gains and is on a multidrug antihypertensive regimen
Type 1 diabetes mellitus (CMS/HHS)01/15/200909/15/2015
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
(DX 1996) JOHN DEVLIN MD Formatting of this note might be different from the original.
- low dose correctional coverage at ac and hs- POC BG ac and hs- Reduce home regimen of detemir to 22 units BID given decreased oral intakeHome regimen of detemir 44units BID
Type 1 diabetes mellitus with diabetic chronic kidney disease (CMS/HHS)09/16/2015
Last Assessment & Plan:Formatting of this note might be different from the original.
I do not believe that his current issue of intracranial hypertension with papilledema was caused by his hypoglycemic episode on August 7, 2015. I could not find anything in the literature relating these 2 and it seems like the onset of his symptoms was later in August.
Anemia due to subacute blood loss01/16/2019
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- Pt is a transplant candidate, so transfusion goal will be Hgb <6 with discussion with Nephrology prior- Try to avoid blood transfusion if possible- Holding off further work-up for inflammatory disease at this time - F/up polyp pathology - Omeprazole 40 mg daily per GI - Will need GI follow up including repeat colonoscopy per GI - Monitor Hgb Q 12 hrs through tomorrow and clinically for any worsening - Iron replacement and Mircera per Nephrology Plan: Iron panel consistent with iron storage depletion, likely due to chronic GI blood loss vs depletion from long-standing inflammatory process.Elevated inflammatory markers (CRP 204, ESR 97) suspicious for further anemia of inflammatory disease. PPI started for esophagitis -- see separate. Now s/p EGD with Dr. Stefan on 5/7 which revealed esophagitis and a hiatal hernia, and colonoscopy on the same day finding multiple adenomatous-appearing polyps including two that were oozing blood. Polyps were removed and the source of bleeding clipped. Pathology pending. History of unexplained anemia (beyond that expected for anemia of ESRD), with Hgb as low as 5 in the past requiring transfusion, and a previous attempt at GI work-up during hospitalization in 2015 deferred due to other health issues.
Pleural effusion01/16/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
See under pneumonia
High blood pressure01/16/2019
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
IMO Dx Update Formatting of this note might be different from the original.
-will hold anti-hypertensives at this timePre syncope event with low BP in 90''s Lisinopril 40mg Labetalol 800mg TID on dialysis days, 200mg TID on alternating days Hydralazine 50mg TID Sun, Tue, Thurs Amlodipine 10mg dailyHome regimen:
Hospital-acquired pneumonia01/16/2019
Type 1 diabetes mellitus with stage 1 chronic kidney disease (CMS-HCC) (CMS/HCC) (CMS/HHS)05/18/2016
Acute nonintractable headache01/16/2019
Coronary artery disease involving native heart without angina pectoris01/16/2019
Type 1 diabetes mellitus with chronic kidney disease on chronic dialysis, with long-term current use of insulin01/16/2019
Acute pulmonary edema (CMS-HCC) (CMS/HHS)11/03/2016
Pneumonia of right lung due to infectious organism01/16/2019
Hemorrhage of arteriovenous fistula, initial encounter01/16/2019
Chronic diarrhea02/04/2022
Open wound of anterior abdominal wall02/09/2022
Acute blood loss anemia11/09/2023
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(chronic kidney disease), stage V (CMS-HCC) (CMS/HHS)", "reference": "Condition/46d95a44-7fc4-e89f-a247-15a4d61ffcb8"}, {"display": "Problem - Hyperkalemia", "reference": "Condition/02c15dc6-729f-1982-be7e-f40e3db61427"}, {"display": "Problem - Severe diabetic hypoglycemia (CMS-HCC) (CMS/HHS)", "reference": "Condition/c8f45f19-40b1-d08a-9eb9-1908d714ae58"}, {"display": "Problem - Type 1 diabetes mellitus (CMS/HHS)", "reference": "Condition/409f300b-5fb3-521f-5bdb-4f0fd1c820b5"}, {"display": "Problem - ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS)", "reference": "Condition/c6fc98e6-4238-2954-b863-782e7a94b1c4"}, {"display": "Problem - Renovascular hypertension", "reference": "Condition/2980ed90-a774-f777-9cff-fae7f7df076c"}, {"display": "Problem - Type 1 diabetes mellitus with diabetic chronic kidney disease (CMS/HHS)", "reference": "Condition/4c730e7b-ff75-8af4-6625-7f06744e1c51"}, {"display": "Problem - Intracranial hypertension", "reference": "Condition/2274e26b-3906-27fb-f257-762670546774"}, {"display": "Problem - NSTEMI (non-ST elevated myocardial infarction) (CMS-HCC) (CMS/HHS)", "reference": "Condition/c11e9c84-2a79-6926-5991-a913001b4a71"}, {"display": "Problem - Syncope", "reference": "Condition/549bbab2-98f3-a436-cec0-3e38c1abeea5"}, {"display": "Problem - Encounter for removal of vascular catheter", "reference": "Condition/1fd319ff-e55e-cde6-c967-68dae1451d35"}, {"display": "Problem - Vitreous hemorrhage of right eye (CMS-HCC) (CMS/HHS)", "reference": "Condition/78536afd-cc26-8181-e02d-a29d0d180123"}, {"display": "Problem - Type 1 diabetes mellitus with nephropathy (CMS/HHS)", "reference": "Condition/485fc8c2-9985-da7c-52c2-7f6e65d37690"}, {"display": "Problem - Complication of AV dialysis fistula", "reference": "Condition/2bb775b9-6c39-9112-70bf-07e9cb7ce07f"}, {"display": "Problem - Healthcare-associated pneumonia", "reference": "Condition/7949b5d4-767b-dff7-e6c8-c5610f23aabe"}, {"display": "Problem - Murmur, cardiac", "reference": "Condition/d10c6027-5864-a4ed-067c-b250b528a866"}, {"display": "Problem - Secondary hyperparathyroidism, renal (CMS-HCC V24)", "reference": "Condition/7c1ad36f-a76f-95d9-08d5-5cb1a756979c"}, {"display": "Problem - Anemia due to blood loss, chronic", "reference": "Condition/b05a7c7b-bc1b-2e53-220a-de0ad1ef9f6f"}, {"display": "Problem - Pleural effusion", "reference": "Condition/5f42a2aa-b07e-2188-886b-df4b9f4bfd1b"}, {"display": "Problem - Colon polyps", "reference": "Condition/e3719be2-3c7b-c5d9-9806-4ffd1a2668b0"}, {"display": "Problem - Coronary artery disease", "reference": "Condition/850767a8-2037-29d9-711e-ec8b60192bac"}, {"display": "Problem - High blood pressure", "reference": "Condition/5b706556-1bc3-a777-361c-124eb73ba71f"}, {"display": "Problem - Esophagitis", "reference": "Condition/7a921454-a5d3-b7fd-33c7-98c4fcfde749"}, {"display": "Problem - Anemia, unspecified", "reference": "Condition/718dd906-9458-b778-39f6-e770b7e7f491"}, {"display": "Problem - 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Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: FormerCigarettes113Quit: 02/01/2007
Smokeless Tobacco: Never
Alcohol UseStandard Drinks/WeekComments
Not Currently0 (1 standard drink = 0.6 oz pure alcohol)very infrequent 1 glass of wine a month
Humiliation, Afraid, Rape, and Kick questionnaireAnswerDate Recorded
Within the last year, have you been afraid of your partner or ex-partner?No08/03/2024
Within the last year, have you been humiliated or emotionally abused in other ways by your partner or ex-partner?No08/03/2024
Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner?No08/03/2024
Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?No08/03/2024
AUDIT-CAnswerDate Recorded
Q1: How often do you have a drink containing alcohol?Monthly or less08/03/2024
Q2: How many drinks containing alcohol do you have on a typical day when you are drinking?1 or 208/03/2024
Q3: How often do you have six or more drinks on one occasion?Never08/03/2024
PHQ-2AnswerDate Recorded
Patient Health Questionnaire-2 Score008/03/2024
Hunger Vital SignAnswerDate Recorded
Within the past 12 months, you worried that your food would run out before you got the money to buy more.Never true08/03/2024
Within the past 12 months, the food you bought just didn''t last and you didn''t have money to get more.Never true08/03/2024
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthMale12/19/2019 1:56 PM EST
Gender IdentityMale12/19/2019 1:56 PM EST
Sexual OrientationStraight04/28/2022 11:54 PM EDT
Job Start DateOccupationIndustry
Not on fileNot on fileNot on file
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DateTypeDepartmentCare Team (Latest Contact Info)Description
08/03/2024 12:31 PM EDT - PresentHospital EncounterMaineHealth Maine Medical Center Portland Richards 522 Bramhall StPortland, ME 04102-3134207-662-2217Sanders, Stephen Patrick, MD22 Bramhall StPortland, ME 04102207-662-7010 (Work)207-662-7025 (Fax)Zarookian, Emily I, MD22 Bramhall StRm 2227Portland, ME 04102-3134207-662-4618 (Work)207-662-6254 (Fax)Klein, Raymond, MD22 Bramhall StRm 2227Portland, ME 04102-3134207-662-4618 (Work)207-662-6254 (Fax)
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Overview:
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Last Assessment & Plan:
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(DX 1996) JOHN DEVLIN MD
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System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/3038c5e1-8a36-6a58-4cde-8331a824543f"}}, {"fullUrl": "urn:uuid:8c99f1cb-cd89-44e9-0ce7-347b5497754c", "resource": {"resourceType": "Condition", "id": "8c99f1cb-cd89-44e9-0ce7-347b5497754c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "182048"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N52.9", "display": "ED (erectile dysfunction)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2009-01-15", "note": [{"text": "Last Assessment & Plan:
problemNote140
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Using TRIMIX as prescribed through urology, he uses this PRN prior to sexual activity. "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8c99f1cb-cd89-44e9-0ce7-347b5497754c"}}, {"fullUrl": "urn:uuid:8f3e1344-bbf0-cdf1-8ce0-568d8a12144d", "resource": {"resourceType": "Condition", "id": "8f3e1344-bbf0-cdf1-8ce0-568d8a12144d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "753141"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I10", "display": "HTN (hypertension)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2009-08-18", "note": [{"text": "Last Assessment & Plan:
problemNote142
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Has struggled with high intradialytic weight gains and is on a multidrug antihypertensive regimen
Hypertension improved as expected with volume removal
Would continue home meds amlodipine, labetalol, and lisinopril"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8f3e1344-bbf0-cdf1-8ce0-568d8a12144d"}}, {"fullUrl": "urn:uuid:4474edf1-b4aa-f5f4-92bb-5bca83623054", "resource": {"resourceType": "Condition", "id": "4474edf1-b4aa-f5f4-92bb-5bca83623054", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "1219953"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E78.5", "display": "Hyperlipidemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2010-09-22", "note": [{"text": "Last Assessment & Plan:
problemNote151
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- Well controlled on atorvastatin, LDL at goal. "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4474edf1-b4aa-f5f4-92bb-5bca83623054"}}, {"fullUrl": "urn:uuid:83ea6255-cdd2-79cd-1fa4-030cda6acc0d", "resource": {"resourceType": "Condition", "id": "83ea6255-cdd2-79cd-1fa4-030cda6acc0d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "1990988"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E83.39", "display": "Hyperphosphatemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2011-08-03", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/83ea6255-cdd2-79cd-1fa4-030cda6acc0d"}}, {"fullUrl": "urn:uuid:0eb5fad4-1f1b-a068-e715-6856b46adc71", "resource": {"resourceType": "Condition", "id": "0eb5fad4-1f1b-a068-e715-6856b46adc71", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "2539950"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.5", "display": "Anemia of chronic renal failure, stage 5 (CMS/HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2012-06-04", "note": [{"text": "Last Assessment & Plan:
problemNote157
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Hgb 8.7 today, stable
Outpatient regimen - Epogen 1300 mg TIW, Venofer 50 mg q4 weeks with last dose 9/18
-Hold IV iron until infection ruled out
-Convert to Aranesp 25 mcg q7 days while here"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/0eb5fad4-1f1b-a068-e715-6856b46adc71"}}, {"fullUrl": "urn:uuid:a205c507-7bfc-be4b-1e5b-bf4dfdbc68f0", "resource": {"resourceType": "Condition", "id": "a205c507-7bfc-be4b-1e5b-bf4dfdbc68f0", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4738407"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M51.06", "display": "Intervertebral lumbar disc disorder with myelopathy, lumbar region", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-01-20", "note": [{"text": "Last Assessment & Plan:
problemNote170
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Assessment:
Procedure performed 1/20. Wound appears stable.
CK elevated to 632-1398.
Plan:
-Follow up as previously directed.
-scheduled tylenol and lower oxycodone 5-10 mg prn to 2.5 prn.
-Recheck CK pending"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a205c507-7bfc-be4b-1e5b-bf4dfdbc68f0"}}, {"fullUrl": "urn:uuid:8d1ed8a7-6d93-f589-73b0-8bc3cae67a7d", "resource": {"resourceType": "Condition", "id": "8d1ed8a7-6d93-f589-73b0-8bc3cae67a7d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4741809"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E16.2", "display": "Hypoglycemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-01-22", "note": [{"text": "Last Assessment & Plan:
problemNote173
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Assessment:
Felt to be secondary to decreased oral intake prior and post surgery. Confusion multifactorial with hypoglycemia and oxycodone playing roles. Clear now.
BS 27 this am- patient has not eaten since 7pm last night (finally got to floor and fell asleep)
Plan:
- 1/2 amp dextrose given with BS 128
- has ordered breakfast
- have dose his meds according to home schedule
- basal insulin decreased from 54 units BID to 15 units BID
- regular diet for now until BS stabilize
- prandial dosing if needed
-if trends up and stabilizes, may be ok to discharge later this afternoon"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8d1ed8a7-6d93-f589-73b0-8bc3cae67a7d"}}, {"fullUrl": "urn:uuid:107349d2-48eb-f5ff-2303-3fca9096850b", "resource": {"resourceType": "Condition", "id": "107349d2-48eb-f5ff-2303-3fca9096850b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4743469"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R33.9", "display": "Urinary retention", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-01-22", "note": [{"text": "Last Assessment & Plan:
problemNote176
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Episode of urinary retention on admission. Uncertain etiology. Potentially secondary to desipramine (which patient reports is a new diagnosis) vs autonomic dysfunction
UA non-infectious appearing
Required straight cath on admission, traumatic with obstruction met per RN documentation
Able to urinate independently now
\u00a0
- Hold desipramine
- Acute urinary retention protocol
- Monitor for constipation
- PVR Bladder scans 1-2x a day"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/107349d2-48eb-f5ff-2303-3fca9096850b"}}, {"fullUrl": "urn:uuid:5d3926cd-dd89-df8e-22ae-081cbf1dcb0b", "resource": {"resourceType": "Condition", "id": "5d3926cd-dd89-df8e-22ae-081cbf1dcb0b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4924680"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N19", "display": "Uremia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-04-09", "note": [{"text": "Last Assessment & Plan:
problemNote181
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Following. Improving with dialysis.
- Nephrology following"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5d3926cd-dd89-df8e-22ae-081cbf1dcb0b"}}, {"fullUrl": "urn:uuid:02d22905-515a-d3b2-5be4-57e57593ca66", "resource": {"resourceType": "Condition", "id": "02d22905-515a-d3b2-5be4-57e57593ca66", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4927025"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "ESRD (end stage renal disease) on dialysis (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-04-10", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote183
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote184
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/02d22905-515a-d3b2-5be4-57e57593ca66"}}, {"fullUrl": "urn:uuid:8bebc841-1edb-42c7-b2b7-6e55c2f92813", "resource": {"resourceType": "Condition", "id": "8bebc841-1edb-42c7-b2b7-6e55c2f92813", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "4931897"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I25.10", "display": "CAD (coronary artery disease)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-04-14", "note": [{"text": "Last Assessment & Plan:
problemNote200
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Follows with Dr. Vasiwalla @ MMP Cardiology, history of PCI with stenting in 2015. "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8bebc841-1edb-42c7-b2b7-6e55c2f92813"}}, {"fullUrl": "urn:uuid:5bc7541c-7f08-b157-b5ba-28b80f43e944", "resource": {"resourceType": "Condition", "id": "5bc7541c-7f08-b157-b5ba-28b80f43e944", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5085587"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I15.0", "display": "Renovascular hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-06-19", "note": [{"text": "Last Assessment & Plan:
problemNote209
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Now with hypertensive urgency. Plan and medications as above."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5bc7541c-7f08-b157-b5ba-28b80f43e944"}}, {"fullUrl": "urn:uuid:01202d2e-e5c0-0d31-1424-031113c60fa9", "resource": {"resourceType": "Condition", "id": "01202d2e-e5c0-0d31-1424-031113c60fa9", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5085868"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I16.0", "display": "Hypertensive urgency", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-06-19", "note": [{"text": "Last Assessment & Plan:
problemNote211
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The patient had a hospitalization in June with hypertensive crisis with symptoms of headache. Interestingly with his intracranial hypertension he did not have headache, only vision loss. I do not believe that his episode of hypertensive crisis in June was the proximate cause to be intracranial hypertension since he did not have papilledema on funduscopic exam until his most recent visit on September 1.."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/01202d2e-e5c0-0d31-1424-031113c60fa9"}}, {"fullUrl": "urn:uuid:bd9c60f7-29a6-5c1c-0a01-9afa5d6b46ff", "resource": {"resourceType": "Condition", "id": "bd9c60f7-29a6-5c1c-0a01-9afa5d6b46ff", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5086107"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R06.02", "display": "Shortness of breath", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-06-19", "note": [{"text": "Last Assessment & Plan:
problemNote214
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Shortness of breath at rest without oxygen requirement, cough/sputum, or chest pain. Also without increased work of breathing. Previously pulmonary edema seen on CXR about 10 days ago. Patient associates with HA and elevated BP, so there may be some pain or anxiety component. CXR with increased institial markings"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/bd9c60f7-29a6-5c1c-0a01-9afa5d6b46ff"}}, {"fullUrl": "urn:uuid:46d95a44-7fc4-e89f-a247-15a4d61ffcb8", "resource": {"resourceType": "Condition", "id": "46d95a44-7fc4-e89f-a247-15a4d61ffcb8", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5186003"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.5", "display": "CKD (chronic kidney disease), stage V (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-04", "note": [{"text": "Last Assessment & Plan:
problemNote216
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I will need to discuss with his nephrologist whether there could be any relationship between his kidney failure and This otherwise idiopathic intracranial hypertension. I am also uncertain whether it would be safe or even effective to use Diamox."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/46d95a44-7fc4-e89f-a247-15a4d61ffcb8"}}, {"fullUrl": "urn:uuid:02c15dc6-729f-1982-be7e-f40e3db61427", "resource": {"resourceType": "Condition", "id": "02c15dc6-729f-1982-be7e-f40e3db61427", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5194532"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E87.5", "display": "Hyperkalemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-07", "note": [{"text": "Last Assessment & Plan:
problemNote218
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Potassium elevated to 7 post procedure of renal bx. Peaked T waves noted on EKG. potassium remained elevated despite sodium bicarb, insulin, calcium gluconate,lokelma.
Plan:
-remain on telemetry
-plan for hemodialysis for hyperkalemia
-sodium bicarb 150 mEq at 100 cc/h"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/02c15dc6-729f-1982-be7e-f40e3db61427"}}, {"fullUrl": "urn:uuid:c8f45f19-40b1-d08a-9eb9-1908d714ae58", "resource": {"resourceType": "Condition", "id": "c8f45f19-40b1-d08a-9eb9-1908d714ae58", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5194728"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.649", "display": "Severe diabetic hypoglycemia (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-07", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/c8f45f19-40b1-d08a-9eb9-1908d714ae58"}}, {"fullUrl": "urn:uuid:409f300b-5fb3-521f-5bdb-4f0fd1c820b5", "resource": {"resourceType": "Condition", "id": "409f300b-5fb3-521f-5bdb-4f0fd1c820b5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5194868"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.9", "display": "Type 1 diabetes mellitus (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-07", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/409f300b-5fb3-521f-5bdb-4f0fd1c820b5"}}, {"fullUrl": "urn:uuid:c6fc98e6-4238-2954-b863-782e7a94b1c4", "resource": {"resourceType": "Condition", "id": "c6fc98e6-4238-2954-b863-782e7a94b1c4", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5194869"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-07", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/c6fc98e6-4238-2954-b863-782e7a94b1c4"}}, {"fullUrl": "urn:uuid:2980ed90-a774-f777-9cff-fae7f7df076c", "resource": {"resourceType": "Condition", "id": "2980ed90-a774-f777-9cff-fae7f7df076c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5194874"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I15.0", "display": "Renovascular hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-08-07", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/2980ed90-a774-f777-9cff-fae7f7df076c"}}, {"fullUrl": "urn:uuid:4c730e7b-ff75-8af4-6625-7f06744e1c51", "resource": {"resourceType": "Condition", "id": "4c730e7b-ff75-8af4-6625-7f06744e1c51", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5196442"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.22", "display": "Type 1 diabetes mellitus with diabetic chronic kidney disease (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-09-16T07:35:25-04:00", "note": [{"text": "Last Assessment & Plan:
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I do not believe that his current issue of intracranial hypertension with papilledema was caused by his hypoglycemic episode on August 7, 2015. I could not find anything in the literature relating these 2 and it seems like the onset of his symptoms was later in August."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4c730e7b-ff75-8af4-6625-7f06744e1c51"}}, {"fullUrl": "urn:uuid:2274e26b-3906-27fb-f257-762670546774", "resource": {"resourceType": "Condition", "id": "2274e26b-3906-27fb-f257-762670546774", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5257628"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "G93.2", "display": "Intracranial hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-09-03", "note": [{"text": "Last Assessment & Plan:
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Ryan has a complex ophthalmologic history given multiple pathology in the eye related to his diabetes. From review of his ophthalmologists records, it seems pretty clear that he had an acute change a week ago. Prior eye exams did not demonstrate papilledema in contrast to his ophthalmologic exam from September 1, 2015. His neuro imaging suggests that this is idiopathic intracranial hypertension at least in so much as there is no structural problem and no venous sinus thrombosis. This condition has been known to develop in the setting of hypertensive crisis and profound hypotension such as cardiogenic shock. I find nothing in the literature to suggest it could be a delayed complication of profound hypoglycemia although he was hospitalized 2 weeks or earlier with severe hypoglycemia. This is not a condition typically associated with end-stage renal disease and dialysis. The kidney problem complicates management of ICP following today''s lumbar puncture. It is my opinion that Diamox would not be effective although I will discuss it tomorrow with his nephrologist. Because this is such an unusual presentation in a patient with severe chronic conditions, there is no way of predicting whether the ICP will rise again and over what period of time. It will be hard to monitor her vision complaints because of coexisting diabetic retinopathy, vitreal hemorrhages and cataracts. I think the better part of valor is to refer him for a neuro-ophthalmology to evaluation at Tufts University with Dr. Hedges. I spoke to the patient''s ophthalmologist who will arrange to see him and repeat his funduscopic and visual assessment tomorrow and arrange for subsequent periodic visits in conjunction with a neuro-ophthalmologist."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/2274e26b-3906-27fb-f257-762670546774"}}, {"fullUrl": "urn:uuid:c11e9c84-2a79-6926-5991-a913001b4a71", "resource": {"resourceType": "Condition", "id": "c11e9c84-2a79-6926-5991-a913001b4a71", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5283442"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I21.4", "display": "NSTEMI (non-ST elevated myocardial infarction) (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-09-15", "note": [{"text": "Last Assessment & Plan:
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Trop > 0.3, now trending down. No baseline trop. Given anemia, difficult to convince myself this is not a type 2. Has underlying atherosclerosis d/t years of IDDM
- no more trop
- f/u with outpatient cardiologist next week"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/c11e9c84-2a79-6926-5991-a913001b4a71"}}, {"fullUrl": "urn:uuid:549bbab2-98f3-a436-cec0-3e38c1abeea5", "resource": {"resourceType": "Condition", "id": "549bbab2-98f3-a436-cec0-3e38c1abeea5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5283782"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R55", "display": "Syncope", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-09-16", "note": [{"text": "Last Assessment & Plan:
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Atraumatic/non LOC syncopal event x 1 yesterday with preceding dizziness. Sugar wnl, found to be orthostatic upon standing. With Hgb 6.3, first concern is for anemia induced syncope. Does have CAD with recent elective stent placement, but denies palpitations during the event. No neuro deficits to suggest central process
- tele
- f/u with cards next week, consideration for loop recorder if arrhythmia is felt as likely cause of syncope, although anemia is first on DDx"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/549bbab2-98f3-a436-cec0-3e38c1abeea5"}}, {"fullUrl": "urn:uuid:1fd319ff-e55e-cde6-c967-68dae1451d35", "resource": {"resourceType": "Condition", "id": "1fd319ff-e55e-cde6-c967-68dae1451d35", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5355340"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z45.2", "display": "Encounter for removal of vascular catheter", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-10-09", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1fd319ff-e55e-cde6-c967-68dae1451d35"}}, {"fullUrl": "urn:uuid:78536afd-cc26-8181-e02d-a29d0d180123", "resource": {"resourceType": "Condition", "id": "78536afd-cc26-8181-e02d-a29d0d180123", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5534389"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "H43.11", "display": "Vitreous hemorrhage of right eye (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-12-10", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/78536afd-cc26-8181-e02d-a29d0d180123"}}, {"fullUrl": "urn:uuid:485fc8c2-9985-da7c-52c2-7f6e65d37690", "resource": {"resourceType": "Condition", "id": "485fc8c2-9985-da7c-52c2-7f6e65d37690", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5534393"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.21", "display": "Type 1 diabetes mellitus with nephropathy (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2015-12-10", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote234
System.Collections.Generic.Dictionary`2[System.String,System.Object]

IMO Dx Update
problemNote235
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Remote history of diabetes type 1 insulin-dependent, since his islet cell transplantation he no longer has insulin dependency and is making his own endogenous insulin."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/485fc8c2-9985-da7c-52c2-7f6e65d37690"}}, {"fullUrl": "urn:uuid:2bb775b9-6c39-9112-70bf-07e9cb7ce07f", "resource": {"resourceType": "Condition", "id": "2bb775b9-6c39-9112-70bf-07e9cb7ce07f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5729952"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "T82.9XXA", "display": "Complication of AV dialysis fistula", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-03-01", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/2bb775b9-6c39-9112-70bf-07e9cb7ce07f"}}, {"fullUrl": "urn:uuid:7949b5d4-767b-dff7-e6c8-c5610f23aabe", "resource": {"resourceType": "Condition", "id": "7949b5d4-767b-dff7-e6c8-c5610f23aabe", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5890088"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J18.9", "display": "Healthcare-associated pneumonia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-05", "note": [{"text": "Last Assessment & Plan:
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Primary complaint of dyspnea on exertion and weakness on presentation.
Pattern appears most consistent with a bacterial infection given loculation on CXR.
Hemodynamically stable, on 2L O2 (none at baseline), does not meet SIRS criteria.
Treated for HCAP with cefepime + vancomycin given HD exposure, with ciprofloxacin added initially for GI coverage.
Flu swab negative in ED.
Sputum culture with polymicrobial mix (GPC, GPR, GNR).
Upright and lateral CXRs showed sizeable, mobile pleural effusion on the right -- likely infectious vs inflammatory in origin.
This effusion appears reduced in side on repeat CXR today and on bedside ultrasound by Pulmonology fellow Dr. Ranganath. Therefore thoracentesis was not attempted.
Antibiotics narrowed to vancomycin + cefepime on 5/8.
Not likely this is a MRSA pneumonia given his rapid improvement, relative stability from a pulmonary point of view, and no dramatic findings on lung exam or imaging.
Plan:
- D/c IV antibiotics and will complete treatment with PO levofloxacin dosed for dialysis - 250 mg Q 48 hrs
- Incentive spirometry
- Supplemental O2
- Blood cultures reported sent from Casco HD on 5/2 -- no results of this found at NorDx Microbiology - we will follow up with the dialysis center prior to discharge. "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7949b5d4-767b-dff7-e6c8-c5610f23aabe"}}, {"fullUrl": "urn:uuid:d10c6027-5864-a4ed-067c-b250b528a866", "resource": {"resourceType": "Condition", "id": "d10c6027-5864-a4ed-067c-b250b528a866", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5890161"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R01.1", "display": "Murmur, cardiac", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-06", "note": [{"text": "Last Assessment & Plan:
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Most likely transmitted noise from fistula vs flow murmur vs pericardial rub.
TTE showed mild MR and mild TR and a small circumferential pericardial effusion.
Discussed with Nephrology, their impression is that this is possibly uremic pericarditis.
Given also pleural effusion and profound anemia, this is suspicious for an additional systemic inflammatory process e.g lupus. Infections (viral) pericarditis with effusion also possible. However, as the rub appears to improve after he received extra HD yesterday, uremic etiology is supported.
Unable to follow through with prior plan of obtaining fluid sample from pleural effusion, as the effusion is reduced today.
- Further dialysis per Nephrology
- Monitor clinically "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/d10c6027-5864-a4ed-067c-b250b528a866"}}, {"fullUrl": "urn:uuid:7c1ad36f-a76f-95d9-08d5-5cb1a756979c", "resource": {"resourceType": "Condition", "id": "7c1ad36f-a76f-95d9-08d5-5cb1a756979c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5891603"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N25.81", "display": "Secondary hyperparathyroidism, renal (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-06", "note": [{"text": "Last Assessment & Plan:
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-Continue calcitriol 0.75 mcg 3 times weekly
-Continue cholecalciferol "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7c1ad36f-a76f-95d9-08d5-5cb1a756979c"}}, {"fullUrl": "urn:uuid:b05a7c7b-bc1b-2e53-220a-de0ad1ef9f6f", "resource": {"resourceType": "Condition", "id": "b05a7c7b-bc1b-2e53-220a-de0ad1ef9f6f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5892458"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D50.0", "display": "Anemia due to blood loss, chronic", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:05-05:00", "note": [{"text": "Last Assessment & Plan:
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History of unexplained anemia (beyond that expected for anemia of ESRD), with Hgb as low as 5 in the past requiring transfusion, and a previous attempt at GI work-up during hospitalization in 2015 deferred due to other health issues.
Now s/p EGD with Dr. Stefan on 5/7 which revealed esophagitis and a hiatal hernia, and colonoscopy on the same day finding multiple adenomatous-appearing polyps including two that were oozing blood. Polyps were removed and the source of bleeding clipped. Pathology pending.
PPI started for esophagitis -- see separate.
Elevated inflammatory markers (CRP 204, ESR 97) suspicious for further anemia of inflammatory disease.
Iron panel consistent with iron storage depletion, likely due to chronic GI blood loss vs depletion from long-standing inflammatory process.
Plan:
- Iron replacement and Mircera per Nephrology
- Monitor Hgb Q 12 hrs through tomorrow and clinically for any worsening
- Will need GI follow up including repeat colonoscopy per GI
- Omeprazole 40 mg daily per GI
- F/up polyp pathology
- Holding off further work-up for inflammatory disease at this time
- Try to avoid blood transfusion if possible
- Pt is a transplant candidate, so transfusion goal will be Hgb <6 with discussion with Nephrology prior"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/b05a7c7b-bc1b-2e53-220a-de0ad1ef9f6f"}}, {"fullUrl": "urn:uuid:5f42a2aa-b07e-2188-886b-df4b9f4bfd1b", "resource": {"resourceType": "Condition", "id": "5f42a2aa-b07e-2188-886b-df4b9f4bfd1b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5892459"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J90", "display": "Pleural effusion", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:07-05:00", "note": [{"text": "Last Assessment & Plan:
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See under pneumonia"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5f42a2aa-b07e-2188-886b-df4b9f4bfd1b"}}, {"fullUrl": "urn:uuid:e3719be2-3c7b-c5d9-9806-4ffd1a2668b0", "resource": {"resourceType": "Condition", "id": "e3719be2-3c7b-c5d9-9806-4ffd1a2668b0", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5893500"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K63.5", "display": "Colon polyps", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-07", "note": [{"text": "Last Assessment & Plan:
problemNote268
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New finding on colonoscopy today. Prep quality was poor, therefore possibly not all polyps were visualized.
Unusual finding in a young patient.
- Monitor for further GI bleeding
- F/up biopsy results
- Will need a follow-up colonoscopy in 1 year with better prep "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e3719be2-3c7b-c5d9-9806-4ffd1a2668b0"}}, {"fullUrl": "urn:uuid:850767a8-2037-29d9-711e-ec8b60192bac", "resource": {"resourceType": "Condition", "id": "850767a8-2037-29d9-711e-ec8b60192bac", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5893521"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I25.10", "display": "Coronary artery disease", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-07", "note": [{"text": "Last Assessment & Plan:
problemNote270
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History of DES to LAD in 2015 following MI.
Diffuse ST elevations on admission due to pericarditis. Flat troponins x3 likely elevated due to ESRD
-Continue home meds: ASA, statin, plavix, blocker"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/850767a8-2037-29d9-711e-ec8b60192bac"}}, {"fullUrl": "urn:uuid:5b706556-1bc3-a777-361c-124eb73ba71f", "resource": {"resourceType": "Condition", "id": "5b706556-1bc3-a777-361c-124eb73ba71f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5893544"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I10", "display": "High blood pressure", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-06-05T18:43:09-04:00", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote273
System.Collections.Generic.Dictionary`2[System.String,System.Object]

IMO Dx Update
problemNote274
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5b706556-1bc3-a777-361c-124eb73ba71f"}}, {"fullUrl": "urn:uuid:7a921454-a5d3-b7fd-33c7-98c4fcfde749", "resource": {"resourceType": "Condition", "id": "7a921454-a5d3-b7fd-33c7-98c4fcfde749", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5894176"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K20.90", "display": "Esophagitis", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-08", "note": [{"text": "Last Assessment & Plan:
problemNote276
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Found on EGD; likely caused by his chronic vomiting 2/2 gastroparesis.
PPI started per GI recs; as discussed with the patient by Dr. Buzanoski today, this is not for relief of symptoms (he denies any) but for prevention of long-term damage and Barrett''s Esophagus.
- F/up biopsies
- Omeprazole 40 mg PO daily
- Also takes TUMS for renal indications "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7a921454-a5d3-b7fd-33c7-98c4fcfde749"}}, {"fullUrl": "urn:uuid:718dd906-9458-b778-39f6-e770b7e7f491", "resource": {"resourceType": "Condition", "id": "718dd906-9458-b778-39f6-e770b7e7f491", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5894213"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D64.9", "display": "Anemia, unspecified", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-04-29T12:43:14-04:00", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote278
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote279
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/718dd906-9458-b778-39f6-e770b7e7f491"}}, {"fullUrl": "urn:uuid:9b9372e1-f6e5-73ba-9780-0636fa745c08", "resource": {"resourceType": "Condition", "id": "9b9372e1-f6e5-73ba-9780-0636fa745c08", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5894214"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J18.9", "display": "Hospital-acquired pneumonia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:10-05:00", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/9b9372e1-f6e5-73ba-9780-0636fa745c08"}}, {"fullUrl": "urn:uuid:dcc87aa2-0d98-05dd-9920-164019884713", "resource": {"resourceType": "Condition", "id": "dcc87aa2-0d98-05dd-9920-164019884713", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5896518"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R09.02", "display": "Hypoxia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-09", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/dcc87aa2-0d98-05dd-9920-164019884713"}}, {"fullUrl": "urn:uuid:ae288c1c-a44b-7703-b582-65d9ab673e8b", "resource": {"resourceType": "Condition", "id": "ae288c1c-a44b-7703-b582-65d9ab673e8b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904272"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I31.39", "display": "Pericardial effusion", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote288
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Repeat echo with cardiology follow up arranged"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ae288c1c-a44b-7703-b582-65d9ab673e8b"}}, {"fullUrl": "urn:uuid:06afe382-4c94-9cba-aee1-331f9aeb098c", "resource": {"resourceType": "Condition", "id": "06afe382-4c94-9cba-aee1-331f9aeb098c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904365"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.9", "display": "Uremic pericarditis", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote290
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Very much improved clinically
Will monitor on regular hemodialysis
Short course of steroids completed today"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/06afe382-4c94-9cba-aee1-331f9aeb098c"}}, {"fullUrl": "urn:uuid:b3f477b9-8c68-8449-b38e-ccd1cd439fb1", "resource": {"resourceType": "Condition", "id": "b3f477b9-8c68-8449-b38e-ccd1cd439fb1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904366"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "End-stage renal disease on hemodialysis (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/b3f477b9-8c68-8449-b38e-ccd1cd439fb1"}}, {"fullUrl": "urn:uuid:8e598dd5-86c2-14ef-2be7-eb4029201a94", "resource": {"resourceType": "Condition", "id": "8e598dd5-86c2-14ef-2be7-eb4029201a94", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904368"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I15.0", "display": "Renovascular hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote297
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BPs elevated, likely some aspect of volume overload contributing
-Continue amlodipine"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8e598dd5-86c2-14ef-2be7-eb4029201a94"}}, {"fullUrl": "urn:uuid:4b63a48b-c54f-3aed-30a1-f39278b0b670", "resource": {"resourceType": "Condition", "id": "4b63a48b-c54f-3aed-30a1-f39278b0b670", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904371"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.22", "display": "Type 1 diabetes mellitus with diabetic chronic kidney disease (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote299
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History of type 1 diabetes mellitus now s/p kidney and pancreatic transplant 2018 followed by Dr. Gilligan (Massachusetts General Hospital).
Also c/b autonomic dysfunction w/ known gastroparesis.
- See immunosuppression"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4b63a48b-c54f-3aed-30a1-f39278b0b670"}}, {"fullUrl": "urn:uuid:3a068841-c6ad-ef07-72e7-598491e9d15c", "resource": {"resourceType": "Condition", "id": "3a068841-c6ad-ef07-72e7-598491e9d15c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904373"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I25.10", "display": "Coronary artery disease involving native coronary artery of native heart without angina pectoris", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote304
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History of coronary stents
Dual antiplatelet therapy (DAPT) with Aspirin (ASA) 81 mg daily and Clopidogrel (Plavix) 75 mg daily
Labetalol and high intensity statin"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/3a068841-c6ad-ef07-72e7-598491e9d15c"}}, {"fullUrl": "urn:uuid:e2276a15-9584-c248-94f9-d10c4ad49147", "resource": {"resourceType": "Condition", "id": "e2276a15-9584-c248-94f9-d10c4ad49147", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904626"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E87.70", "display": "Volume overload", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote306
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HD again today for further volume overload, will continue to challenge EDW as tolerated
-Continue daily HD (except Sundays)
-Fluid restriction, low Na diet"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e2276a15-9584-c248-94f9-d10c4ad49147"}}, {"fullUrl": "urn:uuid:5f8d6cad-c773-1e3e-d880-2aa88110cd9f", "resource": {"resourceType": "Condition", "id": "5f8d6cad-c773-1e3e-d880-2aa88110cd9f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904637"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E87.1", "display": "Hyponatremia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5f8d6cad-c773-1e3e-d880-2aa88110cd9f"}}, {"fullUrl": "urn:uuid:7c0126b4-7f33-871e-2862-855ee868f565", "resource": {"resourceType": "Condition", "id": "7c0126b4-7f33-871e-2862-855ee868f565", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5904662"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J18.9", "display": "Pneumonia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-11", "note": [{"text": "Last Assessment & Plan:
problemNote309
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Recently discharged on PO treatment of RML PNA on levofloxacin, now presenting with profound weakness, increased O2 requirement.
Blood cultures negative at 48 hours
- stop vancomycin and cefepime (pt s/p a 10 day treatment course)
- O2 support PRN"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7c0126b4-7f33-871e-2862-855ee868f565"}}, {"fullUrl": "urn:uuid:07b988c8-4f74-d04a-416a-1c3940751ea7", "resource": {"resourceType": "Condition", "id": "07b988c8-4f74-d04a-416a-1c3940751ea7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5907834"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J96.01", "display": "Acute hypoxemic respiratory failure (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-12", "note": [{"text": "Last Assessment & Plan:
problemNote311
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Likely multifactorial, due to pleural effusions R >> L, new opacity of RLL
-ABX as above
-HD per Nephrology
-O2 protocol, wean as tolerated"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/07b988c8-4f74-d04a-416a-1c3940751ea7"}}, {"fullUrl": "urn:uuid:765a8744-1fd3-aebb-f503-f6d17017daf4", "resource": {"resourceType": "Condition", "id": "765a8744-1fd3-aebb-f503-f6d17017daf4", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5909355"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.22", "display": "Type 1 diabetes mellitus with stage 1 chronic kidney disease (CMS-HCC) (CMS/HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-18T13:50:09-04:00", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/765a8744-1fd3-aebb-f503-f6d17017daf4"}}, {"fullUrl": "urn:uuid:ce63193f-b7d7-f443-908e-ee70869591d7", "resource": {"resourceType": "Condition", "id": "ce63193f-b7d7-f443-908e-ee70869591d7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5914166"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "A04.72", "display": "Clostridium difficile diarrhea", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-16", "note": [{"text": "Last Assessment & Plan:
problemNote316
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Acute onset of frequent liquid stools 5/16 without abdominal pain - C.diff +
-cont Metronidazole day 2/10
-Enteric precautions"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ce63193f-b7d7-f443-908e-ee70869591d7"}}, {"fullUrl": "urn:uuid:ca95c441-6cdd-aba7-4341-252557eacb1e", "resource": {"resourceType": "Condition", "id": "ca95c441-6cdd-aba7-4341-252557eacb1e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5919909"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I15.1", "display": "Hypertension secondary to other renal disorders", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-18", "note": [{"text": "Last Assessment & Plan:
problemNote318
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Hx of HTN
+ Anasarca. He is ~ 8 kg above his pre hospital weight
B/P 145/72 - 129/73 AP 80
Home meds:
- bumex 2&1 ( am & pm)
- carvedilol 25 bid
- lisinopril 2.5
Rx:
Bumetanide 4 mg po am and Bumetanide tablet 2 mg po daily before dinner.
Aim for net negative 1 liter/24 hrs
Carvedilol 25 mg po BID
Hydralazine 50 mg po TID
Labetalol 10 mg IV q 6 hr prn for systolic > 160
Monitor daily serum magnesium "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ca95c441-6cdd-aba7-4341-252557eacb1e"}}, {"fullUrl": "urn:uuid:59823cf1-e6f4-1c4a-53fb-25cee87f8b02", "resource": {"resourceType": "Condition", "id": "59823cf1-e6f4-1c4a-53fb-25cee87f8b02", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "5920988"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R55", "display": "Near syncope", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-05-18", "note": [{"text": "Last Assessment & Plan:
problemNote322
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Presyncope event in dialysis with SBP in 90''s which increased to 120''s once patient was laying flat. Likely due to volume depletion from aggressive dialysis for pericardial effusion and now with diarrhea. No new signs to suggest respiratory process. Echo from yesterday was improved so doubt any enlargement of pericardial effusion or tamponade physiology. WBC is improving with treatment of C.diff
-hold on dialysis today
-500cc fluid bolus
-hold antihypertensives
-no indication to broaden antibiotics or reculture at this time. "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/59823cf1-e6f4-1c4a-53fb-25cee87f8b02"}}, {"fullUrl": "urn:uuid:af02a647-50f9-88e6-cc19-aab79bb013d5", "resource": {"resourceType": "Condition", "id": "af02a647-50f9-88e6-cc19-aab79bb013d5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6195210"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I16.0", "display": "Hypertensive urgency", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-09-09", "note": [{"text": "Last Assessment & Plan:
problemNote324
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No clear end organ dysfunction (troponin at baseline, creatinine elevated in setting of ESRD, no chest pain, no changes in mentation). Unclear etiology, patient reports he was compliant with all of his home meds and does not appearing significantly fluid overloaded on exam. Has had similar hypertensive episodes in the past that have been unprovoked.
- continue home oral anti-hypertensives including labetalol 400 mg TID, hydralazine 50 mg TID, lisinopril 40 mg, amlodipine 10 mg
- labetalol 10 mg IV prn SBP > 160
- dialysis this AM
- Will hold on addition more antihypertensives this AM, to avoid hypotension/reletive hypotension in HD. Will reconsider after HD today. "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/af02a647-50f9-88e6-cc19-aab79bb013d5"}}, {"fullUrl": "urn:uuid:efb04477-2de9-60f0-1ada-9102d88896bc", "resource": {"resourceType": "Condition", "id": "efb04477-2de9-60f0-1ada-9102d88896bc", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6195598"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R51.9", "display": "Acute nonintractable headache", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:17:41-05:00", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/efb04477-2de9-60f0-1ada-9102d88896bc"}}, {"fullUrl": "urn:uuid:a9176f51-2827-27d8-1eae-5905347521b3", "resource": {"resourceType": "Condition", "id": "a9176f51-2827-27d8-1eae-5905347521b3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6195599"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "ESRD on hemodialysis (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03T14:34:54-04:00", "note": [{"text": "Last Assessment & Plan:
problemNote327
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-HD T/T/S while in patient
-Appreciate nephrology consultation
-Renal diet
-Left arm precautions"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a9176f51-2827-27d8-1eae-5905347521b3"}}, {"fullUrl": "urn:uuid:a7c8ed4d-85cc-5c47-2a2e-b794cbc02ff3", "resource": {"resourceType": "Condition", "id": "a7c8ed4d-85cc-5c47-2a2e-b794cbc02ff3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6196322"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I25.10", "display": "Coronary artery disease involving native heart without angina pectoris", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:50-05:00", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a7c8ed4d-85cc-5c47-2a2e-b794cbc02ff3"}}, {"fullUrl": "urn:uuid:3c273341-65c3-54ab-2e4f-da457d2ca651", "resource": {"resourceType": "Condition", "id": "3c273341-65c3-54ab-2e4f-da457d2ca651", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6196323"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.22", "display": "Type 1 diabetes mellitus with chronic kidney disease on chronic dialysis, with long-term current use of insulin (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:47-05:00", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/3c273341-65c3-54ab-2e4f-da457d2ca651"}}, {"fullUrl": "urn:uuid:ccabb0c8-ca79-b084-ac63-2d10bfdeef0f", "resource": {"resourceType": "Condition", "id": "ccabb0c8-ca79-b084-ac63-2d10bfdeef0f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6370914"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R53.83", "display": "Fatigue", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-11-02", "note": [{"text": "Last Assessment & Plan:
problemNote342
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Significantly improved
No clear single etiology
Has tolerated volume removal well
Receiving empiric antibiotics for pneumonia
Worsened anemia probably playing a partial role, but he has tolerated as bad previously - see anemia plan above"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ccabb0c8-ca79-b084-ac63-2d10bfdeef0f"}}, {"fullUrl": "urn:uuid:a4463fe6-68df-3223-c4d0-907cc817be4f", "resource": {"resourceType": "Condition", "id": "a4463fe6-68df-3223-c4d0-907cc817be4f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6371242"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J81.0", "display": "Acute pulmonary edema (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2016-11-03T15:18:09-04:00", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a4463fe6-68df-3223-c4d0-907cc817be4f"}}, {"fullUrl": "urn:uuid:ceee7958-1db4-0d19-ebb2-7bb95e3c1f14", "resource": {"resourceType": "Condition", "id": "ceee7958-1db4-0d19-ebb2-7bb95e3c1f14", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6371243"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J18.9", "display": "Pneumonia of right lung due to infectious organism", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:19:28-05:00", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ceee7958-1db4-0d19-ebb2-7bb95e3c1f14"}}, {"fullUrl": "urn:uuid:26a0b0ac-7491-9f88-241b-0ae4fda9fd78", "resource": {"resourceType": "Condition", "id": "26a0b0ac-7491-9f88-241b-0ae4fda9fd78", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6540175"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "T82.838A", "display": "Hemorrhage of arteriovenous fistula, initial encounter (CMS-HCC) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16T12:18:22-05:00", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/26a0b0ac-7491-9f88-241b-0ae4fda9fd78"}}, {"fullUrl": "urn:uuid:5057e963-0027-c69b-9c0c-05132914e12a", "resource": {"resourceType": "Condition", "id": "5057e963-0027-c69b-9c0c-05132914e12a", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8133274"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "J96.01", "display": "Acute respiratory failure with hypoxia (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-09-25", "note": [{"text": "Last Assessment & Plan:
problemNote348
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Has had a dry cough for ~1 month. The patient was started on 2 L of oxygen in the emergency department. Chest CT shows calcified nodules, ground glass, and lymphadenopathy. Differential diagnosis for hypoxemia includes pneumonia versus pulmonary edema. Potential exposures to mold in his workplace.
-Appreciate ID recs:
F/u legionella, mycoplasma, MRSA nares
Consider CrAg, bdglucan, asp ag, silver stain for PJP
Azithromycin 3 days 500mg in case this is CAP
-Will discuss antibiotic regimen with ID today
-Continue supplemental oxygen as needed with goal SpO2 greater than 92%
-Appreciate nephrology assistance with volume management via dialysis"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5057e963-0027-c69b-9c0c-05132914e12a"}}, {"fullUrl": "urn:uuid:d5e68d06-5e4e-d485-73b3-0d1c42257f99", "resource": {"resourceType": "Condition", "id": "d5e68d06-5e4e-d485-73b3-0d1c42257f99", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8133328"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E10.9", "display": "Diabetes type I (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-09-25", "note": [{"text": "Last Assessment & Plan:
problemNote357
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Apparently well controlled but with complications as above.
Takes detemir 35 units in am and 30 units at night along with correctional insulin.
Reportedly last A1c 7.4.
- reduce his am dose to 28 units and his night dose to 24 units.
- continue correctional short acting.
- diabetic diet.
- hypoglycemia protocol in place. "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/d5e68d06-5e4e-d485-73b3-0d1c42257f99"}}, {"fullUrl": "urn:uuid:5476e1b3-75fe-466f-bc8a-2c07215f51a1", "resource": {"resourceType": "Condition", "id": "5476e1b3-75fe-466f-bc8a-2c07215f51a1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8133338"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "End-stage renal disease on hemodialysis (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-09-25", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote359
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Casco Bay dialysis - MWF; Dr. Cantlin
problemNote360
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5476e1b3-75fe-466f-bc8a-2c07215f51a1"}}, {"fullUrl": "urn:uuid:c39a0be9-4e53-2124-2d0f-ea69070a863d", "resource": {"resourceType": "Condition", "id": "c39a0be9-4e53-2124-2d0f-ea69070a863d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8133340"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I10", "display": "Hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-09-25", "note": [{"text": "Last Assessment & Plan:
problemNote364
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-Continue to monitor blood pressure closely
-Continue outpatient doses of losartan, amlodipine, carvedilol"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/c39a0be9-4e53-2124-2d0f-ea69070a863d"}}, {"fullUrl": "urn:uuid:5ae62d33-11ae-7fdf-4063-662347ba0d42", "resource": {"resourceType": "Condition", "id": "5ae62d33-11ae-7fdf-4063-662347ba0d42", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8480745"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I25.10", "display": "Coronary artery disease involving native coronary artery", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-11-24", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote376
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote377
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5ae62d33-11ae-7fdf-4063-662347ba0d42"}}, {"fullUrl": "urn:uuid:257fde15-9024-e3f3-43fd-9a1ca4695879", "resource": {"resourceType": "Condition", "id": "257fde15-9024-e3f3-43fd-9a1ca4695879", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8529725"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z01.810", "display": "Preop cardiovascular exam", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-12-05", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/257fde15-9024-e3f3-43fd-9a1ca4695879"}}, {"fullUrl": "urn:uuid:9135d9da-34e8-f952-8ad5-abb86fcbc860", "resource": {"resourceType": "Condition", "id": "9135d9da-34e8-f952-8ad5-abb86fcbc860", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10122254"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z94.83", "display": "Pancreas transplant status (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote383
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote384
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/9135d9da-34e8-f952-8ad5-abb86fcbc860"}}, {"fullUrl": "urn:uuid:eb973ccf-0337-8117-6890-112ed73867db", "resource": {"resourceType": "Condition", "id": "eb973ccf-0337-8117-6890-112ed73867db", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10122255"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D84.9", "display": "Immunosuppression (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-01-16", "note": [{"text": "Last Assessment & Plan:
problemNote394
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-Appreciate nephrology/transplant consultation
-Continue azathioprine 100 mg daily
-Continue prednisone 5 mg daily
-Continue tacrolimus 2 mg in the morning and 1 mg in the evening
-Follow-up tacrolimus level ordered for 8/5/2024"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/eb973ccf-0337-8117-6890-112ed73867db"}}, {"fullUrl": "urn:uuid:59d0eda9-5826-805d-9c52-3c16e107373f", "resource": {"resourceType": "Condition", "id": "59d0eda9-5826-805d-9c52-3c16e107373f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10574190"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.628", "display": "Diabetic foot infection (CMS-HCC) (CMS/HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-04-05", "note": [{"text": "Last Assessment & Plan:
problemNote408
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Left plantar foot ulcer, ?probed to 5th TMA head. No wet gangrene or drainage. Erythema improving.
- MR: Positive for left TM head/phalanx osteomyelitis.
- Continue vancomycin, cefepime
- F/u with primary team and ID reguarding optimal PO abx and plan for IV abx initiation after return from trip.
- Dressings: betadine paint to the ulcer with dry guaze."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/59d0eda9-5826-805d-9c52-3c16e107373f"}}, {"fullUrl": "urn:uuid:47d1e7cc-d5dc-8387-49df-5b6bae6e7426", "resource": {"resourceType": "Condition", "id": "47d1e7cc-d5dc-8387-49df-5b6bae6e7426", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10575958"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z86.79", "display": "History of orthostatic hypotension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-04-06", "note": [{"text": "Last Assessment & Plan:
problemNote413
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History of orthostatic hypotension and has been taking fludrocortisone for this.
-Restarting fludrocortisone when able to tolerate PO.
-Maintenance fluids, clear liquid diet, monitor BP"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/47d1e7cc-d5dc-8387-49df-5b6bae6e7426"}}, {"fullUrl": "urn:uuid:0984763d-8df8-beb4-bcf8-3d5eee0e79f7", "resource": {"resourceType": "Condition", "id": "0984763d-8df8-beb4-bcf8-3d5eee0e79f7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10619592"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M86.172", "display": "Osteomyelitis of ankle or foot, acute, left (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-04-16", "note": [{"text": "Last Assessment & Plan:
problemNote417
Formatting of this note might be different from the original.

Patient presenting with left foot wound after stepping on stone 5 weeks prior to admission 4/5, found to have osteomyelitis by MRI, poor pulse with associated loss of waveform in left foot on US doppler 4/7. Refused surgical intervention at prior admission and left AMA on 4/8. Representing today as planned admission. Interval drainage of left foot wound since 4/15
Plan:
- Continue IV vancomycin and cefepime
- Will follow-up ID re: antibiotics after culture returns
- Vascular consulted, wound culture sent, follow-up with wound center and Dr. Aranson set up
- Blood cultures, wound cultures pending
- Consult to PICC team placed"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/0984763d-8df8-beb4-bcf8-3d5eee0e79f7"}}, {"fullUrl": "urn:uuid:edda6ba9-d349-ecf5-a678-83e375883ff3", "resource": {"resourceType": "Condition", "id": "edda6ba9-d349-ecf5-a678-83e375883ff3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "13709591"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z94.0", "display": "Renal transplant recipient", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-11-11", "note": [{"text": "Last Assessment & Plan:
problemNote419
Formatting of this note might be different from the original.

Renal transplant MGH in May 2018
Followed by Dr. Gilligan
Baseline creatinine from last labs done in December 2021 appears to be ~1.9-2.1
CTAP without obvious concern in the kidneys though transplanted kidney not able to be fully evaluated without contrast
Plan:
-Immunosuppression as elsewhere"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/edda6ba9-d349-ecf5-a678-83e375883ff3"}}, {"fullUrl": "urn:uuid:642c9f48-a88c-5bd6-c942-a5ed25159c66", "resource": {"resourceType": "Condition", "id": "642c9f48-a88c-5bd6-c942-a5ed25159c66", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "14218494"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R11.2", "display": "Nausea vomiting and diarrhea", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-12-19", "note": [{"text": "Last Assessment & Plan:
problemNote422
Formatting of this note might be different from the original.

Improving with conservative treatment (anti-emetics, bowel rest, IV fluids). Leading differential: viral gastroenteritis. Though given transplant status, need to consider CMV, C Diff, bacterial infections.
Dx:
- Follow-up blood cultures x2, Stool cultures (bacterial and viral), CMV Serum PCR
- Follow-up C Diff
Tx:
- Will progress diet to clear liquids
- IVF LR maintanence fluid
- PRN compazine
- Replete Mg IV, hold oral magnesium given diarrhea
- Will check in around noon, if nausea/vomiting continues to improve - will restart oral home meds. May hold myfortic for one more day given side effect of GI upset. Received 8 mg methylprednisone this AM (higher dose than home prednisone as may need to hold myfortic today)."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/642c9f48-a88c-5bd6-c942-a5ed25159c66"}}, {"fullUrl": "urn:uuid:8a014617-d76b-804b-0114-393b19cbc577", "resource": {"resourceType": "Condition", "id": "8a014617-d76b-804b-0114-393b19cbc577", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "30148542"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z80.42", "display": "Family hx of prostate cancer", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-08-05", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8a014617-d76b-804b-0114-393b19cbc577"}}, {"fullUrl": "urn:uuid:979e58f2-9f3b-4200-f7b5-da69cedd494a", "resource": {"resourceType": "Condition", "id": "979e58f2-9f3b-4200-f7b5-da69cedd494a", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "30148543"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R39.12", "display": "Weak urine stream", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-08-05", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/979e58f2-9f3b-4200-f7b5-da69cedd494a"}}, {"fullUrl": "urn:uuid:fb2cca4e-7626-ff80-f9ee-b4a55abec1b2", "resource": {"resourceType": "Condition", "id": "fb2cca4e-7626-ff80-f9ee-b4a55abec1b2", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "31732743"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "L97.521", "display": "Skin ulcer of left foot, limited to breakdown of skin (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-10-06", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/fb2cca4e-7626-ff80-f9ee-b4a55abec1b2"}}, {"fullUrl": "urn:uuid:8b706be8-17b9-c88e-2bd8-47f194ec5405", "resource": {"resourceType": "Condition", "id": "8b706be8-17b9-c88e-2bd8-47f194ec5405", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "31732744"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I73.9", "display": "PVD (peripheral vascular disease) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-10-06", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8b706be8-17b9-c88e-2bd8-47f194ec5405"}}, {"fullUrl": "urn:uuid:fc997077-5aae-7fed-2df2-8e7654e06806", "resource": {"resourceType": "Condition", "id": "fc997077-5aae-7fed-2df2-8e7654e06806", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "31732763"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R19.7", "display": "Diarrhea, unspecified", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-10-06", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote428
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote429
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/fc997077-5aae-7fed-2df2-8e7654e06806"}}, {"fullUrl": "urn:uuid:217a801e-4399-7874-d180-b9c21e77c950", "resource": {"resourceType": "Condition", "id": "217a801e-4399-7874-d180-b9c21e77c950", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "31784041"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R68.82", "display": "Decreased libido", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-10-08", "note": [{"text": "Last Assessment & Plan:
problemNote432
Formatting of this note might be different from the original.

This is been a relatively new finding for Ryan, we review his prior testosterone readings which were in the lower ranges of normal. We discussed that there is some variability with testosterone readings depending on the time of day this is done. Would also want to consider upstream signaling. We discussed that decreased libido can be multifaceted in etiology, overall he is in a very strong relationship and can identify no additional stressors. We will go ahead and work this up and screen for low testosterone again.
Discussed with endocrine, they do not suspect hypogonadism"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/217a801e-4399-7874-d180-b9c21e77c950"}}, {"fullUrl": "urn:uuid:e894b7bf-19aa-3209-468e-286aabd823ba", "resource": {"resourceType": "Condition", "id": "e894b7bf-19aa-3209-468e-286aabd823ba", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "31784053"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z71.85", "display": "Vaccine counseling", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2021-10-08", "note": [{"text": "Last Assessment & Plan:
problemNote435
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Pleasant 43-year-old who who request the high-dose flu vaccination, we discussed that the indication for this is age over 65 not for underlying immunosuppression. He discusses that he has received a high-dose flu vaccine as the recommendation of his transplant team for numerous years. There shared decision making we do administer this vaccine today. He is fully vaccinated against COVID-19."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e894b7bf-19aa-3209-468e-286aabd823ba"}}, {"fullUrl": "urn:uuid:40cd57c9-9f69-10f8-ecd6-8decffc9e2fe", "resource": {"resourceType": "Condition", "id": "40cd57c9-9f69-10f8-ecd6-8decffc9e2fe", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35121498"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E87.20", "display": "Metabolic acidosis, normal anion gap (NAG)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-12", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote437
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Serum ketones negative, Elevated serum osm 308 with a calculated osm of 316, serum osm gap is 6, less than 8 so less likely to be a toxic ingestion
problemNote438
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/40cd57c9-9f69-10f8-ecd6-8decffc9e2fe"}}, {"fullUrl": "urn:uuid:a2d8c876-f5e0-38d7-c6df-e1bc439f606d", "resource": {"resourceType": "Condition", "id": "a2d8c876-f5e0-38d7-c6df-e1bc439f606d", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35121831"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E87.8", "display": "Electrolyte disturbance", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-12", "note": [{"text": "Last Assessment & Plan:
problemNote440
Formatting of this note might be different from the original.

Has h/o of hyperkalemia, on lokelma every 2 to 3 days at home
K normal on presentation but mag low likely 2/2 diarrhea vs tacro
K now low as well
Plan:
-Hold home lokelma
-Monitor with daily BMP, mag
-Replet prn
-Replace Mag prn, will try magnesium gluconnate to see if this is a better option than mag oxide for outpatient use"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a2d8c876-f5e0-38d7-c6df-e1bc439f606d"}}, {"fullUrl": "urn:uuid:14bc3a7b-7eaa-885c-f7ab-d3e0b60851b3", "resource": {"resourceType": "Condition", "id": "14bc3a7b-7eaa-885c-f7ab-d3e0b60851b3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35123356"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R53.1", "display": "Weakness", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-12", "note": [{"text": "Last Assessment & Plan:
problemNote442
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Likely due to dehydration and non-anion gap metabolic acidosis as well as anemia versus infection versus electrolyte abnormalities
-Encourage p.o. intake as tolerated
-Consider PT/OT consults pending functional status"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/14bc3a7b-7eaa-885c-f7ab-d3e0b60851b3"}}, {"fullUrl": "urn:uuid:37b680b4-f738-d25a-9018-2b0b80ebd94a", "resource": {"resourceType": "Condition", "id": "37b680b4-f738-d25a-9018-2b0b80ebd94a", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35123592"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N17.9", "display": "AKI (acute kidney injury) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-12", "note": [{"text": "Last Assessment & Plan:
problemNote444
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Baseline creatinine ~1.9-2.1 as of December 2021, however was at a baseline of approximately 1.5 in the summer 2021
Creatinine on admission 2.63 likely iso volume depletion/hypotension
Creatinine now nearly at baseline
Plan:
-Monitor daily BMP"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/37b680b4-f738-d25a-9018-2b0b80ebd94a"}}, {"fullUrl": "urn:uuid:426c32a2-0b2d-9d11-26c0-c240094ddc6a", "resource": {"resourceType": "Condition", "id": "426c32a2-0b2d-9d11-26c0-c240094ddc6a", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35157547"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K52.9", "display": "Chronic diarrhea", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-04T11:32:39-05:00", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/426c32a2-0b2d-9d11-26c0-c240094ddc6a"}}, {"fullUrl": "urn:uuid:69ed940b-bda5-d6ac-6a01-406a6986d362", "resource": {"resourceType": "Condition", "id": "69ed940b-bda5-d6ac-6a01-406a6986d362", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35387803"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N04.9", "display": "Nephrotic syndrome", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-20", "note": [{"text": "Last Assessment & Plan:
problemNote447
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Hypervolemia noted on admission. Pro-BNP 6K. Received Bumex 2 mg IV in ED, put out 500cc independently. CXR with bilateral pleural effusions.
Patient has a history of nephrotic syndrome managed by MGH with asa 325 mg and lisinopril. Patient with notable proteinuria and hypoalbuminemia on admission. Of note he was seen at BWH in March 2020 with 3+ nephrotic range proteinuria, dx with Antibody Mediated Rejection and was given rituxin. Considered protal vein thrombosis with elevated liver enzymes on admission but resolved so less likely. CHF less likely given TTE demonstrating normal LV size with moderately increased wall thickness, EF 65%, normal right ventricular size and systolic function.
Had been prescribed Bumex 1 mg prn in outpatient setting due to nephrotic syndrome after receiving rituxin last year but has not been taking recently
Currently diuresing with Bumex with good output.
Spot urine protein to creatinine ratio 7.5.
Transplant US demonstrated minimal pelvicaliectasis with small amount of adjacent fluid with elevated resistive indices and urinary bladder distention to 459 mL.
Plan:
- Change Bumex 2 mg IV BID to Bumex 4 mg PO BID
- Telemetry to assess for tachy mediated cause of CHF, patient has been refusing
- 24 hr urine protein, creatinine
- consider renal biopsy if 24 hr UPC is elevated
- Strict in/outs (with urinary retention protocol)
- Daily standing weights
- Low salt diet, 2L fluid restriction diet
- Nutrition consult placed for hypoalbuminemia "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/69ed940b-bda5-d6ac-6a01-406a6986d362"}}, {"fullUrl": "urn:uuid:9643c53a-6c24-1dd2-9f76-171df6ba78ae", "resource": {"resourceType": "Condition", "id": "9643c53a-6c24-1dd2-9f76-171df6ba78ae", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35388834"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R79.89", "display": "Elevated troponin level", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-20", "note": [{"text": "Last Assessment & Plan:
problemNote450
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Troponin 0.05 on admission with EKG that appears similar to previous without convincing signs of active ischemia and without symptoms concerning for ACS (though with history of type 1 diabetes could present with silent ischemia)
Suspect elevated troponin is secondary to myocardial injury due to hypervolemia, in addition to elevation in the setting of ESRD.
Refused telemetry, risks awknowledged
Delta troponin 0.04
- Telemetry, patient refusing
- Monitor closely for ACS
- STAT EKG for chest pain"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/9643c53a-6c24-1dd2-9f76-171df6ba78ae"}}, {"fullUrl": "urn:uuid:5ab1a3d0-dc53-316e-5603-3620e94206aa", "resource": {"resourceType": "Condition", "id": "5ab1a3d0-dc53-316e-5603-3620e94206aa", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35388849"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R74.8", "display": "Elevated liver enzymes", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-20", "note": [{"text": "Last Assessment & Plan:
problemNote453
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R factor of 1 suggestive of cholestatic injury, suspect from hepatic congestion in light of hypervolemia. Less likely infiltrative disease (Ferritin last checked 1/13/22 and was 391, no elevated calcium to suspect granulomatous disease). Lipase last checked and was 82 (1/12/2022). CMV PCR 1/13/22 not detected.
- Continue to monitor for now
- Will need further assessment if not improved with diuresis
- Consider abdominal ultrasound of portal venous system if further work-up of hypervolemia is unrevealing."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5ab1a3d0-dc53-316e-5603-3620e94206aa"}}, {"fullUrl": "urn:uuid:a36619ef-6bc3-fab7-50ac-6ca6f4149bbf", "resource": {"resourceType": "Condition", "id": "a36619ef-6bc3-fab7-50ac-6ca6f4149bbf", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35388853"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D64.9", "display": "Anemia, unspecified", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-21", "note": [{"text": "Last Assessment & Plan:
problemNote456
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Appreciate work-up at last admission and given darbopoeitin at that time.
Hgb 8.2 on admission was down to 6.9 with improvement to 8.2 on repeat. Zinc slightly low at 36.
- Monitor for now
- Vitamin with minerals given low copper"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a36619ef-6bc3-fab7-50ac-6ca6f4149bbf"}}, {"fullUrl": "urn:uuid:7f3cea94-00b9-993c-3f93-22dd5f8e6c18", "resource": {"resourceType": "Condition", "id": "7f3cea94-00b9-993c-3f93-22dd5f8e6c18", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35415541"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z94.0", "display": "Status post simultaneous kidney and pancreas transplant (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-21", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote459
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]
problemNote460
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I have asked him to address whether or not he would be a candidate for Evusheld with his transplant docs."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7f3cea94-00b9-993c-3f93-22dd5f8e6c18"}}, {"fullUrl": "urn:uuid:14caedb6-bbd1-0747-f3d3-ba1ce977c9b0", "resource": {"resourceType": "Condition", "id": "14caedb6-bbd1-0747-f3d3-ba1ce977c9b0", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35484397"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I50.32", "display": "Chronic diastolic congestive heart failure (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-01-25", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote467
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Clapp DO agreed with CDI query for Acute on chronic diastolic (congestive) heart failure on 01/24/22 1620
problemNote468
System.Collections.Generic.Dictionary`2[System.String,System.Object]
System.Collections.Generic.List`1[System.Object]
System.Collections.Generic.List`1[System.Object]"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/14caedb6-bbd1-0747-f3d3-ba1ce977c9b0"}}, {"fullUrl": "urn:uuid:a696d069-05bd-e188-ad55-ed9aace759a8", "resource": {"resourceType": "Condition", "id": "a696d069-05bd-e188-ad55-ed9aace759a8", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35782814"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R57.8", "display": "Hemorrhagic shock (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-03", "note": [{"text": "Last Assessment & Plan:
problemNote470
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Noted to be hypotensive to 70 systolic with dropping hemoglobin in the setting of post procedure for renal biopsy to evaluate for nephrotic syndrome. CT of abdomen/pelvis demonstrated left rectus sheath hematoma. CT was done without contrast due to poor renal function, creatinine 2.6. Patient was initially admitted to transplant service. Given that patient remained hypotensive with altered mental status with further driving hemoglobin to 5.3 status post 3 L of IV fluids, general surgery consulted for control of bleed and went to the OR. Critical care was involved at this time. Patient received three units of packed red blood cells. Transfusion complicated by patient having co-current refractory hyperkalemia with with peaked T waves on stat EKG.
Plan:
-OR with surgery for control of bleeding
-patient will be transferred to surgery ICU primary after OR procedure
-plan for hemodialysis for hyperkalemia"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a696d069-05bd-e188-ad55-ed9aace759a8"}}, {"fullUrl": "urn:uuid:1d35164f-85be-83ca-971c-9614b0aec62b", "resource": {"resourceType": "Condition", "id": "1d35164f-85be-83ca-971c-9614b0aec62b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35809427"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "S31.109A", "display": "Open wound of anterior abdominal wall", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-09T07:46:51-05:00", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1d35164f-85be-83ca-971c-9614b0aec62b"}}, {"fullUrl": "urn:uuid:a47f6be5-261e-6a81-98f7-2c3a15985284", "resource": {"resourceType": "Condition", "id": "a47f6be5-261e-6a81-98f7-2c3a15985284", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "35834040"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K66.1", "display": "Hemoperitoneum", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-07", "note": [{"text": "Last Assessment & Plan:
problemNote473
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Kidney biopsy on c/b hemoperitoneum and hemorrhagic shock requiring pressors, intubation for ex-lap on 2/3, and fascial closure on 2/3
Overnight HDS
HgB this AM slightly lower than priors (7.3 from 7.9 )
Access: LIJ
- Trend HgB - 1500 check.
- Transfuse for <6 given immunocompromised
- Monitor abdominal exam closely, low threshold to re-engage surgery if needed
- Wound:\u00a0midline incision closed with staples, dressed with gauze and tape, change prn for soiling; wicks to be removed POD 3 (?by surg)
- pain well controlled not requiring PRNs overnight"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a47f6be5-261e-6a81-98f7-2c3a15985284"}}, {"fullUrl": "urn:uuid:fbf3b8e1-4463-129a-b1ba-52d85ad7b3f3", "resource": {"resourceType": "Condition", "id": "fbf3b8e1-4463-129a-b1ba-52d85ad7b3f3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "36135934"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E61.0", "display": "Copper deficiency", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-02-17", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/fbf3b8e1-4463-129a-b1ba-52d85ad7b3f3"}}, {"fullUrl": "urn:uuid:e8660799-35fd-aca6-0426-7ae5ffe9bf2f", "resource": {"resourceType": "Condition", "id": "e8660799-35fd-aca6-0426-7ae5ffe9bf2f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37789459"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "S91.109A", "display": "Open toe wound", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-04-28", "note": [{"text": "Last Assessment & Plan:
problemNote476
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Unfortunately today Ryan has a extensive wound over the great toe on the left foot. This is malodorous. The wound beds are actively leaking a purulent material and there is gas production. The toe overall is very soft. This is very concerning for extensive necrotic tissue and also gangrene. I spoke with the wound care center to see if we can get him in urgently, the physician on-call they reviewed the pictures and expected extensive soft tissue infection and possible osteomyelitis and recommended an emergency department assessment. I discussed this with Ryan. The final recommendation is to present to the emergency department given the concern for this wound which is certainly toe threatening if not foot threatening. He states today that he is not sure if he will present to the emergency room. I was very frank with Ryan, I told him that I can certainly understand the stress he has been through recently and the fact the last place he wants to be is back in the hospital but the formal medical advice is to present urgently as I suspect he needs IV antibiotics and urgent imaging. He asked if this could be coordinated as an outpatient, this is virtually impossible at this time given delays in our imaging capabilities and the fact there is an active infection at this time. I asked Ryan again if he will present and he states he is not sure. I encouraged he and his wife who are each capable adults to have this conversation but again reemphasized the formal medical advice to present urgently to the emergency room. I did provide handoff to the emergency department providers so they are aware of his potential arrival."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e8660799-35fd-aca6-0426-7ae5ffe9bf2f"}}, {"fullUrl": "urn:uuid:84deb6c8-1a55-b0f0-9d42-ca2339a4c9f1", "resource": {"resourceType": "Condition", "id": "84deb6c8-1a55-b0f0-9d42-ca2339a4c9f1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37810082"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M86.9", "display": "Osteomyelitis of great toe of right foot (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-04-28", "note": [{"text": "Last Assessment & Plan:
problemNote478
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Followed by vascular now.
He should remain nonweightbearing or at least have his foot upright when he is sitting down until he is off his antibiotics.
I wrote a letter to his place of employment to reflect this restriction.
He will continue vancomycin and cefepime through infectious diseases. Estimated completion date in Mid June. "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/84deb6c8-1a55-b0f0-9d42-ca2339a4c9f1"}}, {"fullUrl": "urn:uuid:14144666-fcd1-98b5-0e02-c9f12ae384fc", "resource": {"resourceType": "Condition", "id": "14144666-fcd1-98b5-0e02-c9f12ae384fc", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37811607"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "A41.9", "display": "Sepsis (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-04-29", "note": [{"text": "Last Assessment & Plan:
problemNote484
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- continue vancomycin + cefepime
- monitor inflammatory labs
-UA?
-blood culture?"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/14144666-fcd1-98b5-0e02-c9f12ae384fc"}}, {"fullUrl": "urn:uuid:508e0d6b-4b20-2e56-d779-c8658a117aa6", "resource": {"resourceType": "Condition", "id": "508e0d6b-4b20-2e56-d779-c8658a117aa6", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37844025"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D62", "display": "Acute blood loss anemia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-11-09T07:49:30-05:00", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/508e0d6b-4b20-2e56-d779-c8658a117aa6"}}, {"fullUrl": "urn:uuid:6a5ba3ab-0932-2d22-005e-c5dc4b4a8911", "resource": {"resourceType": "Condition", "id": "6a5ba3ab-0932-2d22-005e-c5dc4b4a8911", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37906140"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M65.9", "display": "Tenosynovitis of right foot", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-05-03", "note": [{"text": "Last Assessment & Plan:
problemNote488
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Initially presenting with diabetic foot wound that progressed to osteomyelitis and tracked into the tendon. No growth on culture of tendon specifically, but right toe amputation growing 4+ alpha strep (likely culprit for purulent material found in tendon), 1+ corynebacterium, and 4+ gram positive organism that by gross appearance looks like Actinomyces. Additional organism have identified including campylobacter ureolyticus, finegoldia (pepto strep) magna. Path shows residual inflammation at margins on right toe but not from right toe tendon.
Immunosuppressed status does push the duration of treatment to longer (4 vs 3 weeks), but would be considered effectively treated at 3 week mark, at which point he would from an infectious perspective be able to okay for transplantation. "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/6a5ba3ab-0932-2d22-005e-c5dc4b4a8911"}}, {"fullUrl": "urn:uuid:edc8c34b-a259-d5c2-2753-1fd29a12cc1c", "resource": {"resourceType": "Condition", "id": "edc8c34b-a259-d5c2-2753-1fd29a12cc1c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37946108"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D72.819", "display": "Leukopenia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-05-04", "note": [{"text": "Last Assessment & Plan:
problemNote490
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Patient with leukopenia.
Wondering if cefepime is causing marrow suppression and if he needs other antibiotic however multiple other causes.
- continue current abx regimen pending specificities"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/edc8c34b-a259-d5c2-2753-1fd29a12cc1c"}}, {"fullUrl": "urn:uuid:94425ecc-d151-41a4-10f5-1fa60b7c6dc9", "resource": {"resourceType": "Condition", "id": "94425ecc-d151-41a4-10f5-1fa60b7c6dc9", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "37981476"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "T82.898A", "display": "Inadequate flow of dialysis arteriovenous fistula, initial encounter (CMS-HCC) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-05-05", "note": [{"text": "Last Assessment & Plan:
problemNote493
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Fistulogram and angioplasty 5/6.
- has a stitch in place that will need to be removed 5/9 at dialysis"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/94425ecc-d151-41a4-10f5-1fa60b7c6dc9"}}, {"fullUrl": "urn:uuid:1f58bd67-c6e4-a2ef-c1fb-ffef5d396a9f", "resource": {"resourceType": "Condition", "id": "1f58bd67-c6e4-a2ef-c1fb-ffef5d396a9f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41053735"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R78.81", "display": "Bacteremia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "note": [{"text": "Last Assessment & Plan:
problemNote495
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Source not obvious, however chronic wounds - DM foot ulcer (though look good), home dialysis line
Now blood cultures with serratia
mri thoracic and lumbar spine negative
-Continue with IV antibiotics: cefepime for now. Bactrim at discharge
-US fistula pending"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/1f58bd67-c6e4-a2ef-c1fb-ffef5d396a9f"}}, {"fullUrl": "urn:uuid:6d421cf7-7378-208f-7e1a-e09179c185d0", "resource": {"resourceType": "Condition", "id": "6d421cf7-7378-208f-7e1a-e09179c185d0", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41053749"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D61.818", "display": "Pancytopenia (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/6d421cf7-7378-208f-7e1a-e09179c185d0"}}, {"fullUrl": "urn:uuid:6c017f61-87f9-d26a-dc7a-7ad0fdce6484", "resource": {"resourceType": "Condition", "id": "6c017f61-87f9-d26a-dc7a-7ad0fdce6484", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41053750"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.621", "display": "Type 2 diabetes mellitus with foot ulcer (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/6c017f61-87f9-d26a-dc7a-7ad0fdce6484"}}, {"fullUrl": "urn:uuid:4a0d686f-da94-1739-374f-6d4bc67c9d24", "resource": {"resourceType": "Condition", "id": "4a0d686f-da94-1739-374f-6d4bc67c9d24", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41053822"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D61.818", "display": "Pancytopenia (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "note": [{"text": "Last Assessment & Plan:
problemNote502
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WBC 1.5, lymphopenia, mild absolute neutropenia
New thrombocytopenia, mild at 124
Macrocytic anemia (not new and HgB improved from previously)
Suspect related to acute illness.
Now WBC rapidly transitioned to leukocytosis, 19 today.
Plan:
- trend
- HIV, chronic hep panel
- consider DIC if worsening TCP with AM labs"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4a0d686f-da94-1739-374f-6d4bc67c9d24"}}, {"fullUrl": "urn:uuid:a3b1bb7d-ec94-1e4c-8230-af431aaef1d5", "resource": {"resourceType": "Condition", "id": "a3b1bb7d-ec94-1e4c-8230-af431aaef1d5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41053827"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R40.4", "display": "Unresponsive episode", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "note": [{"text": "Last Assessment & Plan:
problemNote504
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Reportedly EMS found him unresponsive with low systolic? Wife reports he became unresponsive w BP 94/60 and tachycardic
Suspect his syncope was secondary to a low flow state with hypotension. Additionally he reports restarting his lisinopril today for the first time in 2 weeks.
Plan:
-tele x24 hours, uneventful. Removing. "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a3b1bb7d-ec94-1e4c-8230-af431aaef1d5"}}, {"fullUrl": "urn:uuid:932062a2-1e24-334c-fdb9-2b9a6d11ab6b", "resource": {"resourceType": "Condition", "id": "932062a2-1e24-334c-fdb9-2b9a6d11ab6b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41074580"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I77.0", "display": "AV fistula (CMS-HCC) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "note": [{"text": "Last Assessment & Plan:
problemNote506
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R/o active infection/abscess along fistula.
- Obtain US Soft Tissue left upper extremity"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/932062a2-1e24-334c-fdb9-2b9a6d11ab6b"}}, {"fullUrl": "urn:uuid:07a9c828-fde0-47f4-c05f-f477e230bc6c", "resource": {"resourceType": "Condition", "id": "07a9c828-fde0-47f4-c05f-f477e230bc6c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "41074674"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D63.8", "display": "Anemia in other chronic diseases classified elsewhere", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2022-10-11", "note": [{"text": "Last Assessment & Plan:
problemNote509
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Hemoglobin below goal. Likely superimposed acute and chronic anemias. Differential diagnosis includes DIC/hemolysis, anemia of chronic inflammation, ESRD. Schistocytes seen on blood smear, raising concern for DIC/hemolysis, but high fibrinogen is reassuring that this is not DIC. No evidence of acute blood loss.
-Transfuse RBCs for hemoglobin less than 7 - he wants to be notified before additional RBC units are ordered, as he is on a kidney transplant list
-Epogen per nephrology recommendations
-Check LDH, haptoglobin, fibrinogen, INR, iron studies, ferritin"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/07a9c828-fde0-47f4-c05f-f477e230bc6c"}}, {"fullUrl": "urn:uuid:4cb27556-8324-e5ee-7a70-279506c898db", "resource": {"resourceType": "Condition", "id": "4cb27556-8324-e5ee-7a70-279506c898db", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "42980322"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z89.411", "display": "History of amputation of right great toe (CMS-HCC) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-01-29", "note": [{"text": "Last Assessment & Plan:
problemNote516
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Stable no concern for infection "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4cb27556-8324-e5ee-7a70-279506c898db"}}, {"fullUrl": "urn:uuid:4a652ed5-3434-d89e-1509-c8dca60035a8", "resource": {"resourceType": "Condition", "id": "4a652ed5-3434-d89e-1509-c8dca60035a8", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "42980323"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E46", "display": "Protein-calorie malnutrition, unspecified severity (CMS-HCC) (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-01-29", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4a652ed5-3434-d89e-1509-c8dca60035a8"}}, {"fullUrl": "urn:uuid:95c66594-62e9-3711-162e-edb323192554", "resource": {"resourceType": "Condition", "id": "95c66594-62e9-3711-162e-edb323192554", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "42980324"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D68.8", "display": "Other specified coagulation defects (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-01-29", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/95c66594-62e9-3711-162e-edb323192554"}}, {"fullUrl": "urn:uuid:cfe7936c-00dd-3bb8-5533-50d119dd1507", "resource": {"resourceType": "Condition", "id": "cfe7936c-00dd-3bb8-5533-50d119dd1507", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "44878599"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "U07.1", "display": "COVID-19", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-06-05", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/cfe7936c-00dd-3bb8-5533-50d119dd1507"}}, {"fullUrl": "urn:uuid:8fb96c7c-732a-8636-24ff-19f0edf804ec", "resource": {"resourceType": "Condition", "id": "8fb96c7c-732a-8636-24ff-19f0edf804ec", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "47252423"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.9", "display": "Type 2 diabetes mellitus without complication, without long-term current use of insulin (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-11-09", "note": [{"text": "Last Assessment & Plan:
problemNote521
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Well controlled
Discussed fructosamine declines at this time
Continue to track yearly A1c "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8fb96c7c-732a-8636-24ff-19f0edf804ec"}}, {"fullUrl": "urn:uuid:0a0953b8-0289-4b88-8776-7f88c38a63be", "resource": {"resourceType": "Condition", "id": "0a0953b8-0289-4b88-8776-7f88c38a63be", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "47252487"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "I10", "display": "Primary hypertension", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-11-09", "note": [{"text": "Last Assessment & Plan:
problemNote523
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On amlodipine and lisinoril
147/70 today
Well controlled at home and during dialysis
Continue current regiment amlodipine and lisinopril "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/0a0953b8-0289-4b88-8776-7f88c38a63be"}}, {"fullUrl": "urn:uuid:d866c1e8-8068-15e1-4332-8ec402652eb3", "resource": {"resourceType": "Condition", "id": "d866c1e8-8068-15e1-4332-8ec402652eb3", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "47252612"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.43", "display": "Diabetic autonomic neuropathy associated with type 2 diabetes mellitus (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-11-09", "note": [{"text": "Last Assessment & Plan:
problemNote525
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In the bilateral feet
On gabapentin
Bilateral neuropathy, well controlled on low-dose gabapentin, uses 100 to 300 mg nightly. Foot exam done today. No open wounds. No concerning findings."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/d866c1e8-8068-15e1-4332-8ec402652eb3"}}, {"fullUrl": "urn:uuid:db0af2db-b8d3-3526-3468-00e5afca180b", "resource": {"resourceType": "Condition", "id": "db0af2db-b8d3-3526-3468-00e5afca180b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "47253039"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z00.00", "display": "Healthcare maintenance", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-11-09", "note": [{"text": "Last Assessment & Plan:
problemNote527
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TDAP today
PCV 20
Got flu shot through MaineHealth
UTD COVID booster
- Up to date with all blood work. We will do a lipid panel, hemoglobin A1c yearly.
- Discussed using fructosamine instead; however, he declines at this time.
- His fasting glucose has always been within normal limits."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/db0af2db-b8d3-3526-3468-00e5afca180b"}}, {"fullUrl": "urn:uuid:9645b737-19b5-78c9-18e8-ce697b2b7632", "resource": {"resourceType": "Condition", "id": "9645b737-19b5-78c9-18e8-ce697b2b7632", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50329936"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N36.2", "display": "Urethral polyp", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-06-21", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/9645b737-19b5-78c9-18e8-ce697b2b7632"}}, {"fullUrl": "urn:uuid:5e8e7f01-a70f-a0d6-dec4-fc9b812f58f7", "resource": {"resourceType": "Condition", "id": "5e8e7f01-a70f-a0d6-dec4-fc9b812f58f7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50329937"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "A63.0", "display": "Condyloma acuminatum", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-06-21", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5e8e7f01-a70f-a0d6-dec4-fc9b812f58f7"}}, {"fullUrl": "urn:uuid:8009a824-d947-f556-7de9-90c10f28bd21", "resource": {"resourceType": "Condition", "id": "8009a824-d947-f556-7de9-90c10f28bd21", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50337107"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "E11.622", "display": "Diabetic ulcer of right ankle (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-06-21", "note": [{"text": "Last Assessment & Plan:
problemNote531
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Right ankle ulceration with increased depth, noted 2.5 cm straight and. Was not able to palpate any bone at the base but I anticipate this is very close.
Heavy amount of drainage continues to flow from the open area of the wound, lower leg is significantly edematous 3+ pitting to foot ankle and lower leg.
Was not able to express any wispy thick yellow fluid as I was last week.
Patient does have an MRI coming up next Wednesday.
He has arterial studies next Thursday.
He will return to see us next Friday.
I did discuss with Ryan today that I believe he would benefit from negative pressure wound therapy assuming that the MRI was negative for any underlying infection in the bone.
Ryan states that he would be agreeable to this at this time.
Until he sees us back next Friday I would like him to dress the wounds with the following:
Mesalt gauze tucked into the depth of the wound followed by ABD pad, rolled gauze, Ace wrap for higher level of compression than he is achieving currently with his own compression stocking. Change dressing daily.
Patient to begin taking doxycycline, prescribed 10-day course to be completed on 8/12/24
Return to see us next Friday."}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8009a824-d947-f556-7de9-90c10f28bd21"}}, {"fullUrl": "urn:uuid:dff1a842-fe5c-4f0a-19cf-b1977399cdd9", "resource": {"resourceType": "Condition", "id": "dff1a842-fe5c-4f0a-19cf-b1977399cdd9", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924407"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "D84.9", "display": "Immunosuppressed status (CMS-HCC V24)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/dff1a842-fe5c-4f0a-19cf-b1977399cdd9"}}, {"fullUrl": "urn:uuid:457adb01-1630-2c1c-a604-4b07e2a3b972", "resource": {"resourceType": "Condition", "id": "457adb01-1630-2c1c-a604-4b07e2a3b972", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924442"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z94.89", "display": "Transplant recipient", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Last Assessment & Plan:
problemNote537
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S/p kidney and pancreas transplant at MGH
Now ESRD with some urine production
Pancreas stable, lipase 11"}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/457adb01-1630-2c1c-a604-4b07e2a3b972"}}, {"fullUrl": "urn:uuid:54e3b0bd-6a63-b094-8f7b-418b87b88b78", "resource": {"resourceType": "Condition", "id": "54e3b0bd-6a63-b094-8f7b-418b87b88b78", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924763"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R78.81", "display": "MSSA bacteremia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Last Assessment & Plan:
problemNote539
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Presented with high fevers (first fever reported 7/30/24), malaise, dry cough.
Blood culture resulted positive for methicillin-susceptible S. aureus.
Source likely R ankle osteomyelitis seen on MRI. Warrants workup for valvular involvement via TTE and involvement of fistula via US.
-Treat osteomyelitis (below)
-Appreciate ID recs:
Cefazolin 2g q8h for 6 weeks for osteo
-F/u TTE and fistula US
-Narrow antibiotics to cefazolin (will review with ID whether any additional coverage is needed for question of pneumonia)
-Repeat blood culture to evaluate for clearance of bacteremia tomorrow (8/5) "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/54e3b0bd-6a63-b094-8f7b-418b87b88b78"}}, {"fullUrl": "urn:uuid:7ba81e30-0c52-3d80-c247-f14d1ed7a8ce", "resource": {"resourceType": "Condition", "id": "7ba81e30-0c52-3d80-c247-f14d1ed7a8ce", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50924764"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M86.9", "display": "Osteomyelitis of right ankle (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Last Assessment & Plan:
problemNote543
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Osteomyelitis seen on 8/3 MRI. Likely related to medial malleolar ulcer present for 3 months, which started as a burn. The patient is followed by the wound care clinic. Per MRI, cannot exclude septic joint.
-Consult ortho re: drainage for septic joint
-Wound care nursing consult with low threshold for burn and soft tissue surgery consult
-Wound care per prior outpatient recommendations:
Mesalt gauze tucked into the depth of the wound followed by ABD pad, rolled gauze, Ace wrap for higher level of compression than he is achieving currently with his own compression stocking. Change dressing daily. "}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/7ba81e30-0c52-3d80-c247-f14d1ed7a8ce"}}, {"fullUrl": "urn:uuid:49511150-fca1-ab3c-7e67-54b5759bdd46", "resource": {"resourceType": "Condition", "id": "49511150-fca1-ab3c-7e67-54b5759bdd46", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50927212"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R50.9", "display": "Fever in adult", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-04", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/49511150-fca1-ab3c-7e67-54b5759bdd46"}}, {"fullUrl": "urn:uuid:45b5366d-e6d3-3744-6b9c-e66825969a31", "resource": {"resourceType": "Condition", "id": "45b5366d-e6d3-3744-6b9c-e66825969a31", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50927213"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "N18.6", "display": "ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-04", "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/45b5366d-e6d3-3744-6b9c-e66825969a31"}}, {"fullUrl": "urn:uuid:91bc1e05-8b85-6901-5dec-03a6826f358b", "resource": {"resourceType": "DiagnosticReport", "id": "91bc1e05-8b85-6901-5dec-03a6826f358b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "353417712"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.206.2.798268.2.353417712.1"}], "status": "final", "code": {"coding": [{"code": "33480", "display": "XR Chest PA And Lateral", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-08-03T16:30:00Z", "end": "2024-08-03T16:30:00Z"}, "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "performer": [{"reference": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}], "result": [{"reference": "Observation/886a8a96-b98d-a9f3-bb01-8449be8536f5"}, {"reference": "Observation/b8412ac2-a738-3286-c93e-769de7306ac9"}, {"reference": "Observation/c381eed1-336a-3436-294d-d4ef70f13600"}, {"reference": "Observation/ea475221-55e7-209f-eefb-30ceab60ee3a"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/91bc1e05-8b85-6901-5dec-03a6826f358b"}}, {"fullUrl": "urn:uuid:6785067f-cee7-c612-c204-069a2bb67949", "resource": {"resourceType": "Organization", "id": "6785067f-cee7-c612-c204-069a2bb67949", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}}, {"fullUrl": "urn:uuid:886a8a96-b98d-a9f3-bb01-8449be8536f5", "resource": {"resourceType": "Observation", "id": "886a8a96-b98d-a9f3-bb01-8449be8536f5", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.3.696580.52175", "value": "33480"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-08-03T17:17:00Z", "end": "2024-08-03T17:48:03Z"}, "bodySite": {"coding": [{"code": "101", "display": "Chest", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.10.696580.52010"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T16:30:00Z"}]}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}}, "request": {"method": "PUT", "url": "Observation/886a8a96-b98d-a9f3-bb01-8449be8536f5"}}, {"fullUrl": "urn:uuid:b8412ac2-a738-3286-c93e-769de7306ac9", "resource": {"resourceType": "Observation", "id": "b8412ac2-a738-3286-c93e-769de7306ac9", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.7.798268.1000", "value": "353417712"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-03T17:56:51Z", "valueString": "EXAM: XR CHEST PA AND LATERAL
INDICATION: Sepsis
COMPARISON: 10/11/2022.
TECHNIQUE: AP and lateral radiographs of the chest.
FINDINGS:
The lungs are well expanded.
Diffuse bibasilar and bihilar predominant pulmonary interstitial alveolar opacities. There is the appearance of early confluent consolidation associated with the retrocardiac lungs. The remainder lungs otherwise clear of focal consolidative change.
Costophrenic sulci blunting posteriorly may reflect trace effusions and/or more confluent pulmonary opacification. There is no pneumothorax.
Cardiomegaly and pulmonary vascular congestion appears more pronounced from prior examination.
No acute osseous or joint abnormality.
IMPRESSION:
Pulmonary interstitial and alveolar opacities with early confluent consolidation of the retrocardiac position which is likely reflective of early organizing pneumonia given the clinical history. There could be some possible associated trace pleural
effusion. Prominence of the heart and pulmonary vascularity could be somewhat due to technique, however, cardiogenic pulmonary edema may also be within the differential. Clinical correlation for concomitant congestive heart failure would be recommended.
WORKSTATION: WS30
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/3/2024 1:54 PM \u00a0Christopher Mutter, DO", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T16:30:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.353417712.Narrative"}]}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/b8412ac2-a738-3286-c93e-769de7306ac9"}}, {"fullUrl": "urn:uuid:cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "resource": {"resourceType": "Organization", "id": "cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}}, {"fullUrl": "urn:uuid:c381eed1-336a-3436-294d-d4ef70f13600", "resource": {"resourceType": "Observation", "id": "c381eed1-336a-3436-294d-d4ef70f13600", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051849932"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-03T17:56:51Z", "valueString": "RECOGNITION * * 8/3/2024 1:54 PM Christopher Mutter, DO
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: WS30
congestive heart failure would be recommended.
be within the differential. Clinical correlation for concomitant
somewhat due to technique, however, cardiogenic pulmonary edema may also
effusion. Prominence of the heart and pulmonary vascularity could be
possible associated trace pleural
early organizing pneumonia given the clinical history. There could be some
consolidation of the retrocardiac position which is likely reflective of
Pulmonary interstitial and alveolar opacities with early confluent
IMPRESSION:
No acute osseous or joint abnormality.
from prior examination.
Cardiomegaly and pulmonary vascular congestion appears more pronounced
more confluent pulmonary opacification. There is no pneumothorax.
Costophrenic sulci blunting posteriorly may reflect trace effusions and/or
clear of focal consolidative change.
associated with the retrocardiac lungs. The remainder lungs otherwise
opacities. There is the appearance of early confluent consolidation
Diffuse bibasilar and bihilar predominant pulmonary interstitial alveolar
The lungs are well expanded.
FINDINGS:
TECHNIQUE: AP and lateral radiographs of the chest.
COMPARISON: 10/11/2022.
INDICATION: Sepsis
EXAM: XR CHEST PA AND LATERAL
Formatting of this note might be different from the original.
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Date: 8/4/2024 5:00 PM
History: Male, 46 years old. INDICATIONS: 46 yo M with immunocompromised status due to kidney transplant, presents with high fevers. Chronic wound of R ankle followed by wound care. Please evaluate for evidence of osteomyelitis. \u00a0STUDY NOTES: \u00a0Prior
imaging on pacs. Patient presenting with medial right ankle ulceration. Evaluate for osteomyelitis. \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Hx Questions: \u00a0Hx \u00a0of Diabetes, Renal Insuf., Multiple Myeloma? Yes \u00a0 \u00a0
COMPARISON: \u00a0None.
Technique: Right foot and ankle imaged. Routine MRI was performed without intravenous contrast.
FINDINGS:
Soft tissues: Diffuse superficial edema. There is no muscular edema or atrophy.
Bones: Abnormal marrow edema of the medial malleolus and talus noted. Talar dome is intact; no fracture or bone lesion.
Joints: Mild ankle joint effusion with heterogeneous signal within the. No loose body. \u00a0
Medial Flexor Tendons: Fluid in tendon sheath. Otherwise visualized PT, FDL and FHL are intact. \u00a0Peroneal Tendons: Fluid in the tendon; otherwise peroneus longus and brevis are intact.
Anterior Extensor Tendons: The AT, EHL and EDL are intact. \u00a0
Lateral Ligaments: Tibiofibular, talofibular and calcaneofibular ligaments are intact.
Medial Ligaments: The deltoid (deep and superficial) ligaments are intact.
Achilles Tendon: Intact.
Plantar Fascia: Intact. Small plantar calcaneal enthesophyte noted.
Additional comments: None.
IMPRESSION: Cellulitis with findings suggestive for early medial malleoli relating talar osteomyelitis.
Nonspecific small ankle joint effusion. Cannot exclude septic joint.
Nonspecific fluid or tenosynovitis of medial flexor and peroneal tendons.
WSN:SHU-CA91301
* * * THIS IS AN ELECTRONICALLY VERIFIED REPORT * * *
8/4/2024 8:18:54 PM \u00a0Fred Shu
For questions regarding this report, Monday through Friday, 8am-5pm, please contact Spectrum Radiology Support at 1-844-764-7237. \u00a0Otherwise, please contact Synergy at 1-877-671-6119.", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T21:00:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355151809.Narrative"}]}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/9509befa-603e-e04d-dc7c-643b18b61b36"}}, {"fullUrl": "urn:uuid:732ad115-8904-c4eb-475a-149d8e14c17e", "resource": {"resourceType": "Observation", "id": "732ad115-8904-c4eb-475a-149d8e14c17e", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2052100449"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-05T00:19:46Z", "valueString": "please contact Synergy at 1-877-671-6119.
please contact Spectrum Radiology Support at 1-844-764-7237. Otherwise,
For questions regarding this report, Monday through Friday, 8am-5pm,
8/4/2024 8:18:54 PM Fred Shu
* * * THIS IS AN ELECTRONICALLY VERIFIED REPORT * * *
WSN:SHU-CA91301
tendons.
Nonspecific fluid or tenosynovitis of medial flexor and peroneal
Nonspecific small ankle joint effusion. Cannot exclude septic joint.
relating talar osteomyelitis.
IMPRESSION: Cellulitis with findings suggestive for early medial malleoli
Additional comments: None.
Plantar Fascia: Intact. Small plantar calcaneal enthesophyte noted.
Achilles Tendon: Intact.
intact.
Medial Ligaments: The deltoid (deep and superficial) ligaments are
are intact.
Lateral Ligaments: Tibiofibular, talofibular and calcaneofibular ligaments
Anterior Extensor Tendons: The AT, EHL and EDL are intact.
peroneus longus and brevis are intact.
FDL and FHL are intact. Peroneal Tendons: Fluid in the tendon; otherwise
Medial Flexor Tendons: Fluid in tendon sheath. Otherwise visualized PT,
loose body.
Joints: Mild ankle joint effusion with heterogeneous signal within the. No
Talar dome is intact; no fracture or bone lesion.
Bones: Abnormal marrow edema of the medial malleolus and talus noted.
atrophy.
Soft tissues: Diffuse superficial edema. There is no muscular edema or
FINDINGS:
intravenous contrast.
Technique: Right foot and ankle imaged. Routine MRI was performed without
COMPARISON: None.
Renal Insuf., Multiple Myeloma? Yes
Evaluate for osteomyelitis. Hx Questions: Hx of Diabetes,
imaging on pacs. Patient presenting with medial right ankle ulceration.
osteomyelitis. STUDY NOTES: Prior
of R ankle followed by wound care. Please evaluate for evidence of
status due to kidney transplant, presents with high fevers. Chronic wound
History: Male, 46 years old. INDICATIONS: 46 yo M with immunocompromised
Date: 8/4/2024 5:00 PM
EXAMINATION: MRI ANKLE RT, W/O CONTRAST
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INDICATION: 46 yo M with immuncompromised status from renal transplant, presents with MSSA bacteremia, question of pneumonia. History of potential mold exposures.
COMPARISON: August 3, 2024
TECHNIQUE: CT of the chest was performed without intravenous contrast. Axial, sagittal, coronal, and MIP images.
FINDINGS:
Lungs/Pleura: Small bilateral pleural effusions are noted. Calcific granulomas are seen in both lungs. There also several noncalcified nodules measuring up to 8 mm. Follow up CT scanning is recommended in 6 months for reevaluation. Septal line prominence
is seen and mild pulmonary edema may be present. Mild groundglass opacity is also seen bilaterally.
Heart: The heart is enlarged. Coronary artery calcification is noted. No pericardial effusion is seen.
Mediastinum: No vascular abnormality, mass, or inflammation.
Lymph Nodes: Bilateral hilar lymphadenopathy is suggested with lymph nodes measuring up to 1.5 cm.
Thyroid: There is a 3.3 cm left thyroid nodule with calcifications. Sonographic correlation is recommended.
Esophagus: Negative.
Chest Wall: Intact without mass.
Upper Abdomen: The spleen is not completely included though it appears to be enlarged. A right renal cyst is noted.
Musculoskeletal: The bones are diffusely hyperdense in appearance this finding may be related to secondary hyperparathyroidism given the patient''s history. Clinical correlation is recommended.
IMPRESSION: Small bilateral pleural effusions are noted. Calcified and noncalcified lung nodules are seen. Noncalcified nodules measuring up to 8 mm and follow up CT scan is recommended in 6 months for reevaluation. Possible mild pulmonary edema is
suspected. Mild groundglass opacity is also seen bilaterally. Cardiomegaly and coronary artery calcification are noted. Bilateral hilar lymphadenopathy. A large left thyroid nodule is noted with calcifications and sonographic evaluation is indicated.
Splenomegaly. Right renal cyst. The bones are hyperdense appearance which may be related to secondary hyperparathyroidism though clinical and laboratory correlation recommended.
WORKSTATION: MILES-MG-DS1
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/4/2024 6:23 PM \u00a0Charles Mullen, MD", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T22:15:34Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355119233.Narrative"}]}], "subject": {"reference": "Patient/3b03b244-cdb6-4612-bc88-8671b7836a83"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/8d428a2f-306b-f328-c735-cb706f2e30b9"}}, {"fullUrl": "urn:uuid:27432093-40ef-9949-745c-7051c5c74e81", "resource": {"resourceType": "Observation", "id": "27432093-40ef-9949-745c-7051c5c74e81", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2052088598"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T22:23:42Z", "valueString": "RECOGNITION * * 8/4/2024 6:23 PM Charles Mullen, MD
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: MILES-MG-DS1
laboratory correlation recommended.
may be related to secondary hyperparathyroidism though clinical and
Splenomegaly. Right renal cyst. The bones are hyperdense appearance which
and sonographic evaluation is indicated.
lymphadenopathy. A large left thyroid nodule is noted with calcifications
and coronary artery calcification are noted. Bilateral hilar
suspected. Mild groundglass opacity is also seen bilaterally. Cardiomegaly
Possible mild pulmonary edema is
mm and follow up CT scan is recommended in 6 months for reevaluation.
noncalcified lung nodules are seen. Noncalcified nodules measuring up to 8
IMPRESSION: Small bilateral pleural effusions are noted. Calcified and
patient''s history. Clinical correlation is recommended.
finding may be related to secondary hyperparathyroidism given the
Musculoskeletal: The bones are diffusely hyperdense in appearance this
be enlarged. A right renal cyst is noted.
Upper Abdomen: The spleen is not completely included though it appears to
Chest Wall: Intact without mass.
Esophagus: Negative.
Sonographic correlation is recommended.
Thyroid: There is a 3.3 cm left thyroid nodule with calcifications.
measuring up to 1.5 cm.
Lymph Nodes: Bilateral hilar lymphadenopathy is suggested with lymph nodes
Mediastinum: No vascular abnormality, mass, or inflammation.
pericardial effusion is seen.
Heart: The heart is enlarged. Coronary artery calcification is noted. No
is also seen bilaterally.
is seen and mild pulmonary edema may be present. Mild groundglass opacity
reevaluation. Septal line prominence
measuring up to 8 mm. Follow up CT scanning is recommended in 6 months for
granulomas are seen in both lungs. There also several noncalcified nodules
Lungs/Pleura: Small bilateral pleural effusions are noted. Calcific
FINDINGS:
Axial, sagittal, coronal, and MIP images.
TECHNIQUE: CT of the chest was performed without intravenous contrast.
COMPARISON: August 3, 2024
mold exposures.
presents with MSSA bacteremia, question of pneumonia. History of potential
INDICATION: 46 yo M with immuncompromised status from renal transplant,
EXAM: CT CHEST WO CONTRAST
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60%.
Normal right ventricular cavity size and systolic function.
There is an echodensity seen in the LVOT just in the vicinity of the right
coronary cusp. This may represent calcium versus possible vegetation.
Moderate mitral annular calcification. \u00a0There is trace mitral
regurgitation.
Compared to prior study of 1/21/2022, the aortic valve findings are new. \u00a0
If clinically indicated, TEE would better evaluate for infective
endocarditis.
Left Ventricle
Left ventricular cavity is normal in size. Normal wall thickness. Normal wall motion. Normal systolic function with a visually estimated EF of 55 - 60%. Diastolic dysfunction present, indeterminate grade.
Right Ventricle
Right ventricle size is normal. Normal systolic function.
Left Atrium
Left atrium is mildly dilated.
Right Atrium
Right atrium size is normal. The right atrial pressure is estimated at 15 mmHg.
IVC/SVC
IVC diameter is greater than 21 mm and decreases less than 50% during inspiration.
Mitral Valve
Mildly calcified leaflets. Moderate posterior mitral annular calcification. Trace regurgitation. No stenosis.
Tricuspid Valve
Valve structure is normal. Trace regurgitation. No stenosis.
Aortic Valve
Trileaflet. Mildly calcified cusps. There is an echodensity seen in the LVOT just in the vicinity of the right coronary cusp. This may represent calcium versus possible vegetation. No Doppler abnormalities.
Pulmonic Valve
Not well visualized. No Doppler abnormalities.
Ascending Aorta
Normal sized sinuses of Valsalva and ascending aorta.
Pericardium
No pericardial effusion.
Pulmonary Artery
Not well visualized but probably normal.
Study Details
A complete echo was performed using complete 2D, color flow Doppler and spectral Doppler. Overall the study quality was adequate.
Wall Scoring Baseline
Score Index: 1.00
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>12 months post renal transplant: 3.0-6.0 ng/mL
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prophylaxis prior to surgery/invasive procedure, if the
FFP is rarely indicated in a bleeding patient, or as
\u00a0 \u00a0 HIGH DOSE THERAPY: 2.5 - 3.5
\u00a0 \u00a0 STANDARD THERAPY: 2.0 - 3.0
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<= 3 months post renal transplant: 12.0-15.0 ng/mL
3-12 months post renal transplant: 8.0-12.0 ng/mL
>12 months post renal transplant: 3.0-6.0 ng/mL
Potentially toxic: 15.1-20.0 ng/mL
Toxic: > 20.0 ng/mL
Analytical Method: Chemiluminescence Microparticle
Immunoassay (CMIA)
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"primarySource": true, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Immunization/50f259a0-9cd7-beaf-edde-b3a28053fc79"}}, {"fullUrl": "urn:uuid:710f858e-7436-d5c9-9b1c-084e014a391f", "resource": {"resourceType": "Organization", "id": "710f858e-7436-d5c9-9b1c-084e014a391f", "name": "Wyeth Pharmaceuticals, Inc", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/710f858e-7436-d5c9-9b1c-084e014a391f"}}, {"fullUrl": "urn:uuid:9223c21b-b604-994f-9b47-64479453487c", "resource": {"resourceType": "Immunization", "id": "9223c21b-b604-994f-9b47-64479453487c", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "47253933"}], "occurrenceDateTime": "2023-10-20", "note": {"text": "Pfizer Comirnaty (12+)covid-19,mrna,lnp-s,pf,tris-sucrose,30mcg/0.3mL(IMM10263)"}, "vaccineCode": {"coding": [{"display": "Pfizer Comirnaty (12+)covid-19,mrna,lnp-s,pf,tris-sucrose,30mcg/0.3mL(IMM10263)"}]}, "status": "completed", 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"generated", "div": "Not on file documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E6-B5CB-D69B-FFA4C7D55C45", "title": "Immunizations", "text": {"status": "generated", "div": "
NameAdministration DatesNext Due
HH Influenza Vaccine Quadrivalent 0.5ML IM10/25/2021
Moderna Red Cap(12+)Covid-19,Monovalent,mrna,lnp-s,pf,.5mL (IMM10222)02/11/2021 01/14/2021 ,
documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-25E6-B5D7-D69B-FFA4C7D55C45", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
cefTRIAXone (Rocephin) syringe infusion 1 gm1 gm, Intravenous, Daily, First dose on Sun 8/4/24 at 0300, For 5 doses, Ceftriaxone: NOT admin. via Y-site with calcium-containing (ie: Lactated Ringers). Flush lines between sequent. admin. of ceftriaxone and calcium-containing soln. Possible side effects: Nausea, diarrhea, rash Reconstitute 1gm vial of ceftriaxone in 20 mL of SWFI or 0.9% NaCl. For locations with access to Plum360 pump: Connect syringe to Plum360 Pump and infuse over 5 minutes (4 mL/min). Upon completion of infusion, flush with 20 mL at the same rate to ensure all antibiotic in tubing has been administered. In locations where Plum360 pump is unavailable: push syringe over 2 minutes. Upon completion of IV push, flush with 20 mL of NS or maintenance fluid to ensure all antibiotic in tubing has been administered.Given08/05/2024 9:02 AM EDT1 gm
Given08/04/2024 3:33 AM EDT1 gm
enoxaparin (Lovenox) injection 40 mg40 mg, Subcutaneous, Every 24 hours, First dose on Sun 8/4/24 at 0900, Abdomen is the preferred site of administration. Possible side effects: bleeding & bruising, mild pain at injection siteGiven08/04/2024 9:14 AM EDT40 mgLeft Lower Abdomen
lactated ringers infusion100 mL/hr, Intravenous, Continuous, Starting on Sun 8/4/24 at 0845New Bag08/04/2024 5:57 PM EDT100 mL/hr100 mL/hr
New Bag08/04/2024 9:15 AM EDT100 mL/hr100 mL/hr
remdesivir (Veklury) 100 mg in NaCl 0.9% 250 mL infusion100 mg, Intravenous, Administer over 30 Minutes, Every 24 hours, First dose on Mon 8/5/24 at 0500, For 2 days, The entire volume of the prepared remdesivir solution for infusion in 0.9% saline should be infused. When the administration of remdesivir solution is complete, flush the IV line with at least 30 mL of 0.9% saline at the same rate to ensure that all of the remdesivir solution has been administered.New Bag08/05/2024 5:48 AM EDT100 mg500 mL/hr
senna (Senokot) tablet 2 Tablet2 Tablet, Oral, Daily, First dose on Sun 8/4/24 at 0900, 1st line therapy (Adult Bowel Management - 1 or more Risk Factors): Switch to 2nd line therapy if no BM by 48 hours after using 1st line therapy. Hold for Bristol Type 6 or 7 stoolsGiven08/05/2024 9:00 AM EDT2 Tablets
Given08/04/2024 2:56 PM EDT2 Tablets
sodium chloride (NS) 0.9 % flush 5 mL5 mL, Intravenous, As needed, Line Care, Starting on Sat 8/3/24 at 2027
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (Ofirmev) 10 MG/ML injection 1,000 mg1,000 mg, Intravenous, at 400 mL/hr, Every 6 hours, First dose on Sun 8/4/24 at 0300, For 2 doses, Infuse over 15 minutes, Indications: Patient NPO and cannot take oral medications, want take PONew Bag08/04/2024 9:14 AM EDT1,000 mg400 mL/hr
New Bag08/04/2024 2:14 AM EDT1,000 mg400 mL/hr
acetaminophen (TYLENOL) 32 mg/mL oral solution (650mg cup) 650 mg650 mg, Oral, Once, On Sat 8/3/24 at 1945, For 1 dose, Maximum dose of acetaminophen is 4000 mg from all sources in 24 hours. Possible side effects: upset stomach, rashGiven08/03/2024 7:51 PM EDT650 mg
iohexol (OMNIPAQUE) 350 MG/ML injection 70 mL70 mL, Intravenous, Once PRN, Starting on Sun 8/4/24 at 0207, For 1 doseGiven08/04/2024 2:07 AM EDT70 mL
lactated ringers infusion bolus 1,000 mL1,000 mL, Intravenous, Administer over 1 Hours, Every hour, First dose on Sat 8/3/24 at 2100, For 1 doseNew Bag08/03/2024 9:22 PM EDT1,000 mL1000 mL/hr
lactated ringers infusion bolus 1,000 mL1,000 mL, Intravenous, Administer over 2 Hours, Once, On Sun 8/4/24 at 0345, For 1 doseNew Bag08/04/2024 3:43 AM EDT1,000 mL500 mL/hr
midazolam (Versed) injection 2 mg2 mg, Intramuscular, Once, On Sat 8/3/24 at 2045, For 1 doseGiven08/03/2024 8:42 PM EDT2 mgLeft Anterior Thigh
morphine (PF) 2 MG/ML injection 4 mg4 mg, Intravenous, Once, On Sat 8/3/24 at 2245, For 1 dose, For IV Push: May be administered undiluted as IV push over 4-5 minutes; however further dilution with 5 ml Sterile Water or 0.9% NS to facilitate dose titration is appropriate. Use injectable agent if urgent/rapid analgesia is required or patient unable to take oral agent or oral agent ineffective after 60 minutes. Possible side effects: drowsiness, constipation, nausea/vomiting, rash.Given08/03/2024 10:48 PM EDT4 mg
remdesivir (Veklury) 200 mg in NaCl 0.9% 250 mL infusion200 mg, Intravenous, Administer over 30 Minutes, Every 24 hours, First dose on Sun 8/4/24 at 0145, For 1 day, The entire volume of the prepared remdesivir solution for infusion in 0.9% saline should be infused. When the administration of remdesivir solution is complete, flush the IV line with at least 30 mL of 0.9% saline at the same rate to ensure that all of the remdesivir solution has been administered.New Bag08/04/2024 5:00 AM EDT200 mg500 mL/hr
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Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
Culture Blood - #1 of 1MicrobiologySTAT08/03/2024 9:13 PM EDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
POC Bedside Glucose TestPoint of Care TestingSTATAs Needed until discontinued starting 8/4/24
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/0007b46d-3f28-5741-6258-898730fe28db"}]}, {"id": "00000000-25E6-B5E5-D69B-FFA4C7D55C45", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
COVID08/03/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
Gentle IVF given soft BPWill d/w CM if group home can take back if continues asymptomatic course.3 day course remdesivir Plan:Treated with remdesivir given dev. DelayTested positive for COVID upon admission. No resp symptoms, satting fine, CXR neg.
Right hip pain08/03/2024
Last Assessment & Plan:Formatting of this note might be different from the original.
-observe-ceftriaxone for possible UTI, culture pendingPlan:Appears resolved. Suspect is was related to myalgia/arthralgias from COVID although UTI symptoms also possible. CT without joint effusion and hardware of R hip intact. CRP <3
Obstipation05/01/2023
Fever in adult10/03/2020
Rash, fever10/03/2020
Last Assessment & Plan:Formatting of this note might be different from the original.
- f/u viral serologies but neg so far - prn benadryl but would try to avoid- will cont pred for short course, will change to oral and 30 today Patient came in with her biggest complaint being increased agitation and appearing extremely uncomfortable per her father. Very abnormal for her and normally very nice and sweet. Unclear the etiology but almost gone after 1 dose of steroids and does not look like she is itching it
Status post total hip replacement, right06/03/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
- needs to ambulate - tylenol - foot area looks more like bruise to me - XR already done that is negIt is unclear if it her hip or foot that is causing to not put weight on it. The pain she had when I touched her right foot are makes me think that is the etiology
Urinary retention06/03/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
Likely due to constipation. No evidence of retention, constipation controlled. Urinalysis was negative for infection. Continue to monitor for constipation.
Constipation06/03/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
-Continue magnesium supplement natural,-Will make MiraLAX as needed if no BM for greater than 2 days-Continue Colace-Family to make prunes available, staff to offer for prunes dailyPatient starting to have softer stools and concern for incontinence with patient using a pool to swim throughout the week. Discussed at length with parents with plan as follows:
Osteoarthritis resulting from right hip dysplasia05/28/2019
Cellulitis of foot, right02/01/2019
Last Assessment & Plan:Formatting of this note might be different from the original.
- hold abx for now As above
Angelman syndrome12/26/2017
Last Assessment & Plan:Formatting of this note might be different from the original.
-Continue PT/OTPatient to return to supportive environment at group home with parents support.
Abnormality of gait and mobility03/13/2017
Last Assessment & Plan:Formatting of this note might be different from the original.
Note that today''s visit total time 1 hour and 10 minutes greater than 50% in discussionWe will discuss this with the joint replacement team and get back to the family on thisHer parents are very interested in pursuing thisI suspect that the only thing that would substantially alter this for her would be hip replacement surgeryI suspect that her deteriorating gait and difficulty with pain is related to issues with her hipsBilateral hips she has what appears to be considerable issues with the hips the right appears to be perhaps subluxed and there is significant arthritic change in both hips with the right being more prominent than leftWe will obtain radiology review of theseFusion of spine as expectedX-rays taken today of her lumbar spine reveal hardware in place there is not seem to be any malalignment or issues with the hardwareMultifactorial gait abnormality
Seizures (CMS/HHS)
Overview:Last Assessment & Plan:Formatting of this note might be different from the original.
Tapered off Depakote at ~ 19 Y/O Formatting of this note might be different from the original.
No recurrence of seizure activity, likely medication related, suspect oxycodone.
Resolved ProblemsNoted DateDiagnosed DateResolved Date
Suspected COVID-19 virus infection10/03/202010/05/2020
Last Assessment & Plan:Formatting of this note might be different from the original.
-Remove covid precautions. PLAN:A: COVID-19 Testing obtained due to symptoms which could be consistent with coronavirus infection. Covid swab negative x 1.
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Average Number of DrinksNot on file05/01/2023
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Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
Job Start DateOccupationIndustry
Not on fileNot on fileNot on file
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"Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "medicationReference": {"reference": "Medication/1c468002-ae9b-71b8-0aa4-94f8a73a6909"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/2304edf2-d0e2-bfe9-c7d5-4a743b1fea90"}}, {"fullUrl": "urn:uuid:1c468002-ae9b-71b8-0aa4-94f8a73a6909", "resource": {"resourceType": "Medication", "id": "1c468002-ae9b-71b8-0aa4-94f8a73a6909", "code": {"coding": [{"code": "216989", "system": "urn:oid:2.16.840.1.113883.6.253"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/1c468002-ae9b-71b8-0aa4-94f8a73a6909"}}, {"fullUrl": "urn:uuid:c9375ae5-9e6e-5115-e994-63e4cf8c381e", "resource": {"resourceType": "MedicationAdministration", "id": "c9375ae5-9e6e-5115-e994-63e4cf8c381e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355103327"}], "status": "in-progress", "effectivePeriod": {"start": "2024-08-05T09:00:00Z", "end": "2024-08-07T08:59:00Z"}, "dosage": {"route": {"coding": [{"code": "C38276", "display": "Intravenous", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 100, "unit": "mg"}}, "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "medicationReference": {"reference": "Medication/0118b4e3-86a3-cd1f-d574-855b195b83b8"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/c9375ae5-9e6e-5115-e994-63e4cf8c381e"}}, {"fullUrl": "urn:uuid:0118b4e3-86a3-cd1f-d574-855b195b83b8", "resource": {"resourceType": "Medication", "id": "0118b4e3-86a3-cd1f-d574-855b195b83b8", "code": {"coding": [{"display": "remdesivir (Veklury) 100 mg in NaCl 0.9% 250 mL infusion", "system": "http://www.nlm.nih.gov/research/umls/rxnorm"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/0118b4e3-86a3-cd1f-d574-855b195b83b8"}}, {"fullUrl": "urn:uuid:d1d182ea-a312-34e5-3950-70a3fecb7fd1", "resource": {"resourceType": "MedicationAdministration", "id": "d1d182ea-a312-34e5-3950-70a3fecb7fd1", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355103302"}], "status": "completed", "effectiveDateTime": "2024-08-04T02:45:00Z", "dosage": {"route": {"coding": [{"code": "C38276", "display": "Intravenous", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 4, "unit": "mg"}}, "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "medicationReference": {"reference": "Medication/1fd65b9e-e0f8-883f-60be-f76c4383818f"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/d1d182ea-a312-34e5-3950-70a3fecb7fd1"}}, {"fullUrl": "urn:uuid:1fd65b9e-e0f8-883f-60be-f76c4383818f", "resource": {"resourceType": "Medication", "id": "1fd65b9e-e0f8-883f-60be-f76c4383818f", "code": {"coding": [{"code": "0409-1890-01", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/1fd65b9e-e0f8-883f-60be-f76c4383818f"}}, {"fullUrl": "urn:uuid:a17d39f8-2936-6490-3d11-bb8ff11f7797", "resource": {"resourceType": "MedicationAdministration", "id": "a17d39f8-2936-6490-3d11-bb8ff11f7797", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355099956"}], "status": "completed", "effectiveDateTime": "2024-08-04T00:30:00Z", "dosage": {"route": {"coding": [{"code": "C28161", "display": "Intramuscular", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 2, "unit": "mg"}}, "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "medicationReference": {"reference": "Medication/f54a322b-08ac-bc98-e9b0-48a9c6c27fde"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/a17d39f8-2936-6490-3d11-bb8ff11f7797"}}, {"fullUrl": "urn:uuid:f54a322b-08ac-bc98-e9b0-48a9c6c27fde", "resource": {"resourceType": "Medication", "id": "f54a322b-08ac-bc98-e9b0-48a9c6c27fde", "code": {"coding": [{"code": "63323-412-25", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/f54a322b-08ac-bc98-e9b0-48a9c6c27fde"}}, {"fullUrl": "urn:uuid:f69b4cdf-3243-fa85-c60b-bac20aee5594", "resource": {"resourceType": "MedicationAdministration", "id": "f69b4cdf-3243-fa85-c60b-bac20aee5594", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355099933"}], "status": "in-progress", "effectivePeriod": {"start": "2024-08-04T00:27:00Z"}, "dosage": {"route": {"coding": [{"code": "C38276", "display": "Intravenous", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 5, "unit": "mL"}}, "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "medicationReference": {"reference": "Medication/45537cdd-cfb0-9e72-21d6-a0faefc787c4"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/f69b4cdf-3243-fa85-c60b-bac20aee5594"}}, {"fullUrl": "urn:uuid:45537cdd-cfb0-9e72-21d6-a0faefc787c4", "resource": {"resourceType": "Medication", "id": "45537cdd-cfb0-9e72-21d6-a0faefc787c4", "code": {"coding": [{"code": "64253-111-21", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/45537cdd-cfb0-9e72-21d6-a0faefc787c4"}}, {"fullUrl": "urn:uuid:08bbaca1-d382-1376-23ea-6f980693a554", "resource": {"resourceType": "MedicationAdministration", "id": "08bbaca1-d382-1376-23ea-6f980693a554", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "301061479"}], "status": "completed", "effectiveDateTime": "2024-08-03T23:45:00Z", "dosage": {"route": {"coding": [{"code": "C38288", "display": "Oral", "system": "urn:oid:2.16.840.1.113883.3.26.1.1"}]}, "dose": {"value": 650, "unit": "mg"}}, "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "medicationReference": {"reference": "Medication/ae94bad8-912a-cf33-9ac7-cf917556be06"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "MedicationAdministration/08bbaca1-d382-1376-23ea-6f980693a554"}}, {"fullUrl": "urn:uuid:ae94bad8-912a-cf33-9ac7-cf917556be06", "resource": {"resourceType": "Medication", "id": "ae94bad8-912a-cf33-9ac7-cf917556be06", "code": {"coding": [{"code": "0904-7014-16", "system": "urn:oid:2.16.840.1.113883.6.69"}]}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Medication/ae94bad8-912a-cf33-9ac7-cf917556be06"}}, {"fullUrl": "urn:uuid:9a640d37-ed14-25c3-497b-5645af44caa2", "resource": {"resourceType": "RelatedPerson", "id": "9a640d37-ed14-25c3-497b-5645af44caa2", "relationship": [{"coding": [{"display": "Guardian"}]}], "telecom": [{"system": "phone", "value": "+1-207-272-4878", "use": "mobile"}, {"system": "phone", "value": "+1-207-772-5629", "use": "home"}], "address": [{"use": "home", "line": ["34 Whitney Ave"], "city": "PORTLAND", "state": "ME", "country": "US", "postalCode": "04102", "district": "CUMBERLAND"}], "patient": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "RelatedPerson/9a640d37-ed14-25c3-497b-5645af44caa2"}}, {"fullUrl": "urn:uuid:ec726500-8b2a-90f0-d9ad-ca3b2f59c108", "resource": {"resourceType": "Condition", "id": "ec726500-8b2a-90f0-d9ad-ca3b2f59c108", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "6799651"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R26.9", "display": "Abnormality of gait and mobility", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-03-13", "note": [{"text": "Last Assessment & Plan:
problemNote68
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Multifactorial gait abnormality
X-rays taken today of her lumbar spine reveal hardware in place there is not seem to be any malalignment or issues with the hardware
Fusion of spine as expected
We will obtain radiology review of these
Bilateral hips she has what appears to be considerable issues with the hips the right appears to be perhaps subluxed and there is significant arthritic change in both hips with the right being more prominent than left
I suspect that her deteriorating gait and difficulty with pain is related to issues with her hips
I suspect that the only thing that would substantially alter this for her would be hip replacement surgery
Her parents are very interested in pursuing this
We will discuss this with the joint replacement team and get back to the family on this
Note that today''s visit total time 1 hour and 10 minutes greater than 50% in discussion"}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ec726500-8b2a-90f0-d9ad-ca3b2f59c108"}}, {"fullUrl": "urn:uuid:8cce3789-8238-31aa-0160-04a2e5d7da01", "resource": {"resourceType": "Condition", "id": "8cce3789-8238-31aa-0160-04a2e5d7da01", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "8622909"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Q93.51", "display": "Angelman syndrome", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2017-12-26", "note": [{"text": "Last Assessment & Plan:
problemNote73
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Patient to return to supportive environment at group home with parents support.
-Continue PT/OT"}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/8cce3789-8238-31aa-0160-04a2e5d7da01"}}, {"fullUrl": "urn:uuid:38b74520-06a0-8a67-e999-27095ce304c5", "resource": {"resourceType": "Condition", "id": "38b74520-06a0-8a67-e999-27095ce304c5", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10829469"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M16.31", "display": "Osteoarthritis resulting from right hip dysplasia", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-05-28", "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/38b74520-06a0-8a67-e999-27095ce304c5"}}, {"fullUrl": "urn:uuid:e0a58a6e-df6f-88ce-c0ab-3a6c8b093279", "resource": {"resourceType": "Condition", "id": "e0a58a6e-df6f-88ce-c0ab-3a6c8b093279", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10856509"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z96.641", "display": "Status post total hip replacement, right", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-06-03", "note": [{"text": "Last Assessment & Plan:
problemNote76
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It is unclear if it her hip or foot that is causing to not put weight on it. The pain she had when I touched her right foot are makes me think that is the etiology
- XR already done that is neg
- foot area looks more like bruise to me
- tylenol
- needs to ambulate "}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e0a58a6e-df6f-88ce-c0ab-3a6c8b093279"}}, {"fullUrl": "urn:uuid:770d83e6-1144-f80a-3e81-85b882f6c7f7", "resource": {"resourceType": "Condition", "id": "770d83e6-1144-f80a-3e81-85b882f6c7f7", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10856543"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R56.9", "display": "Seizures (CMS/HHS)", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-06-03T10:42:29-04:00", "note": [{"text": "xcellHeader
Overview:
xcellHeader
Last Assessment & Plan:
problemNote85
System.Collections.Generic.Dictionary`2[System.String,System.Object]

Tapered off Depakote at ~ 19 Y/O
problemNote86
System.Collections.Generic.Dictionary`2[System.String,System.Object]

No recurrence of seizure activity, likely medication related, suspect oxycodone."}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/770d83e6-1144-f80a-3e81-85b882f6c7f7"}}, {"fullUrl": "urn:uuid:5ee3bf04-b857-bd5e-fc0c-f5695f57668e", "resource": {"resourceType": "Condition", "id": "5ee3bf04-b857-bd5e-fc0c-f5695f57668e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10856580"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R33.9", "display": "Urinary retention", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-06-03", "note": [{"text": "Last Assessment & Plan:
problemNote91
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Likely due to constipation. No evidence of retention, constipation controlled. Urinalysis was negative for infection. Continue to monitor for constipation."}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/5ee3bf04-b857-bd5e-fc0c-f5695f57668e"}}, {"fullUrl": "urn:uuid:4a90b937-cd2e-34d1-a6ba-c473beba0f3b", "resource": {"resourceType": "Condition", "id": "4a90b937-cd2e-34d1-a6ba-c473beba0f3b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "10857287"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K59.00", "display": "Constipation", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-06-03", "note": [{"text": "Last Assessment & Plan:
problemNote95
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Patient starting to have softer stools and concern for incontinence with patient using a pool to swim throughout the week. Discussed at length with parents with plan as follows:
-Family to make prunes available, staff to offer for prunes daily
-Continue Colace
-Will make MiraLAX as needed if no BM for greater than 2 days
-Continue magnesium supplement natural,"}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/4a90b937-cd2e-34d1-a6ba-c473beba0f3b"}}, {"fullUrl": "urn:uuid:565230a9-73bd-62de-cd59-17e24b88d16b", "resource": {"resourceType": "Condition", "id": "565230a9-73bd-62de-cd59-17e24b88d16b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "22035894"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R50.9", "display": "Fever in adult", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2020-10-03", "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/565230a9-73bd-62de-cd59-17e24b88d16b"}}, {"fullUrl": "urn:uuid:e9653872-52e9-193c-c799-e8d4fddb6105", "resource": {"resourceType": "Condition", "id": "e9653872-52e9-193c-c799-e8d4fddb6105", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "22036033"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "R21", "display": "Rash", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2020-10-03", "note": [{"text": "Last Assessment & Plan:
problemNote101
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Patient came in with her biggest complaint being increased agitation and appearing extremely uncomfortable per her father. Very abnormal for her and normally very nice and sweet. Unclear the etiology but almost gone after 1 dose of steroids and does not look like she is itching it
- will cont pred for short course, will change to oral and 30 today
- prn benadryl but would try to avoid
- f/u viral serologies but neg so far "}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/e9653872-52e9-193c-c799-e8d4fddb6105"}}, {"fullUrl": "urn:uuid:ffd96a59-d0a5-ab28-8f62-be5af3f1301b", "resource": {"resourceType": "Condition", "id": "ffd96a59-d0a5-ab28-8f62-be5af3f1301b", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "22036036"}], "clinicalStatus": {"coding": [{"code": "413322009", "display": "Resolved", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "Z20.822", "display": "Suspected COVID-19 virus infection", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2020-10-03", "note": [{"text": "Last Assessment & Plan:
problemNote105
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A: COVID-19 Testing obtained due to symptoms which could be consistent with coronavirus infection. Covid swab negative x 1.
PLAN:
-Remove covid precautions. "}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/ffd96a59-d0a5-ab28-8f62-be5af3f1301b"}}, {"fullUrl": "urn:uuid:42d0f244-82bb-6001-ace3-dd186d4a0ec2", "resource": {"resourceType": "Condition", "id": "42d0f244-82bb-6001-ace3-dd186d4a0ec2", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "22038215"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "L03.115", "display": "Cellulitis of foot, right", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2019-02-01", "note": [{"text": "Last Assessment & Plan:
problemNote107
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As above
- hold abx for now "}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/42d0f244-82bb-6001-ace3-dd186d4a0ec2"}}, {"fullUrl": "urn:uuid:adf320a7-a4c1-b16c-6098-b7a2e319a305", "resource": {"resourceType": "Condition", "id": "adf320a7-a4c1-b16c-6098-b7a2e319a305", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "44365008"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "K59.00", "display": "Obstipation", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2023-05-01", "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/adf320a7-a4c1-b16c-6098-b7a2e319a305"}}, {"fullUrl": "urn:uuid:f6bf6993-4834-f742-1f37-65a62409a8ee", "resource": {"resourceType": "Condition", "id": "f6bf6993-4834-f742-1f37-65a62409a8ee", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50925367"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "U07.1", "display": "COVID", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Last Assessment & Plan:
problemNote112
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Tested positive for COVID upon admission. No resp symptoms, satting fine, CXR neg.
Treated with remdesivir given dev. Delay
Plan:
3 day course remdesivir
Will d/w CM if group home can take back if continues asymptomatic course.
Gentle IVF given soft BP"}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}, "extension": [{"url": "https://reportstream.cdc.gov/fhir/StructureDefinition/condition-code", "coding": [{"code": "840539006", "system": "http://snomed.info/sct"}]}]}, "request": {"method": "PUT", "url": "Condition/f6bf6993-4834-f742-1f37-65a62409a8ee"}}, {"fullUrl": "urn:uuid:a4711a0c-9b26-d2ea-8d13-b5d420ad36f8", "resource": {"resourceType": "Condition", "id": "a4711a0c-9b26-d2ea-8d13-b5d420ad36f8", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.768076", "value": "50925372"}], "clinicalStatus": {"coding": [{"code": "55561003", "display": "Active", "system": "http://snomed.info/sct"}]}, "category": [{"coding": [{"code": "problem-item-list", "display": "Problem List Item", "system": "http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category"}]}], "code": {"coding": [{"code": "M25.551", "display": "Right hip pain", "system": "urn:oid:2.16.840.1.113883.6.90"}]}, "onsetDateTime": "2024-08-03", "note": [{"text": "Last Assessment & Plan:
problemNote114
Formatting of this note might be different from the original.

Appears resolved. Suspect is was related to myalgia/arthralgias from COVID although UTI symptoms also possible. CT without joint effusion and hardware of R hip intact. CRP <3
Plan:
-ceftriaxone for possible UTI, culture pending
-observe"}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Condition/a4711a0c-9b26-d2ea-8d13-b5d420ad36f8"}}, {"fullUrl": "urn:uuid:f3c11085-1e91-313d-1380-b62712aaef8e", "resource": {"resourceType": "DiagnosticReport", "id": "f3c11085-1e91-313d-1380-b62712aaef8e", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355110765"}], "status": "final", "code": {"coding": [{"code": "509", "display": "EKG 12 lead", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-08-04T15:11:33Z", "end": "2024-08-04T15:11:33Z"}, "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "performer": [{"reference": "Organization/880f0079-d8c3-956f-caa4-2373a91a4047"}], "result": [{"reference": "Observation/2d8afbab-62a3-4726-d420-e2a235b8a0d3"}, {"reference": "Observation/2fac14ad-aedf-bf50-5b94-70233e56d42c"}, {"reference": 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"effectiveDateTime": "2024-08-04T16:18:08Z", "valueQuantity": {"value": 22, "unit": "deg"}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T15:11:33Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355110765.Comp7"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "performer": [{"display": "TRACEMASTER VUE", "reference": "Organization/e08532e0-ef77-fac2-14ef-e5570f973c02"}]}, "request": {"method": "PUT", "url": "Observation/e2c61823-9ca6-3fa4-3f26-fc21a02455f0"}}, {"fullUrl": "urn:uuid:18a13855-7329-bd9a-54f9-f43157c99d33", "resource": {"resourceType": "Observation", "id": "18a13855-7329-bd9a-54f9-f43157c99d33", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.7.798268.1010", "value": "355110765"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "IMP", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T16:18:08Z", "valueString": "Sinus rhythm
Ventricular premature complex
Borderline \u00a0low voltage, extremity leads
RSR'' in V1 or V2, right VCD or RVH
Baseline artifact precludes further analysis, repeat tracing suggested ", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T15:11:33Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355110765.Impression"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "performer": [{"display": "TRACEMASTER VUE", "reference": "Organization/e08532e0-ef77-fac2-14ef-e5570f973c02"}]}, "request": {"method": "PUT", "url": "Observation/18a13855-7329-bd9a-54f9-f43157c99d33"}}, {"fullUrl": "urn:uuid:11fbaebb-7b5a-a7c5-7047-1c25794debad", "resource": {"resourceType": "Observation", "id": "11fbaebb-7b5a-a7c5-7047-1c25794debad", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2052031767"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T16:18:08Z", "valueString": "Baseline artifact precludes further analysis, repeat tracing suggested
RSR'' in V1 or V2, right VCD or RVH
Borderline low voltage, extremity leads
Ventricular premature complex
Sinus rhythm
IMPRESSION
Formatting of this note might be different from the original.
", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T15:11:33Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355110765.ProcedureNote2052031767"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}}, "request": {"method": "PUT", "url": "Observation/11fbaebb-7b5a-a7c5-7047-1c25794debad"}}, {"fullUrl": "urn:uuid:78143d8f-5da4-9416-8357-4877ca2a264a", "resource": {"resourceType": "Observation", "id": "78143d8f-5da4-9416-8357-4877ca2a264a", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "355110765"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2024-08-04T16:18:08Z", "valueCodeableConcept": {"coding": [{"code": "6", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T15:11:33Z"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}}, "request": {"method": "PUT", "url": "Observation/78143d8f-5da4-9416-8357-4877ca2a264a"}}, {"fullUrl": "urn:uuid:922ec7ab-a429-0b91-2787-6570e568a543", "resource": {"resourceType": "DiagnosticReport", "id": "922ec7ab-a429-0b91-2787-6570e568a543", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "301061478"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.206.2.798268.2.301061478.1"}], "status": "final", "code": {"coding": [{"code": "10215653", "display": "XR Hip Right 2 or 3 VW With or without Pelvis", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-08-03T23:35:00Z", "end": "2024-08-03T23:35:00Z"}, "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "performer": [{"reference": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}], "result": [{"reference": "Observation/38de3813-9458-f4bf-74f7-0227d98b82e3"}, {"reference": "Observation/672aa703-a80d-d1d0-1f53-8cc51a5a1fb5"}, {"reference": "Observation/92be5d78-1c66-5053-00da-f9eab2dd5522"}, {"reference": "Observation/a2ac4ebd-4ee3-f386-6a2a-860aad75255e"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/922ec7ab-a429-0b91-2787-6570e568a543"}}, {"fullUrl": "urn:uuid:6785067f-cee7-c612-c204-069a2bb67949", "resource": {"resourceType": "Organization", "id": "6785067f-cee7-c612-c204-069a2bb67949", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}}, {"fullUrl": "urn:uuid:38de3813-9458-f4bf-74f7-0227d98b82e3", "resource": {"resourceType": "Observation", "id": "38de3813-9458-f4bf-74f7-0227d98b82e3", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.3.696580.52175", "value": "10215653"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-08-04T03:30:00Z", "end": "2024-08-04T04:05:49Z"}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:35:00Z"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}}, "request": {"method": "PUT", "url": "Observation/38de3813-9458-f4bf-74f7-0227d98b82e3"}}, {"fullUrl": "urn:uuid:672aa703-a80d-d1d0-1f53-8cc51a5a1fb5", "resource": {"resourceType": "Observation", "id": "672aa703-a80d-d1d0-1f53-8cc51a5a1fb5", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.7.798268.1000", "value": "301061478"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T12:18:17Z", "valueString": "EXAM: XR HIP RIGHT 2 OR 3 VW WITH OR WITHOUT PELVIS
INDICATION: History of replacement
COMPARISON: Abdominal radiograph dated 9/1/2023 and priors.
TECHNIQUE: Two views of the right hip, including the pelvis were obtained.
FINDINGS: There is no fracture or dislocation. Right total hip arthroplasty prosthesis appears stable when compared to prior. Left hip dysplasia, similar to prior. Partially visualized spinal fusion hardware.
IMPRESSION: Stable right hip arthroplasty.
This report has been read by David Lehman, DO and will be reviewed by the attending radiologist covering this service. 8/4/2024 12:48 AM
I, Sarah Ebert, MD have personally reviewed the images and interpretation and agree with the final report. \u00a0Dictated by David Lehman, DO.
WORKSTATION: SPECTRUMHOME24
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/4/2024 8:16 AM \u00a0Sarah Ebert, MD", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:35:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.301061478.Narrative"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/672aa703-a80d-d1d0-1f53-8cc51a5a1fb5"}}, {"fullUrl": "urn:uuid:cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "resource": {"resourceType": "Organization", "id": "cc3b4e5d-86d7-e37a-0f30-945d0f0ff902", "name": "MH RADIOLOGY", "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}}, {"fullUrl": "urn:uuid:92be5d78-1c66-5053-00da-f9eab2dd5522", "resource": {"resourceType": "Observation", "id": "92be5d78-1c66-5053-00da-f9eab2dd5522", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051981140"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T12:18:17Z", "valueString": "RECOGNITION * * 8/4/2024 8:16 AM Sarah Ebert, MD
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: SPECTRUMHOME24
and agree with the final report. Dictated by David Lehman, DO.
I, Sarah Ebert, MD have personally reviewed the images and interpretation
attending radiologist covering this service. 8/4/2024 12:48 AM
This report has been read by David Lehman, DO and will be reviewed by the
IMPRESSION: Stable right hip arthroplasty.
hardware.
dysplasia, similar to prior. Partially visualized spinal fusion
arthroplasty prosthesis appears stable when compared to prior. Left hip
FINDINGS: There is no fracture or dislocation. Right total hip
TECHNIQUE: Two views of the right hip, including the pelvis were obtained.
COMPARISON: Abdominal radiograph dated 9/1/2023 and priors.
INDICATION: History of replacement
EXAM: XR HIP RIGHT 2 OR 3 VW WITH OR WITHOUT PELVIS
Formatting of this note might be different from the original.
", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:35:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.301061478.ProcedureNote2051981140"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}}, "request": {"method": "PUT", "url": "Observation/92be5d78-1c66-5053-00da-f9eab2dd5522"}}, {"fullUrl": "urn:uuid:a2ac4ebd-4ee3-f386-6a2a-860aad75255e", "resource": {"resourceType": "Observation", "id": "a2ac4ebd-4ee3-f386-6a2a-860aad75255e", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "301061478"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2024-08-04T12:18:17Z", "valueCodeableConcept": {"coding": [{"code": "7", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:35:00Z"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}}, "request": {"method": "PUT", "url": "Observation/a2ac4ebd-4ee3-f386-6a2a-860aad75255e"}}, {"fullUrl": "urn:uuid:3f4d67c6-d237-4ac6-cd50-3462165f8cad", "resource": {"resourceType": "DiagnosticReport", "id": "3f4d67c6-d237-4ac6-cd50-3462165f8cad", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.798268", "value": "301061477"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.206.2.798268.2.301061477.1"}], "status": "final", "code": {"coding": [{"code": "33716", "display": "XR Abdomen 1 VW", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-08-03T23:40:00Z", "end": "2024-08-03T23:40:00Z"}, "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "performer": [{"reference": "Organization/6785067f-cee7-c612-c204-069a2bb67949"}], "result": [{"reference": "Observation/63ba3999-7efb-6b5b-f0e8-dc8fcf26d44e"}, {"reference": "Observation/57a95df9-f3ef-1b46-f3db-5fa2e7f2f755"}, {"reference": "Observation/d2ed483e-8c83-4535-22cc-77274b82fb2d"}, {"reference": "Observation/35a607c6-30e1-1fe6-b1a0-99596473fc63"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/3f4d67c6-d237-4ac6-cd50-3462165f8cad"}}, {"fullUrl": "urn:uuid:63ba3999-7efb-6b5b-f0e8-dc8fcf26d44e", "resource": {"resourceType": "Observation", "id": "63ba3999-7efb-6b5b-f0e8-dc8fcf26d44e", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.3.696580.52175", "value": "33716"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-08-04T03:30:00Z", "end": "2024-08-04T04:06:17Z"}, "bodySite": {"coding": [{"code": "10", "display": "Abdomen", "system": "urn:oid:1.2.840.114350.1.13.206.2.7.10.696580.52010"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:40:00Z"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}}, "request": {"method": "PUT", "url": "Observation/63ba3999-7efb-6b5b-f0e8-dc8fcf26d44e"}}, {"fullUrl": "urn:uuid:57a95df9-f3ef-1b46-f3db-5fa2e7f2f755", "resource": {"resourceType": "Observation", "id": "57a95df9-f3ef-1b46-f3db-5fa2e7f2f755", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.7.798268.1000", "value": "301061477"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T12:19:27Z", "valueString": "EXAM: XR ABDOMEN 1VW
INDICATION: History of constipation
COMPARISON: Abdominal radiograph dated 9/1/2023 and priors.
TECHNIQUE: A single view of the abdomen was obtained.
FINDINGS: \u00a0There is a nonobstructive bowel gas pattern. Mild to moderate colonic stool burden.
Stable appearance of extensive spinal fusion hardware.
IMPRESSION: Nonobstructive bowel gas pattern.
This report has been read by David Lehman, DO and will be reviewed by the attending radiologist covering this service. 8/4/2024 12:49 AM
I, Sarah Ebert, MD have personally reviewed the images and interpretation and agree with the final report. \u00a0Dictated by David Lehman, DO.
WORKSTATION: SPECTRUMHOME24
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/4/2024 8:17 AM \u00a0Sarah Ebert, MD", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-03T23:40:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.301061477.Narrative"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/57a95df9-f3ef-1b46-f3db-5fa2e7f2f755"}}, {"fullUrl": "urn:uuid:d2ed483e-8c83-4535-22cc-77274b82fb2d", "resource": {"resourceType": "Observation", "id": "d2ed483e-8c83-4535-22cc-77274b82fb2d", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051981315"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T12:19:27Z", "valueString": "RECOGNITION * * 8/4/2024 8:17 AM Sarah Ebert, MD
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: SPECTRUMHOME24
and agree with the final report. Dictated by David Lehman, DO.
I, Sarah Ebert, MD have personally reviewed the images and interpretation
attending radiologist covering this service. 8/4/2024 12:49 AM
This report has been read by David Lehman, DO and will be reviewed by the
IMPRESSION: Nonobstructive bowel gas pattern.
Stable appearance of extensive spinal fusion hardware.
colonic stool burden.
FINDINGS: There is a nonobstructive bowel gas pattern. Mild to moderate
TECHNIQUE: A single view of the abdomen was obtained.
COMPARISON: Abdominal radiograph dated 9/1/2023 and priors.
INDICATION: History of constipation
EXAM: XR ABDOMEN 1VW
Formatting of this note might be different from the original.
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INDICATION: Sepsis
COMPARISON: Chest radiograph dated 10/3/2020.
TECHNIQUE: Two views of the chest.
FINDINGS:
Low lung volumes. Patchy left basilar opacity. There is no pleural effusion or pneumothorax. Mediastinal contour, hilar contour, heart size and pulmonary vascularity are within normal limits.
Spinal fusion hardware appears unchanged. Old right proximal humeral fracture is noted.
IMPRESSION:
Patchy left basilar opacity, possibly atelectasis, aspiration or pneumonia.
This report has been read by David Lehman, DO and will be reviewed by the attending radiologist covering this service. 8/4/2024 12:53 AM
I, Sarah Ebert, MD have personally reviewed the images and interpretation and agree with the final report. \u00a0Dictated by David Lehman, DO.
WORKSTATION: SPECTRUMHOME24
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE RECOGNITION \u00a0* * 8/4/2024 8:18 AM \u00a0Sarah Ebert, MD", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T00:30:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355099951.Narrative"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/5c7b8491-0a21-a45a-f582-38503906377b"}}, {"fullUrl": "urn:uuid:d43b114b-8945-e968-7592-0f5d15c6b6b4", "resource": {"resourceType": "Observation", "id": "d43b114b-8945-e968-7592-0f5d15c6b6b4", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051981417"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T12:20:40Z", "valueString": "RECOGNITION * * 8/4/2024 8:18 AM Sarah Ebert, MD
* * THIS IS AN ELECTRONICALLY VERIFIED REPORT CREATED USING VOICE
WORKSTATION: SPECTRUMHOME24
and agree with the final report. Dictated by David Lehman, DO.
I, Sarah Ebert, MD have personally reviewed the images and interpretation
attending radiologist covering this service. 8/4/2024 12:53 AM
This report has been read by David Lehman, DO and will be reviewed by the
pneumonia.
Patchy left basilar opacity, possibly atelectasis, aspiration or
IMPRESSION:
fracture is noted.
Spinal fusion hardware appears unchanged. Old right proximal humeral
and pulmonary vascularity are within normal limits.
effusion or pneumothorax. Mediastinal contour, hilar contour, heart size
Low lung volumes. Patchy left basilar opacity. There is no pleural
FINDINGS:
TECHNIQUE: Two views of the chest.
COMPARISON: Chest radiograph dated 10/3/2020.
INDICATION: Sepsis
EXAM: XR CHEST PA AND LATERAL
Formatting of this note might be different from the original.
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Date: 8/4/2024 1:45 AM
History: Female, 44 years old. Hip pain, infection
COMPARISON: \u00a0None.
Technique: Routine CT of the pelvis with intravenous contrast. One or more of these dose optimization techniques were utilized: Automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to
clinical indication); or iterative reconstruction.
FINDINGS:
Abdomen (visible): Unremarkable.
Vessels: Normal.
Lymph nodes: No adenopathy.
Small bowel: Unremarkable visualized small bowel; no obstruction. Colon: Unremarkable visualized colon.
Appendix: No findings of appendicitis.
Peritoneum: No free air or fluid.
GU: Unremarkable.
Bones: Right hip arthroplasty is intact. There is a left hip dysplasia and moderate arthropathy. No joint effusion identified. There are surgical fusion of the lumbosacral spine.
Soft tissue including the abdominal wall: No acute abnormality.
Additional comments: None.
IMPRESSION:
1. \u00a0There is a left hip dysplasia and moderate arthropathy. No joint effusion identified.
2. \u00a0Right hip arthroplasty is intact. No joint effusion identified.
3. \u00a0Surgical fusion of the lumbosacral spine.
WSN:CLI-SC29407
* * * THIS IS AN ELECTRONICALLY VERIFIED REPORT * * *
8/4/2024 4:37:49 AM \u00a0Richard Clinton
For questions regarding this report, Monday through Friday, 8am-5pm, please contact Spectrum Radiology Support at 1-844-764-7237. \u00a0Otherwise, please contact Synergy at 1-877-671-6119.", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-08-04T05:45:00Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.206.2.7.2.798268.355110761.Narrative"}]}], "subject": {"reference": "Patient/eb1fdec2-1826-4a51-9af7-a34382887880"}, "performer": [{"display": "MH RADIOLOGY", "reference": "Organization/cc3b4e5d-86d7-e37a-0f30-945d0f0ff902"}]}, "request": {"method": "PUT", "url": "Observation/1e991eac-52d4-4d6b-eadf-a53e1fc0c44f"}}, {"fullUrl": "urn:uuid:0355288f-d1b0-1f6f-b0fd-d257d306a3bd", "resource": {"resourceType": "Observation", "id": "0355288f-d1b0-1f6f-b0fd-d257d306a3bd", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.206.2.7.2.727879", "value": "2051963944"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-08-04T08:38:49Z", "valueString": "please contact Synergy at 1-877-671-6119.
please contact Spectrum Radiology Support at 1-844-764-7237. Otherwise,
For questions regarding this report, Monday through Friday, 8am-5pm,
8/4/2024 4:37:49 AM Richard Clinton
* * * THIS IS AN ELECTRONICALLY VERIFIED REPORT * * *
WSN:CLI-SC29407
3. Surgical fusion of the lumbosacral spine.
2. Right hip arthroplasty is intact. No joint effusion identified.
effusion identified.
1. There is a left hip dysplasia and moderate arthropathy. No joint
IMPRESSION:
Additional comments: None.
Soft tissue including the abdominal wall: No acute abnormality.
fusion of the lumbosacral spine.
moderate arthropathy. No joint effusion identified. There are surgical
Bones: Right hip arthroplasty is intact. There is a left hip dysplasia and
GU: Unremarkable.
Peritoneum: No free air or fluid.
Appendix: No findings of appendicitis.
Unremarkable visualized colon.
Small bowel: Unremarkable visualized small bowel; no obstruction. Colon:
Lymph nodes: No adenopathy.
Vessels: Normal.
Abdomen (visible): Unremarkable.
FINDINGS:
clinical indication); or iterative reconstruction.
where dose is matched to
control; mA and/or kV adjustment per patient size (includes targeted exams
of these dose optimization techniques were utilized: Automated exposure
Technique: Routine CT of the pelvis with intravenous contrast. One or more
COMPARISON: None.
History: Female, 44 years old. Hip pain, infection
Date: 8/4/2024 1:45 AM
EXAMINATION: CT PELVIS W/ CONTRAST
Formatting of this note might be different from the original.
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Upcoming Encounters
DateTypeDepartmentCare Team (Latest Contact Info)Description
07/26/2024 1:00 PM EDTOffice VisitKDMS TRI-STATE HEMATOLOGY ONCOLOGY617 23rd STSUITE 2789Louisville, KY 40203-2845606-325-2221Benty, Tad, MD234 LaneSUITE 2789Louisville, KY 40203606-325-2221 (Work)606-324-1326 (Fax)
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
ErythropoietinLabRoutinePolycythemia03/26/2024 2:04 PM EDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
ErythropoietinLabRoutinePolycythemiaExpected: 3/26/24, Expires: 3/26/25
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Smoking Tobacco: FormerCigarettesQuit: 02/26/2020
Smokeless Tobacco: Never
Tobacco Cessation:
Counseling Given: Not Answered
Alcohol UseStandard Drinks/WeekComments
Never0 (1 standard drink = 0.6 oz pure alcohol)
PHQ-2AnswerDate Recorded
PHQ-2 SCORE003/26/2024
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
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DateTypeDepartmentCare Team (Latest Contact Info)Description
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"system": "http://loinc.org"}]}, "effectivePeriod": {"end": "2020-02-26"}, "valueCodeableConcept": {"coding": [{"code": "77176002", "display": "Current smoker", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/7b07ba91-a34c-45da-a991-9e9e0812c5f7"}}, "request": {"method": "PUT", "url": "Observation/937d59b9-00da-7fa6-d2c1-c15d179b674c"}}, {"fullUrl": "urn:uuid:f5845edc-0eea-0353-1081-83069ce69066", "resource": {"resourceType": "Observation", "id": "f5845edc-0eea-0353-1081-83069ce69066", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.205.2.7.1.1040.2", "value": "Z776744^^65568007"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "11367-0", "display": "History of tobacco use", "system": "http://loinc.org"}]}, "effectivePeriod": {"end": "2020-02-26"}, "valueCodeableConcept": {"coding": [{"code": "65568007", "display": "Cigarette Smoker", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/7b07ba91-a34c-45da-a991-9e9e0812c5f7"}}, "request": {"method": "PUT", "url": "Observation/f5845edc-0eea-0353-1081-83069ce69066"}}, {"fullUrl": "urn:uuid:95aedb77-f134-e0ea-5461-41c93715ece8", "resource": {"resourceType": "Observation", "id": "95aedb77-f134-e0ea-5461-41c93715ece8", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.205.2.7.1.1040.8", "value": "Z776744^^713914004"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "229819007", "display": "Tobacco use and exposure", "system": "http://snomed.info/sct"}]}, "effectiveDateTime": "2024-03-26", "valueCodeableConcept": {"coding": [{"code": "451381000124107", "display": "Smokeless tobacco non-user", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/7b07ba91-a34c-45da-a991-9e9e0812c5f7"}}, "request": {"method": "PUT", "url": "Observation/95aedb77-f134-e0ea-5461-41c93715ece8"}}, {"fullUrl": "urn:uuid:1c896c83-0ef7-a56a-5d90-166103cfb369", "resource": {"resourceType": "Observation", "id": "1c896c83-0ef7-a56a-5d90-166103cfb369", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.205.2.7.1.1040.12", "value": "Z776744^54605.98^160573003"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "160573003", "display": "Alcohol intake", "system": "http://snomed.info/sct"}]}, "effectiveDateTime": "2024-03-26", "valueCodeableConcept": {"coding": [{"code": "228274009", "display": "Lifetime non-drinker (finding)", "system": "http://snomed.info/sct"}]}, "subject": {"reference": "Patient/7b07ba91-a34c-45da-a991-9e9e0812c5f7"}}, "request": {"method": "PUT", "url": "Observation/1c896c83-0ef7-a56a-5d90-166103cfb369"}}, {"fullUrl": "urn:uuid:433b4082-5a2d-166a-ec96-4ec7f1e78d83", "resource": {"resourceType": "Observation", "id": "433b4082-5a2d-166a-ec96-4ec7f1e78d83", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.205.2.7.1.1040.21", "value": "5782383091-97003-Z776744"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "8689-2", "display": "History of Social function", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-03-26", "subject": 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{"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}]}') ON CONFLICT (ecr_id) DO NOTHING; +INSERT INTO fhir (ecr_id, data) VALUES ('2.16.840.1.113883.4.6.70100819.50711007', '{"resourceType": "Bundle", "type": "batch", "entry": [{"fullUrl": "urn:uuid:2.16.840.1.113883.4.6.70100819.50711007", "resource": {"resourceType": "Composition", "id": "2.16.840.1.113883.4.6.70100819.50711007", "meta": {"profile": ["http://hl7.org/fhir/us/ecr/StructureDefinition/eicr-composition"], "source": "ecr"}, "identifier": [{"use": "official", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "value": "00000000-27b7-cd91-8dac-1e9de913fa0a", "assigner": {"display": "EPC"}}], "extension": [{"url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "6"}, {"url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", "valueString": "2016-12-01"}], "status": "final", "type": {"coding": [{"code": "55751-2", "display": "Initial Public Health Case Report", "system": "http://loinc.org"}]}, "date": "2024-03-26T07:58:25-05:00", "title": "Initial Public Health Case Report", "confidentiality": "N", "section": [{"id": "e0d1a0db-5825-d48a-8475-17d2d22c3b00", "title": "Miscellaneous Notes", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "10164-2", "display": "HISTORY OF PRESENT ILLNESS", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-0160-4AF5-E2B9-97C06EE89637", "title": "Immunizations", "text": {"status": "generated", "div": "Not on file documented as of this encounter"}, "code": {"coding": [{"code": "11369-6", "display": "History of Immunization Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "00000000-0160-4AF6-E2B9-97C06EE89637", "title": "Administered Medications", "text": {"status": "generated", "div": "
Active Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
0.9% NaCl intermittent flush25 mL, Intravenous, Continuous PRN, Flush, Starting on Mon 3/25/24 at 2227, Use 0.9% NaCl flush for IVPBs mixed in 0.9% NaCl.
acetaminophen (TYLENOL) tablet 650 mg650 mg, Oral, Every 4 Hours PRN, Mild Pain (1-4), Starting on Mon 3/25/24 at 2232
bisacodyL (DULCOLAX) suppository 10 mg10 mg, Rectal, Daily PRN, Constipation unrelieved by Milk of Magnesia., Starting on Mon 3/25/24 at 2229
dextrose 5 % intermittent flush25 mL, Intravenous, Continuous PRN, Flush, Starting on Mon 3/25/24 at 2227, Use dextrose 5% flush for IVPBs mixed in dextrose 5%.
magnesium hydroxide (MILK OF MAGNESIA) 400 mg/5 mL suspension 30 mL30 mL, Oral, Daily PRN, Constipation, Starting on Mon 3/25/24 at 2229
ondansetron (ZOFRAN-ODT) disintegrating tablet 4 mg4 mg, Oral, Every 6 Hours PRN, Nausea, Vomiting, Use prior to IV unless NPO., Starting on Mon 3/25/24 at 2229
ondansetron HCl (PF) (ZOFRAN) injection 4 mg4 mg, Intravenous, Every 6 Hours PRN, Nausea, Vomiting if PO is ineffective or patient is NPO., Starting on Mon 3/25/24 at 2229
ondansetron HCl (PF) (ZOFRAN) injection 4 mg4 mg, Intramuscular, Every 6 Hours PRN, Nausea, Vomiting if patient is NPO and no IV access., Starting on Mon 3/25/24 at 2229
pantoprazole (PROTONIX) EC tablet 40 mg40 mg, Oral, Every Morning Before Breakfast, First dose on Tue 3/26/24 at 0630Given03/26/2024 7:38 AM CDT40 mg
sodium chloride injection 10 mL10 mL, Intravenous Flush, Every 12 Hours Scheduled (2 times per day), First dose on Mon 3/25/24 at 2300Given03/26/2024 7:38 AM CDT10 mLs
Given03/25/2024 11:48 PM CDT10 mLs
sodium chloride injection 10 mL10 mL, Intravenous Flush, PRN, Other, pre (ensure placement) & post medications (clear line), Starting on Mon 3/25/24 at 2227
sodium chloride injection 20 mL20 mL, Intravenous Flush, PRN, Other, prior to and after blood draw, Starting on Mon 3/25/24 at 2227
sodium phosphate (FLEET) enema 1 enema1 enema, Rectal, Daily PRN, Constipation unrelieved by Dulcolax suppository, Starting on Mon 3/25/24 at 2229
Inactive Administered Medications - up to 3 most recent administrations
Medication OrderMAR ActionAction DateDoseRateSite
acetaminophen (OFIRMEV) IV 1,000 mg1,000 mg, Intravenous, Administer over 15 Minutes, Once, On Mon 3/25/24 at 1645, For 1 dose, Please send in-basket MAR message to pharmacy 1 hour before new bag is needed. Maximum dose of acetaminophen is 4000mg from all sources in 24 hours. Per the organization''s medication management policy, may administer less potent pain medication, if ordered, based on patient request. Use within 6 hours of vial puncture.New Bag03/25/2024 4:31 PM CDT1,000 mg400 mL/hr
albumin human 25 % IV solution 25 g25 g, Intravenous, Once, On Mon 3/25/24 at 2045, For 1 dose, Do not exceed 1 mL/minute in patients with normal plasma volume; 2 to 3 mL/minute in patients with hypoproteinemiaNew Bag03/25/2024 9:49 PM CDT25 g60 mL/hr
iohexoL (OMNIPAQUE) 350 mg iodine/mL injection 100 mL100 mL, Intravenous, img Once PRN, contrast, Starting on Mon 3/25/24 at 1639, For 1 doseGiven03/25/2024 4:51 PM CDT100 mLs
lidocaine 10 mg/mL (1 %) injectionStarting on Mon 3/25/24 at 1857, For 1 doseGiven03/25/2024 7:51 PM CDT100 mgRight Lower Abdomen
sodium chloride 0.9% mini-bag flush100 mL, Intravenous, img Once PRN, flush, Starting on Mon 3/25/24 at 1639, For 1 doseGiven03/25/2024 4:51 PM CDT100 mLs
sodium chloride injection 10 mL10 mL, Intravenous Flush, img Once PRN, Other, flush, Starting on Mon 3/25/24 at 1639, For 1 doseGiven03/25/2024 4:51 PM CDT10 mLs
documented in this encounter"}, "code": {"coding": [{"code": "29549-3", "display": "MEDICATIONS ADMINISTERED", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "MedicationAdministration/0a9aec3e-7448-9fae-1133-7172257d5710"}, {"reference": "MedicationAdministration/04c0fdce-55fe-fa15-e94f-c0ca38678247"}, {"reference": "MedicationAdministration/bc4d58d3-c892-ab4a-eae8-32a0f89ca7e1"}, {"reference": "MedicationAdministration/0a16bbc9-b254-2122-1b73-d030706768af"}, {"reference": "MedicationAdministration/5ed6a1a2-0c60-59d2-3009-2c99a3d433c6"}, {"reference": "MedicationAdministration/48025cdf-2750-664b-8d70-647f150963d2"}, {"reference": "MedicationAdministration/62d888c3-3a75-b738-b11f-d404c782a6b4"}, {"reference": "MedicationAdministration/e50e7fe8-1355-efc1-490b-9395d401d56f"}, {"reference": "MedicationAdministration/701a01fb-185a-3f91-310e-54ece3316edb"}, {"reference": "MedicationAdministration/c94e5543-acde-6a49-d8de-c04777f372a1"}, {"reference": "MedicationAdministration/73f52a72-9fb9-ff6e-cf7d-aa41f892687c"}, {"reference": "MedicationAdministration/bbbcd3f9-092a-d84a-03da-6c030132a021"}, {"reference": "MedicationAdministration/ebe9022e-e4cc-412b-0868-935e636c185f"}, {"reference": "MedicationAdministration/551be827-89e2-d797-4899-cfb65d84a6c4"}, {"reference": "MedicationAdministration/f52b7039-ad85-e31e-5543-7cd8f2c22437"}, {"reference": "MedicationAdministration/f95da995-17a4-72c7-76df-88f60a0fb437"}, {"reference": "MedicationAdministration/97223b4f-05da-a650-7a17-94f26880aeef"}]}, {"id": "8fd37a64-3d26-8bd1-ea89-7ef7fafc96b2", "title": "Plan of Treatment", "text": {"status": "generated", "div": "
Pending Results
NameTypePriorityAssociated DiagnosesDate/Time
ED EKG 12 lead W/INTERP93005ECGSTAT03/25/2024 4:31 PM CDT
Ultrasound guided paracentesisImagingSTAT03/25/2024 8:43 PM CDT
Culture-fluid/aspirate (includes gram stain)MicrobiologySTAT03/25/2024 8:03 PM CDT
Scheduled Orders
NameTypePriorityAssociated DiagnosesOrder Schedule
Occult blood-feces (hemoccult)LabSTATSTAT - one time for 1 Occurrences starting 3/25/24 until 3/25/24
Ultrasound guided paracentesisImagingSTATOne time imaging One time imaging for 1 Occurrences starting 3/25/24 until 3/25/24
CBC With DifferentialLabRoutineDaily at 0600 until discontinued starting 3/26/24, 1 completed
Comprehensive metabolic panelLabRoutineDaily at 0600 until discontinued starting 3/26/24, 1 completed
Magnesium (Mg) (Blood)LabRoutineDaily at 0600 until discontinued starting 3/26/24, 1 completed
documented as of this encounter"}, "code": {"coding": [{"code": "18776-5", "display": "Plan of care note", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"reference": "CarePlan/8ce7ed82-7925-e3ee-b98a-66c5c3b5ce76"}]}, {"id": "00000000-0160-4AF7-E2B9-97C06EE89637", "title": "Problems", "text": {"status": "generated", "div": "
Active ProblemsNoted DateDiagnosed Date
Pancytopenia03/26/2024
Cirrhosis of liver with ascites03/25/2024
Liver cancer03/25/2024
Hypertension03/25/2024
Gastroesophageal reflux disease03/25/2024
Blood per rectum03/25/2024
documented as of this encounter (statuses as of 03/26/2024) One or more reportable conditions added to problem list during processing"}, "code": {"coding": [{"code": "11450-4", "display": "Problem list - Reported", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Problem - Cirrhosis of liver with ascites", "reference": "Condition/129670ad-6add-2217-96c1-0e5528e8bf99"}, {"display": "Problem - Liver cancer", "reference": "Condition/5ffc1ca1-2fa8-1ed1-6ef4-40cab977f294"}, {"display": "Problem - Hypertension", "reference": "Condition/1ee9dea2-8d83-373b-05c0-a7d2b3a83a14"}, {"display": "Problem - Gastroesophageal reflux disease", "reference": "Condition/81c53140-add2-5038-d5cb-950b80c4116c"}, {"display": "Problem - Blood per rectum", "reference": "Condition/1e63d06f-3bf6-3780-5f45-da194a2066ba"}, {"display": "Problem - Pancytopenia", "reference": "Condition/9b254173-3dd6-654e-3e59-1fde24501f27"}, {"display": "Problem - Viral hepatitis type C (disorder)", "reference": "Condition/5bf407e1-1cdc-f28e-a276-51aa2d973426"}]}, {"id": "9d96874d-6ce9-91a8-8bff-c2e23b151dfd", "title": "Reason for Visit", "text": {"status": "generated", "div": ""}, "code": {"coding": [{"code": "29299-5", "display": "REASON FOR VISIT", "system": "http://loinc.org"}]}, "mode": "snapshot", "extension": [{"url": "http://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.2.12", "valueString": "Abdominal Pain"}]}, {"id": "00000000-0160-4AF9-E2B9-97C06EE89637", "title": "Results", "text": {"status": "generated", "div": "documented in this encounter"}, "code": {"coding": [{"code": "30954-2", "display": "Relevant diagnostic tests/laboratory data Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot", "entry": [{"display": "Radiology Study observation (narrative)", "reference": "Observation/841f17e6-a916-5ebc-d278-fd3fd5f63eb5"}, {"display": "Radiology Study observation (narrative)", "reference": 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"Observation/ef418944-cffd-60ae-d1b2-88fa3e7c5cb0"}, {"display": "Alkaline Phosphatase", "reference": "Observation/e7b1704c-868e-c14a-338f-a1a4611a95e3"}, {"display": "Glomerular Filtration Rate, Est.", "reference": "Observation/16d3b54f-03c2-c8ef-a850-3954647ab6c6"}, {"display": "Anion Gap", "reference": "Observation/d109b8d5-fea8-370c-6d4f-f0006497093b"}, {"display": "Lab Interpretation", "reference": "Observation/40788d79-45a7-d4dd-c460-6ac8bdc4a297"}, {"display": "Magnesium", "reference": "Observation/e92d5772-bbe7-2bd9-0ceb-85ba9e3cbfc0"}, {"display": "Lab Interpretation", "reference": "Observation/0232bc78-3544-2a12-419a-433f5f87a223"}, {"display": "Hepatitis B Surface Antigen", "reference": "Observation/f2760263-6e81-a8f2-ed19-76f3b699f295"}, {"display": "Hepatitis B Core IgM", "reference": "Observation/bed0bb49-1855-e2af-b723-d6a8e56529ec"}, {"display": "Anti Hepatitis A Virus IgM", "reference": "Observation/1bed15ef-15c9-8b92-b73f-4e7a03ab4f2c"}, {"display": "Hepatitis C Virus", "reference": "Observation/987a1a48-957f-a7c4-3f63-cea2887af631"}, {"display": "Lab Interpretation", "reference": "Observation/4239be2e-ac07-42b9-0637-7fe4bbda4d23"}, {"display": "HIV-1 and 2 Antibodies", "reference": "Observation/f76c5378-a453-d65b-aeb2-93d1b49a048d"}]}, {"id": "7a715c65-611d-47c5-aa74-caaba9dfe799", "title": "Social History", "text": {"status": "generated", "div": "
Tobacco UseTypesPacks/DayYears UsedDate
Smoking Tobacco: Never Assessed
AHC UtilitiesAnswerDate Recorded
In the past 12 months has the electric, gas, oil or water company threatened to shut off services in your home?03/25/2024
AUDIT-CAnswerDate Recorded
Q1: How often do you have a drink containing alcohol?Monthly or less03/25/2024
Q2: How many drinks containing alcohol do you have on a typical day when you are drinking?Patient unable to answer03/25/2024
Q3: How often do you have six or more drinks on one occasion?Patient unable to answer03/25/2024
Overall Financial Resource Strain (CARDIA)AnswerDate Recorded
How hard is it for you to pay for the very basics like food, housing, medical care, and heating?Patient declined03/25/2024
Finnish Institute of Occupational Health - Occupational Stress QuestionnaireAnswerDate Recorded
Do you feel stress - tense, restless, nervous, or anxious, or unable to sleep at night because your mind is troubled all the time - these days?Patient declined03/25/2024
Exercise Vital SignAnswerDate Recorded
On average, how many days per week do you engage in moderate to strenuous exercise (like a brisk walk)?Patient declined03/25/2024
On average, how many minutes do you engage in exercise at this level?Patient declined03/25/2024
Hunger Vital SignAnswerDate Recorded
Within the past 12 months, you worried that your food would run out before you got the money to buy more.Patient declined03/25/2024
Within the past 12 months, the food you bought just didn''t last and you didn''t have money to get more.Patient declined03/25/2024
PRAPARE - TransportationAnswerDate Recorded
In the past 12 months, has lack of transportation kept you from medical appointments or from getting medications?Patient declined03/25/2024
In the past 12 months, has lack of transportation kept you from meetings, work, or from getting things needed for daily living?Patient declined03/25/2024
UtilitiesAnswerDate Recorded
In the past 12 months has the electric, gas, oil or water company threatened to shut off services in your home?patient declined03/25/2024
OH Housing Stability Vital SignAnswerDate Recorded
What is your living situation today?steady place to live03/25/2024
Think about the place you live. Do you have problems with any of the following?patient declined03/25/2024
Safety and EnvironmentAnswerDate Recorded
How often does anyone, including family and friends, physically hurt you?never03/25/2024
How often does anyone, including family and friends, insult or talk down to you?never03/25/2024
How often does anyone, including family and friends, threaten you with harm?never03/25/2024
How often does anyone, including family and friends, scream or curse at you?never03/25/2024
Sex and Gender InformationValueDate Recorded
Sex Assigned at BirthNot on file
Gender IdentityNot on file
Sexual OrientationNot on file
documented as of this encounter"}, "code": {"coding": [{"code": "29762-2", "display": "Social history Narrative", "system": "http://loinc.org"}]}, "mode": "snapshot"}, {"id": "046910f0-5586-dcdf-bb92-d401e9e5b341", "title": "Encounter Details", "text": {"status": "generated", "div": "
DateTypeDepartmentCare Team (Latest Contact Info)Description
03/25/2024 2:38 PM CDT - PresentHospital EncounterOHRH ONCOLOGY-MEDICAL UNIT1201 Pleasant Valley RoadOwensboro, KY 40245270-417-2800Jerry, Benny, MD811 E Parrish AveSuite 102OWENSBORO, KY 40245270-688-2077 (Work)270-688-2078 (Fax)
Pleural effusion on rightPrimary malignant neoplasm of liver (CMS/HCC); Alcoholic cirrhosis of liver with ascites (CMS/HCC) (Primary Dx);
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Derived Reportability Response Information
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"8c99b003-2ee9-f49c-428d-2b2a337659ae", "name": "EMC RAD", "address": [{"line": ["5301 Tokay Blvd."], "city": "Madison", "state": "WI", "postalCode": "53711"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/8c99b003-2ee9-f49c-428d-2b2a337659ae"}}, {"fullUrl": "urn:uuid:841f17e6-a916-5ebc-d278-fd3fd5f63eb5", "resource": {"resourceType": "Observation", "id": "841f17e6-a916-5ebc-d278-fd3fd5f63eb5", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.3.696580.52175", "value": "61611"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-03-25T21:36:41Z", "end": "2024-03-25T21:46:06Z"}, "bodySite": {"coding": [{"code": "101", "display": "Chest", "system": "urn:oid:1.2.840.114350.1.13.276.2.7.10.696580.52010"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:36:41Z"}]}], "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}}, "request": {"method": "PUT", "url": "Observation/841f17e6-a916-5ebc-d278-fd3fd5f63eb5"}}, {"fullUrl": "urn:uuid:a5d68ff0-cb03-758f-d2be-797dc48bbdce", "resource": {"resourceType": "Observation", "id": "a5d68ff0-cb03-758f-d2be-797dc48bbdce", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.7.798268.1000", "value": "152882674"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-03-25T22:05:24Z", "valueString": "PORTABLE CHEST
HISTORY: Abdominal pain.
Portable AP supine semierect upright film of the chest was obtained at.
COMPARISON: None
FINDINGS:
Chronic obstructive pulmonary disease.
Small to moderate-sized right pleural effusion.
There may be underlying atelectasis or infiltrate at the right lung base.
Some elevation of the left hemidiaphragm.
The heart is not enlarged.
The pulmonary vasculature is not increased.
No pneumothorax.
No acute osseous abnormality.
Conclusion:
Chronic obstructive pulmonary disease.
Small to moderate-sized right pleural effusion.
There may be underlying atelectasis or infiltrate at the right lung base.
37205
Workstation: 109-1130", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:36:41Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.276.2.7.2.798268.152882674.Narrative"}]}], "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}, "performer": [{"display": "EMC RAD", "reference": "Organization/58d6b643-fc97-c7bc-c97d-be7495f13477"}]}, "request": {"method": "PUT", "url": "Observation/a5d68ff0-cb03-758f-d2be-797dc48bbdce"}}, {"fullUrl": "urn:uuid:58d6b643-fc97-c7bc-c97d-be7495f13477", "resource": {"resourceType": "Organization", "id": "58d6b643-fc97-c7bc-c97d-be7495f13477", "name": "EMC RAD", "address": [{"line": ["5301 Tokay Blvd."], "city": "Madison", "state": "WI", "postalCode": "53711"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "Organization/58d6b643-fc97-c7bc-c97d-be7495f13477"}}, {"fullUrl": "urn:uuid:4014c566-28e5-8247-f898-3b77fd7093e6", "resource": {"resourceType": "Observation", "id": "4014c566-28e5-8247-f898-3b77fd7093e6", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.2.727879", "value": "673563981"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-03-25T22:05:24Z", "valueString": "Workstation: 109-1130
37205
base.
There may be underlying atelectasis or infiltrate at the right lung
Small to moderate-sized right pleural effusion.
Chronic obstructive pulmonary disease.
Conclusion:
No acute osseous abnormality.
No pneumothorax.
The pulmonary vasculature is not increased.
The heart is not enlarged.
Some elevation of the left hemidiaphragm.
base.
There may be underlying atelectasis or infiltrate at the right lung
Small to moderate-sized right pleural effusion.
Chronic obstructive pulmonary disease.
FINDINGS:
COMPARISON: None
Portable AP supine semierect upright film of the chest was obtained at.
HISTORY: Abdominal pain.
PORTABLE CHEST
Formatting of this note might be different from the original.
", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:36:41Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.276.2.7.2.798268.152882674.ProcedureNote673563981"}]}], "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}}, "request": {"method": "PUT", "url": "Observation/4014c566-28e5-8247-f898-3b77fd7093e6"}}, {"fullUrl": "urn:uuid:66b9baa4-df04-1a9c-8bbe-fb33d320b550", "resource": {"resourceType": "Observation", "id": "66b9baa4-df04-1a9c-8bbe-fb33d320b550", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.2.798268", "value": "152882674"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "effectiveDateTime": "2024-03-25T22:05:24Z", "valueCodeableConcept": {"coding": [{"code": "7", "system": "urn:oid:1.2.840.114350.1.72.1.5007"}]}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:36:41Z"}]}], "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}}, "request": {"method": "PUT", "url": "Observation/66b9baa4-df04-1a9c-8bbe-fb33d320b550"}}, {"fullUrl": "urn:uuid:f4221d31-fca7-ba85-179d-33429ce57b4f", "resource": {"resourceType": "DiagnosticReport", "id": "f4221d31-fca7-ba85-179d-33429ce57b4f", "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.2.798268", "value": "152882665"}, {"system": "urn:oid:1.2.840.10008.6.1.535.110180", "value": "1.2.840.114350.2.276.2.798268.2.152882665.1"}], "status": "final", "code": {"coding": [{"code": "96030", "display": "CT Abdomen Pelvis w/Contrast IV Only per Contrast Protocol", "system": "urn:oid:1.2.840.114350.1.13.276.2.7.2.696580"}]}, "effectivePeriod": {"start": "2024-03-25T21:39:35Z", "end": "2024-03-25T21:39:35Z"}, "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}, "performer": [{"reference": "Organization/8c99b003-2ee9-f49c-428d-2b2a337659ae"}], "result": [{"reference": "Observation/4b6154cf-31fe-0683-8222-d188cfe26fb3"}, {"reference": "Observation/40b510df-777d-a6c2-6c83-24a5e35ed947"}, {"reference": "Observation/e07d4107-29b1-25d4-08d3-b1ba2a36cefb"}, {"reference": "Observation/54c09f48-5eaf-4010-b5f5-2f8bda9abee9"}, {"reference": "Observation/c60dd5a8-2ad3-13fb-723e-2f9d7f218aff"}], "meta": {"source": "ecr"}}, "request": {"method": "PUT", "url": "DiagnosticReport/f4221d31-fca7-ba85-179d-33429ce57b4f"}}, {"fullUrl": "urn:uuid:4b6154cf-31fe-0683-8222-d188cfe26fb3", "resource": {"resourceType": "Observation", "id": "4b6154cf-31fe-0683-8222-d188cfe26fb3", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.3.696580.52175", "value": "96030"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "18782-3", "display": "Radiology Study observation (narrative)", "system": "http://loinc.org"}]}, "effectivePeriod": {"start": "2024-03-25T21:39:35Z", "end": "2024-03-25T22:04:33Z"}, "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:39:35Z"}]}], "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}}, "request": {"method": "PUT", "url": "Observation/4b6154cf-31fe-0683-8222-d188cfe26fb3"}}, {"fullUrl": "urn:uuid:40b510df-777d-a6c2-6c83-24a5e35ed947", "resource": {"resourceType": "Observation", "id": "40b510df-777d-a6c2-6c83-24a5e35ed947", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.7.798268.1010", "value": "152882665"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "IMP", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-03-25T22:34:50Z", "valueString": " \ufffd
1. \ufffdCirrhosis with sequela of portal hypertension including large volume ascites, splenomegaly, and extensive gastric and esophageal varices.
2. \ufffdA 5.2 x 5.8 cm mass in hepatic segment 4 is incompletely characterized. Recommend further evaluation with a nonemergent MRI liver protocol. If the patient is not MR compatible, recommend evaluation with CT.
3. \ufffdDiffuse wall thickening of the colon is nonspecific and could represent infectious/inflammatory colitis or portal colopathy from significant portal hypertension. Recommend clinical correlation.
4. \ufffdSmall to moderate right pleural effusion.
Workstation: 109-93730WH", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:39:35Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.276.2.7.2.798268.152882665.Impression"}]}], "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}, "performer": [{"display": "EMC RAD", "reference": "Organization/58d6b643-fc97-c7bc-c97d-be7495f13477"}]}, "request": {"method": "PUT", "url": "Observation/40b510df-777d-a6c2-6c83-24a5e35ed947"}}, {"fullUrl": "urn:uuid:e07d4107-29b1-25d4-08d3-b1ba2a36cefb", "resource": {"resourceType": "Observation", "id": "e07d4107-29b1-25d4-08d3-b1ba2a36cefb", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.7.798268.1000", "value": "152882665"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "NAR", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-03-25T22:34:50Z", "valueString": "EXAM: CT ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST
INDICATION: 60 years year old Male with Abdominal pain, acute, nonlocalized
COMPARISON: None
TECHNIQUE: Computed tomographic imaging was performed of the abdomen and pelvis with intravenous contrast. This examination was performed according to our departmental dose optimization program which includes automated exposure control, adjustment of the
MA and kV according to patient size, and/or use of iterative reconstruction technique.
FINDINGS:
There is a small moderate right pleural effusion. Airspace opacity in the lower lungs most likely represents atelectasis.
There is significant contour nodularity of the liver surface with enlargement of the caudate lobe and left lateral section in addition to capsular retraction. These findings are compatible with cirrhosis. There is a 5.2 x 5.8 cm mass in hepatic segment 4
which is incompletely characterized. Extensive sequela of portal hypertension including large volume ascites, splenomegaly which measures up to 17.7 cm in greatest dimension, and extensive gastric and esophageal varices which measure up to 0.9 cm in
transverse diameter.
Large volume ascites results in significant mass effect with displacement of bowel towards the central abdomen. There is diffuse wall thickening involving the colon which is nonspecific and could represent colitis or portal colopathy. No evidence of a
high-grade bowel obstruction. The adrenals and pancreas are unremarkable.
No free peritoneal gas is identified. The abdominal aorta is patent normal caliber. The urinary bladder is poorly distended. No aggressive lytic or sclerotic bone lesions are identified. There is multilevel disc space narrowing, most prominent at L4-5
and L5-S1. No major abdominal wall hernia is identified. Kidneys have normal size and symmetric enhancement with no hydronephrosis.", "extension": [{"url": "http://hl7.org/fhir/R4/specimen.html", "extension": [{"url": "specimen collection time", "valueDateTime": "2024-03-25T21:39:35Z"}, {"url": "observation entry reference value", "valueString": "#Result.1.2.840.114350.1.13.276.2.7.2.798268.152882665.Narrative"}]}], "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}, "performer": [{"display": "EMC RAD", "reference": "Organization/58d6b643-fc97-c7bc-c97d-be7495f13477"}]}, "request": {"method": "PUT", "url": "Observation/e07d4107-29b1-25d4-08d3-b1ba2a36cefb"}}, {"fullUrl": "urn:uuid:54c09f48-5eaf-4010-b5f5-2f8bda9abee9", "resource": {"resourceType": "Observation", "id": "54c09f48-5eaf-4010-b5f5-2f8bda9abee9", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.2.727879", "value": "673567852"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory"}]}], "status": "final", "code": {"coding": [{"code": "PXN", "system": "urn:oid:1.2.840.114350.1.72.1.5220"}]}, "effectiveDateTime": "2024-03-25T22:34:50Z", "valueString": "Workstation: 109-93730WH
4. Small to moderate right pleural effusion.
significant portal hypertension. Recommend clinical correlation.
represent infectious/inflammatory colitis or portal colopathy from
3. Diffuse wall thickening of the colon is nonspecific and could
CT.
protocol. If the patient is not MR compatible, recommend evaluation with
characterized. Recommend further evaluation with a nonemergent MRI liver
2. A 5.2 x 5.8 cm mass in hepatic segment 4 is incompletely
ascites, splenomegaly, and extensive gastric and esophageal varices.
1. Cirrhosis with sequela of portal hypertension including large volume
IMPRESSION:
normal size and symmetric enhancement with no hydronephrosis.
and L5-S1. No major abdominal wall hernia is identified. Kidneys have
narrowing, most prominent at L4-5
sclerotic bone lesions are identified. There is multilevel disc space
caliber. The urinary bladder is poorly distended. No aggressive lytic or
No free peritoneal gas is identified. The abdominal aorta is patent normal
unremarkable.
high-grade bowel obstruction. The adrenals and pancreas are
portal colopathy. No evidence of a
involving the colon which is nonspecific and could represent colitis or
of bowel towards the central abdomen. There is diffuse wall thickening
Large volume ascites results in significant mass effect with displacement
transverse diameter.
varices which measure up to 0.9 cm in
up to 17.7 cm in greatest dimension, and extensive gastric and esophageal
hypertension including large volume ascites, splenomegaly which measures
which is incompletely characterized. Extensive sequela of portal
is a 5.2 x 5.8 cm mass in hepatic segment 4
capsular retraction. These findings are compatible with cirrhosis. There
enlargement of the caudate lobe and left lateral section in addition to
There is significant contour nodularity of the liver surface with
lower lungs most likely represents atelectasis.
There is a small moderate right pleural effusion. Airspace opacity in the
FINDINGS:
reconstruction technique.
MA and kV according to patient size, and/or use of iterative
exposure control, adjustment of the
to our departmental dose optimization program which includes automated
pelvis with intravenous contrast. This examination was performed according
TECHNIQUE: Computed tomographic imaging was performed of the abdomen and
COMPARISON: None
nonlocalized
INDICATION: 60 years year old Male with Abdominal pain, acute,
EXAM: CT ABDOMEN AND PELVIS WITH INTRAVENOUS CONTRAST
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"2024-03-26T10:36:00Z"}, {"url": "specimen receive time", "valueDateTime": "2024-03-26T11:01:00Z"}]}], "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}}, "request": {"method": "PUT", "url": "Observation/51030823-09e8-075d-43cb-e85edfced5b4"}}, {"fullUrl": "urn:uuid:8336295b-3582-d32d-5aa6-869c13c7f7ff", "resource": {"resourceType": "Observation", "id": "8336295b-3582-d32d-5aa6-869c13c7f7ff", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.1.1040.1", "value": "Z885682^^72166-2"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "72166-2", "display": "Tobacco smoking status NHIS", "system": "http://loinc.org"}]}, "valueCodeableConcept": {"coding": [{"code": "266927001", "display": "Tobacco smoking 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"display": "History of Social function", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-03-25", "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}}, "request": {"method": "PUT", "url": "Observation/7c705e35-23ce-99b8-5480-0da9d9101f40"}}, {"fullUrl": "urn:uuid:6ffdde3f-8983-d90d-8c23-9353c943e16b", "resource": {"resourceType": "Observation", "id": "6ffdde3f-8983-d90d-8c23-9353c943e16b", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.1.1040.21", "value": "5782332564-100017-Z885682"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "8689-2", "display": "History of Social function", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-03-25", "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}}, "request": {"method": "PUT", "url": "Observation/6ffdde3f-8983-d90d-8c23-9353c943e16b"}}, {"fullUrl": "urn:uuid:b4411b3a-c813-75af-1d39-2257e21a772c", "resource": {"resourceType": "Observation", "id": "b4411b3a-c813-75af-1d39-2257e21a772c", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.1.1040.21", "value": "5782332564-100028-Z885682"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "8689-2", "display": "History of Social function", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-03-25", "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}}, "request": {"method": "PUT", "url": "Observation/b4411b3a-c813-75af-1d39-2257e21a772c"}}, {"fullUrl": "urn:uuid:ff28e55f-f2b2-aaf9-05af-72e14da6ea5e", "resource": {"resourceType": "Observation", "id": "ff28e55f-f2b2-aaf9-05af-72e14da6ea5e", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}, "identifier": [{"system": "urn:oid:1.2.840.114350.1.13.276.2.7.1.1040.21", "value": "5782332564-100029-Z885682"}], "category": [{"coding": [{"system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "social-history"}]}], "status": "final", "code": {"coding": [{"code": "8689-2", "display": "History of Social function", "system": "http://loinc.org"}]}, "effectiveDateTime": "2024-03-25", "subject": {"reference": "Patient/70e273f1-dc2a-45ca-94ec-adbdfdca2990"}}, "request": {"method": "PUT", "url": "Observation/ff28e55f-f2b2-aaf9-05af-72e14da6ea5e"}}, {"fullUrl": "urn:uuid:", "resource": {"resourceType": "Observation", "meta": {"profile": ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-observationresults"], "source": "ecr"}}, "request": {"method": "PUT", "url": "Observation/"}}]}') ON CONFLICT (ecr_id) DO NOTHING; INSERT INTO fhir_metadata ( ecr_id,patient_name_last,patient_name_first,patient_birth_date,data_source,reportable_condition,rule_summary,report_date ) VALUES ( diff --git a/containers/ecr-viewer/src/app/api/fhirPath.yml b/containers/ecr-viewer/src/app/api/fhirPath.yml index 5d0d0d678a..251df587ca 100644 --- a/containers/ecr-viewer/src/app/api/fhirPath.yml +++ b/containers/ecr-viewer/src/app/api/fhirPath.yml @@ -34,9 +34,11 @@ patientSexualOrientation: "Bundle.entry.resource.where(resourceType='Observation patientGenderIdentity: "Bundle.entry.resource.where(resourceType = 'Patient').extension.where(url='http: //hl7.org/fhir/us/ecr/StructureDefinition/us-ph-genderidentity-extension').extension.value.coding.display" eicrIdentifier: "Bundle.entry.resource.where(resourceType= 'Composition').id" +eicrReleaseVersion: "Bundle.entry.resource.where(resourceType='Composition').extension.where(url='https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436').valueString" eicrCustodianRef: "Bundle.entry.resource.where(resourceType= 'Composition').custodian.reference" dateTimeEcrCreated: "Bundle.entry.resource.where(resourceType = 'Composition').date" -senderSoftware: "Bundle.entry.resource.where(resourceType = 'Device').where(property[0].type.coding.code='software').type.coding.display" +ehrSoftware: "Bundle.entry.resource.where(resourceType = 'Device').where(property[0].type.coding.code='software').version.value" +ehrManufacturerModel: "Bundle.entry.resource.where(resourceType = 'Device').where(property[0].type.coding.code='software').manufacturer" senderFacilityName: "Bundle.entry.resource.where(resourceType = 'Encounter')[0].location[0].location.display" # Encounter Info diff --git a/containers/ecr-viewer/src/app/services/ecrMetadataService.ts b/containers/ecr-viewer/src/app/services/ecrMetadataService.ts index bee4e92127..67d369afd8 100644 --- a/containers/ecr-viewer/src/app/services/ecrMetadataService.ts +++ b/containers/ecr-viewer/src/app/services/ecrMetadataService.ts @@ -1,16 +1,7 @@ -import { - formatAddress, - formatContactPoint, - formatDateTime, -} from "@/app/services/formatService"; +import { formatDateTime } from "@/app/services/formatService"; import { PathMappings, evaluateData } from "@/app/view-data/utils/utils"; -import { Bundle, Organization } from "fhir/r4"; +import { Bundle } from "fhir/r4"; import { evaluate } from "@/app/view-data/utils/evaluate"; -import { - evaluateFacilityAddress, - evaluateReference, - evaluateFacilityId, -} from "./evaluateFhirDataService"; import { DisplayDataProps } from "@/app/view-data/components/DataDisplay"; export interface ReportableConditions { @@ -57,12 +48,18 @@ export const evaluateEcrMetadata = ( ); } } - const custodianRef = evaluate(fhirBundle, mappings.eicrCustodianRef)[0] ?? ""; - const custodian = evaluateReference( - fhirBundle, - mappings, - custodianRef, - ) as Organization; + + const eicrReleaseVersion = (fhirBundle: any, mappings: any) => { + const releaseVersion = evaluate(fhirBundle, mappings.eicrReleaseVersion)[0]; + console.log(releaseVersion); + if (releaseVersion === "2016-12-01") { + return "R1.1 (2016-12-01)"; + } else if (releaseVersion === "2021-01-01") { + return "R3.1 (2021-01-01)"; + } else { + return releaseVersion; + } + }; const eicrDetails: DisplayDataProps[] = [ { @@ -71,26 +68,6 @@ export const evaluateEcrMetadata = ( "Unique document ID for the eICR that originates from the medical record. Different from the Document ID that NBS creates for all incoming records.", value: evaluate(fhirBundle, mappings.eicrIdentifier)[0], }, - { - title: "Document Author", - value: custodian?.name, - }, - { - title: "Author Address", - value: formatAddress( - custodian?.address?.[0].line ?? [], - custodian?.address?.[0].city ?? "", - custodian?.address?.[0].state ?? "", - custodian?.address?.[0].postalCode ?? "", - custodian?.address?.[0].country ?? "", - ), - }, - { - title: "Author Contact", - value: formatContactPoint(custodian?.telecom).join("\n"), - }, - ]; - const ecrSenderDetails: DisplayDataProps[] = [ { title: "Date/Time eCR Created", value: formatDateTime( @@ -98,30 +75,21 @@ export const evaluateEcrMetadata = ( ), }, { - title: "Sender Software", - toolTip: "EHR system used by the sending provider.", - value: evaluate(fhirBundle, mappings.senderSoftware)[0], - }, - { - title: "Sender Facility Name", - value: evaluate(fhirBundle, mappings.senderFacilityName)[0], - }, - { - title: "Facility Address", - value: evaluateFacilityAddress(fhirBundle, mappings), + title: "eICR Release Version", + value: eicrReleaseVersion(fhirBundle, mappings), }, { - title: "Facility Contact", - value: evaluate(fhirBundle, mappings.facilityContact)[0], + title: "EHR Software Name", + toolTip: "EHR system used by the sending provider.", + value: evaluate(fhirBundle, mappings.ehrSoftware)[0], }, { - title: "Facility ID", - value: evaluateFacilityId(fhirBundle, mappings), + title: "EHR Manufacturer Model Name", + value: evaluate(fhirBundle, mappings.ehrManufacturerModel)[0], }, ]; return { eicrDetails: evaluateData(eicrDetails), - ecrSenderDetails: evaluateData(ecrSenderDetails), rrDetails: reportableConditionsList, }; }; diff --git a/containers/ecr-viewer/src/app/tests/assets/BundleEcrMetadata.json b/containers/ecr-viewer/src/app/tests/assets/BundleEcrMetadata.json index 69c8040c99..f37ee2b58b 100644 --- a/containers/ecr-viewer/src/app/tests/assets/BundleEcrMetadata.json +++ b/containers/ecr-viewer/src/app/tests/assets/BundleEcrMetadata.json @@ -37,6 +37,10 @@ { "url": "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString": "2" + }, + { + "url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", + "valueString": "2016-12-01" } ], "status": "final", @@ -440,6 +444,48 @@ "url": "Composition/1.2.840.114350.1.13.478.3.7.8.688883.230886" } }, + { + "fullUrl": "urn:uuid:a57ef88d-1c60-d952-e7ca-5e9e16c7ef05", + "resource": { + "resourceType": "Device", + "id": "a57ef88d-1c60-d952-e7ca-5e9e16c7ef05", + "identifier": [ + { + "system": "urn:oid:1.2.840.114350.1.1", + "value": "10.1" + } + ], + "manufacturer": "Epic - Version 10.1", + "version": [ + { + "value": "Epic - Version 10.1" + } + ], + "property": [ + { + "type": { + "coding": [ + { + "system": "http://hl7.org/fhir/device-category", + "code": "software", + "display": "software" + } + ] + } + } + ], + "owner": { + "reference": "Organization/d319a926-0eb3-5847-3b21-db8b778b4f07" + }, + "meta": { + "source": "ecr" + } + }, + "request": { + "method": "PUT", + "url": "Device/a57ef88d-1c60-d952-e7ca-5e9e16c7ef05" + } + }, { "fullUrl": "urn:uuid:21e7aca1-7a03-43dc-15e6-8f7ee24b6613", "resource": { diff --git a/containers/ecr-viewer/src/app/tests/components/EcrMetadata.test.tsx b/containers/ecr-viewer/src/app/tests/components/EcrMetadata.test.tsx index f1bad8786a..706d25cd93 100644 --- a/containers/ecr-viewer/src/app/tests/components/EcrMetadata.test.tsx +++ b/containers/ecr-viewer/src/app/tests/components/EcrMetadata.test.tsx @@ -34,40 +34,19 @@ describe("ECR Metadata", () => { title: "eICR Identifier", value: "1dd10047-2207-4eac-a993-0f706c88be5d", }, - ]; - const ecrSenderDetails: DisplayDataProps[] = [ { title: "Date/Time eCR Created", value: "2022-05-14T12:56:38Z", }, + { title: "eICR Release Version", value: "R1.1 (2016-12-01)" }, { - title: "Sender Software", - value: "", - }, - { - title: "Sender Facility Name", - value: "PRM- Palmdale Regional Medical Center", - }, - { - title: "Facility Address", - value: "38600 Medical Center Drive\nPalmdale, CA\n93551, USA", - }, - { - title: "Facility Contact", - value: "(661)382-5000", - }, - { - title: "Facility ID", - value: "2.16.840.1.113883.4.6", + title: "EHR Software Name", + value: "Epic - Version 10.1", }, + { title: "EHR Manufacturer Model Name", value: "Epic - Version 10.1" }, ]; - container = render( - , + , ).container; }); it("should match snapshot", () => { diff --git a/containers/ecr-viewer/src/app/tests/components/Unavailable.test.tsx b/containers/ecr-viewer/src/app/tests/components/Unavailable.test.tsx index d28e2c69bf..d53a948cb8 100644 --- a/containers/ecr-viewer/src/app/tests/components/Unavailable.test.tsx +++ b/containers/ecr-viewer/src/app/tests/components/Unavailable.test.tsx @@ -93,7 +93,7 @@ describe("UnavailableInfo", () => { ]; const ecrMetadata = [ { - title: "Sender Software", + title: "EHR Software Name", value: "", }, ]; diff --git a/containers/ecr-viewer/src/app/tests/components/__snapshots__/AccordionContent.test.tsx.snap b/containers/ecr-viewer/src/app/tests/components/__snapshots__/AccordionContent.test.tsx.snap index c7d776779b..38bf664a0c 100644 --- a/containers/ecr-viewer/src/app/tests/components/__snapshots__/AccordionContent.test.tsx.snap +++ b/containers/ecr-viewer/src/app/tests/components/__snapshots__/AccordionContent.test.tsx.snap @@ -1301,45 +1301,7 @@ exports[`Snapshot test for Accordion Content Given no data, info message for emp
- Document Author -
-
- No data -
- -
-
-
-
-
- Author Address -
-
- No data -
-
-
-
-
-
-
- Author Contact + Date/Time eCR Created
- Date/Time eCR Created + eICR Release Version
- Sender Software + EHR Software Name
-
- No data -
-
-
-
-
-
-
- Facility Address -
-
- No data -
-
-
-
-
-
-
- Facility Contact -
-
- No data -
-
-
-
-
-
-
- Facility ID + EHR Manufacturer Model Name
-
-

- eCR Sender Details -

- Sender Software -
-
-
-
-
-
-
-
- Sender Facility Name -
-
- PRM- Palmdale Regional Medical Center -
-
-
-
-
-
-
- Facility Address + eICR Release Version
- 38600 Medical Center Drive -Palmdale, CA -93551, USA + R1.1 (2016-12-01)
- Facility Contact + EHR Software Name
- (661)382-5000 + Epic - Version 10.1
- Facility ID + EHR Manufacturer Model Name
- 2.16.840.1.113883.4.6 + Epic - Version 10.1
-
-
-
-
-   -
-
-
-   -
-
-
-
-
-
-
-
-
-
-
-

- - eCR Sender Details - -

-
-
-
-
-
-
-   -
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-
-   -
-
-
-
- Sender Software + EHR Software Name
{ const mappings = loadYamlConfig(); it("should have no available data where there is no data", () => { const actual = evaluateEcrMetadata(undefined as any, mappings); - expect(actual.ecrSenderDetails.availableData).toBeEmpty(); - expect(actual.ecrSenderDetails.unavailableData).not.toBeEmpty(); expect(actual.eicrDetails.availableData).toBeEmpty(); expect(actual.eicrDetails.unavailableData).not.toBeEmpty(); expect(actual.rrDetails.availableData).toBeUndefined(); }); - it("should have ecrSenderDetails", () => { - const actual = evaluateEcrMetadata( - BundleWithEcrMetadata as unknown as Bundle, - mappings, - ); - - expect(actual.ecrSenderDetails.availableData).toEqual([ - { title: "Date/Time eCR Created", value: "07/28/2022 9:01 AM -05:00" }, - { - title: "Sender Facility Name", - value: "Vanderbilt University Adult Hospital", - }, - { - title: "Facility Address", - value: "1211 Medical Center Dr\nNashville, TN\n37232", - }, - { title: "Facility Contact", value: "+1-615-322-5000" }, - { title: "Facility ID", value: "7162024" }, - ]); - expect(actual.ecrSenderDetails.unavailableData).toEqual([ - { - title: "Sender Software", - toolTip: "EHR system used by the sending provider.", - }, - ]); - }); it("should have eicrDetails", () => { const actual = evaluateEcrMetadata( BundleWithEcrMetadata as unknown as Bundle, @@ -54,18 +26,14 @@ describe("Evaluate Ecr Metadata", () => { "Unique document ID for the eICR that originates from the medical record. Different from the Document ID that NBS creates for all incoming records.", value: "1.2.840.114350.1.13.478.3.7.8.688883.230886", }, + { title: "Date/Time eCR Created", value: "07/28/2022 9:01 AM -05:00" }, + { title: "eICR Release Version", value: "R1.1 (2016-12-01)" }, { - title: "Document Author", - value: "Vanderbilt University Medical Center", - }, - { - title: "Author Address", - value: "3401 West End Ave\nNASHVILLE, TN\n37203, USA", - }, - { - title: "Author Contact", - value: "Work 615-322-5000", + title: "EHR Software Name", + toolTip: "EHR system used by the sending provider.", + value: "Epic - Version 10.1", }, + { title: "EHR Manufacturer Model Name", value: "Epic - Version 10.1" }, ]); expect(actual.eicrDetails.unavailableData).toBeEmpty(); }); diff --git a/containers/ecr-viewer/src/app/view-data/components/AccordionContent.tsx b/containers/ecr-viewer/src/app/view-data/components/AccordionContent.tsx index 45efaa2d76..90a7e69b65 100644 --- a/containers/ecr-viewer/src/app/view-data/components/AccordionContent.tsx +++ b/containers/ecr-viewer/src/app/view-data/components/AccordionContent.tsx @@ -66,7 +66,6 @@ const AccordionContent: React.FC = ({ clinicalData.treatmentData.unavailableData, clinicalData.clinicalNotes.unavailableData, ...ecrMetadata.eicrDetails.unavailableData, - ...ecrMetadata.ecrSenderDetails.unavailableData, ]; return unavailableDataArrays.some( (array) => Array.isArray(array) && array.length > 0, @@ -161,11 +160,9 @@ const AccordionContent: React.FC = ({ content: ( <> {Object.keys(ecrMetadata.rrDetails).length > 0 || - ecrMetadata.eicrDetails.availableData.length > 0 || - ecrMetadata.ecrSenderDetails.availableData.length > 0 ? ( + ecrMetadata.eicrDetails.availableData.length > 0 ? ( ) : ( @@ -201,7 +198,6 @@ const AccordionContent: React.FC = ({ clinicalNotesData={clinicalData.clinicalNotes.unavailableData} ecrMetadataUnavailableData={[ ...ecrMetadata.eicrDetails.unavailableData, - ...ecrMetadata.ecrSenderDetails.unavailableData, ]} /> ) : ( diff --git a/containers/ecr-viewer/src/app/view-data/components/EcrMetadata.tsx b/containers/ecr-viewer/src/app/view-data/components/EcrMetadata.tsx index 419723d0c9..72f5420b77 100644 --- a/containers/ecr-viewer/src/app/view-data/components/EcrMetadata.tsx +++ b/containers/ecr-viewer/src/app/view-data/components/EcrMetadata.tsx @@ -15,7 +15,6 @@ import React from "react"; interface EcrMetadataProps { rrDetails: ReportableConditions; eicrDetails: DisplayDataProps[]; - eCRSenderDetails: DisplayDataProps[]; } interface ReportableConditionsList { @@ -66,14 +65,9 @@ const convertDictionaryToRows = (dictionary: ReportableConditionsList) => { * @param props - Props containing eCR metadata. * @param props.rrDetails - The reportable conditions details. * @param props.eicrDetails - The eICR details. - * @param props.eCRSenderDetails - The eCR sender details. * @returns The JSX element representing the eCR metadata. */ -const EcrMetadata = ({ - rrDetails, - eicrDetails, - eCRSenderDetails, -}: EcrMetadataProps) => { +const EcrMetadata = ({ rrDetails, eicrDetails }: EcrMetadataProps) => { return ( RR Details @@ -120,11 +114,6 @@ const EcrMetadata = ({ {eicrDetails.map((item, index) => { return ; })} -
- eCR Sender Details - {eCRSenderDetails.map((item, index) => { - return ; - })} ); diff --git a/containers/ecr-viewer/src/app/view-data/components/LoadingComponent.tsx b/containers/ecr-viewer/src/app/view-data/components/LoadingComponent.tsx index 3044d02c91..0684dbaf0b 100644 --- a/containers/ecr-viewer/src/app/view-data/components/LoadingComponent.tsx +++ b/containers/ecr-viewer/src/app/view-data/components/LoadingComponent.tsx @@ -215,8 +215,7 @@ const AccordionLoadingSkeleton = () => { content: ( <> {renderEcrDocumentFiller("RR Details", 1)} - {renderEcrDocumentFiller("eICR Details", 1)} - {renderEcrDocumentFiller("eCR Sender Details", 6)} + {renderEcrDocumentFiller("eICR Details", 5)} ), headingLevel: "h3", diff --git a/containers/fhir-converter/Templates/eCR/Resource/_Composition.liquid b/containers/fhir-converter/Templates/eCR/Resource/_Composition.liquid index e2da83f936..83731fda8f 100644 --- a/containers/fhir-converter/Templates/eCR/Resource/_Composition.liquid +++ b/containers/fhir-converter/Templates/eCR/Resource/_Composition.liquid @@ -30,6 +30,14 @@ "url" : "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber", "valueString" : "{{ composition.versionNumber.value }}" }, + {% for template in msg.ClinicalDocument.templateId %} + {% if template.root == "2.16.840.1.113883.10.20.15.2" %} + { + "url": "https://www.hl7.org/implement/standards/product_brief.cfm?product_id=436", + "valueString": "{{ template.extension }}" + }, + {% endif %} + {% endfor %} ], "status":"final", "type": diff --git a/containers/fhir-converter/Templates/eCR/Resource/_Device.liquid b/containers/fhir-converter/Templates/eCR/Resource/_Device.liquid index 9043fa5a6f..3fd7e40a76 100644 --- a/containers/fhir-converter/Templates/eCR/Resource/_Device.liquid +++ b/containers/fhir-converter/Templates/eCR/Resource/_Device.liquid @@ -10,15 +10,6 @@ { {% include 'DataType/Identifier' Identifier: id -%} }, {% endfor -%} ], - "type": - { - "coding": - [ - { - "display":"{{ author.assignedAuthoringDevice.manufacturerModelName._ }}", - }, - ], - }, "manufacturer":"{{ author.assignedAuthoringDevice.manufacturerModelName._ }}", "version": [