- Office Visit
-
-
- Hematology and Oncology
-
-
- Hematology and Oncology
-
-
-
-
- For questions regarding acute hepatitis C please
- notify the Kentucky Department for Public Health (KDPH): - During
- regular business hours (8:00 am – 4:30 pm, M-F): Primary contact
- is: Amanda Odegard at 502-564-6773 - After hours or on weekends:
- Call 888-9-REPORT (888-973-7678)
-
-
-
-
- Other
-
-
- Office Visit
-
-
- Hematology and Oncology
-
-
- Hematology and Oncology
-
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 07/26/2024 1:00 PM EDT | -Office Visit | -
- |
-
- |
- - |
| Name | -Type | -Priority | -Associated Diagnoses | -Date/Time | -
|---|---|---|---|---|
|
- |
- Lab | -Routine | -
- |
- 03/26/2024 2:04 PM EDT | -
| Name | -Type | -Priority | -Associated Diagnoses | -Order Schedule | -
|---|---|---|---|---|
|
- |
- Lab | -Routine | -
- |
- Expected: 3/26/24, Expires: 3/26/25 | -
-
-
-
-
- Hematology and Oncology
-
-
-
-
-
-
-
-
-
-
- Hematology and Oncology
-
-
- Hematology and Oncology
-
- | Reason | -Comments | -
|---|---|
| Consultation | -Hepatitis cThrombocytopenia | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| HBC - TOTAL AB | -NEGATIVE | -Negative | -- | 03/26/2024 5:15 PM EDT | -KDMC Louisville LAB | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 03/26/2024 2:04 PM EDT | -03/26/2024 2:12 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Tad Benty MD | -LAB SEND OUT ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| HBSAG | -NEGATIVE | -Negative | -- | 03/26/2024 4:31 PM EDT | -KDMC Louisville LAB | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 03/26/2024 2:04 PM EDT | -03/26/2024 2:12 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Tad Benty MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| HCV - RNA, QT | -
- |
- Not detected [IU]/mL | -- | 03/27/2024 2:40 PM EDT | -KDMC Louisville LAB | -- |
| HCV - RNA, QT | -
- |
- Not Detected {log IU}/mL | -- | 03/27/2024 2:40 PM EDT | -KDMC Louisville LAB | -- |
|
- - The quantification range of this assay is 10-100,000,000 IU/mL - (1.00 log-8.00 log IU/mL). Aptima's HCV Quant Dx Assay was used - which utilizes RT transcription-mediated amplification (TAM). Performed - at: KDMC Healthpark, 10650 US RT 60, Louisville, KY 41102. CLIA: - 18D0973033 - - - - |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 03/26/2024 2:04 PM EDT | -03/26/2024 2:12 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Tad Benty MD | -LAB SEND OUT ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Neutrophils | -
- |
- 35.0 - 66.0 % | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| - Lymphocytes | -
- |
- 24.0 - 44.0 % | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| - Monocytes | -5.9 | -2.1 - 13.3 % | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| - Eosinophils | -2.0 | -0.3 - 5.0 % | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| - Metamyelocytes | -1.0 | -% | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| Variant - Lymphocytes | -2.0 | -% | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| Neutrophils - Abs | -6.2 | -1.5 - 8.5 10*3/uL | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| Lymphocytes - Abs | -1.8 | -1.1 - 5.0 10*3/uL | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| Monocytes - Abs | -0.5 | -0.0 - 1.4 10*3/uL | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| Eosinophils - Abs | -0.2 | -0.0 - 0.5 10*3/uL | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| Metamyelocytes - Abs | -0.1 | -10*3/uL | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| Variant - Lymphocytes Abs | -0.2 | -10*3/uL | -- | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| - Morphology | -
- |
- - | - | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
|
- |
- ||||||
| - Anisocytosis | -1+ | -- | - | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| - Macrocytosis | -1+ | -- | - | 03/26/2024 3:20 PM EDT | -KDMC Louisville LAB | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 03/26/2024 2:04 PM EDT | -03/26/2024 2:12 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Tad Benty MD | -HEMATOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| WBC | -9.0 | -4.5 - 11.0 10*3/uL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| RBC | -5.88 | -4.50 - 5.90 10*6/uL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| HGB | -
- |
- 13.5 - 17.5 g/dL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| HCT | -
- |
- 37.0 - 53.0 % | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| MCV | -91.0 | -80.0 - 100.0 fL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| MCHC | -33.6 | -32.0 - 36.0 g/dL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| MCH | -30.6 | -26.0 - 34.0 pg | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| RDW | -13.7 | -10.7 - 18.7 % | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| MPV | -
- |
- 6.5 - 10.0 fL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| Platelet - Cnt | -157 | -150 - 450 10*3/uL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| - Neutrophils | -66.0 | -35.0 - 66.0 % | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| - Lymphocytes | -
- |
- 24.0 - 44.0 % | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| - Monocytes | -7.8 | -2.1 - 13.3 % | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| - Eosinophils | -2.6 | -0.3 - 5.0 % | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| - Basophils | -
- |
- 0.0 - 1.0 % | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| Neutrophils - Abs | -5.9 | -1.5 - 8.5 10*3/uL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| Lymphocytes - Abs | -2.0 | -1.1 - 5.0 10*3/uL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| Monocytes - Abs | -0.7 | -0.0 - 1.4 10*3/uL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| Eosinophils - Abs | -0.2 | -0.0 - 0.5 10*3/uL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| Basophils - Abs | -0.1 | -0.0 - 0.1 10*3/uL | -- | 03/26/2024 2:20 PM EDT | -KDMC Louisville LAB | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 03/26/2024 2:04 PM EDT | -03/26/2024 2:12 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Tad Benty MD | -HEMATOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- CBC w/Differential
-
-
- Hematology and Oncology
-
-
- WBC
-
-
- RBC
-
-
- HGB
-
-
- HCT
-
-
- MCV
-
-
- MCHC
-
-
- MCH
-
-
- RDW
-
-
- MPV
-
-
- Platelet Cnt
-
-
- Neutrophils
-
-
- Lymphocytes
-
-
- Monocytes
-
-
- Eosinophils
-
-
- Basophils
-
-
- Neutrophils Abs
-
-
- Lymphocytes Abs
-
-
- Monocytes Abs
-
-
- Eosinophils Abs
-
-
- Basophils Abs
-
-
-
-
- Narrative
-
-
- Lab Interpretation
-
-
- Differential Manual
-
-
- Hematology and Oncology
-
-
- Neutrophils
-
-
- Lymphocytes
-
-
- Monocytes
-
-
- Eosinophils
-
-
- Metamyelocytes
-
-
- Variant Lymphocytes
-
-
- Neutrophils Abs
-
-
- Lymphocytes Abs
-
-
- Monocytes Abs
-
-
- Eosinophils Abs
-
-
- Metamyelocytes Abs
-
-
- Variant Lymphocytes Abs
-
-
- Morphology
-
-
- Anisocytosis
-
-
- Macrocytosis
-
-
-
-
- Narrative
-
-
- Lab Interpretation
-
-
- HCV By Rt-PCR
-
-
- Hematology and Oncology
-
-
- HCV RNA, QT
-
-
- HCV RNA, QT
-
-
-
-
- Narrative
-
-
- Lab Interpretation
-
-
- HBSAG
-
-
- Hematology and Oncology
-
-
- HBSAG
-
-
-
-
- Narrative
-
-
- HEP B Core TOT. AB QL , S
-
-
- Hematology and Oncology
-
-
- HBC TOTAL AB
-
-
-
-
- Narrative
-
- | Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Former | -Cigarettes | -- | - | Quit: 02/26/2020 | -
| Smokeless Tobacco: Never | -- | - | - | - |
|
- - |
-
| Alcohol Use | -Standard Drinks/Week | -Comments | -
|---|---|---|
| Never | -0 (1 standard drink = 0.6 oz pure alcohol) | -- |
| PHQ-2 | -Answer | -Date Recorded | -
|---|---|---|
| PHQ-2 SCORE | -0 | -03/26/2024 | -
| Sex and Gender Information | -Value | -Date Recorded | -
|---|---|---|
| Sex Assigned at Birth | -Not on file | -- |
| Gender Identity | -Not on file | -- |
| Sexual Orientation | -Not on file | -- |
-
-
-
-
- Patient History
-
-
- Smoking Tobacco Use
-
-
- Smokeless Tobacco Use
-
-
- Passive Exposure
-
-
- PHQ-2
-
-
-
-
-
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 03/26/2024 1:30 PM EDT | -Office Visit | -
- |
-
- |
-
- - Polycythemia; Chronic hepatitis C without hepatic coma (CMS/HCC) |
-
-
-
-
-
- Hematology and Oncology
-
-
- Hematology and Oncology
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Hospital Encounter
-
-
- Family Medicine
-
-
- Family Medicine
-
-
- Oncology
-
-
-
-
- For questions regarding acute hepatitis C please
- notify the Kentucky Department for Public Health (KDPH): - During
- regular business hours (8:00 am – 4:30 pm, M-F): Primary contact
- is: Amanda Odegard at 502-564-6773 - After hours or on weekends:
- Call 888-9-REPORT (888-973-7678)
-
-
-
-
- Relative / Patient Representative
-
-
- Hospital Encounter
-
-
- Family Medicine
-
-
- Family Medicine
-
-
- Oncology
-
- | Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- Given | -03/26/2024 7:38 AM CDT | -40 mg | -- | - |
| - | - | ||||
|
- |
- Given | -03/26/2024 7:38 AM CDT | -10 mLs | -- | - |
| Given | -03/25/2024 11:48 PM CDT | -10 mLs | -- | - | |
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
| - | |||||
| Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- New Bag | -03/25/2024 4:31 PM CDT | -1,000 mg | -400 mL/hr | -- |
| - | - | ||||
|
- |
- New Bag | -03/25/2024 9:49 PM CDT | -25 g | -60 mL/hr | -- |
| - | - | ||||
|
- |
- Given | -03/25/2024 4:51 PM CDT | -100 mLs | -- | - |
| - | - | ||||
|
- |
- Given | -03/25/2024 7:51 PM CDT | -100 mg | -- | Right Lower Abdomen | -
| - | - | ||||
|
- |
- Given | -03/25/2024 4:51 PM CDT | -100 mLs | -- | - |
| - | - | ||||
|
- |
- Given | -03/25/2024 4:51 PM CDT | -10 mLs | -- | - |
| - | - | ||||
-
-
-
-
- Family Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Physician Assistant
-
-
-
-
-
-
- Internal Medicine - Infectious Disease
-
-
-
-
-
-
- Physician Assistant
-
-
-
-
-
-
-
-
-
-
-
-
-
- | Name | -Type | -Priority | -Associated Diagnoses | -Date/Time | -
|---|---|---|---|---|
|
- |
- ECG | -STAT | -- | 03/25/2024 4:31 PM CDT | -
|
- |
- Imaging | -STAT | -- | 03/25/2024 8:43 PM CDT | -
|
- |
- Microbiology | -STAT | -- | 03/25/2024 8:03 PM CDT | -
| Name | -Type | -Priority | -Associated Diagnoses | -Order Schedule | -
|---|---|---|---|---|
|
- |
- Lab | -STAT | -- | STAT - one time for 1 Occurrences starting 3/25/24 - until 3/25/24 | -
|
- |
- Imaging | -STAT | -- | One time imaging One time imaging for 1 Occurrences - starting 3/25/24 until 3/25/24 | -
|
- |
- Lab | -Routine | -- | Daily at 0600 until discontinued starting 3/26/24, 1 - completed | -
|
- |
- Lab | -Routine | -- | Daily at 0600 until discontinued starting 3/26/24, 1 - completed | -
|
- |
- Lab | -Routine | -- | Daily at 0600 until discontinued starting 3/26/24, 1 - completed | -
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- | Active Problems | -Noted Date | -Diagnosed Date | -
|---|---|---|
| Pancytopenia | -03/26/2024 | -- |
| Cirrhosis of liver with ascites | -03/25/2024 | -- |
| Liver cancer | -03/25/2024 | -- |
| Hypertension | -03/25/2024 | -- |
| Gastroesophageal reflux disease | -03/25/2024 | -- |
| Blood per rectum | -03/25/2024 | -- |
-
-
- Family Medicine
-
-
-
-
-
-
-
-
-
-
-
- | Reason | -Comments | -
|---|---|
| Abdominal Pain | -- |
| Specialty | -Diagnoses / Procedures | -Referred By Contact | -Referred To Contact | -
|---|---|---|---|
| - | - |
- |
-
- |
-
| Referral ID | -Status | -Reason | -Start Date | -Expiration Date | -Visits Requested | -Visits Authorized | -
|---|---|---|---|---|---|---|
| 3480047 | -- | - | - | - | 1 | -1 | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| HIV-1 - and 2 Antibodies | -NON-REACTIVE | -NONREACTIVE | -- | 03/26/2024 7:56 AM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Serum | -SERUM SPECIMEN / Unknown | -- | 03/26/2024 5:36 AM CDT | -03/26/2024 6:01 AM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Jones Steward MD | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Hepatitis - B Surface Antigen | -NON-REACTIVE | -NONREACTIVE | -- | 03/26/2024 7:56 AM CDT | -Owensboro Health Regional Hospital | -- |
| Hepatitis - B Core IgM | -NON-REACTIVE | -NONREACTIVE | -- | 03/26/2024 7:56 AM CDT | -Owensboro Health Regional Hospital | -- |
| Anti - Hepatitis A Virus IgM | -NON-REACTIVE | -NONREACTIVE | -- | 03/26/2024 7:56 AM CDT | -Owensboro Health Regional Hospital | -- |
| Hepatitis - C Virus | -
- |
- NONREACTIVE | -- | 03/26/2024 7:57 AM CDT | -Owensboro Health Regional Hospital | -- |
|
- - - REACTIVE: ANTI HCV INDICATES EITHER ACTIVE HEPATITIS C OR - PAST INFECTION - - - |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Serum | -SERUM SPECIMEN / Unknown | -- | 03/26/2024 5:36 AM CDT | -03/26/2024 6:00 AM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Jones Steward MD | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Magnesium | -
- |
- 1.9 - 2.7 mg/dL | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Plasma | -PLASMA SPECIMEN / Unknown | -- | 03/26/2024 5:36 AM CDT | -03/26/2024 6:00 AM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Jones Steward MD | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Glucose | -105 | -74 - 109 mg/dL | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| BUN | -8 | -7 - 25 mg/dL | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| - Creatinine | -
- |
- 0.7 - 1.3 mg/dL | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| - Sodium | -137 | -136 - 145 mmol/L | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| - Potassium | -3.5 | -3.5 - 5.1 mmol/L | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| - Chloride | -105 | -98 - 107 mmol/L | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| Carbon - Dioxide | -25 | -21 - 31 mmol/L | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| - Calcium | -
- |
- 8.6 - 10.3 mg/dL | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| - Protein | -
- |
- 6.4 - 8.9 g/dL | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| - Albumin | -
- |
- 3.5 - 5.7 g/dL | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| - Bilirubin | -
- |
- 0.3 - 1.0 mg/dL | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| SGOT- - AST | -37 | -13 - 39 U/L | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| SGPT- - ALT | -17 | -7 - 52 U/L | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| Alkaline - Phosphatase | -
- |
- 34 - 104 U/L | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| Glomerular - Filtration Rate, Est. | -
- |
- mL/min | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
|
- - - GFR � �WITH KIDNEY DAMAGE � � W/O DAMAGE >=90 � � � - � STAGE 1 � � � � � �NORMAL 60-89 � � � �STAGE 2 � � � � � �DEC GFR 30-59 - � � � �STAGE 3 � � � � � �STAGE 3 15-29 � � � �STAGE 4 � � � � � - �STAGE 4 <15 � � � � �STAGE 5 � � � � � �STAGE 5 - - The - formula is valid only for adults between age 18 and 70. - - |
- ||||||
| Anion - Gap | -7 | -4 - 12 mmol/L | -- | 03/26/2024 6:30 AM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Plasma | -PLASMA SPECIMEN / Unknown | -- | 03/26/2024 5:36 AM CDT | -03/26/2024 6:00 AM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Jones Steward MD | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| White - Blood Cells | -
- |
- 4.8 - 10.8 10*3/uL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Red - Blood Cells | -
- |
- 4.7 - 6.1 10*6/uL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| - Hemoglobin | -
- |
- 14.0 - 18.0 g/dL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| - Hematocrit | -
- |
- 42 - 54 % | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| MCV | -90.9 | -80 - 100 fL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| MCH | -31.0 | -26 - 34 pg | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| MCHC | -34.1 | -31 - 36 g/dL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| RDW | -
- |
- 11.5 - 14.5 % | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Platelet - Count | -
- |
- 150 - 450 10*3/uL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| MPV | -8.9 | -7.4 - 10.4 fL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Differential - Type | -AUTOMATED | -- | - | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Percent - Neutrophils | -66.9 | -% | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Percent - Lymphs | -17.2 | -% | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Percent - Monocytes | -9.7 | -% | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Percent - Eosinophils | -5.2 | -% | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Percent - basophil | -1.0 | -% | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Absolute - Neutrophil | -
- |
- 1.800 - 7.700 10*3/uL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Absolute - Lymphs | -
- |
- 0.800 - 4.800 10*3/uL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Absolute - Monocytes | -0.250 | -0.200 - 0.900 10*3/uL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Absolute - Eosinophils | -0.135 | -0.000 - 0.800 10*3/uL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Absolute - Basophils | -0.026 | -0.000 - 0.100 10*3/uL | -- | 03/26/2024 6:22 AM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Whole - Blood | -WHOLE BLOOD SPECIMEN / Unknown | -- | 03/26/2024 5:36 AM CDT | -03/26/2024 6:00 AM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Jones Steward MD | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Fluid - Total Protein | -
- |
- g/dL | -- | 03/25/2024 9:30 PM CDT | -Owensboro Health Regional Hospital | -- |
|
- - THE REFERENCE RANGE AND OTHER METHOD PERFORMANCE SPECIFICATIONS - HAVE NOT BEEN ESTABLISHED FOR THIS TEST FOR BODY FLUIDS. THE TEST - RESULTS SHOULD BE INTEGRATED INTO THE CLINICAL CONTEXT FOR - INTERPRETATION. - - |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Abdominal - Fluid | -SPECIMEN FROM ABDOMINAL CAVITY / Unknown | -- | 03/25/2024 8:03 PM CDT | -03/25/2024 8:38 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Amanda Kaye Howard PA-C | -BODY FLUIDS AND STOOLS ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Fluid - Glucose | -
- |
- mg/dL | -- | 03/25/2024 9:11 PM CDT | -Owensboro Health Regional Hospital | -- |
|
- - THE REFERENCE RANGE AND OTHER METHOD PERFORMANCE SPECIFICATIONS - HAVE NOT BEEN ESTABLISHED FOR THIS TEST FOR BODY FLUIDS. THE TEST - RESULTS SHOULD BE INTEGRATED INTO THE CLINICAL CONTEXT FOR - INTERPRETATION. - - |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Abdominal - Fluid | -SPECIMEN FROM ABDOMINAL CAVITY / Unknown | -- | 03/25/2024 8:03 PM CDT | -03/25/2024 8:38 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Amanda Kaye Howard PA-C | -BODY FLUIDS AND STOOLS ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Color, - Fluid | -YELLOW | -- | - | 03/25/2024 9:18 PM CDT | -Owensboro Health Regional Hospital | -- |
| Character, - Fluid | -CLOUDY | -- | - | 03/25/2024 9:18 PM CDT | -Owensboro Health Regional Hospital | -- |
| Fluid - Clot Present? | -NO | -- | - | 03/25/2024 9:18 PM CDT | -Owensboro Health Regional Hospital | -- |
| WBCs, - Fluid | -63 | -/mm3 | -- | 03/25/2024 9:18 PM CDT | -Owensboro Health Regional Hospital | -- |
| RBCs, - Fluid | -445 | -/mm3 | -- | 03/25/2024 9:24 PM CDT | -Owensboro Health Regional Hospital | -- |
| Polys, - Fluid | -36 | -% | -- | 03/25/2024 11:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Lymphs, - Fluid | -22 | -% | -- | 03/25/2024 11:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Monos/Macros/Mesos, - Fluid | -42 | -% | -- | 03/25/2024 11:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Eos/Basos, - Fluid | -
- |
- % | -- | 03/25/2024 11:23 PM CDT | -Owensboro Health Regional Hospital | -- |
|
- - - PERFORMED AT OHRH 1201 PLEASANT VALLEY ROAD O PHONE - 270(417-6500) - - |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Abdominal - Fluid | -SPECIMEN FROM ABDOMINAL CAVITY / Unknown | -- | 03/25/2024 8:03 PM CDT | -03/25/2024 8:37 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Amanda Kaye Howard PA-C | -BODY FLUIDS AND STOOLS ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| CYTOLOGY - PREP | -SENT TO CYTOLOGY | -- | - | 03/26/2024 7:24 AM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Body - Fluid | -BODY FLUID SPECIMEN / Unknown | -- | 03/25/2024 8:00 PM CDT | -03/25/2024 8:37 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Amanda Kaye Howard PA-C | -PATHOLOGY/CYTOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Abdomen, Pelvis, Hip, CTBODY | -- | Computed Tomography | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 03/25/2024 4:39 PM CDT | -- |
| Impressions | -
|---|
|
- - - - - - |
-
| Narrative | -
|---|
|
- - - - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Amanda Kaye Howard PA-C | -IMG CT ORDERABLES | -
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Chest | -- | Computed Radiography | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 03/25/2024 4:36 PM CDT | -- |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Amanda Kaye Howard PA-C | -IMG DIAGNOSTIC IMAGING ORDERABLES | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Urine - Color | -YELLOW | -- | - | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Urine - Character | -CLEAR | -- | - | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Urine - Glucose | -NEGATIVE | -NEG mg/dL | -- | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Urine - Bilirubin | -NEGATIVE | -NEG mg/dL | -- | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Urine - Ketones | -NEGATIVE | -NEG mg/dL | -- | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Urine - Specific Gravity | -1.024 | -1.005 - 1.030 | -- | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Urine - Blood | -NEGATIVE | -NEG mg/dL | -- | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Urine - PH | -6.0 | -5.0 - 7.0 | -- | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Urine - Albumin | -NEGATIVE | -NEG mg/dL | -- | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Urine - Urobilinogen | -
- |
- 0.2 - 1.0 mg/dL | -- | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Urine - Nitrites | -NEGATIVE | -NEG | -- | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Urine - Leukocytes | -NEGATIVE | -NEG | -- | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| MICROSCOPIC - URINALYSIS | -NotDone | -- | - | 03/25/2024 3:23 PM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Clean - Catch Urine | -URINE SPECIMEN OBTAINED BY CLEAN CATCH PROCEDURE / Unknown | -- | 03/25/2024 3:15 PM CDT | -03/25/2024 3:18 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Brett J Dickens MD | -URINE ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| High - sensitivity troponin result | -3 | -<20 pg/mL | -- | 03/25/2024 5:10 PM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Plasma | -PLASMA SPECIMEN / Unknown | -- | 03/25/2024 3:08 PM CDT | -03/25/2024 4:40 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Amanda Kaye Howard PA-C | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| BNP | -42.7 | -0 - 100 pg/mL | -- | 03/25/2024 5:19 PM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| EDTA - Plasma | -PLASMA SPECIMEN WITH ETHYLENEDIAMINE TETRAACETIC ACID / Unknown | -- | 03/25/2024 3:08 PM CDT | -03/25/2024 4:24 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Amanda Kaye Howard PA-C | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| PTT - (Partial Thromboplastin Time) | -26.2 | -23.1 - 32.1 SEC | -- | 03/25/2024 5:14 PM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Citrated - Plasma | -PLASMA SPECIMEN WITH CITRATE / Unknown | -- | 03/25/2024 3:08 PM CDT | -03/25/2024 4:23 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Amanda Kaye Howard PA-C | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| PT - (Prothrombin Time) | -
- |
- 9.5 - 12.4 SEC | -- | 03/25/2024 5:14 PM CDT | -Owensboro Health Regional Hospital | -- |
| INR | -
- |
- 0.89 - 1.18 | -- | 03/25/2024 5:14 PM CDT | -Owensboro Health Regional Hospital | -- |
|
- - - INR of 2.0-3.0 is recommended for all conditions with the - exception of patients anticoagulated for thrombotic complications of - mechanical heart valves for which an INR of 2.5-3.5 is recommended.Use - of a thromboplastin with high sensitivity is recommended. - - |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Citrated - Plasma | -PLASMA SPECIMEN WITH CITRATE / Unknown | -- | 03/25/2024 3:08 PM CDT | -03/25/2024 4:23 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Amanda Kaye Howard PA-C | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Lipase | -15 | -11 - 82 U/L | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Plasma | -PLASMA SPECIMEN / Unknown | -- | 03/25/2024 3:08 PM CDT | -03/25/2024 3:16 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Brett J Dickens MD | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Glucose | -101 | -74 - 109 mg/dL | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| BUN | -8 | -7 - 25 mg/dL | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| - Creatinine | -0.7 | -0.7 - 1.3 mg/dL | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| - Sodium | -137 | -136 - 145 mmol/L | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| - Potassium | -3.5 | -3.5 - 5.1 mmol/L | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| - Chloride | -104 | -98 - 107 mmol/L | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| Carbon - Dioxide | -23 | -21 - 31 mmol/L | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| - Calcium | -
- |
- 8.6 - 10.3 mg/dL | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| - Protein | -7.8 | -6.4 - 8.9 g/dL | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| - Albumin | -
- |
- 3.5 - 5.7 g/dL | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| - Bilirubin | -
- |
- 0.3 - 1.0 mg/dL | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| SGOT- - AST | -31 | -13 - 39 U/L | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| SGPT- - ALT | -15 | -7 - 52 U/L | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| Alkaline - Phosphatase | -
- |
- 34 - 104 U/L | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| Glomerular - Filtration Rate, Est. | -
- |
- mL/min | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
|
- - - GFR � �WITH KIDNEY DAMAGE � � W/O DAMAGE >=90 � � � - � STAGE 1 � � � � � �NORMAL 60-89 � � � �STAGE 2 � � � � � �DEC GFR 30-59 - � � � �STAGE 3 � � � � � �STAGE 3 15-29 � � � �STAGE 4 � � � � � - �STAGE 4 <15 � � � � �STAGE 5 � � � � � �STAGE 5 - - The - formula is valid only for adults between age 18 and 70. - - |
- ||||||
| Anion - Gap | -10 | -4 - 12 mmol/L | -- | 03/25/2024 3:56 PM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Plasma | -PLASMA SPECIMEN / Unknown | -- | 03/25/2024 3:08 PM CDT | -03/25/2024 3:16 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Brett J Dickens MD | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| White - Blood Cells | -
- |
- 4.8 - 10.8 10*3/uL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Red - Blood Cells | -
- |
- 4.7 - 6.1 10*6/uL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| - Hemoglobin | -
- |
- 14.0 - 18.0 g/dL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| - Hematocrit | -
- |
- 42 - 54 % | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| MCV | -92.1 | -80 - 100 fL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| MCH | -30.7 | -26 - 34 pg | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| MCHC | -33.3 | -31 - 36 g/dL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| RDW | -
- |
- 11.5 - 14.5 % | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Platelet - Count | -
- |
- 150 - 450 10*3/uL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| MPV | -8.7 | -7.4 - 10.4 fL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Differential - Type | -AUTOMATED | -- | - | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Percent - Neutrophils | -71.7 | -% | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Percent - Lymphs | -15.5 | -% | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Percent - Monocytes | -8.1 | -% | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Percent - Eosinophils | -3.7 | -% | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Percent - basophil | -1.0 | -% | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Absolute - Neutrophil | -2.500 | -1.800 - 7.700 10*3/uL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Absolute - Lymphs | -
- |
- 0.800 - 4.800 10*3/uL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Absolute - Monocytes | -0.284 | -0.200 - 0.900 10*3/uL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Absolute - Eosinophils | -0.130 | -0.000 - 0.800 10*3/uL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Absolute - Basophils | -0.036 | -0.000 - 0.100 10*3/uL | -- | 03/25/2024 3:32 PM CDT | -Owensboro Health Regional Hospital | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Whole - Blood | -WHOLE BLOOD SPECIMEN / Unknown | -- | 03/25/2024 3:08 PM CDT | -03/25/2024 3:16 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Brett J Dickens MD | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- X-ray chest AP portable
-
-
- Radiology
-
-
- Physician Assistant
-
-
- Radiology Study observation (narrative)
-
-
-
-
- Narrative
-
-
-
-
- Procedure Note
-
-
- CT Abdomen Pelvis w/Contrast IV Only per Contrast Protocol
-
-
- Radiology
-
-
- Physician Assistant
-
-
- Radiology Study observation (narrative)
-
-
-
-
- Impression
-
-
-
-
- Narrative
-
-
-
-
- Procedure Note
-
-
- CBC With Differential
-
-
- Emergency Medicine
-
-
-
-
-
- White Blood Cells
-
-
-
- Red Blood Cells
-
-
-
- Hemoglobin
-
-
-
- Hematocrit
-
-
- MCV
-
-
- MCH
-
-
- MCHC
-
-
- RDW
-
-
-
- Platelet Count
-
-
- MPV
-
-
-
- Differential Type
-
-
-
- Percent Neutrophils
-
-
-
- Percent Lymphs
-
-
-
- Percent Monocytes
-
-
-
- Percent Eosinophils
-
-
-
- Percent basophil
-
-
-
- Absolute Neutrophil
-
-
-
- Absolute Lymphs
-
-
-
- Absolute Monocytes
-
-
-
- Absolute Eosinophils
-
-
-
- Absolute Basophils
-
-
- Lab Interpretation
-
-
- Comprehensive metabolic panel
-
-
- Emergency Medicine
-
-
-
-
- Glucose
-
-
- BUN
-
-
-
- Creatinine
-
-
- Sodium
-
-
-
- Potassium
-
-
- Chloride
-
-
-
- Carbon Dioxide
-
-
- Calcium
-
-
- Protein
-
-
- Albumin
-
-
-
- Bilirubin
-
-
-
- SGOT- AST
-
-
-
- SGPT- ALT
-
-
-
- Alkaline Phosphatase
-
-
-
- Glomerular Filtration Rate, Est.
-
-
-
- Anion Gap
-
-
- Lab Interpretation
-
-
- Lipase
-
-
- Emergency Medicine
-
-
-
-
- Lipase
-
-
- Prothrombin time (PT with INR)
-
-
- Physician Assistant
-
-
-
-
-
- PT (Prothrombin Time)
-
-
- INR
-
-
- Lab Interpretation
-
-
- Partial thromboplastin time (PTT)
-
-
- Physician Assistant
-
-
-
-
-
- PTT (Partial Thromboplastin Time)
-
-
- BNP peptide
-
-
- Physician Assistant
-
-
-
-
- BNP
-
-
- High Sensitivity Troponin
-
-
- Physician Assistant
-
-
-
-
-
- High sensitivity troponin result
-
-
- Urinalysis
-
-
- Emergency Medicine
-
-
-
-
-
- Urine Color
-
-
-
- Urine Character
-
-
-
- Urine Glucose
-
-
-
- Urine Bilirubin
-
-
-
- Urine Ketones
-
-
-
- Urine Specific Gravity
-
-
-
- Urine Blood
-
-
- Urine PH
-
-
-
- Urine Albumin
-
-
-
- Urine Urobilinogen
-
-
-
- Urine Nitrites
-
-
-
- Urine Leukocytes
-
-
-
- MICROSCOPIC URINALYSIS
-
-
- Lab Interpretation
-
-
- Cytology - non GYN (requisition only)
-
-
- Physician Assistant
-
-
-
-
-
- CYTOLOGY PREP
-
-
- Body fluid cell count Abdominal Fluid
-
-
- Physician Assistant
-
-
-
-
-
- Color, Fluid
-
-
-
- Character, Fluid
-
-
-
- Fluid Clot Present?
-
-
-
- WBCs, Fluid
-
-
-
- RBCs, Fluid
-
-
-
- Polys, Fluid
-
-
-
- Lymphs, Fluid
-
-
-
- Monos/Macros/Mesos, Fluid
-
-
-
- Eos/Basos, Fluid
-
-
- Fluid glucose Abdominal Fluid
-
-
- Physician Assistant
-
-
-
-
-
- Fluid Glucose
-
-
- Fluid total protein Abdominal Fluid
-
-
- Physician Assistant
-
-
-
-
-
- Fluid Total Protein
-
-
- CBC With Differential
-
-
- Family Medicine
-
-
-
-
-
- White Blood Cells
-
-
-
- Red Blood Cells
-
-
-
- Hemoglobin
-
-
-
- Hematocrit
-
-
- MCV
-
-
- MCH
-
-
- MCHC
-
-
- RDW
-
-
-
- Platelet Count
-
-
- MPV
-
-
-
- Differential Type
-
-
-
- Percent Neutrophils
-
-
-
- Percent Lymphs
-
-
-
- Percent Monocytes
-
-
-
- Percent Eosinophils
-
-
-
- Percent basophil
-
-
-
- Absolute Neutrophil
-
-
-
- Absolute Lymphs
-
-
-
- Absolute Monocytes
-
-
-
- Absolute Eosinophils
-
-
-
- Absolute Basophils
-
-
- Lab Interpretation
-
-
- Comprehensive metabolic panel
-
-
- Family Medicine
-
-
-
-
- Glucose
-
-
- BUN
-
-
-
- Creatinine
-
-
- Sodium
-
-
-
- Potassium
-
-
- Chloride
-
-
-
- Carbon Dioxide
-
-
- Calcium
-
-
- Protein
-
-
- Albumin
-
-
-
- Bilirubin
-
-
-
- SGOT- AST
-
-
-
- SGPT- ALT
-
-
-
- Alkaline Phosphatase
-
-
-
- Glomerular Filtration Rate, Est.
-
-
-
- Anion Gap
-
-
- Lab Interpretation
-
-
- Magnesium (Mg) (Blood)
-
-
- Family Medicine
-
-
-
-
-
- Magnesium
-
-
- Lab Interpretation
-
-
- Acute hepatitis panel
-
-
- Family Medicine
-
-
-
-
-
- Hepatitis B Surface Antigen
-
-
-
- Hepatitis B Core IgM
-
-
-
- Anti Hepatitis A Virus IgM
-
-
-
- Hepatitis C Virus
-
-
- Lab Interpretation
-
-
- HIV-1 and 2 antibodies
-
-
- Family Medicine
-
-
-
-
-
- HIV-1 and 2 Antibodies
-
- | Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Never Assessed | -- | - | - | - |
| AHC Utilities | -Answer | -Date 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-C | -Answer | -Date Recorded | -
|---|---|---|
| Q1: How often do you have a drink containing - alcohol? | -Monthly or less | -03/25/2024 | -
| Q2: How many drinks containing alcohol do you have - on a typical day when you are drinking? | -Patient unable to answer | -03/25/2024 | -
| Q3: How often do you have six or more drinks on one - occasion? | -Patient unable to answer | -03/25/2024 | -
| Overall Financial Resource Strain (CARDIA) | -Answer | -Date Recorded | -
|---|---|---|
| How hard is it for you to pay for the very basics - like food, housing, medical care, and heating? | -Patient declined | -03/25/2024 | -
| Finnish Institute of Occupational Health - Occupational Stress Questionnaire | -Answer | -Date 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 declined | -03/25/2024 | -
| Exercise Vital Sign | -Answer | -Date Recorded | -
|---|---|---|
| On average, how many days per week do you engage in - moderate to strenuous exercise (like a brisk walk)? | -Patient declined | -03/25/2024 | -
| On average, how many minutes do you engage in - exercise at this level? | -Patient declined | -03/25/2024 | -
| Hunger Vital Sign | -Answer | -Date Recorded | -
|---|---|---|
| Within the past 12 months, you worried that your - food would run out before you got the money to buy more. | -Patient declined | -03/25/2024 | -
| Within the past 12 months, the food you bought just - didn't last and you didn't have money to get more. | -Patient declined | -03/25/2024 | -
| PRAPARE - Transportation | -Answer | -Date Recorded | -
|---|---|---|
| In the past 12 months, has lack of transportation - kept you from medical appointments or from getting medications? | -Patient declined | -03/25/2024 | -
| In the past 12 months, has lack of transportation - kept you from meetings, work, or from getting things needed for daily living? | -Patient declined | -03/25/2024 | -
| Utilities | -Answer | -Date Recorded | -
|---|---|---|
| In the past 12 months has the electric, gas, oil or - water company threatened to shut off services in your home? | -patient declined | -03/25/2024 | -
| OH Housing Stability Vital Sign | -Answer | -Date Recorded | -
|---|---|---|
| What is your living situation today? | -steady place to live | -03/25/2024 | -
| Think about the place you live. Do you have problems - with any of the following? | -patient declined | -03/25/2024 | -
| Safety and Environment | -Answer | -Date Recorded | -
|---|---|---|
| How often does anyone, including family and friends, - physically hurt you? | -never | -03/25/2024 | -
| How often does anyone, including family and friends, - insult or talk down to you? | -never | -03/25/2024 | -
| How often does anyone, including family and friends, - threaten you with harm? | -never | -03/25/2024 | -
| How often does anyone, including family and friends, - scream or curse at you? | -never | -03/25/2024 | -
| Sex and Gender Information | -Value | -Date Recorded | -
|---|---|---|
| Sex Assigned at Birth | -Not on file | -- |
| Gender Identity | -Not on file | -- |
| Sexual Orientation | -Not on file | -- |
- AHC Utilities
-
-
-
-
-
-
- AUDIT-C
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Overall Financial Resource Strain (CARDIA)
-
-
-
-
-
-
- Finnish Institute of Occupational Health - Occupational Stress
- Questionnaire
-
-
-
-
-
-
- Exercise Vital Sign
-
-
-
-
-
-
-
-
-
-
- Hunger Vital Sign
-
-
-
-
-
-
-
-
-
-
- PRAPARE - Transportation
-
-
-
-
-
-
-
-
-
-
- Utilities
-
-
-
-
-
-
- OH Housing Stability Vital Sign
-
-
-
-
-
-
-
-
-
-
- Safety and Environment
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 03/25/2024 2:38 PM CDT - Present | -Hospital Encounter | -
- |
-
- |
-
- Primary malignant neoplasm of liver (CMS/HCC); Pleural - effusion on right |
-
-
-
-
-
- Family Medicine
-
-
- Oncology
-
-
-
-
- Emergency Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- For questions regarding acute hepatitis C please
- notify the Kentucky Department for Public Health (KDPH): - During
- regular business hours (8:00 am � 4:30 pm, M-F): Primary contact
- is: Amanda Odegard at 502-564-6773 - After hours or on weekends:
- Call 888-9-REPORT (888-973-7678)
-
-
- NA
-
-
- Mother
-
-
- Hospital Encounter
-
-
- Pediatrics
-
-
- Pediatrics
-
-
- Neonatology
-
-
-
-
- Mother
-
-
- Hospital Encounter
-
-
- Pediatrics
-
-
- Pediatrics
-
-
- Neonatology
-
- | Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- Given | -08/04/2024 4:14 AM EDT | -23.04 mg | -- | - |
| - | - | ||||
| - | |||||
| Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- Given | -08/04/2024 6:40 AM EDT | -115 mg | -- | - |
| Given | -08/03/2024 7:08 PM EDT | -115 mg | -- | - | |
| - | - | ||||
|
- |
- Rate/Dose Verify | -08/04/2024 5:00 PM EDT | -1.1 mL/hr | -1.1 mL/hr | -- |
| Rate/Dose Verify | -08/04/2024 4:00 PM EDT | -1.1 mL/hr | -1.1 mL/hr | -- | |
| Rate/Dose Verify | -08/04/2024 3:00 PM EDT | -1.1 mL/hr | -1.1 mL/hr | -- | |
| - | - | ||||
|
- |
- Given | -08/03/2024 10:57 AM EDT | -0.116 mg | -- | - |
| - | - | ||||
|
- |
- Given | -08/03/2024 12:12 PM EDT | -0.116 mg | -- | - |
| - | - | ||||
|
- |
- Given | -08/03/2024 3:08 PM EDT | -5.8 mL | -- | - |
| - | - | ||||
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
-
-
- Nurse Practitioner
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- | Name | -Type | -Priority | -Associated Diagnoses | -Order Schedule | -
|---|---|---|---|---|
|
- |
- Respiratory Care | -Routine | -- | Until Discontinued until discontinued starting 8/3/24 | -
|
- |
- Point of Care Testing | -Routine | -- | As Needed until discontinued starting 8/3/24 | -
|
- |
- Respiratory Care | -Routine | -- | Until Discontinued until discontinued starting 8/3/24 | -
|
- |
- Lab | -Timed | -- | prn until discontinued starting 8/3/24, 3 completed | -
|
- |
- Respiratory Care | -Routine | -- | Continuous until discontinued starting 8/4/24 | -
-
-
-
-
- Nurse Practitioner
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Pediatrics
-
-
-
-
-
- | Active Problems | -Noted Date | -Diagnosed Date | -
|---|---|---|
| High risk social situation | -08/04/2024 | -- |
|
- 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 - |
- ||
| Respiratory distress | -08/03/2024 | -- |
|
- 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 - |
- ||
| Healthcare maintenance | -08/03/2024 | -- |
|
- 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. - |
- ||
| FEN | -08/03/2024 | -- |
|
- 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 - - |
- ||
| r/o sepsis | -08/03/2024 | -- |
|
- 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. - |
- ||
| Preterm infant estimated 34 weeks gestation | -08/03/2024 | -- |
|
- 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. - |
- ||
| Newborn affected by maternal use of other drugs of - addiction (CMS-HCC V28) | -08/03/2024 | -- |
|
- 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 - |
- ||
| Incomplete foreskin with concern for hypospadias | -08/03/2024 | -- |
|
- Infant with incomplete foreskin and apparent - hypospadias. Plan: -Consider Urology consult week of 8/5 - |
- ||
| At risk for hyperbilirubinemia | -08/03/2024 | -- |
|
- 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 - |
- ||
-
-
-
-
- Nurse Practitioner
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- | Specialty | -Diagnoses / Procedures | -Referred By Contact | -Referred To Contact | -
|---|---|---|---|
| - |
- - |
-
- |
-
- |
-
| Referral ID | -Status | -Reason | -Start Date | -Expiration Date | -Visits Requested | -Visits Authorized | -
|---|---|---|---|---|---|---|
| 10643115 | -- | - | - | - | 1 | -1 | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Bilirubin | -12.4 | -Refer to www.bilitool.org for information on age-specific (postnatal hour - of life)serum bilirubin values. mg/dL | -- | 08/05/2024 3:55 AM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/05/2024 2:54 AM EDT | -08/05/2024 3:07 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Carole Messenger-Rioux Neonatal Nurse Practitioner | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| GLUCOSE, - POINT OF CARE | -
- |
- 50 - 80 mg/dL | -- | 08/05/2024 12:03 AM EDT | -MAINE MEDICAL CENTER POCT | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -FINGER STRUCTURE / Unknown | -- | 08/04/2024 11:59 PM EDT | -08/05/2024 12:03 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Resulting_Poc_Glucose Mainehealth | -POINT OF CARE INTERFACED | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
- - |
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| GLUCOSE, - POINT OF CARE | -
- |
- 50 - 80 mg/dL | -- | 08/04/2024 9:13 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -FINGER STRUCTURE / Unknown | -- | 08/04/2024 8:56 PM EDT | -08/04/2024 9:13 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Resulting_Poc_Glucose Mainehealth | -POINT OF CARE INTERFACED | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
- - |
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Rapid - Plasma Reagin QL | -Negative | -Negative | -- | 08/05/2024 12:45 PM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -FINGER STRUCTURE / Unknown | -Capillary / Unknown | -08/04/2024 3:00 PM EDT | -08/04/2024 3:26 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Carole Messenger-Rioux Neonatal Nurse Practitioner | -IMMUNOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Glucose | -
- |
- 50 - 80 mg/dL | -- | 08/04/2024 3:45 PM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -FINGER STRUCTURE / Unknown | -Capillary / Unknown | -08/04/2024 3:00 PM EDT | -08/04/2024 3:26 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Eric J Frehm MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Glucose | -
- |
- 50 - 80 mg/dL | -- | 08/04/2024 9:41 AM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -FINGER STRUCTURE / Unknown | -Capillary / Unknown | -08/04/2024 9:04 AM EDT | -08/04/2024 9:09 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Eric J Frehm MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Bilirubin | -9.3 | -Refer to www.bilitool.org for information on age-specific (postnatal hour - of life)serum bilirubin values. mg/dL | -- | 08/04/2024 4:19 AM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -FINGER STRUCTURE / Unknown | -Capillary / Unknown | -08/04/2024 2:50 AM EDT | -08/04/2024 2:58 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Eric J Frehm MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Sodium | -141 | -135 - 145 mEq/L | -- | 08/04/2024 3:24 AM EDT | -NORDX MMC CAMPUS | -- |
| - Potassium | -- | - | - | 08/04/2024 3:24 AM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| - Chloride | -104 | -96 - 108 mEq/L | -- | 08/04/2024 3:24 AM EDT | -NORDX MMC CAMPUS | -- |
| Carbon - Dioxide | -21 | -21 - 30 mEq/L | -- | 08/04/2024 3:24 AM EDT | -NORDX MMC CAMPUS | -- |
| Blood - Urea Nitrogen | -18 | -4 - 19 mg/dL | -- | 08/04/2024 3:24 AM EDT | -NORDX MMC CAMPUS | -- |
| - Creatinine | -
- |
- 0.17 - 0.42 mg/dL | -- | 08/04/2024 3:24 AM EDT | -NORDX MMC CAMPUS | -- |
| - Calcium | -9.0 | -7.6 - 10.4 mg/dL | -- | 08/04/2024 3:24 AM EDT | -NORDX MMC CAMPUS | -- |
| - Glucose | -63 | -50 - 80 mg/dL | -- | 08/04/2024 3:24 AM EDT | -NORDX MMC CAMPUS | -- |
| Anion - Gap | -16 | -7 - 16 mEq/L | -- | 08/04/2024 3:24 AM EDT | -NORDX MMC CAMPUS | -- |
| BUN - Creatinine Ratio | -23.1 | -- | - | 08/04/2024 3:24 AM EDT | -NORDX MMC CAMPUS | -- |
| EGFR - (MDRD) | -- | - | - | 08/04/2024 3:24 AM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -FINGER STRUCTURE / Unknown | -Capillary / Unknown | -08/04/2024 2:50 AM EDT | -08/04/2024 2:58 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Eric J Frehm MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Glucose | -
- |
- 50 - 80 mg/dL | -- | 08/03/2024 9:28 PM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -FINGER STRUCTURE / Unknown | -Capillary / Unknown | -08/03/2024 8:57 PM EDT | -08/03/2024 9:09 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Eric J Frehm MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Bilirubin - Direct | -- | - | - | 08/03/2024 2:57 PM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| - Bilirubin | -5.1 | -Refer to www.bilitool.org for information on age-specific (postnatal hour - of life)serum bilirubin values. mg/dL | -- | 08/03/2024 2:57 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -FINGER STRUCTURE / Unknown | -Capillary / Unknown | -08/03/2024 2:21 PM EDT | -08/03/2024 2:28 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Katherine A Cotton NP | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| PH, - POINT OF CARE | -7.38 | -No established reference ranges for Capillary Collection. | -- | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| PCO2, - POINT OF CARE | -39 | -No established reference ranges for Capillary Collection. mmHg | -- | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| HCO3, - POINT OF CARE | -23 | -No established reference ranges for Capillary Collection. mmol/L | -- | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| PO2, - POINT OF CARE | -46 | -No established reference ranges for Capillary Collection. mmHg | -- | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| BASE - EXCESS, POINT OF CARE | --2 | -No established reference ranges for Capillary Collection. mmol/L | -- | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| SODIUM, - POINT OF CARE | -139 | -135 - 145 mmol/L | -- | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| POTASSIUM, - POINT OF CARE | -4.8 | -3.5 - 5.1 mmol/L | -- | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| CHLORIDE, - POINT OF CARE | -107 | -96 - 108 mmol/L | -- | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| GLUCOSE, - POINT OF CARE | -
- |
- 50 - 80 mg/dL | -- | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| IONIZED - CALCIUM, POINT OF CARE | -1.16 | -1.10 - 1.40 mmol/L | -- | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| POC - METHEMOGLOBIN | -0.6 | -No established reference ranges for Capillary Collection. % | -- | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| SOURCE, - POINT OF CARE | -BLDC | -- | - | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| Allen - Test | -Not applicable | -- | - | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
| User | -
- |
- - | - | 08/03/2024 2:16 PM EDT | -MAINE MEDICAL CENTER POCT | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -FINGER STRUCTURE / Unknown | -Capillary / Unknown | -08/03/2024 2:09 PM EDT | -08/03/2024 2:09 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Eric J Frehm MD | -POINT OF CARE INTERFACED | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
- - |
- |
-
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Chest | -- | Computed Radiography | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 08/03/2024 1:55 PM EDT | -- |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Katherine A Cotton NP | -IMG DIAGNOSTIC IMAGING ORDERABLES | -
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Katherine A Cotton NP | -PROCEDURE/MINOR SURGICAL ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
- - |
- |
-
- XR Chest Portable
-
-
- Radiology
-
-
- Nurse Practitioner
-
-
- Radiology Study observation (narrative)
-
-
-
-
- Narrative
-
-
-
-
- Procedure Note
-
-
- POC NICU Blood Gas + Lytes + Glu + Ion CA + MetHgb
-
-
- Pediatrics
-
-
- Blood
-
-
- PH, POINT OF CARE
-
-
- PCO2, POINT OF CARE
-
-
- HCO3, POINT OF CARE
-
-
- PO2, POINT OF CARE
-
-
- BASE EXCESS, POINT OF CARE
-
-
- SODIUM, POINT OF CARE
-
-
- POTASSIUM, POINT OF CARE
-
-
- CHLORIDE, POINT OF CARE
-
-
- GLUCOSE, POINT OF CARE
-
-
- IONIZED CALCIUM, POINT OF CARE
-
-
- POC METHEMOGLOBIN
-
-
- SOURCE, POINT OF CARE
-
-
- Allen Test
-
-
- User
-
-
- Lab Interpretation
-
-
- Capillary
-
-
- Bilirubin Total + Direct
-
-
- Nurse Practitioner
-
-
- Blood
-
-
- Bilirubin Direct
-
-
- Bilirubin
-
-
- Capillary
-
-
- Glucose Random
-
-
- Pediatrics
-
-
- Blood
-
-
- Glucose
-
-
- Lab Interpretation
-
-
- Capillary
-
-
- Basic Metabolic Panel
-
-
- Pediatrics
-
-
- Blood
-
-
- Sodium
-
-
- Potassium
-
-
- Chloride
-
-
- Carbon Dioxide
-
-
- Blood Urea Nitrogen
-
-
- Creatinine
-
-
- Calcium
-
-
- Glucose
-
-
- Anion Gap
-
-
- BUN Creatinine Ratio
-
-
- EGFR (MDRD)
-
-
- Lab Interpretation
-
-
- Capillary
-
-
- Bilirubin
-
-
- Pediatrics
-
-
- Blood
-
-
- Bilirubin
-
-
- Lab Interpretation
-
-
- Capillary
-
-
- Glucose Random
-
-
- Pediatrics
-
-
- Blood
-
-
- Glucose
-
-
- Lab Interpretation
-
-
- Capillary
-
-
- Glucose Random
-
-
- Pediatrics
-
-
- Blood
-
-
- Glucose
-
-
- Lab Interpretation
-
-
- Capillary
-
-
- Non Spec-Trep Ab Infant
-
-
- Lab
-
-
- Nurse Practitioner
-
-
- Blood
-
-
- Rapid Plasma Reagin QL
-
-
- Lab Interpretation
-
-
- Capillary
-
-
- Glucose, Point of Care
-
-
- Blood
-
-
- GLUCOSE, POINT OF CARE
-
-
- Lab Interpretation
-
-
- Glucose, Point of Care
-
-
- Blood
-
-
- GLUCOSE, POINT OF CARE
-
-
- Lab Interpretation
-
-
- Bilirubin
-
-
- Nurse Practitioner
-
-
- Blood
-
-
- Bilirubin
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- MH IP INTUBATION
-
-
- Pediatrics
-
-
- Nurse Practitioner
-
-
-
-
- Narrative
-
- | Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Never Assessed | -- | - | - | - |
| Sex and Gender Information | -Value | -Date Recorded | -
|---|---|---|
| Sex Assigned at Birth | -Not on file | -- |
| Gender Identity | -Not on file | -- |
| Sexual Orientation | -Not on file | -- |
| Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 08/03/2024 1:31 PM EDT - Present | -Hospital Encounter | -
- |
-
- |
- - |
-
-
-
-
- Pediatrics
-
-
- Neonatology
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Hospital Encounter
-
-
- Emergency Medicine
-
-
- Internal Medicine
-
-
- Internal Medicine
-
-
- Internal Medicine
-
-
- Nephrology
-
-
-
-
- Spouse
-
-
- Mother
-
-
- Father
-
-
- Hospital Encounter
-
-
- Emergency Medicine
-
-
- Internal Medicine
-
-
- Internal Medicine
-
-
- Internal Medicine
-
-
- Nephrology
-
- | Name | -Administration Dates | -Next Due | -
|---|---|---|
| Hepatitis B Vaccine | -
- |
- - |
| Influenza A H1N1 2009 | -
- |
- - |
| Influenza Vaccine | -
- |
- - |
| Influenza Vaccine 0.5mL IM High Dose Age 65+ (IMM90) | -
- |
- - |
| Influenza Vaccine 0.7mL IM High Dose Age 65+ - (IMM10220) | -
- |
- - |
| Influenza Vaccine Age 3+ PF | -
- |
- - |
| MMR Vaccine | -
- |
- - |
| Moderna Red - Cap(12+)Covid-19,Monovalent,mrna,lnp-s,pf,.5mL (IMM10222) | -
- |
- - |
| PREVNAR 20,(PCV-20),Pneumococcal Conjugate Vaccine - (IMM21058) | -
- |
- - |
| Pfizer Bivalent (12+)Gray - Cap,Tris-Sucrose,Covid-19,PF,30mcg/0.3mL(IMM10252) | -
- |
- - |
| Pfizer Comirnaty - (12+)covid-19,mrna,lnp-s,pf,tris-sucrose,30mcg/0.3mL(IMM10263) | -
- |
- - |
| Tdap Vaccine Age 7+ | -
- |
- - |
-
-
-
-
-
-
-
-
- Internal Medicine/Pediatrics
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Nursing
-
-
- Nursing
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Nursing
-
-
- Nursing
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- | Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- - | ||||
| - | - | ||||
|
- |
- Given | -08/05/2024 8:24 AM EDT | -10 mg | -- | - |
| Given | -08/04/2024 9:28 AM EDT | -10 mg | -- | - | |
| - | - | ||||
|
- |
- Given | -08/05/2024 8:24 AM EDT | -81 mg | -- | - |
| Given | -08/04/2024 9:25 AM EDT | -81 mg | -- | - | |
| - | - | ||||
|
- |
- Given | -08/05/2024 8:24 AM EDT | -40 mg | -- | - |
| Given | -08/04/2024 9:25 AM EDT | -40 mg | -- | - | |
| - | - | ||||
|
- |
- Given | -08/05/2024 8:26 AM EDT | -100 mg | -- | - |
| Given | -08/04/2024 9:25 AM EDT | -100 mg | -- | - | |
| Given | -08/03/2024 8:18 PM EDT | -100 mg | -- | - | |
| - | - | ||||
|
- |
- Restarted | -08/04/2024 9:29 PM EDT | -- | 250 mL/hr | -- |
| New Bag | -08/04/2024 4:28 PM EDT | -500 mg | -250 mL/hr | -- | |
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- Given | -08/05/2024 8:25 AM EDT | -25 mg | -- | - |
| Given | -08/04/2024 9:30 PM EDT | -25 mg | -- | - | |
| Given | -08/04/2024 9:24 AM EDT | -25 mg | -- | - | |
| - | - | ||||
|
- |
- Given | -08/04/2024 10:53 AM EDT | -1 gm | -- | - |
| - | - | ||||
|
- |
- Given | -08/05/2024 8:24 AM EDT | -1,000 Units | -- | - |
| Given | -08/04/2024 9:35 AM EDT | -1,000 Units | -- | - | |
| - | - | ||||
|
- |
- Given | -08/04/2024 6:40 AM EDT | -40 mcg | -- | Left Lower Abdomen | -
| - | - | ||||
|
- |
- Given | -08/05/2024 8:25 AM EDT | -10 mg | -- | - |
| Given | -08/04/2024 9:25 AM EDT | -10 mg | -- | - | |
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- Given | -08/05/2024 8:24 AM EDT | -100 mg | -- | - |
| Given | -08/04/2024 9:25 AM EDT | -100 mg | -- | - | |
| - | - | ||||
|
- |
- Given | -08/05/2024 10:48 AM EDT | -50 mg | -- | - |
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- Given | -08/05/2024 8:24 AM EDT | -5 mg | -- | - |
| Given | -08/04/2024 9:24 AM EDT | -5 mg | -- | - | |
| - | - | ||||
|
- |
- Given | -08/05/2024 8:24 AM EDT | -1 Capsule | -- | - |
| Given | -08/04/2024 9:23 AM EDT | -1 Capsule | -- | - | |
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- Given | -08/05/2024 8:23 AM EDT | -1,600 mg | -- | - |
| Given | -08/04/2024 6:34 PM EDT | -1,600 mg | -- | - | |
| Given | -08/04/2024 2:10 PM EDT | -1,600 mg | -- | - | |
| - | - | ||||
|
- |
- Given | -08/05/2024 8:23 AM EDT | -1,300 mg | -- | - |
| Given | -08/04/2024 9:25 AM EDT | -1,300 mg | -- | - | |
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- Given | -08/04/2024 6:34 PM EDT | -1 mg | -- | - |
| Given | -08/03/2024 8:10 PM EDT | -1 mg | -- | - | |
| - | - | ||||
|
- |
- Given | -08/05/2024 5:28 AM EDT | -2 mg | -- | - |
| Given | -08/04/2024 6:39 AM EDT | -2 mg | -- | - | |
| - | - | ||||
| - | |||||
| Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- Given | -08/04/2024 2:07 AM EDT | -1,000 mg | -- | - |
| - | - | ||||
|
- |
- New Bag | -08/03/2024 2:05 PM EDT | -500 mg | -250 mL/hr | -- |
| - | - | ||||
|
- |
- New Bag | -08/03/2024 1:13 PM EDT | -2 gm | -100 mL/hr | -- |
| - | - | ||||
|
- |
- Given | -08/05/2024 8:26 AM EDT | -100 mg | -- | - |
| Given | -08/04/2024 9:30 PM EDT | -100 mg | -- | - | |
| Given | -08/04/2024 4:37 PM EDT | -100 mg | -- | - | |
| - | - | ||||
|
- |
- New Bag | -08/03/2024 1:18 PM EDT | -1,000 mL | -1000 mL/hr | -- |
| - | - | ||||
|
- |
- New Bag | -08/03/2024 1:18 PM EDT | -1,500 mg | -333.3 mL/hr | -- |
| - | - | ||||
-
-
-
-
- Infectious Disease
-
-
-
-
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- sodium bicarbonate tablet 1,300 mg
-
-
- sodium bicarbonate tablet 1,300 mg
-
-
- sevelamer (Renvela) tablet 1,600 mg
-
-
- sevelamer (Renvela) tablet 1,600 mg
-
-
- predniSONE (Deltasone) tablet 5 mg
-
-
- predniSONE (Deltasone) tablet 5 mg
-
-
- niacin (VITAMIN B3) tablet 50 mg
-
-
- niacin (VITAMIN B3) tablet 50 mg
-
-
- renal multivitamin capsule 1 Capsule
-
-
- renal multivitamin capsule 1 Capsule
-
-
- losartan (Cozaar) tablet 100 mg
-
-
- losartan (Cozaar) tablet 100 mg
-
-
- gabapentin (Neurontin) capsule 100 mg
-
-
- gabapentin (Neurontin) capsule 100 mg
-
-
- cholecalciferol (VITAMIN D3) tablet 1,000 Units
-
-
- cholecalciferol (VITAMIN D3) tablet 1,000 Units
-
-
- carvedilol (Coreg) tablet 25 mg
-
-
- carvedilol (Coreg) tablet 25 mg
-
-
- calcitRIOL (Rocaltrol) capsule 0.75 mcg
-
-
- calcitRIOL (Rocaltrol) capsule 0.75 mcg
-
-
- atorvastatin (Lipitor) tablet 40 mg
-
-
- atorvastatin (Lipitor) tablet 40 mg
-
-
- aspirin chewable tablet 81 mg
-
-
- aspirin chewable tablet 81 mg
-
-
- amLODIPine (Norvasc) tablet 10 mg
-
-
- amLODIPine (Norvasc) tablet 10 mg
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- tacrolimus (Prograf) capsule 1 mg
-
-
- tacrolimus (Prograf) capsule 1 mg
-
-
- tacrolimus (Prograf) capsule 2 mg
-
-
- tacrolimus (Prograf) capsule 2 mg
-
-
- azaTHIOprine (Imuran) tablet 100 mg
-
-
- azaTHIOprine (Imuran) tablet 100 mg
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Emergency Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 08/08/2024 3:30 PM EDT | -Appointment | -
- |
- - | - |
| 08/09/2024 8:00 AM EDT | -Office Visit | -
- |
-
- |
- - |
| 09/18/2024 2:00 PM EDT | -Office Visit | -
- |
-
- |
- - |
| Name | -Type | -Priority | -Associated Diagnoses | -Date/Time | -
|---|---|---|---|---|
|
- |
- Microbiology | -STAT | -- | 08/03/2024 12:51 PM EDT | -
|
- |
- Blood Bank | -Timed | -- | 08/04/2024 9:45 AM EDT | -
|
- |
- Nursing Transfusion | -STAT | -- | 08/04/2024 11:49 AM EDT | -
|
- |
- Lab | -Add-On | -- | 08/04/2024 7:47 AM EDT | -
|
- |
- Lab | -Add-On | -- | 08/04/2024 7:47 AM EDT | -
|
- |
- Lab | -Add-On | -- | 08/04/2024 7:47 AM EDT | -
|
- |
- Nursing Transfusion | -STAT | -- | 08/04/2024 11:44 AM EDT | -
|
- |
- Lab | -Routine | -- | 08/05/2024 12:03 AM EDT | -
|
- |
- Vascular Imaging | -Routine | -- | 08/05/2024 11:31 AM EDT | -
|
- |
- Lab | -Routine | -- | 08/05/2024 5:17 AM EDT | -
|
- |
- Lab | -Routine | -- | 08/05/2024 5:17 AM EDT | -
| Name | -Type | -Priority | -Associated Diagnoses | -Order Schedule | -
|---|---|---|---|---|
|
- |
- Point of Care Testing | -STAT | -- | As Needed until discontinued starting 8/3/24 | -
|
- |
- Lab | -Add-On | -- | Routine Today Routine Today for 1 Occurrences - starting 8/4/24 until 8/4/24 | -
|
- |
- Lab | -Add-On | -- | Routine Today Routine Today for 1 Occurrences - starting 8/4/24 until 8/4/24 | -
|
- |
- Lab | -Add-On | -- | Routine Today Routine Today for 1 Occurrences - starting 8/4/24 until 8/4/24, 1 completed | -
|
- |
- Lab | -Routine | -- | Orders placed after 4am will default to tomorr for 1 - Occurrences starting 8/5/24 until 8/5/24 | -
|
- |
- Lab | -Add-On | -- | Routine Today Routine Today for 1 Occurrences - starting 8/4/24 until 8/4/24 | -
|
- |
- Vascular Imaging | -Routine | -- | One time imaging One time imaging for 1 Occurrences - starting 8/5/24 until 8/5/24 | -
|
- |
- Microbiology | -Routine | -- | Orders placed after 4am will default to tomorr for 1 - Occurrences starting 8/6/24 until 8/6/24 | -
|
- |
- Microbiology | -STAT | -- | STAT for 1 Occurrences starting 8/5/24 until 8/5/24 | -
-
-
-
-
- Emergency Medicine
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Infectious Disease
-
-
-
-
-
-
- Infectious Disease
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Radiology
-
-
-
-
-
-
- Wound Care
-
-
- Wound Care
-
-
-
-
-
-
- Hematology
-
-
- Oncology
-
- | Active Problems | -Noted Date | -Diagnosed Date | -
|---|---|---|
| Fever in adult | -08/04/2024 | -- |
| ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS) | -08/04/2024 | -- |
| Immunosuppressed status (CMS-HCC V24) | -08/03/2024 | -- |
| Transplant recipient | -08/03/2024 | -- |
|
- S/p kidney and pancreas transplant at MGH Now - ESRD with some urine production Pancreas stable, lipase 11 - |
- ||
| MSSA bacteremia | -08/03/2024 | -- |
|
- 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) - |
- ||
| Osteomyelitis of right ankle (CMS/HHS) | -08/03/2024 | -- |
|
- 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. " - |
- ||
| Urethral polyp | -06/21/2024 | -- |
| Condyloma acuminatum | -06/21/2024 | -- |
| Diabetic ulcer of right ankle (CMS/HHS) | -06/21/2024 | -- |
|
- 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. - |
- ||
| Type 2 diabetes mellitus without complication, without - long-term current use of insulin (CMS-HCC) (CMS/HHS) | -11/09/2023 | -- |
|
- Well controlled Discussed fructosamine - declines at this time Continue to track yearly A1c - |
- ||
| Primary hypertension | -11/09/2023 | -- |
|
- On amlodipine and lisinoril 147/70 today Well - controlled at home and during dialysis Continue current regiment - amlodipine and lisinopril - |
- ||
| Diabetic autonomic neuropathy associated with type 2 - diabetes mellitus (CMS/HHS) | -11/09/2023 | -- |
|
- 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. - |
- ||
| Healthcare maintenance | -11/09/2023 | -- |
|
- 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. - |
- ||
| COVID-19 | -06/05/2023 | -- |
| History of amputation of right great toe (CMS-HCC) - (CMS-HCC V24) | -01/29/2023 | -- |
|
- 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 | -- |
|
- - R/o active infection/abscess along - fistula. - Obtain US Soft Tissue left upper extremity - |
- ||
| Anemia in other chronic diseases classified elsewhere | -10/11/2022 | -- |
|
- 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 - |
- ||
| Open toe wound | -04/28/2022 | -- |
|
- 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 | -- |
|
- 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. - |
- ||
| Copper deficiency | -02/17/2022 | -- |
| Chronic diastolic congestive heart failure (CMS-HCC) - (CMS/HHS) | -01/25/2022 | -- |
|
- Clapp DO agreed with CDI query for Acute on - chronic diastolic (congestive) heart failure on 01/24/22 1620 - - Stable no recent exacerbations Had a 80% - blockage with PCI and stent placed Euvolemic on exam On asa and - statin - |
- ||
| Status post simultaneous kidney and pancreas transplant - 5/31/2018 | -01/21/2022 | -- |
|
- Transplant Surgery: MGH 5/31/2018 Standard - Criteria Donor . KDPI 29% CMV D-R- Complicated by Delayed graft - function in the early postoperative period Type of kidney transplant: DBD HLA - A2 B50 B62 Bw6 Cw4 Cw6 DR7 DR9 DR53 DQ2 DQ9 Class I PRA: 0% Class II PRA0 - % DSA: no Functional Status: 80% Dialysis pre-transplant? yes Initiation - date:4/10/2015 Pre-operative creatinine: 8.36 Day of DC creatinine: - 7.236 CMV D-/R - Donor ID: AFE2322 Kidney: KDPI%: 29% WIT: - 25 mins, CIT 3 hours, 44mins - - I have asked him to address whether or not he - would be a candidate for Evusheld with his transplant docs. - |
- ||
| Nephrotic syndrome | -01/20/2022 | -- |
|
- 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 - |
- ||
| Decreased libido | -10/08/2021 | -- |
|
- 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 - |
- ||
| PVD (peripheral vascular disease) (CMS-HCC V24) | -10/06/2021 | -- |
| Immunosuppression (CMS-HCC) | -01/16/2019 | -- |
|
- -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 - |
- ||
| Coronary artery disease involving native coronary artery | -11/24/2017 | -- |
|
- DES to mid LAD April 2015 PTCA of LAD and - diag1 Dec 2017 - - Hx of PCI to LAD 5/2015 and POBA to - LAD/diagonal bifurcation with POBA to existing LAD stent 12/2017 Continues - on asa and plavix - |
- ||
| Acute respiratory failure with hypoxia with question of - pneumonia | -09/25/2017 | -- |
|
- 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 - |
- ||
| Hypertension | -09/25/2017 | -- |
|
- -Continue to monitor blood pressure closely -Continue - outpatient doses of losartan, amlodipine, carvedilol - |
- ||
| Hypertension secondary to other renal disorders | -05/18/2016 | -- |
|
- 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 - |
- ||
| Secondary hyperparathyroidism, renal (CMS-HCC) | -05/06/2016 | -- |
|
- -Continue calcitriol 0.75 mcg 3 times weekly -Continue - cholecalciferol - |
- ||
| Urinary retention | -01/22/2015 | -- |
|
- 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 - Hold - desipramine - Acute urinary retention protocol - Monitor for - constipation - PVR Bladder scans 1-2x a day - |
- ||
| Hyperlipidemia | -09/22/2010 | -- |
|
- - Well controlled on atorvastatin, LDL at goal. - |
- ||
| ED (erectile dysfunction) | -01/15/2009 | -- |
|
- Using TRIMIX as prescribed through urology, he - uses this PRN prior to sexual activity. - |
- ||
| Chronic anemia with concern for possible GIB | -- | - |
|
- Hemoglobin 7 on admission which may be - contributing to his weakness and fatigue. Wbc and plt normal on admission. - Baseline hemoglobin around 10 (December 2021) Anemia is likely chronic - in the setting of his CKD however MCV elevated 103, though B12 elevated to - ~2000 and folate normal Fe 96, TIBC low at 133, % sat 72, not c/w iron - deficiency. LDH, haptoglobin, and bili are normal so less likely to be - consumption/hemolysis, though tacro can cause MTA. Bone marrow - suppression/MDS is possible though would likely see all cell lines decreased - vs isolated anemia Stool occult blood negative and capsule study did not - show any GI bleeding - - Patient has anemia of chronic disease as well - as iron deficiency Labs on 4/27 showing hemoglobin of 5.6 --> he - presented to the emergency department to receive 2 units of blood Semi- - 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. Patient denies black/bloody stools, hematemesis S/p 5 - units of blood. - PO PPI - transfuse for Hgb < 5 - -(irradiated, cmv negative); or symptomatic - 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) - cont to monitor hgb/hct - monitor for overt GI - bleeding - ldh and haptoglobin for evidence of hemolysis were not c/w - that - restarted oral iron - |
- ||
| ESRD on hemodialysis (CMS-HCC) (CMS/HHS) | -- | - |
|
- -HD T/T/S while in patient -Appreciate - nephrology consultation -Renal diet -Left arm precautions - |
- ||
| Resolved Problems | -Noted Date | -Diagnosed Date | -Resolved Date | -
|---|---|---|---|
| Protein-calorie malnutrition, unspecified severity - (CMS-HCC) (CMS-HCC V24) | -01/29/2023 | -- | 11/09/2023 | -
| Bacteremia | -10/11/2022 | -- | 11/09/2023 | -
|
- 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 - |
- |||
| Pancytopenia (CMS/HHS) | -10/11/2022 | -- | 11/09/2023 | -
| Pancytopenia (CMS/HHS) | -10/11/2022 | -- | 11/09/2023 | -
|
- 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 - |
- |||
| Unresponsive episode | -10/11/2022 | -- | 11/09/2023 | -
|
- 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. - |
- |||
| Inadequate flow of dialysis arteriovenous fistula, initial - encounter (CMS-HCC) (CMS-HCC V24) | -05/05/2022 | -- | 11/09/2023 | -
|
- Fistulogram and angioplasty 5/6. - has a - stitch in place that will need to be removed 5/9 at dialysis - |
- |||
| Leukopenia | -05/04/2022 | -- | 05/13/2022 | -
|
- 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 - |
- |||
| Tenosynovitis of right foot | -05/03/2022 | -- | 05/13/2022 | -
|
- 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. - |
- |||
| Sepsis (CMS/HHS) | -04/29/2022 | -- | 05/02/2022 | -
|
- - continue vancomycin + cefepime - monitor - inflammatory labs -UA? -blood culture? - |
- |||
| Hemoperitoneum | -02/07/2022 | -- | 02/09/2022 | -
|
- 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: midline 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 - |
- |||
| Hemorrhagic shock (CMS-HCC) (CMS/HHS) | -02/03/2022 | -- | 02/07/2022 | -
|
- 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 - |
- |||
| Anemia, unspecified | -01/21/2022 | -- | 02/04/2022 | -
|
- 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 - |
- |||
| Elevated troponin level | -01/20/2022 | -- | 01/23/2022 | -
|
- 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 - |
- |||
| Elevated liver enzymes | -01/20/2022 | -- | 01/21/2022 | -
|
- 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. - |
- |||
| Metabolic acidosis, normal anion gap (NAG) | -01/12/2022 | -- | 01/16/2022 | -
|
- 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 - - Presented 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 - Discontinue bicarb ggt - - Compression stockings for LE edema - |
- |||
| Electrolyte disturbance | -01/12/2022 | -- | 01/17/2022 | -
|
- 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 - |
- |||
| Weakness | -01/12/2022 | -- | 01/17/2022 | -
|
- 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 - |
- |||
| AKI (acute kidney injury) (CMS-HCC V24) | -01/12/2022 | -- | 01/17/2022 | -
|
- 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 - |
- |||
| Vaccine counseling | -10/08/2021 | -- | 01/21/2022 | -
|
- 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) | -10/06/2021 | -- | 10/06/2021 | -
| Diarrhea, unspecified | -10/06/2021 | -- | 02/04/2022 | -
|
- 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. In 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. 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 - immunosuppression CTAP w/ fluid in distal colon suggestive of - diarrhea, no calcification or diverticula of pancreas seen - - ~10-12 months of diarrhea Etiology 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 C. Diff negative, CMV negative, - Giardia negative Capsule endoscopy unrevealing Fecal calprotectin - normal Norovirus 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. Plan -Imodium 2 mg q2h prn w/ max of 16 mg - daily -GI consulted, appreciate recommendations -Stool leukocyte - ordered -Follow-up Fecal elastase -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 - |
- |||
| Family hx of prostate cancer | -08/05/2021 | -- | 02/04/2022 | -
| Weak urine stream | -08/05/2021 | -- | 02/04/2022 | -
| Nausea vomiting and diarrhea | -12/19/2019 | -- | 12/21/2019 | -
|
- 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). - |
- |||
| Renal transplant recipient | -11/11/2019 | -- | 01/21/2022 | -
|
- 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 - |
- |||
| Osteomyelitis of ankle or foot, acute, left (CMS/HHS) | -04/16/2019 | -- | 10/06/2021 | -
|
- 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 - |
- |||
| History of orthostatic hypotension | -04/06/2019 | -- | 02/04/2022 | -
|
- 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 - |
- |||
| Diabetic foot infection (CMS-HCC) (CMS/HCC) (CMS/HHS) | -04/05/2019 | -- | 10/06/2021 | -
|
- 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. - |
- |||
| Pancreas transplant status (CMS/HHS) | -01/16/2019 | -- | 02/04/2022 | -
|
- Transplant date:5/31/2018 Original kidney - disease: Diabetes Type of kidney transplant: DBD HLA A2 B50 B62 Bw6 - Cw4 Cw6 DR7 DR9 DR53 DQ2 DQ9 Class I PRA: 0% Class II PRA0 % DSA: - no Functional Status: 80% Dialysis pre-transplant? yes Initiation - date:4/10/2015 Pre-operative creatinine: 8.36 Day of DC creatinine: - 7.236 CMV D-/R - Donor ID: AFE2322 Kidney: KDPI%: 29% WIT: - 25 mins, CIT 3 hours, 44mins Received on ice, stayed on ice - - Received islet cell transplant in 2018 at MGH Synthetic - function of pancreas evaluated on last admission and was wnl - - Immunosuppression as elsewhere - |
- |||
| Preop cardiovascular exam | -12/05/2017 | -- | 01/16/2019 | -
| Diabetes type I | -09/25/2017 | -- | 01/16/2019 | -
|
- 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. - |
- |||
| End-stage renal disease on hemodialysis | -09/25/2017 | -- | 01/16/2019 | -
|
- Casco Bay dialysis - MWF; Dr. Cantlin - - Nephrology Assessment and Plan Patient - has ESRD due to DM1 Attends renal replacement therapy at Casco Bay - Dialysis Facility Access: AVF fistula Location: Left Access - Function: Normal Arm Precautions N Dialysis Days Mon/Wed/Fri Dialysis - Duration 5 hrs Primary outpatient nephrologist: Cantlin Current - Situation: Stable Plan on next dialysis: today Potassium 6, - would like to do HD prior to the cardiac cath Cardio team will dc pt - today before doing cath So the decision was done to dc him to do his hd - session at Cascobay center today as scheduled I talked to the nurse and - arranged for that - |
- |||
| Fatigue | -11/02/2016 | -- | 01/16/2019 | -
|
- 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 - |
- |||
| Hypertensive urgency | -09/09/2016 | -- | 01/16/2019 | -
|
- 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. - |
- |||
| Near syncope | -05/18/2016 | -- | 01/16/2019 | -
|
- 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. - |
- |||
| Clostridium difficile diarrhea | -05/16/2016 | -- | 01/16/2019 | -
|
- Acute onset of frequent liquid stools 5/16 - without abdominal pain - C.diff + -cont Metronidazole day 2/10 -Enteric - precautions - |
- |||
| Acute hypoxemic respiratory failure | -05/12/2016 | -- | 02/08/2022 | -
|
- Likely multifactorial, due to pleural effusions - R >> L, new opacity of RLL -ABX as above -HD per - Nephrology -O2 protocol, wean as tolerated - |
- |||
| Pericardial effusion | -05/11/2016 | -- | 01/16/2019 | -
|
- Repeat echo with cardiology follow up arranged - |
- |||
| Uremic pericarditis | -05/11/2016 | -- | 01/16/2019 | -
|
- Very much improved clinically Will monitor - on regular hemodialysis Short course of steroids completed today - |
- |||
| End-stage renal disease on hemodialysis | -05/11/2016 | -- | 01/16/2019 | -
| Renovascular hypertension | -05/11/2016 | -- | 05/15/2016 | -
|
- BPs elevated, likely some aspect of volume - overload contributing -Continue amlodipine - |
- |||
| Type 1 diabetes mellitus complicated by ESRD now s/p - kidney and pancreaus transplant 2018 | -05/11/2016 | -- | 02/04/2022 | -
|
- 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 - |
- |||
| Coronary artery disease involving native coronary artery - of native heart without angina pectoris | -05/11/2016 | -- | 01/16/2019 | -
|
- 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 - |
- |||
| Volume overload | -05/11/2016 | -- | 02/04/2022 | -
|
- HD again today for further volume overload, - will continue to challenge EDW as tolerated -Continue daily HD (except - Sundays) -Fluid restriction, low Na diet - |
- |||
| Hyponatremia | -05/11/2016 | -- | 01/16/2019 | -
| Pneumonia | -05/11/2016 | -- | 05/17/2016 | -
|
- 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 - |
- |||
| Hypoxia | -05/09/2016 | -- | 01/16/2019 | -
| Esophagitis | -05/08/2016 | -- | 01/16/2019 | -
|
- 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 - |
- |||
| Colon polyps | -05/07/2016 | -- | 01/16/2019 | -
|
- 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 - |
- |||
| Coronary artery disease | -05/07/2016 | -- | 01/21/2022 | -
|
- 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 - |
- |||
| Murmur, cardiac | -05/06/2016 | -- | 01/16/2019 | -
|
- 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 - |
- |||
| Healthcare-associated pneumonia | -05/05/2016 | -- | 01/16/2019 | -
|
- 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. - |
- |||
| Complication of AV dialysis fistula | -03/01/2016 | -- | 11/09/2023 | -
| Vitreous hemorrhage of right eye | -12/10/2015 | -- | 01/16/2019 | -
| Type 1 diabetes mellitus with nephropathy (CMS/HHS) | -12/10/2015 | -- | 05/13/2022 | -
|
- IMO Dx Update - - 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 catheter | -10/09/2015 | -- | 01/16/2019 | -
| Syncope | -09/16/2015 | -- | 05/05/2016 | -
|
- 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 - |
- |||
| NSTEMI (non-ST elevated myocardial infarction) (CMS-HCC) - (CMS/HHS) | -09/15/2015 | -- | 05/05/2016 | -
|
- 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 - |
- |||
| Intracranial hypertension | -09/03/2015 | -- | 01/16/2019 | -
|
- 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. - |
- |||
| Hyperkalemia | -08/07/2015 | -- | 02/04/2022 | -
|
- 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 - |
- |||
| Severe diabetic hypoglycemia (CMS-HCC) (CMS/HHS) | -08/07/2015 | -- | 08/08/2015 | -
| Type 1 diabetes mellitus (CMS/HHS) | -08/07/2015 | -- | 09/16/2015 | -
| ESRD (end stage renal disease) (CMS-HCC) (CMS/HHS) | -08/07/2015 | -- | 09/15/2015 | -
| Renovascular hypertension | -08/07/2015 | -- | 09/16/2015 | -
| CKD (chronic kidney disease), stage V (CMS-HCC) (CMS/HHS) | -08/04/2015 | -- | 09/15/2015 | -
|
- 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 hypertension | -06/19/2015 | -- | 09/15/2015 | -
|
- Now with hypertensive urgency. Plan and - medications as above. - |
- |||
| Hypertensive urgency | -06/19/2015 | -- | 05/05/2016 | -
|
- 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 breath | -06/19/2015 | -- | 09/15/2015 | -
|
- 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) | -04/14/2015 | -- | 01/21/2022 | -
|
- Follows with Dr. Vasiwalla @ MMP Cardiology, - history of PCI with stenting in 2015. - |
- |||
| ESRD (end stage renal disease) on dialysis (CMS/HHS) | -04/10/2015 | -- | 01/16/2019 | -
|
- Receives dialysis MWF at Casco Bay. Fistula - functioning well. EDW 70.2 kg. Reason for dialysis: solute clearance, - volume removal - - MWF at Casco Bay, last dialysis Monday Access - right AV fistula Home prescription 5 hrs, Optiflux 160, BFR 400, EDW 72 - kg, 2K, 2.5Ca, 1 Mg - we are using bigger dialyzer and doing 4 hours Dialysis - today and resume his normal schedule Ultrafiltration only No - Target Dry Weight Other (please specify) 72 kg Fluid removal goal To - be determined Duration of Treatment 5 Hours Dialyzer Optiflux - 160 Blood Flow Rate (cc/min) 400 cc/min Dialysate Flow Rate - (ml/min) 800 ml/min Dialysate type Bicarbonate K+ 2 mEq - Na+ 137 mEq Bicarb 30 mEq Special Instructions 2.5 Ca, low - dose heparin - |
- |||
| Uremia | -04/09/2015 | -- | 09/15/2015 | -
|
- Following. Improving with dialysis. - - Nephrology following - |
- |||
| Hypoglycemia | -01/22/2015 | -- | 06/19/2015 | -
|
- 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 - |
- |||
| Intervertebral lumbar disc disorder with myelopathy, - lumbar region | -01/20/2015 | -- | 01/16/2019 | -
|
- 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 - |
- |||
| Anemia of chronic renal failure, stage 5 (CMS/HCC) - (CMS/HHS) | -06/04/2012 | -- | 01/16/2019 | -
|
- 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 - |
- |||
| Hyperphosphatemia | -08/03/2011 | -- | 01/16/2019 | -
| HTN (hypertension) | -08/18/2009 | -- | 01/16/2019 | -
|
- 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 - |
- |||
| Type 1 diabetes mellitus (CMS/HHS) | -01/15/2009 | -- | 09/15/2015 | -
|
- (DX 1996) JOHN DEVLIN MD - - Home regimen of detemir 44units BID - - Reduce home regimen of detemir to 22 units BID given decreased oral intake - - POC BG ac and hs - low dose correctional coverage at ac and hs - |
- |||
| Type 1 diabetes mellitus with diabetic chronic kidney - disease (CMS/HHS) | -- | - | 09/16/2015 | -
|
- 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 loss | -- | - | 01/16/2019 | -
|
- 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 - |
- |||
| Pleural effusion | -- | - | 01/16/2019 | -
|
- See under pneumonia - |
- |||
| High blood pressure | -- | - | 01/16/2019 | -
|
- IMO Dx Update - - Home regimen: Amlodipine 10mg daily - Hydralazine 50mg TID Sun, Tue, Thurs Labetalol 800mg TID on dialysis - days, 200mg TID on alternating days Lisinopril 40mg Pre - syncope event with low BP in 90's -will hold anti-hypertensives at this - time - |
- |||
| Hospital-acquired pneumonia | -- | - | 01/16/2019 | -
| Type 1 diabetes mellitus with stage 1 chronic kidney - disease (CMS-HCC) (CMS/HCC) (CMS/HHS) | -- | - | 05/18/2016 | -
| Acute nonintractable headache | -- | - | 01/16/2019 | -
| Coronary artery disease involving native heart without - angina pectoris | -- | - | 01/16/2019 | -
| Type 1 diabetes mellitus with chronic kidney disease on - chronic dialysis, with long-term current use of insulin | -- | - | 01/16/2019 | -
| Acute pulmonary edema (CMS-HCC) (CMS/HHS) | -- | - | 11/03/2016 | -
| Pneumonia of right lung due to infectious organism | -- | - | 01/16/2019 | -
| Hemorrhage of arteriovenous fistula, initial encounter | -- | - | 01/16/2019 | -
| Chronic diarrhea | -- | - | 02/04/2022 | -
| Open wound of anterior abdominal wall | -- | - | 02/09/2022 | -
| Acute blood loss anemia | -- | - | 11/09/2023 | -
-
-
- Internal Medicine
-
-
-
-
-
-
- Nephrology
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
- Neurology
-
-
-
-
-
-
-
-
-
-
-
-
- Geriatric Medicine
-
-
-
-
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
- Nephrology
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Anesthesiology
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Physician Assistant
-
-
-
-
-
-
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
- Nurse Practitioner
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
-
-
-
-
-
-
-
-
- Hematology
-
-
-
-
-
-
- Internal Medicine
-
-
-
-
- Nurse Practitioner
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Nephrology
-
-
-
-
-
-
-
-
-
-
-
-
- Physician Assistant
-
-
-
-
-
-
-
-
-
-
-
-
- Urology
-
-
-
-
-
-
- Wound Care
-
-
-
-
-
-
-
-
-
-
-
-
- Infectious Disease
-
-
-
- | Reason | -Comments | -
|---|---|
| Fever | -- |
| Emesis | -- |
| Specialty | -Diagnoses / Procedures | -Referred By Contact | -Referred To Contact | -
|---|---|---|---|
| - |
- - |
-
- |
-
- |
-
| Referral ID | -Status | -Reason | -Start Date | -Expiration Date | -Visits Requested | -Visits Authorized | -
|---|---|---|---|---|---|---|
| 10642959 | -- | - | - | - | 1 | -1 | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Tapse | -2.4 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| Inferior - Vena Cava Diameter | -2.9 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| Diastolic - BP | -65.00 | -mmHg | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| Systolic - BP | -119.00 | -mmHg | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| Patient - Weight | -69.00 | -kg | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| Patient - Height | -180.00 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| BSA | -1.87 | -m2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LA - Volume Index | -36.0 | -mL/m2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LV - Dia Vol | -161 | -mL | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LV - Sys Vol | -71 | -mL | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - Peak A Vel | -1.2 | -m/s | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - VTI | -43.5 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - Peak E Vel | -1.6 | -m/s | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - regurgitation pressure 1/2 time | -66.00 | -ms | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - Peak Gradient | -11 | -mmHg | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| AV - Peak Gradient | -7 | -mmHg | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LVOT - stroke volume | -90 | -mL | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| Ao - VTI | -28.2 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| Ao - Peak Vel | -1.3 | -m/s | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LVOT - peak VTI | -29.0 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LVOT - Peak Vel | -1.4 | -m/s | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LVOT - diameter | -1.9 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| E - wave deceleration time | -224 | -ms | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - E' Tissue Velocity Lateral | -6.4 | -cm/s | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| E/A - ratio | -1.40 | -- | - | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| PV - Peak Gradient | -4 | -mmHg | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - valve area by continuity eq | -1.9 | -cm2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - Mean Gradient | -5 | -mmHg | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LVOT - Peak Gradient | -8 | -mmHg | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| AV - Mean Gradient | -4 | -mmHg | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| RA - 2D Volume | -18.4 | -mL/m2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| SVI | -44.0 | -mL/m2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| AV - area peak vel | -2.9 | -cm2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| AV - area by cont VTI | -2.9 | -cm2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LVOT - Mean Gradient | -4 | -mmHg | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| RV-dias - basal d | -3.7 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| A4C - EF | -54 | -% | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| A2C - EF | -61 | -% | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| AV - VTI Ratio | -1.03 | -- | - | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LA - size | -4.2 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| Asc - Aorta | -3.4 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LA - volume (BP) | -68 | -mL | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| EF | -56 | -% | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| - LVIDS | -3.6 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| Sinuses - of Valsalva | -3.0 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| PW | -1.0 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| IVS | -0.9 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| - LVIDD | -5.2 | -cm | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - valve area P1/2 | -3.3 | -cm2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| PV - PEAK VELOCITY | -106.0 | -cm/s | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LVOT - SI | -48.0 | -mL/m2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - E/E' lateral | -25 | -- | - | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - E/E' septal (medial) | -29 | -- | - | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| MV - E' Tissue Velocity Medial | -5.5 | -cm/s | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| AV - valve area | -2.9 | -cm2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| AV - Velocity Ratio | -1.08 | -- | - | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LVOT - area | -2.8 | -cm2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| LV - Diastolic Volume Index | -86.1 | -mL/m2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| ASCENDING - AORTA DIAMETER INDEX BSA | -1.8 | -cm/m2 | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| Est. - RA pres | -15 | -mmHg | -- | - | .MANUAL ENTRY (EXTERNAL LAB) | -- |
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| TTE, Chest | -- | Ultrasound | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | - | - |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Raymond Klein MD | -ECHO ORDERABLES | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Legionella - Antigen, Urine | -Negative | -Negative | -- | 08/05/2024 12:33 PM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Urine | -VOIDED URINE SPECIMEN / Unknown | -Non-blood Collection / Unknown | -08/05/2024 7:07 AM EDT | -08/05/2024 7:12 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Raymond Klein MD | -URINE ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Erythrocyte - Morphology | -See below: | -- | - | 08/05/2024 6:14 AM EDT | -NORDX MMC CAMPUS | -- |
| - Acanthocytes | -1+ | -- | - | 08/05/2024 6:14 AM EDT | -NORDX MMC CAMPUS | -- |
| - Echinocytes | -1+ | -- | - | 08/05/2024 6:14 AM EDT | -NORDX MMC CAMPUS | -- |
| - Macrocytes | -2+ | -- | - | 08/05/2024 6:14 AM EDT | -NORDX MMC CAMPUS | -- |
| - Ovalocytes | -1+ | -- | - | 08/05/2024 6:14 AM EDT | -NORDX MMC CAMPUS | -- |
| - Polychromasia | -1+ | -- | - | 08/05/2024 6:14 AM EDT | -NORDX MMC CAMPUS | -- |
| - Schistocytes | -
- |
- None Seen | -- | 08/05/2024 6:14 AM EDT | -NORDX MMC CAMPUS | -- |
| Tear - Drop Cells | -1+ | -- | - | 08/05/2024 6:14 AM EDT | -NORDX MMC CAMPUS | -- |
| Toxic - Granulation | -1+ | -- | - | 08/05/2024 6:14 AM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/05/2024 5:17 AM EDT | -08/05/2024 5:26 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Raymond Klein MD | -IMMUNOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Sodium | -138 | -135 - 145 mEq/L | -- | 08/05/2024 5:59 AM EDT | -NORDX MMC CAMPUS | -- |
| - Potassium | -4.1 | -3.5 - 5.1 mEq/L | -- | 08/05/2024 5:59 AM EDT | -NORDX MMC CAMPUS | -- |
| - Chloride | -101 | -96 - 108 mEq/L | -- | 08/05/2024 5:59 AM EDT | -NORDX MMC CAMPUS | -- |
| Carbon - Dioxide | -26 | -21 - 30 mEq/L | -- | 08/05/2024 5:59 AM EDT | -NORDX MMC CAMPUS | -- |
| Blood - Urea Nitrogen | -
- |
- 6 - 20 mg/dL | -- | 08/05/2024 5:59 AM EDT | -NORDX MMC CAMPUS | -- |
| - Creatinine | -
- |
- 0.50 - 1.30 mg/dL | -- | 08/05/2024 5:59 AM EDT | -NORDX MMC CAMPUS | -- |
| - Calcium | -9.5 | -8.6 - 10.0 mg/dL | -- | 08/05/2024 5:59 AM EDT | -NORDX MMC CAMPUS | -- |
| - Glucose | -93 | -70 - 99 mg/dL | -- | 08/05/2024 5:59 AM EDT | -NORDX MMC CAMPUS | -- |
| Anion - Gap | -11 | -7 - 16 mEq/L | -- | 08/05/2024 5:59 AM EDT | -NORDX MMC CAMPUS | -- |
| BUN - Creatinine Ratio | -8.6 | -- | - | 08/05/2024 5:59 AM EDT | -NORDX MMC CAMPUS | -- |
| EGFR - (MDRD) | -
- |
- >60.0 mL/min/1.73m(2) | -- | 08/05/2024 5:59 AM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/05/2024 5:17 AM EDT | -08/05/2024 5:26 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Raymond Klein MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Tacrolimus - Level | -10.9 | -3.0 - 15.0 ng/mL | -- | 08/05/2024 12:01 PM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/05/2024 5:17 AM EDT | -08/05/2024 5:26 AM EDT | -
| Narrative | -
|---|
|
- - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Chest | -- | Computed Tomography | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 08/04/2024 6:15 PM EDT | -- |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Raymond Klein MD | -IMG CT ORDERABLES | -
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Leg, Ankle, Foot | -- | Magnetic Resonance | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 08/04/2024 5:00 PM EDT | -- |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Raymond Klein MD | -IMG MRI ORDERABLES | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| INR | -
- |
- 0.9 - 1.2 | -- | 08/04/2024 10:03 AM EDT | -NORDX MMC CAMPUS | -- |
|
- - - STANDARD THERAPY: 2.0 - 3.0 HIGH DOSE THERAPY: 2.5 - 3.5 FFP - is rarely indicated in a bleeding patient, or as prophylaxis prior - to surgery/invasive procedure, if the INR is <= 1.7 |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/04/2024 9:48 AM EDT | -08/04/2024 9:51 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Raymond Klein MD | -HEMATOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Fibrinogen | -
- |
- 160 - 450 mg/dL | -- | 08/04/2024 10:02 AM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/04/2024 9:48 AM EDT | -08/04/2024 9:51 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Raymond Klein MD | -HEMATOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| ABO - Type | -O | -- | - | 08/04/2024 11:07 AM EDT | -NORDX MMC BLOOD BANK | -- |
| Rh - Type | -POSITIVE | -- | - | 08/04/2024 11:07 AM EDT | -NORDX MMC BLOOD BANK | -- |
| Antibody - Screen | -NEGATIVE | -- | - | 08/04/2024 11:07 AM EDT | -NORDX MMC BLOOD BANK | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/04/2024 9:48 AM EDT | -08/04/2024 9:51 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Raymond Klein MD | -BLOOD BANK ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Lactate - Dehydrogenase | -- | - | - | 08/04/2024 9:59 AM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/04/2024 7:47 AM EDT | -08/04/2024 7:54 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Raymond Klein MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Vancomycin - Level Random | -
- |
- See Comment ug/mL | -- | 08/04/2024 8:43 AM EDT | -NORDX MMC CAMPUS | -- |
|
- - Therapeutic ranges: Trough: 5-15 ug/ml. For - patients on meningitis, osteomyelitis, endocarditis, and pneumonia therapy: - Vancomycin Trough: 15-20 ug/mL Trough concentrations greater than - 30.0 are considered potentially toxic |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/04/2024 7:47 AM EDT | -08/04/2024 7:54 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Raymond Klein MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Leukocytes | -7.6 | -3.6 - 11.8 thou/uL | -- | 08/04/2024 8:03 AM EDT | -NORDX MMC CAMPUS | -- |
| - Erythrocytes | -
- |
- 3.97 - 5.93 mil/uL | -- | 08/04/2024 8:03 AM EDT | -NORDX MMC CAMPUS | -- |
| - Hemoglobin | -
- |
- 12.3 - 16.9 g/dL | -- | 08/04/2024 8:03 AM EDT | -NORDX MMC CAMPUS | -- |
| - Hematocrit | -
- |
- 35.0 - 50.0 % | -- | 08/04/2024 8:03 AM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Corpuscular Volume | -
- |
- 77.3 - 95.6 fL | -- | 08/04/2024 8:03 AM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Corpuscular Hemoglobin | -
- |
- 24.1 - 32.4 pg | -- | 08/04/2024 8:03 AM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Corpuscular Hemoglobin Conc | -
- |
- 30.7 - 35.7 g/dL | -- | 08/04/2024 8:03 AM EDT | -NORDX MMC CAMPUS | -- |
| Platelet - Count | -
- |
- 142 - 390 thou/uL | -- | 08/04/2024 8:03 AM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Platelet Volume | -10.1 | -9.0 - 12.9 fL | -- | 08/04/2024 8:03 AM EDT | -NORDX MMC CAMPUS | -- |
| Erythrocyte - Distribution Width SD | -
- |
- 37.0 - 48.0 fL | -- | 08/04/2024 8:03 AM EDT | -NORDX MMC CAMPUS | -- |
| Erythrocyte - Distribution Width CV | -14.1 | -11.5 - 16.0 % | -- | 08/04/2024 8:03 AM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/04/2024 7:46 AM EDT | -08/04/2024 7:54 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -HEMATOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Sodium | -136 | -135 - 145 mEq/L | -- | 08/04/2024 8:34 AM EDT | -NORDX MMC CAMPUS | -- |
| - Potassium | -4.6 | -3.5 - 5.1 mEq/L | -- | 08/04/2024 8:34 AM EDT | -NORDX MMC CAMPUS | -- |
| - Chloride | -101 | -96 - 108 mEq/L | -- | 08/04/2024 8:34 AM EDT | -NORDX MMC CAMPUS | -- |
| Carbon - Dioxide | -23 | -21 - 30 mEq/L | -- | 08/04/2024 8:34 AM EDT | -NORDX MMC CAMPUS | -- |
| Blood - Urea Nitrogen | -
- |
- 6 - 20 mg/dL | -- | 08/04/2024 8:34 AM EDT | -NORDX MMC CAMPUS | -- |
| - Creatinine | -
- |
- 0.50 - 1.30 mg/dL | -- | 08/04/2024 8:34 AM EDT | -NORDX MMC CAMPUS | -- |
| - Calcium | -9.4 | -8.6 - 10.0 mg/dL | -- | 08/04/2024 8:34 AM EDT | -NORDX MMC CAMPUS | -- |
| - Glucose | -93 | -70 - 99 mg/dL | -- | 08/04/2024 8:34 AM EDT | -NORDX MMC CAMPUS | -- |
| Anion - Gap | -12 | -7 - 16 mEq/L | -- | 08/04/2024 8:34 AM EDT | -NORDX MMC CAMPUS | -- |
| BUN - Creatinine Ratio | -7.1 | -- | - | 08/04/2024 8:34 AM EDT | -NORDX MMC CAMPUS | -- |
| EGFR - (MDRD) | -
- |
- >60.0 mL/min/1.73m(2) | -- | 08/04/2024 8:34 AM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/04/2024 7:46 AM EDT | -08/04/2024 7:54 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Leukocytes | -0-2 | -0 - 2 /HPF | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| - Erythrocytes | -
- |
- 0 - 2 /HPF | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Squamous - Epithelial Cells | -None Seen | -/HPF | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| - Bacteria | -None Seen | -/HPF | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Urine | -URINE SPECIMEN OBTAINED BY CLEAN CATCH PROCEDURE / Unknown | -Non-blood Collection / Unknown | -08/03/2024 11:39 PM EDT | -08/03/2024 11:42 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -URINALYSIS ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Color - UR | -Dark Yellow | -- | - | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Appearance - UR | -Clear | -- | - | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Specific - Gravity UR | -1.016 | -1.005 - 1.030 | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| pH UR | -6.5 | -5.0 - 8.0 | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Leukocyte - Esterase UR | -Negative | -Negative | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Nitrite - UR | -Negative | -Negative | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Protein - UR QL | -
- |
- Negative mg/dL | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Glucose - UR QL | -Negative | -Negative mg/dL | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Ketones - UR QL | -
- |
- Negative | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Urobilinogen - UR | -
- |
- Normal mg/dL | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Hemoglobin - UR | -
- |
- Negative Ery/uL | -- | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Urine - Sediment | -Performed | -- | - | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Urine - Culture Comment | -Not Indicated | -- | - | 08/03/2024 11:53 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Urine | -URINE SPECIMEN OBTAINED BY CLEAN CATCH PROCEDURE / Unknown | -Non-blood Collection / Unknown | -08/03/2024 11:39 PM EDT | -08/03/2024 11:42 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -MICROBIOLOGY - GENERAL ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Culture - MRSA | -No MRSA Isolated | -- | - | 08/04/2024 6:59 PM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Swab - (Naris) | -- | Non-blood Collection / Unknown | -08/03/2024 2:05 PM EDT | -08/03/2024 3:10 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| John W Martel MD | -MICROBIOLOGY - GENERAL ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Chest | -- | Computed Radiography | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 08/03/2024 12:30 PM EDT | -- |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -IMG DIAGNOSTIC IMAGING ORDERABLES | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Lipase | -
- |
- 13 - 60 U/L | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 1:06 PM EDT | -08/03/2024 1:12 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Amber Richards MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Lactate | -0.9 | -0.5 - 2.0 mmol/L | -- | 08/03/2024 1:14 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 1:06 PM EDT | -08/03/2024 1:12 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Sodium | -138 | -135 - 145 mEq/L | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| - Potassium | -3.9 | -3.5 - 5.1 mEq/L | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| - Chloride | -
- |
- 96 - 108 mEq/L | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| Carbon - Dioxide | -25 | -21 - 30 mEq/L | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| Anion - Gap | -
- |
- 7 - 16 mEq/L | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| Blood - Urea Nitrogen | -
- |
- 6 - 20 mg/dL | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| - Creatinine | -
- |
- 0.50 - 1.30 mg/dL | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| BUN - Creatinine Ratio | -8.5 | -- | - | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| - Glucose | -
- |
- 70 - 99 mg/dL | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| - Protein | -6.4 | -6.4 - 8.3 g/dL | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| - Albumin | -
- |
- 3.5 - 5.1 g/dL | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| - Globulin | -3.4 | -2.0 - 3.5 g/dL | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| Albumin/Globulin - Ratio | -0.9 | -- | - | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| - Bilirubin | -0.6 | -<=1.2 mg/dL | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| - Calcium | -9.6 | -8.6 - 10.0 mg/dL | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| Alkaline - Phosphatase | -41 | -40 - 129 U/L | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| AST | -14 | -8 - 48 U/L | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| ALT | -
- |
- 7 - 55 U/L | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
| EGFR - (MDRD) | -
- |
- >60.0 mL/min/1.73m(2) | -- | 08/03/2024 1:47 PM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 1:06 PM EDT | -08/03/2024 1:12 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Enterococcus - faecalis | -Not Detected | -Not Detected | -- | 08/04/2024 9:20 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Enterococcus - faecium | -Not Detected | -Not Detected | -- | 08/04/2024 9:20 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Listeria - spp. | -Not Detected | -Not Detected | -- | 08/04/2024 9:20 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Staphylococcus - aureus | -
- |
- Not Detected | -- | 08/04/2024 9:20 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
|
- - S. aureus - is a pathogen of concern. ID consultation is strongly recommended. MSSA - is susceptible to cefazolin, oxacillin, and nafcillin which are - considered first line therapy. Cefazolin is preferred for adults. |
- ||||||
| Staphylococcus - epidermidis | -Not Detected | -Not Detected | -- | 08/04/2024 9:20 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Staphylococcus - lugdunensis | -Not Detected | -Not Detected | -- | 08/04/2024 9:20 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Streptococcus - spp. | -Not Detected | -Not Detected | -- | 08/04/2024 9:20 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Streptococcus - pneumoniae | -Not Detected | -Not Detected | -- | 08/04/2024 9:20 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Streptococcus - pyogenes | -Not Detected | -Not Detected | -- | 08/04/2024 9:20 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Streptococcus - agalactiae | -Not Detected | -Not Detected | -- | 08/04/2024 9:20 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Streptococcus - anginosus group | -Not Detected | -Not Detected | -- | 08/04/2024 9:20 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 12:51 PM EDT | -08/03/2024 12:55 PM EDT | -
| Narrative | -
|---|
|
- - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -MICROBIOLOGY - GENERAL ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Erythrocyte - Morphology | -See below: | -- | - | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| - Macrocytes | -2+ | -- | - | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| - Ovalocytes | -1+ | -- | - | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| - Polychromasia | -1+ | -- | - | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| - Schistocytes | -
- |
- None Seen | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Tear - Drop Cells | -1+ | -- | - | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 12:51 PM EDT | -08/03/2024 12:55 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -IMMUNOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| SARS - CoV-2 Rapid PCR | -Not Detected | -Not Detected | -- | 08/03/2024 1:40 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Swab | -NASAL TURBINATE STRUCTURE / Unknown | -Non-blood Collection / Unknown | -08/03/2024 12:51 PM EDT | -08/03/2024 1:15 PM EDT | -
| Narrative | -
|---|
|
- - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -MICROBIOLOGY - GENERAL ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Tacrolimus - Level | -5.2 | -3.0 - 15.0 ng/mL | -- | 08/04/2024 1:36 PM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 12:51 PM EDT | -08/03/2024 12:55 PM EDT | -
| Narrative | -
|---|
|
- - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Leukocytes | -10.3 | -3.6 - 11.8 thou/uL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| - Erythrocytes | -
- |
- 3.97 - 5.93 mil/uL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| - Hemoglobin | -
- |
- 12.3 - 16.9 g/dL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| - Hematocrit | -
- |
- 35.0 - 50.0 % | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Corpuscular Volume | -
- |
- 77.3 - 95.6 fL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Corpuscular Hemoglobin | -
- |
- 24.1 - 32.4 pg | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Corpuscular Hemoglobin Conc | -32.6 | -30.7 - 35.7 g/dL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Platelet - Count | -144 | -142 - 390 thou/uL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Platelet Volume | -9.3 | -9.0 - 12.9 fL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Erythrocyte - Distribution Width SD | -
- |
- 37.0 - 48.0 fL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Erythrocyte - Distribution Width CV | -14.2 | -11.5 - 16.0 % | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Neutrophils - Percent | -
- |
- 37 - 73 % | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Lymphocytes - Percent | -
- |
- 15 - 50 % | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Monocytes - Percent | -5 | -5 - 14 % | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Eosinophils - Percent | -0 | -0 - 8 % | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Basophils - Percent | -0 | -0 - 1 % | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Immature - Granulocytes Percent | -1 | -0 - 1 % | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Neutrophils - Absolute | -
- |
- 1.50 - 8.40 thou/uL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Lymphocytes - Absolute | -
- |
- 1.02 - 3.55 thou/uL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Monocytes - Absolute | -0.52 | -0.26 - 1.07 thou/uL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Eosinophils - Absolute | -0.04 | -0.00 - 0.57 thou/uL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Basophils - Absolute | -0.04 | -0.00 - 0.08 thou/uL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Immature - Granulocytes Absolute | -0.05 | -0.00 - 0.10 thou/uL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| NRBC - Percent | -0 | -<1 /100 WBC | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| NRBC - Auto Absolute | -0.00 | -0.00 thou/uL | -- | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Comment - CBC | -Automated instrument CBC/Differential confirmed by manual smear review. | -- | - | 08/03/2024 2:06 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 12:51 PM EDT | -08/03/2024 12:55 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Stephen Patrick Sanders MD | -HEMATOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
- XR Chest PA And Lateral
-
-
- Radiology
-
-
- Emergency Medicine
-
-
- Radiology Study observation (narrative)
-
-
-
-
- Narrative
-
-
-
-
- Procedure Note
-
-
- MR Ankle Right WO Contrast
-
-
- Diagnostic Radiology
-
-
- Internal Medicine
-
-
- Radiology Study observation (narrative)
-
-
- Radiology
-
-
-
-
- Narrative
-
-
-
-
- Procedure Note
-
-
- CT Chest WO Contrast
-
-
- Radiology
-
-
- Internal Medicine
-
-
- Radiology Study observation (narrative)
-
-
-
-
- Narrative
-
-
-
-
- Procedure Note
-
-
- Echo TTE Complete
-
-
- Cardiology
-
-
- Internal Medicine
-
-
- Tapse
-
-
- Inferior Vena Cava Diameter
-
-
- Diastolic BP
-
-
- Systolic BP
-
-
- Patient Weight
-
-
- Patient Height
-
-
- BSA
-
-
- LA Volume Index
-
-
- LV Dia Vol
-
-
- LV Sys Vol
-
-
- MV Peak A Vel
-
-
- MV VTI
-
-
- MV Peak E Vel
-
-
- MV regurgitation pressure 1/2 time
-
-
- MV Peak Gradient
-
-
- AV Peak Gradient
-
-
- LVOT stroke volume
-
-
- Ao VTI
-
-
- Ao Peak Vel
-
-
- LVOT peak VTI
-
-
- LVOT Peak Vel
-
-
- LVOT diameter
-
-
- E wave deceleration time
-
-
- MV E' Tissue Velocity Lateral
-
-
- E/A ratio
-
-
- PV Peak Gradient
-
-
- MV valve area by continuity eq
-
-
- MV Mean Gradient
-
-
- LVOT Peak Gradient
-
-
- AV Mean Gradient
-
-
- RA 2D Volume
-
-
- SVI
-
-
- AV area peak vel
-
-
- AV area by cont VTI
-
-
- LVOT Mean Gradient
-
-
- RV-dias basal d
-
-
- A4C EF
-
-
- A2C EF
-
-
- AV VTI Ratio
-
-
- LA size
-
-
- Asc Aorta
-
-
- LA volume (BP)
-
-
- EF
-
-
- LVIDS
-
-
- Sinuses of Valsalva
-
-
- PW
-
-
- IVS
-
-
- LVIDD
-
-
- MV valve area P1/2
-
-
- PV PEAK VELOCITY
-
-
- LVOT SI
-
-
- MV E/E' lateral
-
-
- MV E/E' septal (medial)
-
-
- MV E' Tissue Velocity Medial
-
-
- AV valve area
-
-
- AV Velocity Ratio
-
-
- LVOT area
-
-
- LV Diastolic Volume Index
-
-
- ASCENDING AORTA DIAMETER INDEX BSA
-
-
- Est. RA pres
-
-
- Radiology Study observation (narrative)
-
-
-
-
- Narrative
-
-
- CBC and Differential
-
-
- Lab
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Leukocytes
-
-
- Erythrocytes
-
-
- Hemoglobin
-
-
- Hematocrit
-
-
- Mean Corpuscular Volume
-
-
- Mean Corpuscular Hemoglobin
-
-
- Mean Corpuscular Hemoglobin Conc
-
-
- Platelet Count
-
-
- Mean Platelet Volume
-
-
- Erythrocyte Distribution Width SD
-
-
- Erythrocyte Distribution Width CV
-
-
- Neutrophils Percent
-
-
- Lymphocytes Percent
-
-
- Monocytes Percent
-
-
- Eosinophils Percent
-
-
- Basophils Percent
-
-
- Immature Granulocytes Percent
-
-
- Neutrophils Absolute
-
-
- Lymphocytes Absolute
-
-
- Monocytes Absolute
-
-
- Eosinophils Absolute
-
-
- Basophils Absolute
-
-
- Immature Granulocytes Absolute
-
-
- NRBC Percent
-
-
- NRBC Auto Absolute
-
-
- Comment CBC
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Tacrolimus Level
-
-
- Lab
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Tacrolimus Level
-
-
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Rapid PCR SARS-COV-2
-
-
- Lab
-
-
- Emergency Medicine
-
-
- Swab
-
-
- SARS CoV-2 Rapid PCR
-
-
-
-
- Lab Interpretation
-
-
- Non-blood Collection
-
-
- RBC Morphology
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Erythrocyte Morphology
-
-
- Macrocytes
-
-
- Ovalocytes
-
-
- Polychromasia
-
-
- Schistocytes
-
-
- Tear Drop Cells
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Rapid Blood Culture Identification Gram Positive
-
-
- Lab
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Enterococcus faecalis
-
-
- Enterococcus faecium
-
-
- Listeria spp.
-
-
- Staphylococcus aureus
-
-
- Staphylococcus epidermidis
-
-
- Staphylococcus lugdunensis
-
-
- Streptococcus spp.
-
-
- Streptococcus pneumoniae
-
-
- Streptococcus pyogenes
-
-
- Streptococcus agalactiae
-
-
- Streptococcus anginosus group
-
-
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Comprehensive Metabolic Panel
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Sodium
-
-
- Potassium
-
-
- Chloride
-
-
- Carbon Dioxide
-
-
- Anion Gap
-
-
- Blood Urea Nitrogen
-
-
- Creatinine
-
-
- BUN Creatinine Ratio
-
-
- Glucose
-
-
- Protein
-
-
- Albumin
-
-
- Globulin
-
-
- Albumin/Globulin Ratio
-
-
- Bilirubin
-
-
- Calcium
-
-
- Alkaline Phosphatase
-
-
- AST
-
-
- ALT
-
-
- EGFR (MDRD)
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Lactate
-
-
- Lab
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Lactate
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Lipase
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Lipase
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Culture MRSA
-
-
- Lab
-
-
- Emergency Medicine
-
-
- Swab
-
-
- Culture MRSA
-
-
- Non-blood Collection
-
-
- Urinalysis Reflex Sediment + Culture
-
-
- Emergency Medicine
-
-
- Urine
-
-
- Color UR
-
-
- Appearance UR
-
-
- Specific Gravity UR
-
-
- pH UR
-
-
- Leukocyte Esterase UR
-
-
- Nitrite UR
-
-
- Protein UR QL
-
-
- Glucose UR QL
-
-
- Ketones UR QL
-
-
- Urobilinogen UR
-
-
- Hemoglobin UR
-
-
- Urine Sediment
-
-
- Urine Culture Comment
-
-
- Lab Interpretation
-
-
- Non-blood Collection
-
-
- URINALYSIS MICROSCOPIC
-
-
- Emergency Medicine
-
-
- Urine
-
-
- Leukocytes
-
-
- Erythrocytes
-
-
- Squamous Epithelial Cells
-
-
- Bacteria
-
-
- Lab Interpretation
-
-
- Non-blood Collection
-
-
- Basic Metabolic Panel
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Sodium
-
-
- Potassium
-
-
- Chloride
-
-
- Carbon Dioxide
-
-
- Blood Urea Nitrogen
-
-
- Creatinine
-
-
- Calcium
-
-
- Glucose
-
-
- Anion Gap
-
-
- BUN Creatinine Ratio
-
-
- EGFR (MDRD)
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- CBC W/O Differential
-
-
- Lab
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Leukocytes
-
-
- Erythrocytes
-
-
- Hemoglobin
-
-
- Hematocrit
-
-
- Mean Corpuscular Volume
-
-
- Mean Corpuscular Hemoglobin
-
-
- Mean Corpuscular Hemoglobin Conc
-
-
- Platelet Count
-
-
- Mean Platelet Volume
-
-
- Erythrocyte Distribution Width SD
-
-
- Erythrocyte Distribution Width CV
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Vancomycin Level, Random
-
-
- Internal Medicine
-
-
- Blood
-
-
- Vancomycin Level Random
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Lactate Dehydrogenase
-
-
- Internal Medicine
-
-
- Blood
-
-
- Lactate Dehydrogenase
-
-
- Venipuncture
-
-
- BLOOD TYPE + SCREEN
-
-
- Internal Medicine
-
-
- Blood
-
-
- ABO Type
-
-
- Rh Type
-
-
- Antibody Screen
-
-
- Venipuncture
-
-
- Fibrinogen
-
-
- Internal Medicine
-
-
- Blood
-
-
- Fibrinogen
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Prothrombin Time (INR)
-
-
- Internal Medicine
-
-
- Blood
-
-
- INR
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Tacrolimus Level
-
-
- Lab
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Tacrolimus Level
-
-
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Basic Metabolic Panel
-
-
- Internal Medicine
-
-
- Blood
-
-
- Sodium
-
-
- Potassium
-
-
- Chloride
-
-
- Carbon Dioxide
-
-
- Blood Urea Nitrogen
-
-
- Creatinine
-
-
- Calcium
-
-
- Glucose
-
-
- Anion Gap
-
-
- BUN Creatinine Ratio
-
-
- EGFR (MDRD)
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- RBC Morphology
-
-
- Lab
-
-
- Internal Medicine
-
-
- Blood
-
-
- Erythrocyte Morphology
-
-
- Acanthocytes
-
-
- Echinocytes
-
-
- Macrocytes
-
-
- Ovalocytes
-
-
- Polychromasia
-
-
- Schistocytes
-
-
- Tear Drop Cells
-
-
- Toxic Granulation
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- LEGIONELLA ANTIGEN, URINE
-
-
- Lab
-
-
- Internal Medicine
-
-
- Urine
-
-
- Legionella Antigen, Urine
-
-
- Lab Interpretation
-
-
- Non-blood Collection
-
- | Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Former | -Cigarettes | -1 | -13 | -Quit: 02/01/2007 | -
| Smokeless Tobacco: Never | -- | - | - | - |
| Alcohol Use | -Standard Drinks/Week | -Comments | -
|---|---|---|
| Not Currently | -0 (1 standard drink = 0.6 oz pure alcohol) | -very infrequent 1 glass of wine a month | -
| Humiliation, Afraid, Rape, and Kick questionnaire | -Answer | -Date Recorded | -
|---|---|---|
| Within the last year, have you been afraid of your - partner or ex-partner? | -No | -08/03/2024 | -
| Within the last year, have you been humiliated or - emotionally abused in other ways by your partner or ex-partner? | -No | -08/03/2024 | -
| Within the last year, have you been kicked, hit, - slapped, or otherwise physically hurt by your partner or ex-partner? | -No | -08/03/2024 | -
| Within the last year, have you been raped or forced - to have any kind of sexual activity by your partner or ex-partner? | -No | -08/03/2024 | -
| AUDIT-C | -Answer | -Date Recorded | -
|---|---|---|
| Q1: How often do you have a drink containing - alcohol? | -Monthly or less | -08/03/2024 | -
| Q2: How many drinks containing alcohol do you have - on a typical day when you are drinking? | -1 or 2 | -08/03/2024 | -
| Q3: How often do you have six or more drinks on one - occasion? | -Never | -08/03/2024 | -
| PHQ-2 | -Answer | -Date Recorded | -
|---|---|---|
| Patient Health Questionnaire-2 Score | -0 | -08/03/2024 | -
| Hunger Vital Sign | -Answer | -Date Recorded | -
|---|---|---|
| Within the past 12 months, you worried that your - food would run out before you got the money to buy more. | -Never true | -08/03/2024 | -
| Within the past 12 months, the food you bought just - didn't last and you didn't have money to get more. | -Never true | -08/03/2024 | -
| Sex and Gender Information | -Value | -Date Recorded | -
|---|---|---|
| Sex Assigned at Birth | -Male | -12/19/2019 1:56 PM EST | -
| Gender Identity | -Male | -12/19/2019 1:56 PM EST | -
| Sexual Orientation | -Straight | -04/28/2022 11:54 PM EDT | -
| Job Start Date | -Occupation | -Industry | -
|---|---|---|
| Not on file | -Not on file | -Not on file | -
- Nursing
-
-
-
-
-
-
-
-
- Humiliation, Afraid, Rape, and Kick questionnaire
-
-
-
-
-
-
- Nursing
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- AUDIT-C
-
-
-
-
-
-
- Nursing
-
-
-
-
-
-
-
-
-
-
- Patient History
-
-
- Smoking Tobacco Use
-
-
- Smokeless Tobacco Use
-
-
- Passive Exposure
-
-
- PHQ-2
-
-
-
-
-
-
- Hunger Vital Sign
-
-
-
-
-
-
-
-
-
-
- Nursing
-
-
- Nursing
-
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 08/03/2024 12:31 PM EDT - Present | -Hospital Encounter | -
- |
-
- - - |
- - |
-
-
-
-
- Emergency Medicine
-
-
- Internal Medicine
-
-
- Internal Medicine
-
-
- Nephrology
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Nursing
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Guardian
-
-
- Hospital Encounter
-
-
- Emergency Medicine
-
-
- Family Medicine
-
-
- Emergency Medicine
-
-
- Family Medicine
-
-
- Cardiology
-
-
-
-
- CDC COVID-19 webpage
-
-
- Public Health Agency Contact Information
-
-
- Guardian
-
-
- Mother
-
-
- Hospital Encounter
-
-
- Emergency Medicine
-
-
- Family Medicine
-
-
- Emergency Medicine
-
-
- Family Medicine
-
-
- Cardiology
-
- | Name | -Administration Dates | -Next Due | -
|---|---|---|
| HH Influenza Vaccine Quadrivalent 0.5ML IM | -
- |
- - |
| Moderna Red - Cap(12+)Covid-19,Monovalent,mrna,lnp-s,pf,.5mL (IMM10222) | -
- |
- - |
-
-
-
-
- Nursing
-
-
-
-
-
-
-
-
-
- | Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- Given | -08/05/2024 9:02 AM EDT | -1 gm | -- | - |
| Given | -08/04/2024 3:33 AM EDT | -1 gm | -- | - | |
| - | - | ||||
|
- |
- Given | -08/04/2024 9:14 AM EDT | -40 mg | -- | Left Lower Abdomen | -
| - | - | ||||
|
- |
- New Bag | -08/04/2024 5:57 PM EDT | -100 mL/hr | -100 mL/hr | -- |
| New Bag | -08/04/2024 9:15 AM EDT | -100 mL/hr | -100 mL/hr | -- | |
| - | - | ||||
|
- |
- New Bag | -08/05/2024 5:48 AM EDT | -100 mg | -500 mL/hr | -- |
| - | - | ||||
|
- |
- Given | -08/05/2024 9:00 AM EDT | -2 Tablets | -- | - |
| Given | -08/04/2024 2:56 PM EDT | -2 Tablets | -- | - | |
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
| - | |||||
| Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- New Bag | -08/04/2024 9:14 AM EDT | -1,000 mg | -400 mL/hr | -- |
| New Bag | -08/04/2024 2:14 AM EDT | -1,000 mg | -400 mL/hr | -- | |
| - | - | ||||
|
- |
- Given | -08/03/2024 7:51 PM EDT | -650 mg | -- | - |
| - | - | ||||
|
- |
- Given | -08/04/2024 2:07 AM EDT | -70 mL | -- | - |
| - | - | ||||
|
- |
- New Bag | -08/03/2024 9:22 PM EDT | -1,000 mL | -1000 mL/hr | -- |
| - | - | ||||
|
- |
- New Bag | -08/04/2024 3:43 AM EDT | -1,000 mL | -500 mL/hr | -- |
| - | - | ||||
|
- |
- Given | -08/03/2024 8:42 PM EDT | -2 mg | -- | Left Anterior Thigh | -
| - | - | ||||
|
- |
- Given | -08/03/2024 10:48 PM EDT | -4 mg | -- | - |
| - | - | ||||
|
- |
- New Bag | -08/04/2024 5:00 AM EDT | -200 mg | -500 mL/hr | -- |
| - | - | ||||
- polyethylene glycol (Miralax) packet 17 gm
-
-
- Physician Assistant
-
-
- polyethylene glycol (Miralax) packet 17 gm
-
-
-
-
-
-
- Family Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Radiology
-
-
-
-
-
-
-
-
-
-
- Family Medicine
-
-
-
-
-
-
- bisacodyl (Dulcolax) rectal suppository 10 mg
-
-
- bisacodyl (Dulcolax) rectal suppository 10 mg
-
-
- polyethylene glycol (Miralax) packet 34 gm
-
-
- polyethylene glycol (Miralax) packet 34 gm
-
-
- senna (Senokot) tablet 2 Tablet
-
-
- senna (Senokot) tablet 2 Tablet
-
-
- potassium chloride 20 mEq in 100 mL IVPB
-
-
- potassium chloride 20 mEq in 100 mL IVPB
-
-
- potassium chloride (Klor-Con M20) CR tablet 20 mEq
-
-
- potassium chloride (Klor-Con M20) CR tablet 20 mEq
-
-
- magnesium sulfate 2 gm in SWFI 50 mL
-
-
- magnesium sulfate 2 gm in SWFI 50 mL
-
-
- sodium chloride (NS) 0.9 % flush 5 mL
-
-
- sodium chloride (NS) 0.9 % flush 5 mL
-
-
- enoxaparin (Lovenox) injection 40 mg
-
-
- enoxaparin (Lovenox) injection 40 mg
-
-
- remdesivir (Veklury) 100 mg in NaCl 0.9% 250 mL infusion
-
-
- remdesivir (Veklury) 100 mg in NaCl 0.9% 250 mL infusion
-
-
-
-
-
-
- Emergency Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Emergency Medicine
-
-
-
-
-
- | Name | -Type | -Priority | -Associated Diagnoses | -Date/Time | -
|---|---|---|---|---|
|
- |
- Microbiology | -STAT | -- | 08/03/2024 9:13 PM EDT | -
| Name | -Type | -Priority | -Associated Diagnoses | -Order Schedule | -
|---|---|---|---|---|
|
- |
- Point of Care Testing | -STAT | -- | As Needed until discontinued starting 8/4/24 | -
-
-
-
-
- Family Medicine
-
-
-
-
-
-
- Emergency Medicine
-
- | Active Problems | -Noted Date | -Diagnosed Date | -
|---|---|---|
| COVID | -08/03/2024 | -- |
|
- 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 - |
- ||
| Right hip pain | -08/03/2024 | -- |
|
- 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 - |
- ||
| Obstipation | -05/01/2023 | -- |
| Fever in adult | -10/03/2020 | -- |
| Rash, fever | -10/03/2020 | -- |
|
- 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 - |
- ||
| Status post total hip replacement, right | -06/03/2019 | -- |
|
- 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 - |
- ||
| Urinary retention | -06/03/2019 | -- |
|
- Likely due to constipation. No evidence of - retention, constipation controlled. Urinalysis was negative for infection. - Continue to monitor for constipation. - |
- ||
| Constipation | -06/03/2019 | -- |
|
- 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," - |
- ||
| Osteoarthritis resulting from right hip dysplasia | -05/28/2019 | -- |
| Cellulitis of foot, right | -02/01/2019 | -- |
|
- As above - hold abx for now - |
- ||
| Angelman syndrome | -12/26/2017 | -- |
|
- Patient to return to supportive environment at - group home with parents support. -Continue PT/OT - |
- ||
| Abnormality of gait and mobility | -03/13/2017 | -- |
|
- 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 - |
- ||
| Seizures (CMS/HHS) | -- | - |
|
- Tapered off Depakote at ~ 19 Y/O - - No recurrence of seizure activity, likely - medication related, suspect oxycodone. - |
- ||
| Resolved Problems | -Noted Date | -Diagnosed Date | -Resolved Date | -
|---|---|---|---|
| Suspected COVID-19 virus infection | -10/03/2020 | -- | 10/05/2020 | -
|
- A: COVID-19 Testing obtained due to symptoms - which could be consistent with coronavirus infection. Covid swab negative x 1. - PLAN: -Remove covid precautions. - |
- |||
-
-
- Family Medicine
-
-
-
-
-
-
- Physician Assistant
-
-
-
-
- Internal Medicine
-
-
-
-
- Geriatric Medicine
-
-
-
-
-
-
-
-
- Emergency Medicine
-
-
-
-
-
-
-
-
-
-
- Physician Assistant
-
-
-
-
-
- | Reason | -Comments | -
|---|---|
| Leg Pain | -- |
| Fever | -- |
| Specialty | -Diagnoses / Procedures | -Referred By Contact | -Referred To Contact | -
|---|---|---|---|
| - |
- - |
-
- |
-
- |
-
| Referral ID | -Status | -Reason | -Start Date | -Expiration Date | -Visits Requested | -Visits Authorized | -
|---|---|---|---|---|---|---|
| 10643053 | -- | - | - | - | 1 | -1 | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| ECG - Heart Rate | -73 | -bpm | -- | - | TRACEMASTER VUE | -- |
| ECG - P-R Interval | -133 | -ms | -- | - | TRACEMASTER VUE | -- |
| ECG - QRSD Interval | -95 | -ms | -- | - | TRACEMASTER VUE | -- |
| ECG - QT Interval | -386 | -ms | -- | - | TRACEMASTER VUE | -- |
| ECG - QTc | -426 | -ms | -- | - | TRACEMASTER VUE | -- |
| ECG - QRS Horizontal Axis | -- | deg | -- | - | TRACEMASTER VUE | -- |
| ECG - QRS Axis | -22 | -deg | -- | - | TRACEMASTER VUE | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 08/04/2024 11:11 AM EDT | -- |
| Impressions | -
|---|
|
- - - - - |
-
| Narrative | -
|---|
|
- |
-
| Procedure Note | -
|---|
|
- - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Christine A Kleinman DO | -ECG ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
- - | - |
- |
-
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Pelvis | -- | Computed Tomography | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 08/04/2024 1:45 AM EDT | -- |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Christine A Kleinman DO | -IMG CT ORDERABLES | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Culture - Urine | -
- |
- - |
- |
- 08/05/2024 12:14 PM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Urine | -URINE SPECIMEN OBTAINED BY CLEAN CATCH PROCEDURE / Unknown | -Non-blood Collection / Unknown | -08/04/2024 12:37 AM EDT | -08/04/2024 12:41 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Organism | -Antibiotic | -Method | -Susceptibility | -
|---|---|---|---|
| Escherichia - coli | -- Amoxicillin/Clavulanate | -MIC | -
- |
-
| Escherichia coli | -- Ampicillin | -MIC | -
- |
-
| Escherichia coli | -- Ampicillin/Sulbactam | -MIC | -
- |
-
| Escherichia coli | -- Aztreonam | -MIC | -
- |
-
| Escherichia coli | -- Cefazolin | -MIC | -
- |
-
| Escherichia coli | -- Cefepime | -MIC | -
- |
-
| Escherichia coli | -- Cefoxitin | -MIC | -
- |
-
| Escherichia coli | -- Ceftazidime | -MIC | -
- |
-
| Escherichia coli | -- Ceftriaxone | -MIC | -
- |
-
| Escherichia coli | -- Cefuroxime | -MIC | -
- |
-
| Escherichia coli | -- Ciprofloxacin | -MIC | -
- |
-
| Escherichia coli | -- Ertapenem | -MIC | -
- |
-
| Escherichia coli | -- Gentamicin | -MIC | -
- |
-
| Escherichia coli | -- Levofloxacin | -MIC | -
- |
-
| Escherichia coli | -- Meropenem | -MIC | -
- |
-
| Escherichia coli | -- Nitrofurantoin | -MIC | -
- |
-
| Escherichia coli | -- Piperacillin/Tazobactam | -MIC | -
- |
-
| Escherichia coli | -- Tetracycline | -MIC | -
- |
-
| Escherichia coli | -- Tobramycin | -MIC | -
- |
-
| Escherichia coli | -- Trimethoprim/Sulfamethoxazole | -MIC | -
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Carin K Malley MD | -MICROBIOLOGY - GENERAL ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Leukocytes | -
- |
- 0 - 2 /HPF | -- | 08/04/2024 1:25 AM EDT | -NORDX MMC CAMPUS | -- |
| - Erythrocytes | -
- |
- 0 - 2 /HPF | -- | 08/04/2024 1:25 AM EDT | -NORDX MMC CAMPUS | -- |
| Squamous - Epithelial Cells | -1+ | -/HPF | -- | 08/04/2024 1:25 AM EDT | -NORDX MMC CAMPUS | -- |
| - Bacteria | -
- |
- /HPF | -- | 08/04/2024 1:25 AM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Urine | -URINE SPECIMEN OBTAINED BY CLEAN CATCH PROCEDURE / Unknown | -Non-blood Collection / Unknown | -08/04/2024 12:37 AM EDT | -08/04/2024 12:41 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Carin K Malley MD | -URINALYSIS ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Color - UR | -Yellow | -- | - | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Appearance - UR | -Turbid | -- | - | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Specific - Gravity UR | -1.020 | -1.005 - 1.030 | -- | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| pH UR | -8.0 | -5.0 - 8.0 | -- | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Leukocyte - Esterase UR | -
- |
- Negative | -- | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Nitrite - UR | -
- |
- Negative | -- | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Protein - UR QL | -Trace | -Negative mg/dL | -- | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Glucose - UR QL | -Negative | -Negative mg/dL | -- | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Ketones - UR QL | -Negative | -Negative | -- | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Urobilinogen - UR | -
- |
- Normal mg/dL | -- | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Hemoglobin - UR | -
- |
- Negative Ery/uL | -- | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Urine - Sediment | -Performed | -- | - | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Urine - Culture Comment | -Set up | -- | - | 08/04/2024 1:26 AM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Urine | -URINE SPECIMEN OBTAINED BY CLEAN CATCH PROCEDURE / Unknown | -Non-blood Collection / Unknown | -08/04/2024 12:37 AM EDT | -08/04/2024 12:41 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Carin K Malley MD | -MICROBIOLOGY - GENERAL ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Chest | -- | Computed Radiography | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 08/03/2024 8:30 PM EDT | -- |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Carin K Malley MD | -IMG DIAGNOSTIC IMAGING ORDERABLES | -
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Abdomen | -- | Computed Radiography | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 08/03/2024 7:40 PM EDT | -- |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Haley Acker PAC | -IMG DIAGNOSTIC IMAGING ORDERABLES | -
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Hip, Pelvis, Thigh | -- | Computed Radiography | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 08/03/2024 7:35 PM EDT | -- |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Haley Acker PAC | -IMG DIAGNOSTIC IMAGING ORDERABLES | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| SARS - CoV-2 Rapid PCR | -
- |
- Not Detected | -- | 08/03/2024 10:17 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Swab | -NASAL TURBINATE STRUCTURE / Unknown | -Non-blood Collection / Unknown | -08/03/2024 9:46 PM EDT | -08/03/2024 9:54 PM EDT | -
| Narrative | -
|---|
|
- - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Carin K Malley MD | -MICROBIOLOGY - GENERAL ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Ammonia | -17 | -11 - 51 umol/L | -- | 08/03/2024 10:10 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 9:45 PM EDT | -08/03/2024 9:54 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Carin K Malley MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Sedimentation - Rate | -15 | -0 - 20 mm/h | -- | 08/04/2024 9:40 AM EDT | -NORDX SCARBOROUGH CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 9:13 PM EDT | -08/03/2024 9:19 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Christine A Kleinman DO | -HEMATOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| C-Reactive - Protein mg/L | -<3.0 | -0.0 - 5.0 mg/L | -- | 08/04/2024 2:13 AM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 9:13 PM EDT | -08/03/2024 9:19 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Christine A Kleinman DO | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Leukocytes | -8.4 | -3.7 - 12.7 thou/uL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| - Erythrocytes | -
- |
- 3.69 - 5.28 mil/uL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| - Hemoglobin | -11.0 | -10.5 - 14.8 g/dL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| - Hematocrit | -32.3 | -31.8 - 44.3 % | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Corpuscular Volume | -90.2 | -73.3 - 96.9 fL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Corpuscular Hemoglobin | -30.7 | -21.9 - 32.6 pg | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Corpuscular Hemoglobin Conc | -34.1 | -29.7 - 34.9 g/dL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Platelet - Count | -230 | -158 - 429 thou/uL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Mean - Platelet Volume | -10.6 | -9.1 - 12.9 fL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Erythrocyte - Distribution Width SD | -46.0 | -37.0 - 48.0 fL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Erythrocyte - Distribution Width CV | -13.9 | -11.5 - 17.6 % | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Neutrophils - Percent | -
- |
- 37 - 75 % | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Lymphocytes - Percent | -
- |
- 15 - 50 % | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Monocytes - Percent | -9 | -5 - 13 % | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Eosinophils - Percent | -1 | -0 - 8 % | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Basophils - Percent | -0 | -0 - 1 % | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Immature - Granulocytes Percent | -0 | -0 - 1 % | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Neutrophils - Absolute | -7.15 | -1.64 - 8.80 thou/uL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Lymphocytes - Absolute | -
- |
- 1.12 - 3.82 thou/uL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Monocytes - Absolute | -0.74 | -0.27 - 0.97 thou/uL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Eosinophils - Absolute | -0.04 | -0.00 - 0.54 thou/uL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Basophils - Absolute | -0.02 | -0.00 - 0.08 thou/uL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Immature - Granulocytes Absolute | -0.02 | -0.00 - 0.08 thou/uL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| NRBC - Percent | -0 | -<1 /100 WBC | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| NRBC - Auto Absolute | -0.00 | -0.00 thou/uL | -- | 08/03/2024 9:23 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 9:13 PM EDT | -08/03/2024 9:19 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Carin K Malley MD | -HEMATOLOGY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Lactate | -1.5 | -0.5 - 2.0 mmol/L | -- | 08/03/2024 9:21 PM EDT | -NORDX MMC CAMPUS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 9:13 PM EDT | -08/03/2024 9:19 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Carin K Malley MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Sodium | -140 | -135 - 145 mEq/L | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| - Potassium | -4.1 | -3.5 - 5.1 mEq/L | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| - Chloride | -104 | -96 - 108 mEq/L | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| Carbon - Dioxide | -25 | -21 - 30 mEq/L | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| Anion - Gap | -11 | -7 - 16 mEq/L | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| Blood - Urea Nitrogen | -12 | -6 - 20 mg/dL | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| - Creatinine | -
- |
- 0.59 - 1.04 mg/dL | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| BUN - Creatinine Ratio | -20.7 | -- | - | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| - Glucose | -
- |
- 70 - 99 mg/dL | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| - Protein | -6.9 | -6.4 - 8.3 g/dL | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| - Albumin | -4.0 | -3.5 - 5.1 g/dL | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| - Globulin | -2.9 | -2.0 - 3.5 g/dL | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| Albumin/Globulin - Ratio | -1.4 | -- | - | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| - Bilirubin | -0.4 | -<=1.2 mg/dL | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| - Calcium | -9.4 | -8.6 - 10.0 mg/dL | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| Alkaline - Phosphatase | -82 | -35 - 104 U/L | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| AST | -25 | -8 - 43 U/L | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| ALT | -12 | -7 - 45 U/L | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
| EGFR - (MDRD) | -
- |
- >60.0 mL/min/1.73m(2) | -- | 08/03/2024 9:40 PM EDT | -NORDX MMC CAMPUS | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -VENOUS STRUCTURE / Unknown | -Venipuncture / Unknown | -08/03/2024 9:13 PM EDT | -08/03/2024 9:19 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Carin K Malley MD | -CHEMISTRY ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
- EKG 12 lead
-
-
- Cardiology Clinical
-
-
- Family Medicine
-
-
- ECG Heart Rate
-
-
- ECG P-R Interval
-
-
- ECG QRSD Interval
-
-
- ECG QT Interval
-
-
- ECG QTc
-
-
- ECG QRS Horizontal Axis
-
-
- ECG QRS Axis
-
-
-
-
- Impression
-
-
-
-
- Procedure Note
-
-
- XR Hip Right 2 or 3 VW With or without Pelvis
-
-
- Radiology
-
-
- Physician Assistant
-
-
- Radiology Study observation (narrative)
-
-
-
-
- Narrative
-
-
-
-
- Procedure Note
-
-
- XR Abdomen 1 VW
-
-
- Physician Assistant
-
-
- Radiology Study observation (narrative)
-
-
-
-
- Narrative
-
-
-
-
- Procedure Note
-
-
- XR Chest PA And Lateral
-
-
- Emergency Medicine
-
-
- Radiology Study observation (narrative)
-
-
-
-
- Narrative
-
-
-
-
- Procedure Note
-
-
- CT Pelvis W Contrast
-
-
- Radiology
-
-
- Family Medicine
-
-
- Radiology Study observation (narrative)
-
-
-
-
- Narrative
-
-
-
-
- Procedure Note
-
-
- Comprehensive Metabolic Panel
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Sodium
-
-
- Potassium
-
-
- Chloride
-
-
- Carbon Dioxide
-
-
- Anion Gap
-
-
- Blood Urea Nitrogen
-
-
- Creatinine
-
-
- BUN Creatinine Ratio
-
-
- Glucose
-
-
- Protein
-
-
- Albumin
-
-
- Globulin
-
-
- Albumin/Globulin Ratio
-
-
- Bilirubin
-
-
- Calcium
-
-
- Alkaline Phosphatase
-
-
- AST
-
-
- ALT
-
-
- EGFR (MDRD)
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Lactate
-
-
- Lab
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Lactate
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- CBC and Differential
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Leukocytes
-
-
- Erythrocytes
-
-
- Hemoglobin
-
-
- Hematocrit
-
-
- Mean Corpuscular Volume
-
-
- Mean Corpuscular Hemoglobin
-
-
- Mean Corpuscular Hemoglobin Conc
-
-
- Platelet Count
-
-
- Mean Platelet Volume
-
-
- Erythrocyte Distribution Width SD
-
-
- Erythrocyte Distribution Width CV
-
-
- Neutrophils Percent
-
-
- Lymphocytes Percent
-
-
- Monocytes Percent
-
-
- Eosinophils Percent
-
-
- Basophils Percent
-
-
- Immature Granulocytes Percent
-
-
- Neutrophils Absolute
-
-
- Lymphocytes Absolute
-
-
- Monocytes Absolute
-
-
- Eosinophils Absolute
-
-
- Basophils Absolute
-
-
- Immature Granulocytes Absolute
-
-
- NRBC Percent
-
-
- NRBC Auto Absolute
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- C-Reactive Protein
-
-
- Family Medicine
-
-
- Blood
-
-
- C-Reactive Protein mg/L
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Sedimentation rate
-
-
- Family Medicine
-
-
- Blood
-
-
- Sedimentation Rate
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Ammonia
-
-
- Emergency Medicine
-
-
- Blood
-
-
- Ammonia
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- Rapid PCR SARS-COV-2
-
-
- Emergency Medicine
-
-
- Swab
-
-
- SARS CoV-2 Rapid PCR
-
-
-
-
- Lab Interpretation
-
-
- Non-blood Collection
-
-
- Urinalysis Reflex Sediment + Culture
-
-
- Lab
-
-
- Emergency Medicine
-
-
- Urine
-
-
- Color UR
-
-
- Appearance UR
-
-
- Specific Gravity UR
-
-
- pH UR
-
-
- Leukocyte Esterase UR
-
-
- Nitrite UR
-
-
- Protein UR QL
-
-
- Glucose UR QL
-
-
- Ketones UR QL
-
-
- Urobilinogen UR
-
-
- Hemoglobin UR
-
-
- Urine Sediment
-
-
- Urine Culture Comment
-
-
- Lab Interpretation
-
-
- Non-blood Collection
-
-
- URINALYSIS MICROSCOPIC
-
-
- Emergency Medicine
-
-
- Urine
-
-
- Leukocytes
-
-
- Erythrocytes
-
-
- Squamous Epithelial Cells
-
-
- Bacteria
-
-
- Lab Interpretation
-
-
- Non-blood Collection
-
-
- Culture Urine
-
-
- Lab
-
-
- Emergency Medicine
-
-
- Urine
-
-
- Culture Urine
-
-
- Lab Interpretation
-
-
- Escherichia coli
-
-
- Amoxicillin/Clavulanate
-
-
- Ampicillin
-
-
- Ampicillin/Sulbactam
-
-
- Aztreonam
-
-
- Cefazolin
-
-
- Cefepime
-
-
- Cefoxitin
-
-
- Ceftazidime
-
-
- Ceftriaxone
-
-
- Cefuroxime
-
-
- Ciprofloxacin
-
-
- Ertapenem
-
-
- Gentamicin
-
-
- Levofloxacin
-
-
- Meropenem
-
-
- Nitrofurantoin
-
-
- Piperacillin/Tazobactam
-
-
- Tetracycline
-
-
- Tobramycin
-
-
- Trimethoprim/Sulfamethoxazole
-
-
- Non-blood Collection
-
- | Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Never | -- | - | - | - |
| Smokeless Tobacco: Never | -- | - | - | - |
| Alcohol Use | -Standard Drinks/Week | -Comments | -
|---|---|---|
| No | -0 (1 standard drink = 0.6 oz pure alcohol) | -- |
| AUDIT-C | -Answer | -Date Recorded | -
|---|---|---|
| Q1: How often do you have a drink containing - alcohol? | -Never | -05/01/2023 | -
| Average Number of Drinks | -Not on file | -05/01/2023 | -
| Frequency of Binge Drinking | -Not on file | -05/01/2023 | -
| Sex and Gender Information | -Value | -Date Recorded | -
|---|---|---|
| Sex Assigned at Birth | -Not on file | -- |
| Gender Identity | -Not on file | -- |
| Sexual Orientation | -Not on file | -- |
| Job Start Date | -Occupation | -Industry | -
|---|---|---|
| Not on file | -Not on file | -Not on file | -
- Nursing
-
-
-
-
-
-
- AUDIT-C
-
-
-
-
-
-
- Nursing
-
-
-
-
-
-
-
-
-
-
- Patient History
-
-
- Smoking Tobacco Use
-
-
- Smokeless Tobacco Use
-
-
- Passive Exposure
-
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 08/03/2024 7:38 PM EDT - Present | -Hospital Encounter | -
- |
-
- - - |
- - |
-
-
-
-
- Emergency Medicine
-
-
- Family Medicine
-
-
- Emergency Medicine
-
-
- Cardiology
-
-
-
-
- Emergency Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Erroneous Encounter
-
-
- Family Medicine, NP
-
-
- Infectious Diseases
-
-
-
-
- Additional information for required disease reporting
- must be submitted to the Tennessee Department of Health within 1
- week. This additional information can be found here.
-
-
- CDC website with STD treatment guidelines.
-
-
- If you have additional questions regarding disease
- reporting, the Tennessee Department of Health can be reached
- 615-741-7247.
-
-
-
-
- Additional information for required disease reporting
- must be submitted to the Tennessee Department of Health within 1
- week. This additional information can be found here.
-
-
- CDC website with STD treatment guidelines.
-
-
- If you have additional questions regarding disease
- reporting, the Tennessee Department of Health can be reached
- 615-741-7247.
-
-
- Erroneous Encounter
-
-
- Family Medicine, NP
-
-
- Infectious Diseases
-
- | Name | -Administration Dates | -Next Due | -
|---|---|---|
| DTP | -- | |
| Flu, Preservative Free | -- | |
| HEP A-HEP B | -- | |
| HIB, HISTORICAL | -
- |
- - |
| Hib (HbOC) | -
- |
- - |
| MMR (MMR II/Priorix) | -
- |
- - |
| Moderna COVID-19 Vaccine, red cap blue label, 12+ - Primary Series | -- | |
| OPV, Trivalent | -- |
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Certified Medical Asst
-
-
- Certified Medical Asst
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 07/30/2024 10:00 AM PDT | -Telemedicine Visit | -
- |
-
- |
- - |
-
-
-
-
- Family Medicine, NP
-
-
- Infectious Diseases
-
- | Active Problems | -Noted Date | -Diagnosed Date | -
|---|---|---|
| Acute left flank pain | -08/03/2023 | -- |
|
- 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 vaccination | -11/08/2022 | -- |
| Erectile dysfunction | -11/08/2022 | -- |
|
- Pt states sildenafil - works well and has had no adrs or se related to medication administration. - Requires refill today. - |
- ||
| Anxiety disorder | -09/30/2020 | -- |
| Obesity | -09/30/2020 | -- |
| Human immunodeficiency virus (HIV) disease (HCC-CMS) | -01/01/2014 | -- |
|
- Pt denies barriers to - care or medication administration at this time. Denies ADRs and s/e to - medication administration and denies any missed doses. Long-term - well-controlled HIV. His primary health concerns are primary care in nature - - Continue current HAART. Encouraged - ongoing adherence to this regimen and discussed side effects, risks and - benefits of antiretroviral therapy. Encouraged overall health behavior - modifications to improve health including diet and exercise. Follow up in - clinic in 6 months for lab results with labs drawn one week before. - |
- ||
| Blood chemistry abnormal | -- | - |
| Controlled type 2 diabetes mellitus without complication, - without long-term current use of insulin (HCC-CMS) | -- | - |
|
- 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 | -- | - |
|
- 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. - - 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 | -- | - |
-
-
- Infectious Diseases
-
-
-
-
-
-
-
-
- Family Medicine, NP
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- FAMILY MEDICINE, PA
-
-
-
-
-
- | Reason | -Onset Date | -Comments | -
|---|---|---|
| Encounter Created in Error | -7/29/24 | -- |
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Trichomonas - vaginalis, Aptima (panther) | -
- |
- - | - | - | PATHGROUP LABS LLC | -- |
|
- - Results should be interpreted in conjunction - with patient history and clinical presentation. This assay is - highly accurate, but rare false positive and negative results may - occur. Positive results in low prevalence populations may require - re-evaluation. A negative result does not preclude a possible - infection due to a specimen inadequacy or sampling error. Test - performed by Associated Pathologists, LLC d/b/a PathGroup, 1010 - Airpark Center Dr., Suite M, Nashville, TN 37217, Pranil K. - Chandra, DO, Laboratory Director, CLIA# 44D2062928 |
- ||||||
| Neisseria - gonorrhoeae | -
- |
- - | - | - | PATHGROUP LABS LLC | -- |
|
- - Results should be interpreted in conjunction - with patient history and clinical presentation. This assay is - highly accurate, but rare false positive and negative results may - occur. Positive results in low prevalence populations may require - re-evaluation. A negative result does not preclude a possible - infection due to a specimen inadequacy or sampling error. Test - performed by Associated Pathologists, LLC d/b/a PathGroup, 1010 - Airpark Center Dr., Suite M, Nashville, TN 37217, Pranil K. - Chandra, DO, Laboratory Director, CLIA# 44D2062928 |
- ||||||
| Chlamydia - trachomatis | -
- |
- - | - | - | PATHGROUP LABS LLC | -- |
|
- - Results should be interpreted in conjunction - with patient history and clinical presentation. This assay is - highly accurate, but rare false positive and negative results may - occur. Positive results in low prevalence populations may require - re-evaluation. A negative result does not preclude a possible - infection due to a specimen inadequacy or sampling error. Test - performed by Associated Pathologists, LLC d/b/a PathGroup, 1010 - Airpark Center Dr., Suite M, Nashville, TN 37217, Pranil K. - Chandra, DO, Laboratory Director, CLIA# 44D2062928 |
- ||||||
| Specimen - Type | -Urine Aptima | -- | - | - | PATHGROUP LABS LLC | -- |
| Specimen - Source | -Urine | -- | - | - | PATHGROUP LABS LLC | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Urine | -Urine specimen / Unknown | -- | 07/24/2024 8:36 AM EDT | -07/24/2024 1:00 AM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Zachary Campbell NP-C | -LAB - NO BLOOD DRAW | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Hemoglobin - A1C | -
- |
- <5.7 % | -- | - | PATHGROUP LABS LLC | -- |
|
- - (ADA) may be used as an aid in - the diagnosis of diabetes mellitus. HA1c - Suggested Diagnosis >=6.5% Diabetic - 5.7% - 6.4% Pre-Diabetic <5.7% - Non-Diabetic |
- ||||||
| ESTIMATED - AVERAGE GLUCOSE | -
- |
- mg/dL | -- | - | PATHGROUP LABS LLC | -- |
|
- - based on the guidelines established by the - ADA. |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Blood / Unknown | -- | 07/24/2024 7:27 AM EDT | -07/24/2024 4:53 PM EDT | -
| Narrative | -
|---|
|
- - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Zachary Campbell NP-C | -LAB - BLOOD DRAW | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Vitamin - D 25-Hydroxy | -
- |
- 30.0 - 100.0 ng/mL | -- | - | PATHGROUP LABS LLC | -- |
|
- - < - 20 ng/mL - Deficiency 20 - 29 ng/mL - Insufficiency - 30 - 100 ng/mL - Sufficiency > 100 ng/mL - - Super-therapeutic- toxicity may occur above this level. - Clinical correlation required. |
- ||||||
| Vitamin - D, 1, 25 Dihydroxy | -32.5 | -19.9 - 79.3 pg/mL | -- | - | PATHGROUP LABS LLC | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Blood / Unknown | -- | 07/24/2024 7:27 AM EDT | -07/24/2024 4:53 PM EDT | -
| Narrative | -
|---|
|
- - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Zachary Campbell NP-C | -LAB - BLOOD DRAW | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Cholesterol | -108 | -<200 mg/dL | -- | - | PATHGROUP LABS LLC | -- |
| - Triglycerides | -52 | -<150 mg/dL | -- | - | PATHGROUP LABS LLC | -- |
| HDL - Cholesterol | -
- |
- >39 mg/dL | -- | - | PATHGROUP LABS LLC | -- |
| Cholesterol - / HDL Ratio | -2.84 | -0.00 - 4.99 Ratio | -- | - | PATHGROUP LABS LLC | -- |
| Non-HDL - Cholesterol | -70 | -<130 mg/dL | -- | - | PATHGROUP LABS LLC | -- |
| LDL - Cholesterol (Calculation) | -
- |
- <130 mg/dL | -- | - | PATHGROUP LABS LLC | -- |
|
- - Less than 100 mg/dL - Optimal 100 to 129 mg/dL Near Optimal/ Above Optimal - 130 to 159 mg/dL Borderline High 160 to 189 mg/dL - High 190 mg/dL and above Very High * - Categories as recommended by the 2004 ATPIII guidelines |
- ||||||
| LDL/HDL - Ratio | -
- |
- <3.3 Ratio | -- | - | PATHGROUP LABS LLC | -- |
|
- - LDL - Cholesterol Patient History - _________________________________________________________________________ Test - Date: 07/21/2023 LDL Results: - 56 Units: - mg/dL % Change: - -18% - ------------------------------------------------------------------------- Test - Date: 01/24/2024 LDL Results: - 75 Units: - mg/dL % Change: - +33% - ------------------------------------------------------------------------- Test - Date: 07/24/2024 LDL Results: - 60 Units: - mg/dL % Change: - -20% - _________________________________________________________________________ |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Blood / Unknown | -- | 07/24/2024 7:27 AM EDT | -07/24/2024 4:53 PM EDT | -
| Narrative | -
|---|
|
- - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Zachary Campbell NP-C | -LAB - BLOOD DRAW | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Sodium | -142 | -135 - 145 mmol/L | -- | - | PATHGROUP LABS LLC | -- |
| - Potassium | -4.3 | -3.5 - 5.3 mmol/L | -- | - | PATHGROUP LABS LLC | -- |
| - Chloride | -100 | -97 - 108 mmol/L | -- | - | PATHGROUP LABS LLC | -- |
| CO2 | -27 | -22 - 32 mmol/L | -- | - | PATHGROUP LABS LLC | -- |
| - Glucose | -98 | -65 - 99 mg/dL | -- | - | PATHGROUP LABS LLC | -- |
| BUN | -11 | -6 - 20 mg/dL | -- | - | PATHGROUP LABS LLC | -- |
| - Creatinine | -
- |
- 0.70 - 1.30 mg/dL | -- | - | PATHGROUP LABS LLC | -- |
| - Calcium | -10.3 | -8.6 - 10.4 mg/dL | -- | - | PATHGROUP LABS LLC | -- |
| eGFR - by Creatinine | -64 | ->59 mL/min/1.73m2 | -- | - | PATHGROUP LABS LLC | -- |
| - Protein | -7.8 | -6.0 - 8.3 g/dL | -- | - | PATHGROUP LABS LLC | -- |
| - Albumin | -4.8 | -3.5 - 5.3 g/dL | -- | - | PATHGROUP LABS LLC | -- |
| Alkaline - Phosphatase | -58 | -40 - 129 IU/L | -- | - | PATHGROUP LABS LLC | -- |
| ALT - (SGPT) | -31 | -<5 - 55 IU/L | -- | - | PATHGROUP LABS LLC | -- |
| AST - (SGOT) | -32 | -<5 - 46 IU/L | -- | - | PATHGROUP LABS LLC | -- |
| Bilirubin, - Total | -0.4 | -<0.2 - 1.2 mg/dL | -- | - | PATHGROUP LABS LLC | -- |
| A/G - Ratio | -1.6 | -1.1 - 2.5 mg/dL | -- | - | PATHGROUP LABS LLC | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Blood / Unknown | -- | 07/24/2024 7:27 AM EDT | -07/24/2024 4:53 PM EDT | -
| Narrative | -
|---|
|
- - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Zachary Campbell NP-C | -LAB - BLOOD DRAW | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| WBC | -10.6 | -3.8 - 11.5 K/uL | -- | - | PATHGROUP LABS LLC | -- |
| Red - Blood Cell Count (RBC) | -4.90 | -4.20 - 5.70 M/mm3 | -- | - | PATHGROUP LABS LLC | -- |
| Hemoglobin - (Hgb) | -14.2 | -13.1 - 17.5 gm/dL | -- | - | PATHGROUP LABS LLC | -- |
| Hematocrit - (HCT) | -43.6 | -39.0 - 51.0 % | -- | - | PATHGROUP LABS LLC | -- |
| MCV | -89.0 | -79.0 - 99.0 fL | -- | - | PATHGROUP LABS LLC | -- |
| MCH | -29.0 | -26.9 - 35.0 pg | -- | - | PATHGROUP LABS LLC | -- |
| MCHC | -32.6 | -30.4 - 34.8 g/dL | -- | - | PATHGROUP LABS LLC | -- |
| RDW | -43.3 | -38.2 - 53.0 fL | -- | - | PATHGROUP LABS LLC | -- |
| Platelet - Count | -262 | -137 - 397 K/cumm | -- | - | PATHGROUP LABS LLC | -- |
| Neutrophils - Automated | -
- |
- 41.0 - 77.0 % | -- | - | PATHGROUP LABS LLC | -- |
| Lymphocytes - Automated | -47.0 | -14.0 - 48.0 % | -- | - | PATHGROUP LABS LLC | -- |
| Monocytes - Automated | -8.8 | -4.0 - 13.0 % | -- | - | PATHGROUP LABS LLC | -- |
| Eosinophils - Automated | -2.3 | -0.0 - 8.0 % | -- | - | PATHGROUP LABS LLC | -- |
| Basophils - Automated | -0.8 | -0.0 - 1.5 % | -- | - | PATHGROUP LABS LLC | -- |
| Immature - Granulocyte Automated | -0.2 | -0.0 - 1.0 % | -- | - | PATHGROUP LABS LLC | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Blood / Unknown | -- | 07/24/2024 7:27 AM EDT | -07/24/2024 4:53 PM EDT | -
| Narrative | -
|---|
|
- - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Zachary Campbell NP-C | -LAB - BLOOD DRAW | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| RPR - (Non-Treponemal) reflex to confirmation | -
- |
- Nonreactive | -- | - | PATHGROUP LABS LLC | -- |
|
- - test by an alternate method - (Treponemal Antibody Screen) as mandated by regulatory agencies. |
- ||||||
| Syphilis - Screening Profile, Treponemal Antibody | -
- |
- Nonreactive | -- | - | PATHGROUP LABS LLC | -- |
| RPR, - Quantitative | -
- |
- - | - | - | PATHGROUP LABS LLC | -- |
|
- - inadequately treated infection, persistent - infection, or reinfection with Treponemal pallidum. Clinical - correlation with patient symptoms and treatment history are - necessary for test interpretation. |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Blood / Unknown | -- | 07/24/2024 7:27 AM EDT | -07/24/2024 5:01 PM EDT | -
| Narrative | -
|---|
|
- - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Zachary Campbell NP-C | -LAB - BLOOD DRAW | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| HIV-1 - Qnt by PCR (copy/mL) | -27 | -20 - 10,000,000 copy/mL | -- | - | PATHGROUP LABS LLC | -- |
| HIV-1 - Qnt by PCR (log copy/mL) | -1.43 | -1.30 - 7.00 Log copies/mL | -- | - | PATHGROUP LABS LLC | -- |
| HIV-1 - Qnt by PCR Interp | -
- |
- Not Detected | -- | - | PATHGROUP LABS LLC | -- |
|
- - Cobas® HIV-1 is an in vitro nucleic - acid amplification test for the quantitation of human - immunodeficiency virus type 1 (HIV-1) RNA in EDTA plasma of - HIV-1-infected individuals using the automated Cobas® 6800/8800 Systems - for specimen processing, amplification and detection. An - interpretation of "Not Detected" does not rule out the presence of - PCR inhibitors or HIV-1 virus RNA concentrations below the level - of detection of the assay. |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Blood / Unknown | -- | 07/24/2024 7:27 AM EDT | -07/24/2024 4:53 PM EDT | -
| Narrative | -
|---|
|
- - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Zachary Campbell NP-C | -LAB - BLOOD DRAW | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Hepatitis - C Antibody (HCV) IgG | -Nonreactive | -Nonreactive | -- | - | PATHGROUP LABS LLC | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Blood / Unknown | -- | 07/24/2024 7:27 AM EDT | -07/24/2024 4:53 PM EDT | -
| Narrative | -
|---|
|
- - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Zachary Campbell NP-C | -LAB - BLOOD DRAW | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Absolute - CD4+ Cells | -1,302 | -430 - 1,800 cells/uL | -- | - | PATHGROUP LABS LLC | -- |
| % CD4 | -
- |
- 32 - 64 % | -- | - | PATHGROUP LABS LLC | -- |
| Lymphocyte - Subset Panel 2 Information | -
- |
- - | - | - | PATHGROUP LABS LLC | -- |
|
- - The CD4 cells are Helper T-cells expressing both CD3 - and CD4. CD4 percentage is reported as a percent of total - lymphocytes. CD4 T-cells levels are a criterion for categorizing - HIV-related clinical conditions by CDC's classification system for - HIV infection. The measurement of CD4 T-cell levels has been used - to establish decision points for initiating P. jirovecii - prophylaxis, antiviral therapy and to monitor the efficacy of - treatment. The Public Health Service (PHS) has recommended that CD4 - T-cell levels be monitored every three to six months in all - HIV-infected persons. This test was developed and its - performance characteristics determined by ARUP Laboratories. It has - not been cleared or approved by the US Food and Drug - Administration. This test was performed in a CLIA certified - laboratory and is intended for clinical purposes. Performed - By: ARUP Laboratories 500 Chipeta Way Salt Lake City, UT 84108 Laboratory - Director: Jonathan R. Genzen, MD, PhD CLIA Number: 46D0523979 |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Blood / Unknown | -- | 07/24/2024 7:27 AM EDT | -07/24/2024 4:53 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Zachary Campbell NP-C | -LAB - BLOOD DRAW | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
- CD4, PERCENT AND ABSOLUTE COUNT
-
-
- Family Medicine, NP
-
-
- Blood
-
-
- Absolute CD4+ Cells
-
-
- % CD4
-
-
- Lymphocyte Subset Panel 2 Information
-
-
- Lab Interpretation
-
-
- HEPATITIS C ANTIBODY (HCV) IGG
-
-
- Family Medicine, NP
-
-
- Blood
-
-
- Hepatitis C Antibody (HCV) IgG
-
-
-
-
- Narrative
-
-
- HUMAN IMMUNODEFICIENCY VIRUS 1 BY QUANTITATIVE PCR
-
-
- Family Medicine, NP
-
-
- Blood
-
-
- HIV-1 Qnt by PCR (copy/mL)
-
-
- HIV-1 Qnt by PCR (log copy/mL)
-
-
- HIV-1 Qnt by PCR Interp
-
-
-
-
- Narrative
-
-
- Lab Interpretation
-
-
- RPR (NON-TREPONEMAL) REFLEX TO CONFIRMATION
-
-
- Family Medicine, NP
-
-
- Blood
-
-
- RPR (Non-Treponemal) reflex to confirmation
-
-
- Syphilis Screening Profile, Treponemal Antibody
-
-
- RPR, Quantitative
-
-
-
-
- Narrative
-
-
- Lab Interpretation
-
-
- CBC WITH PLATELET AND DIFFERENTIAL
-
-
- Family Medicine, NP
-
-
- Blood
-
-
- WBC
-
-
- Red Blood Cell Count (RBC)
-
-
- Hemoglobin (Hgb)
-
-
- Hematocrit (HCT)
-
-
- MCV
-
-
- MCH
-
-
- MCHC
-
-
- RDW
-
-
- Platelet Count
-
-
- Neutrophils Automated
-
-
- Lymphocytes Automated
-
-
- Monocytes Automated
-
-
- Eosinophils Automated
-
-
- Basophils Automated
-
-
- Immature Granulocyte Automated
-
-
-
-
- Narrative
-
-
- Lab Interpretation
-
-
- COMPREHENSIVE METABOLIC PANEL (CMP)
-
-
- Family Medicine, NP
-
-
- Blood
-
-
- Sodium
-
-
- Potassium
-
-
- Chloride
-
-
- CO2
-
-
- Glucose
-
-
- BUN
-
-
- Creatinine
-
-
- Calcium
-
-
- eGFR by Creatinine
-
-
- Protein
-
-
- Albumin
-
-
- Alkaline Phosphatase
-
-
- ALT (SGPT)
-
-
- AST (SGOT)
-
-
- Bilirubin, Total
-
-
- A/G Ratio
-
-
-
-
- Narrative
-
-
- Lab Interpretation
-
-
- LIPID PANEL
-
-
- Family Medicine, NP
-
-
- Blood
-
-
- Cholesterol
-
-
- Triglycerides
-
-
- HDL Cholesterol
-
-
- Cholesterol / HDL Ratio
-
-
- Non-HDL Cholesterol
-
-
- LDL Cholesterol (Calculation)
-
-
- LDL/HDL Ratio
-
-
-
-
- Narrative
-
-
- Lab Interpretation
-
-
- VITAMIN D 1,25-DIHYDROXY AND 25-HYDROXY
-
-
- Family Medicine, NP
-
-
- Blood
-
-
- Vitamin D 25-Hydroxy
-
-
- Vitamin D, 1, 25 Dihydroxy
-
-
-
-
- Narrative
-
-
- Lab Interpretation
-
-
- HEMOGLOBIN A1C
-
-
- Family Medicine, NP
-
-
- Blood
-
-
- Hemoglobin A1C
-
-
- ESTIMATED AVERAGE GLUCOSE
-
-
-
-
- Narrative
-
-
- Lab Interpretation
-
-
- CHLAMYDIA, GONORRHOEAE, AND TRICHOMONAS
-
-
- Family Medicine, NP
-
-
- Urine
-
-
- Trichomonas vaginalis, Aptima (panther)
-
-
- Neisseria gonorrhoeae
-
-
- Chlamydia trachomatis
-
-
- Specimen Type
-
-
- Specimen Source
-
- | Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Never | -- | - | - | - |
| Smokeless Tobacco: Never | -- | - | - | - |
| Alcohol Use | -Standard Drinks/Week | -Comments | -
|---|---|---|
| Yes | -2 (1 standard drink = 0.6 oz pure alcohol) | -1-2 DRINKS 2 TO 4 TIMES A MONTH | -
| Social Connections | -Answer | -Date Recorded | -
|---|---|---|
| Social Connections and Isolation | -0 | -09/02/2022 | -
| Financial Resource Strain | -Answer | -Date Recorded | -
|---|---|---|
| Financial Resource Strain | -0 | -09/02/2022 | -
| Stress | -Answer | -Date Recorded | -
|---|---|---|
| Stress | -0 | -09/02/2022 | -
| Physical Activity | -Answer | -Date Recorded | -
|---|---|---|
| Physical Activity | -0 | -09/02/2022 | -
| Food Insecurity | -Answer | -Date Recorded | -
|---|---|---|
| Food | -0 | -09/02/2022 | -
| Transportation Needs | -Answer | -Date Recorded | -
|---|---|---|
| Transportation | -0 | -09/02/2022 | -
| Housing Stability | -Answer | -Date Recorded | -
|---|---|---|
| Housing | -0 | -09/02/2022 | -
| Safety and Environment | -Answer | -Date Recorded | -
|---|---|---|
| Safety | -0 | -09/02/2022 | -
| Utilities | -Answer | -Date Recorded | -
|---|---|---|
| Utilities | -0 | -09/02/2022 | -
| Employment | -Answer | -Date Recorded | -
|---|---|---|
| Employment | -0 | -09/02/2022 | -
| Sex and Gender Information | -Value | -Date Recorded | -
|---|---|---|
| Sex Assigned at Birth | -Male | -11/08/2022 11:08 AM PST | -
| Gender Identity | -Male | -09/12/2022 7:42 PM PDT | -
| Sexual Orientation | -Lesbian or Gay | -09/12/2022 7:42 PM PDT | -
- Certified Medical Asst
-
-
-
-
-
-
-
-
- Social Connections
-
-
-
-
-
-
- Financial Resource Strain
-
-
-
-
-
-
- Stress
-
-
-
-
-
-
- Physical Activity
-
-
-
-
-
-
- Food Insecurity
-
-
-
-
-
-
- Transportation Needs
-
-
-
-
-
-
- Housing Stability
-
-
-
-
-
-
- Safety and Environment
-
-
-
-
-
-
- Utilities
-
-
-
-
-
-
- Employment
-
-
-
-
-
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 07/24/2024 8:30 AM PDT | -Erroneous Encounter | -
- |
-
- |
-
- Other long term (current) drug therapy; Encounter - for screening for infections with predominantly sexual mode of transmission; Other - problems related to lifestyle; Blood chemistry abnormal; Anxiety - disorder, unspecified type; ERRONEOUS ENCOUNTER--DISREGARD |
-
-
-
-
-
- Family Medicine, NP
-
-
- Infectious Diseases
-
-
-
-
- Certified Medical Asst
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- If you have additional questions are need a consultation, TDH can be reached 615-741-7247 or (800) 404-3006 Additional information might be required for reporting, that can be found here. | Encounter Code | -Date of Encounter | -
|---|---|
|
- |
-
- |
-
| Lab Test Name | -Lab Test Result Value | -Collection Date | -Result Date | -Lab Result Interpretation | -Lab Result Reference Range | -Lab Result Note | -
|---|---|---|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
- |
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- | Medication Name | -Medication Start Date | -Status | -Type | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
|
- |
-
- |
-
- |
-
- |
-
| Social History Observation | -Social History Observation Result | -
|---|---|
|
- |
-
- |
-
| Narrative Text | -
|---|
|
- |
-
|
- |
-
|
- |
-
|
- |
-
|
- |
-
|
- |
-
|
- |
-
|
- |
-
|
- |
-
|
- |
-
| text | -
|---|
|
- |
-
Lab Lab Additional information for required disease reporting must be submitted to the Tennessee Department of Health within 1 week. This additional information can be found here. If you have additional questions regarding disease reporting, the Tennessee Department of Health can be reached 615-741-7247. The mainstay of postexposure prophylaxis (PEP) is hepatitis B vaccine, but, in certain circumstances, hepatitis B immune globulin is recommended in addition to vaccine for added protection. This page provides links to PEP guidelines and resources by type of exposure. Spouse Daughter Sister Lab Lab | Name | -Administration Dates | -Next Due | -
|---|---|---|
| Hepatitis A | -- | |
| Influenza (Historical) | -
- |
- - |
| Influenza Inj. Cell Derived Quadrivalent 4 years+ (PF) | -
- |
- - |
| Influenza Inj. QIV (PF) | -- | |
| Influenza Nasal (Historical) | -
- |
- - |
| Influenza TIV (IM) | -- | |
| Pfizer-BioNTech COVID-19 Vaccine | -- | |
| Pfizer-BioNTech COVID-19 Vaccine 12Y+ Bivalent | -
- |
- - |
| Pneumo Polysaccharide 23-valent | -- | |
| Pneumococcal Conjugate 13-Valent | -
- |
- - |
| Tdap | -
- |
- - |
| Zoster Vaccine Recombinant | -- |
- Medical Assistant
-
-
-
-
- Registered Nurse
-
-
-
- Registered Nurse Registered Nurse
- Registered Nurse
- Registered Nurse
-
-
-
-
-
- Registered Nurse
-
- Registered Nurse Registered Nurse
- Pharmacy Pharmacy
- Pharmacy
- Registered Nurse Registered Nurse
- Pharmacy
-
- Medical Assistant Medical Assistant | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 08/01/2024 1:15 PM CDT | -Post-Op Visit | -
- |
-
- |
- - |
| 08/08/2024 1:15 PM CDT | -Post-Op Visit | -
- |
-
- |
- - |
| 08/21/2024 9:00 AM CDT | -Lab | -
- |
- - | Discharge Disposition: Home | -
| 08/21/2024 9:30 AM CDT | -Office Visit | -
- |
- - | Discharge Disposition: Home | -
| 08/21/2024 10:00 AM CDT | -Appointment | -
- |
- - | Discharge Disposition: Home | -
| 08/21/2024 10:15 AM CDT | -Appointment | -
- |
- - | Discharge Disposition: Home | -
| 11/12/2024 9:30 AM CST | -Office Visit | -
- |
-
- |
- - |
| 06/03/2025 10:15 AM CDT | -Office Visit | -
- |
-
- |
- - |
| Name | -Priority | -Associated Diagnoses | -Date/Time | -
|---|---|---|---|
|
- |
- - |
- |
- - |
- Podiatry Podiatry
- Podiatry Podiatry
- Lab
- Transplant
- Cardiology
- Echo
- Family Medicine Family Medicine
- Endocrinology Endocrinology COLONOSCOPY Gastroenterology | Problem | -Noted Date | -Diagnosed Date | -
|---|---|---|
| History of heart transplant | -05/31/2024 | -- |
| History of arterial ischemic stroke | -05/31/2024 | -- |
| Dilated cardiomyopathy | -04/18/2024 | -- |
|
- Noted by THRELKELD STEPHEN C MD last documented on 20230106 - |
- ||
| Chronic viral hepatitis B without delta-agent | -10/17/2023 | -- |
|
- Noted by CENSEO HEALTH LLC last documented on 20230629 - |
- ||
| Chronic kidney disease, stage 3a | -09/05/2023 | -- |
|
- Noted by SWEAT BONNIE J NP last documented on 20230316 - |
- ||
| Portal hypertension | -09/05/2023 | -- |
|
- Noted by BAPTIST MEMORIAL HOSPITAL last documented on 20220428 - |
- ||
| Uncontrolled type 2 diabetes mellitus with hyperglycemia, without long-term current use of insulin | -09/05/2023 | -- |
|
- Noted by VENEGAS JULIAN L DO last documented on 20230606 - |
- ||
| Localization-related epilepsy | -08/28/2023 | -- |
| Chronic hepatitis, unspecified | -08/28/2023 | -- |
| Paroxysmal atrial fibrillation | -08/28/2023 | -- |
| Encounter for aftercare following heart transplant | -04/28/2023 | -- |
| Blood pressure check | -04/28/2023 | -- |
| Hypomagnesemia | -04/28/2023 | -- |
| Steroid-induced hyperglycemia | -04/28/2023 | -- |
| Seizure-like activity | -03/27/2023 | -- |
| Decreased diffusion capacity of lung | -03/21/2023 | -- |
| Encounter for therapeutic drug level monitoring | -02/22/2023 | -- |
| Hepatitis B core antibody positive | -02/22/2023 | -- |
| Hypertensive cardiovascular-renal disease, stage 1-4 or unspecified chronic kidney disease, without heart failure | -02/22/2023 | -- |
| Heart transplanted | -01/28/2023 | -- |
| Stroke | -01/17/2023 | -- |
| Donor, organ: CMV D (+) / R (+) ; EBV D (+) / R (+); Toxo D (-) / R (-) Hep B core D (+) / Hep B core (+) R | -12/28/2022 | -- |
| CKD (chronic kidney disease) | -04/29/2022 | -- |
| Ulcerative colitis | -03/24/2022 | -- |
| Hyperlipidemia | -03/24/2022 | -- |
| Mixed restrictive and obstructive lung disease | -03/24/2022 | -- |
| Pulmonary emphysema | -03/24/2022 | -- |
| Mixed hyperlipidemia | -03/11/2021 | -- |
| PAH (pulmonary arterial hypertension) with portal hypertension | -12/09/2020 | -- |
| Stage 1 mild COPD by GOLD classification | -08/03/2020 | -- |
Pulmonary Disease Nurse Practitioner Nurse Practitioner Registered Nurse Nurse Practitioner Nurse Practitioner Neurology Registered Nurse Medical Assistant Endocrinology | Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| ImmuKnow | -
- |
- ATP ng/mL | -- | 07/26/2024 7:12 AM CDT | -AEL | -- |
|
- - Assay Range: Low Immune Cell Response <=225 ATP Level ng/mL Moderate Immune Cell Response 226 - 524 ATP Level ng/mL Strong Immune Cell Response >=525 ATP Level ng/mL NOTE: This is a qualitative assay. Therefore the result does not directly quantify the level of immunosuppression. These results should be used in conjunction with clinical presentation, medical history, and other clinical indicators when establishing the immune status of a patient. This test has been cleared or approved for diagnostic use by the U.S. Food and Drug Administration. ImmuKnow (R) is a registered trademark. ____________________________________________________________ Testing Performed At: Eurofins Viracor, LLC 18000 W. 99th Street, Suite 10 Lenexa, KS 66219 Lab Director: Brock Neil, PhD BCLD (ABB) CLIA # 26D-0983643 FLAG Interpretation: A = Abnormal, H = High, L = Low Unless otherwise indicated, all testing performed at: American Esoteric Laboratories 1701 Century Center Cove Memphis, TN 38134 Laboratory Director: Holly H. Pierce, M.D. CLIA# 44D0889744 |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | Venipuncture / Unknown | -07/24/2024 11:35 AM CDT | -07/24/2024 11:48 AM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Andrea N Wallace NP | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Cytomegalovirus DNA PCR | -
- |
- 0.00 IU/mL | -- | 07/26/2024 9:59 PM CDT | -AEL | -- |
| Cytomegalovirus DNA PCR log10 | -
- |
- 0.00 Log IU/mL | -- | 07/26/2024 9:59 PM CDT | -AEL | -- |
|
- - Reference Range: None Detected This test is intended for use as an aid in the management of CMV in solid organ transplant patients and in hematopoietic stem cell transplant patients. In patients receiving anti-CMV therapy, serial DNA measurements can be used to assess viral response to treatment. This CMV assay is not intended for use as a screening tool for blood or blood products. MEM - American Esoteric Laboratories - Memphis CLIA# 44D0889744 1701 Century Center Cove, Memphis, TN 38134-8975 Laboratory Director: Holly H. Pierce, M.D. |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | Venipuncture / Unknown | -07/24/2024 11:35 AM CDT | -07/24/2024 12:52 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Andrea N Wallace NP | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Cryptococcal antigen | -Negative | -Negative | -- | 07/24/2024 2:54 PM CDT | -BMH-MEMPHIS MICROBIOLOGY LABORATORY | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -PERIPHERAL BLOOD SPECIMEN / Unknown | -Venipuncture / Unknown | -07/24/2024 11:35 AM CDT | -07/24/2024 12:52 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Andrea N Wallace NP | -MICROBIOLOGY - GENERAL ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Sodium | -135 | -135 - 145 mmol/L | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Potassium | -4.7 | -3.5 - 5.0 mmol/L | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Chloride | -101 | -98 - 107 mmol/L | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Carbon Dioxide | -24 | -21 - 32 mmol/L | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Anion Gap | -10 | -6 - 16 mmol/L | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Glucose | -
- |
- 70 - 110 mg/dL | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| BUN | -17 | -7 - 18 mg/dL | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Creatinine | -
- |
- 0.60 - 1.30 mg/dL | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| BUN/Creatinine Ratio | -10.7 | -11.7 - 13.9 | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Calcium | -
- |
- 8.5 - 10.1 mg/dL | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
|
- |
- ||||||
| Protein total | -7.7 | -6.4 - 8.2 g/dL | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Albumin | -3.9 | -3.4 - 5.0 g/dL | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Bilirubin Total | -1.0 | -0.0 - 1.0 mg/dL | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| AST | -19 | -7 - 34 U/L | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| ALT | -
- |
- 16 - 62 U/L | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| ALP | -98 | -50 - 136 U/L | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| eGFR non-African American | -
- |
- >=60.0 mL/min/1.73m2 | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| eGFR African American | -
- |
- >=60.0 mL/min/1.73m2 | -- | 07/24/2024 1:19 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | Venipuncture / Unknown | -07/24/2024 11:35 AM CDT | -07/24/2024 12:52 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Andrea N Wallace NP | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| WBC | -
- |
- 5.0 - 10.0 K/uL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| RBC | -4.97 | -4.30 - 5.70 M/uL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Hemoglobin | -
- |
- 14.0 - 18.0 g/dL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Hematocrit | -42.2 | -40.0 - 54.0 % | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| MCV | -84.9 | -80.0 - 97.0 fL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| MCH | -27.8 | -27.0 - 32.0 pg | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| MCHC | -32.7 | -32.0 - 36.0 g/dL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| RDW SD | -40.0 | -35.1 - 43.9 fL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Platelet | -295 | -150 - 500 K/uL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| MPV | -9 | -7.4 - 10.4 fL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| NRBC Absolute | -0.000 | -0.00 - 0.012 K/uL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| NRBC Auto | -0.0 | -0.0 - 0.0 % | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Absolute Neutrophil | -2.8 | -2.5 - 7.5 K/uL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Absolute Lymphocyte | -
- |
- 1.0 - 4.0 K/uL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Absolute Monocyte | -0.25 | -0.05 - 0.60 K/uL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Absolute Eosinophil | -
- |
- 0.05 - 0.50 K/uL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Absolute Basophil | -0.01 | -0.00 - 0.10 K/uL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Absolute Immature Granulocytes | -
- |
- 0 K/uL | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Neutrophil percent | -70.6 | -50.0 - 75.0 % | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Lymphocyte percent | -21.0 | -20.0 - 40.0 % | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Monocyte percent | -
- |
- 0.0 - 6.0 % | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Eosinophil percent | -1.0 | -0.0 - 6.0 % | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Basophils Percent, Automated | -0.3 | -0.0 - 1.0 % | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Immature Granulocytes percent | -
- |
- 0 - 0 % | -- | 07/24/2024 12:55 PM CDT | -BAPTIST MEMORIAL HOSPITAL-MEMPHIS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | Venipuncture / Unknown | -07/24/2024 11:35 AM CDT | -07/24/2024 12:45 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Andrea N Wallace NP | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
CBC with Differential Nurse Practitioner Blood WBC RBC Hemoglobin Hematocrit MCV MCH MCHC RDW SD Platelet MPV NRBC Absolute NRBC Auto Absolute Neutrophil Absolute Lymphocyte Absolute Monocyte Absolute Eosinophil Absolute Basophil Absolute Immature Granulocytes Neutrophil percent Lymphocyte percent Monocyte percent Eosinophil percent Basophils Percent, Automated Immature Granulocytes percent Lab Interpretation Venipuncture Comprehensive Metabolic Panel Nurse Practitioner Blood Sodium Potassium Chloride Carbon Dioxide Anion Gap Glucose BUN Creatinine BUN/Creatinine Ratio Calcium Protein total Albumin Bilirubin Total AST ALT ALP eGFR non-African American eGFR African American Lab Interpretation Venipuncture Cryptococcal Antigen LFA Lab Nurse Practitioner Blood Cryptococcal antigen Lab Interpretation Venipuncture Cytomegalovirus PCR Nurse Practitioner Blood Cytomegalovirus DNA PCR Cytomegalovirus DNA PCR log10 Lab Interpretation Venipuncture ImmuKnow Nurse Practitioner Blood ImmuKnow Venipuncture | Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Former | -Cigarettes | -1 | -47.8 | -01/01/1973 - 10/08/2020 | -
| Smokeless Tobacco: Never | -- | - | - | - |
| Alcohol Use | -Standard Drinks/Week | -Comments | -
|---|---|---|
| Not Currently | -0 (1 standard drink = 0.6 oz pure alcohol) | -- |
| PHQ-2 | -Answer | -Date Recorded | -
|---|---|---|
| PHQ-2 Score | -0 | -05/03/2024 | -
| BOC Food Insecurity | -Answer | -Date Recorded | -
|---|---|---|
| Food Insecurity | -1 | -03/24/2024 | -
| BOC Transportation Needs | -Answer | -Date Recorded | -
|---|---|---|
| Transportation Needs | -1 | -03/24/2024 | -
| BOC Housing Stability Source | -Answer | -Date Recorded | -
|---|---|---|
| Housing Insecurity | -1 | -03/24/2024 | -
| BOC Utility Needs Source | -Answer | -Date Recorded | -
|---|---|---|
| Utility Needs | -1 | -02/28/2024 | -
| BOC Financial Resource Needs | -Answer | -Date Recorded | -
|---|---|---|
| Financial Resource Strain | -1 | -03/24/2024 | -
| Sex and Gender Information | -Value | -Date Recorded | -
|---|---|---|
| Sex Assigned at Birth | -Male | -01/23/2021 7:27 AM CST | -
| Gender Identity | -Male | -01/23/2021 7:27 AM CST | -
| Sexual Orientation | -Straight | -01/23/2021 7:27 AM CST | -
Medical Assistant Registered Nurse Patient History Smoking Tobacco Use Smokeless Tobacco Use Passive Exposure PHQ-2
- BOC Food Insecurity
- BOC Transportation Needs
- BOC Housing Stability Source
- BOC Utility Needs Source
- BOC Financial Resource Needs
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 07/24/2024 10:00 AM CDT | -Lab | -
- |
- - | At high risk for infection; Immunocompromised (HCC); Immunosuppression (HCC); Encounter for aftercare following heart transplant (HCC); Immunosuppressed status (HCC); Hypomagnesemia; Encounter for therapeutic drug level monitoring; Steroid-induced osteopenia; Current chronic use of systemic steroids; Immunosuppression due to chronic steroid use (HCC); Vitamin D deficiency; Thyroid disorder screening; Screening PSA (prostate specific antigen); Steroid-induced diabetes mellitus (HCC); Magnesium deficiency; Mixed hyperlipidemia; Shortness of breath Discharge Disposition: Home |
-
- Lab Mother Emergency Pediatric Emergency Medicine Emergency Medicine Additional information might be required for reporting, that can be found here. If you have additional questions or need a consultation, TDH can be reached 615-741-7247 or (800) 404-3006. CDC website with treatment guidelines Mother Emergency Pediatric Emergency Medicine Emergency Medicine | Name | -Administration Dates | -Next Due | -
|---|---|---|
| DTaP | -
- |
- - |
| DTaP / Hep B / IPV | -- | |
| DTaP / IPV | -
- |
- - |
| Hep A, 2 Dose Pediatric | -- | |
| Hep B, Adolescent or Pediatric | -
- |
- - |
| Hib (PRP-OMP) | -- | |
| Influenza, Quadrivalent, Ped Pres Free IM | -- | |
| Influenza, Quadrivalent, Pres Free (FLUARIX,FLULAVEL,FLUZONE) | -
- |
- - |
| Influenza, Quadrivalent, Pres Free (FLUCELVAX) | -
- |
- - |
| MMR | -
- |
- - |
| MMRV | -
- |
- - |
| Pneumococcal Conjugate 13-Valent | -- | |
| Rotavirus Pentavalent | -- | |
| Varicella | -
- |
- - |
- Obstetrics and Gynecology Obstetrics and Gynecology
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- | Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- New Bag | -07/26/2024 10:33 PM EDT | -356 mL | -356 mL/hr | -- |
| - | - | ||||
- Emergency Medicine | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 11/11/2024 1:10 PM EST | -Office Visit | -
- |
-
- |
- - |
| Name | -Type | -Priority | -Associated Diagnoses | -Date/Time | -
|---|---|---|---|---|
|
- |
- Point of Care Testing | -STAT | -- | 07/26/2024 9:20 PM EDT | -
| Name | -Type | -Priority | -Associated Diagnoses | -Order Schedule | -
|---|---|---|---|---|
|
- |
- Lab | -STAT | -- | STAT for 1 Occurrences starting 7/26/24 until 7/26/24 | -
-
-
- Pediatrics Pediatrics | Problem | -Noted Date | -Diagnosed Date | -
|---|---|---|
| Dental caries | -12/04/2023 | -- |
| Failed vision screen | -10/03/2022 | -- |
|
- Anisometropia, myopia, astimatism and amblyopia. Seen on 8/11/22 and rx for glasses updated - |
- ||
| Myopia | -07/08/2021 | -- |
|
- Wears glasses - |
- ||
Pediatrics Pediatrics | Reason | -Comments | -
|---|---|
| Black or Bloody Stool | -- |
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Body | -N/A | -Ultrasound | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 07/26/2024 11:41 PM EDT | -- |
| Impressions | -
|---|
|
- - - - - - - |
-
| Narrative | -
|---|
|
- - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Angela M Snyder NP | -IMG US PROCEDURES | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Campylobacter | -Not detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Clostridioides difficile (toxin A / B) | -Not Detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Plesiomonas shigelloides | -Not Detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Salmonella | -Not detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Yersinia enterocolitica | -Not detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Vibrio | -Not detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Vibrio cholerae | -Not detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Enteroaggregative E. coli (EAEC) | -Not Detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Enterotoxigenic E. coli (ETEC) | -Not Detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Shiga-like toxin-producing E. coli (STEC) stx1/stx2 | -
- |
- Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| E. Coli 0157 | -
- |
- Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Shigella/ Enteroinvasive E. coli (EIEC) | -Not detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Cryptosporidium | -Not detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Cyclospora cayetanensis | -Not detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Entamoeba histolytica | -Not Detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Giardia lamblia | -Not detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Adenovirus F40 / 41 | -Not Detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Astrovirus | -Not Detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Norovirus GI / GII | -Not Detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Rotavirus A | -Not Detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Sapovirus | -Not Detected | -Not Detected | -- | 07/27/2024 12:07 AM EDT | -BARONESS LAB | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Stool | -Rectal route / Unknown | -Non-blood Collection / Unknown | -07/26/2024 10:31 PM EDT | -07/26/2024 10:37 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Angela M Snyder NP | -LAB MICROBIOLOGY - GENERAL ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Sed Rate | -3 | -0 - 25 mm/hr | -- | 07/26/2024 10:38 PM EDT | -BARONESS LAB | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Venous blood / Unknown | -Venipuncture / Unknown | -07/26/2024 10:01 PM EDT | -07/26/2024 10:03 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Angela M Snyder NP | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| CRP Quant Highly Sen | -0.41 | -0.00 - 0.90 mg/dL | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Venous blood / Unknown | -Venipuncture / Unknown | -07/26/2024 10:01 PM EDT | -07/26/2024 10:03 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Angela M Snyder NP | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| WBC | -
- |
- 5.5 - 10.2 10*3/uL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| RBC | -4.92 | -3.20 - 5.90 10*6/uL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| HEMOGLOBIN | -12.9 | -10.8 - 13.3 g/dL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| HEMATOCRIT | -38.0 | -33.0 - 40.0 % | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| MCV | -77.3 | -74.0 - 90.0 fL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| MCH | -26.3 | -25.0 - 31.0 pg | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| MCHC | -34.0 | -33.0 - 37.0 g/dL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| RDW | -14.3 | -9.0 - 17.0 % | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| PLATELET COUNT | -324 | -130 - 400 10*3/uL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| MPV | -7.6 | -6.7 - 11.0 fL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| NEUT % (AUTO) | -
- |
- 55.0 - 75.0 % | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| LYMPH % (AUTO) | -
- |
- 20.0 - 35.0 % | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| MONO % (AUTO) | -5.3 | -5.0 - 13.0 % | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| EO % (AUTO) | -0.0 | -0.0 - 7.0 % | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| BASO % (AUTO) | -0.2 | -0.0 - 5.0 % | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| NEUT COUNT (AUTO) | -
- |
- 2.4 - 8.3 10*3/uL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| LYMPH COUNT (AUTO) | -1.6 | -0.6 - 4.6 10*3/uL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| MONO COUNT (AUTO) | -0.6 | -0.0 - 1.1 10*3/uL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| EO COUNT (AUTO) | -0.0 | -0.0 - 0.6 10*3/uL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| BASO COUNT (AUTO) | -0.0 | -0.0 - 0.4 10*3/uL | -- | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| DIFF TYPE | -Automated | -- | - | 07/26/2024 10:12 PM EDT | -BARONESS LAB | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Venous blood / Unknown | -Venipuncture / Unknown | -07/26/2024 10:01 PM EDT | -07/26/2024 10:03 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Angela M Snyder NP | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| PTT | -36.2 | -25.1 - 36.5 SEC | -- | 07/26/2024 10:35 PM EDT | -BARONESS LAB | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Venous blood / Unknown | -Venipuncture / Unknown | -07/26/2024 10:01 PM EDT | -07/26/2024 10:03 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Angela M Snyder NP | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Prothrombin Time | -
- |
- 9.4 - 12.5 SEC | -- | 07/26/2024 10:35 PM EDT | -BARONESS LAB | -- |
| INR | -1.13 | -- | - | 07/26/2024 10:35 PM EDT | -BARONESS LAB | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Venous blood / Unknown | -Venipuncture / Unknown | -07/26/2024 10:01 PM EDT | -07/26/2024 10:03 PM EDT | -
| Narrative | -
|---|
|
- - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Angela M Snyder NP | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Sodium | -139 | -138 - 145 mmol/L | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| Potassium | -
- |
- 3.5 - 5.1 mmol/L | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| Chloride | -103 | -98 - 107 mmol/L | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| CO2 | -23 | -20 - 28 mmol/L | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| Calcium | -9.3 | -8.9 - 10.8 mg/dL | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| Glucose | -99 | -60 - 99 mg/dL | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| BUN | -
- |
- 7 - 17 mg/dL | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| Creatinine | -0.4 | -0.3 - 0.7 mg/dL | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| Albumin | -4.1 | -3.8 - 5.4 g/dL | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| Protein Total | -6.7 | -6.0 - 8.0 g/dL | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| Alkaline Phosphatase | -191 | -135 - 320 U/L | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| ALT | -13 | -3 - 55 U/L | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| AST | -24 | -5 - 34 U/L | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| Bilirubin, Total | -0.3 | -0.2 - 1.2 mg/dL | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
| Anion Gap | -
- |
- 3.0 - 14.0 mEq/L | -- | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
|
- |
- ||||||
| Estimated GFR | -- | - | - | 07/26/2024 10:42 PM EDT | -BARONESS LAB | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -Venous blood / Unknown | -Venipuncture / Unknown | -07/26/2024 10:01 PM EDT | -07/26/2024 10:03 PM EDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Angela M Snyder NP | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| Body | -N/A | -Computed Radiography | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 07/26/2024 10:46 PM EDT | -- |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Procedure Note | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Angela M Snyder NP | -IMG XR PROCEDURES | -
X-ray abdomen 2 views AP supine and erect Radiology Emergency Medicine Radiology Study observation (narrative) Narrative Procedure Note Ultrasound abdomen for intussusception Radiology Emergency Medicine Radiology Study observation (narrative) Impression Narrative Procedure Note Comprehensive Metabolic Panel Emergency Medicine Blood Sodium Potassium Chloride CO2 Calcium Glucose BUN Creatinine Albumin Protein Total Alkaline Phosphatase ALT AST Bilirubin, Total Anion Gap Estimated GFR Lab Interpretation Venipuncture PT - INR Emergency Medicine Blood Prothrombin Time INR Lab Interpretation Venipuncture PTT Emergency Medicine Blood PTT Lab Interpretation Venipuncture CBC WITH AUTO DIFF Emergency Medicine Blood WBC RBC HEMOGLOBIN HEMATOCRIT MCV MCH MCHC RDW PLATELET COUNT MPV NEUT % (AUTO) LYMPH % (AUTO) MONO % (AUTO) EO % (AUTO) BASO % (AUTO) NEUT COUNT (AUTO) LYMPH COUNT (AUTO) MONO COUNT (AUTO) EO COUNT (AUTO) BASO COUNT (AUTO) DIFF TYPE Lab Interpretation Venipuncture CRP Emergency Medicine Blood CRP Quant Highly Sen Lab Interpretation Venipuncture ESR Emergency Medicine Blood Sed Rate Lab Interpretation Venipuncture GI Pathogen Panel Lab Emergency Medicine Stool Campylobacter Clostridioides difficile (toxin A / B) Plesiomonas shigelloides Salmonella Yersinia enterocolitica Vibrio Vibrio cholerae Enteroaggregative E. coli (EAEC) Enterotoxigenic E. coli (ETEC) Shiga-like toxin-producing E. coli (STEC) stx1/stx2 E. Coli 0157 Shigella/ Enteroinvasive E. coli (EIEC) Cryptosporidium Cyclospora cayetanensis Entamoeba histolytica Giardia lamblia Adenovirus F40 / 41 Astrovirus Norovirus GI / GII Rotavirus A Sapovirus Lab Interpretation Non-blood Collection | Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Never | -- | - | - | - |
| Smokeless Tobacco: Never | -- | - | - | - |
| Hunger Vital Sign | -Answer | -Date Recorded | -
|---|---|---|
| Within the past 12 months, you worried that your food would run out before you got the money to buy more. | -Never true | -02/08/2021 | -
| Within the past 12 months, the food you bought just didn't last and you didn't have money to get more. | -Never true | -02/08/2021 | -
| Sex and Gender Information | -Value | -Date Recorded | -
|---|---|---|
| Sex Assigned at Birth | -Not on file | -- |
| Gender Identity | -Not on file | -- |
| Sexual Orientation | -Not on file | -- |
| Job Start Date | -Occupation | -Industry | -
|---|---|---|
| Not on file | -Not on file | -Not on file | -
Emergency Medicine Patient History Smoking Tobacco Use Smokeless Tobacco Use Passive Exposure Hunger Vital Sign
- Pediatrics
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 07/26/2024 8:34 PM EDT - Present | -Emergency | -
- |
-
- |
- - |
- Pediatric Emergency Medicine Emergency Medicine
- Hospital Encounter
-
-
- Certified Nurse Midwife
-
-
- Certified Nurse Midwife
-
-
- Certified Nurse Midwife
-
-
- Certified Nurse Midwife
-
-
- Postpartum
-
-
-
-
- Additional information for required disease reporting
- must be submitted to the Tennessee Department of Health within 1
- week. This additional information can be found here.
-
-
- CDC website with STD treatment guidelines.
-
-
- If you have additional questions regarding disease
- reporting, the Tennessee Department of Health can be reached
- 615-741-7247.
-
-
-
-
-
-
-
-
- If you have additional questions regarding disease
- reporting, the Tennessee Department of Health can be reached
- 615-741-7247.
-
-
- Mother
-
-
- Partner
-
-
- Hospital Encounter
-
-
- Certified Nurse Midwife
-
-
- Certified Nurse Midwife
-
-
- Certified Nurse Midwife
-
-
- Certified Nurse Midwife
-
-
- Postpartum
-
- | Name | -Administration Dates | -Next Due | -
|---|---|---|
| Rho (D) Immune Globulin | -
- |
- - |
| Tdap vaccine (Adacel/Boostrix) | -
- |
- - |
-
-
-
-
-
-
-
- | Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- Given | -07/28/2024 8:34 PM CDT | -650 mg | -- | - |
| - | - | ||||
|
- |
- Given | -07/27/2024 11:17 PM CDT | -- | - | - |
| - | - | ||||
|
- |
- Given | -07/28/2024 5:46 PM CDT | -600 mg | -- | - |
| Given | -07/28/2024 12:21 PM CDT | -600 mg | -- | - | |
| Given | -07/28/2024 5:56 AM CDT | -600 mg | -- | - | |
| - | - | ||||
|
- |
- New Bag | -07/27/2024 6:46 PM CDT | -125 mL/hr | -125 mL/hr | -- |
| Rate/Dose Verify | -07/27/2024 2:56 PM CDT | -125 mL/hr | -125 mL/hr | -- | |
| New Bag | -07/27/2024 12:45 PM CDT | -125 mL/hr | -125 mL/hr | -- | |
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- - | ||||
| - | - | ||||
|
- |
- Given | -07/28/2024 10:47 AM CDT | -1 tablet | -- | - |
| - | - | ||||
| - | |||||
| Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- Given | -07/27/2024 7:15 PM CDT | -2,000 mg | -200 mL/hr | -- |
| - | - | ||||
|
- |
- Anesthesia - IntraOp Start Epidural Infusion | -07/27/2024 5:48 PM CDT | -- | - | - |
| Rate/Dose Verify | -07/27/2024 1:10 PM CDT | -- | - | - | |
| Rate/Dose Verify | -07/27/2024 4:18 AM CDT | -- | - | - | |
| - | - | ||||
|
- |
- New Bag | -07/26/2024 11:38 PM CDT | -500 mL | -1000 mL/hr | -- |
| - | - | ||||
|
- |
- Given | -07/26/2024 7:03 PM CDT | -50 mcg | -- | - |
| - | - | ||||
|
- |
- Given | -07/27/2024 4:06 AM CDT | -2.5 mg | -- | - |
| - | - | ||||
|
- |
- Medication Applied | -07/27/2024 12:07 PM CDT | -1 patch | -- | Left Upper Back | -
| Medication Applied | -07/26/2024 5:26 PM CDT | -1 patch | -- | Left Upper Arm | -|
| - | - | ||||
|
- |
- Self Administered Via Pump | -07/27/2024 1:17 PM CDT | -4 mg | -- | - |
| - | - | ||||
|
- |
- Rate/Dose Verify | -07/27/2024 6:30 PM CDT | -18 milli-units/min | -18 mL/hr | -- |
| Rate/Dose Change | -07/27/2024 2:27 PM CDT | -18 milli-units/min | -18 mL/hr | -- | |
| Rate/Dose Change | -07/27/2024 1:12 PM CDT | -16 milli-units/min | -16 mL/hr | -- | |
| - | - | ||||
|
- |
- Rate/Dose Change | -07/26/2024 6:08 PM CDT | -4 milli-units/min | -4 mL/hr | -- |
| New Bag | -07/26/2024 5:38 PM CDT | -2 milli-units/min | -2 mL/hr | -- | |
| - | - | ||||
|
- |
- New Bag | -07/26/2024 9:27 PM CDT | -5 Million Units | -- | - |
| - | - | ||||
|
- |
- New Bag | -07/27/2024 4:54 PM CDT | -2,500,000 Units | -- | - |
| New Bag | -07/27/2024 1:11 PM CDT | -2,500,000 Units | -- | - | |
| New Bag | -07/27/2024 9:00 AM CDT | -2,500,000 Units | -- | - | |
| - | - | ||||
- ibuprofen (ADVIL,MOTRIN) tablet 600 mg
-
-
- Certified Nurse Midwife
-
-
- LR infusion
-
-
- senna (SENOKOT) tablet 1 tablet
-
-
- measles, mumps and rubella (MMR) vaccine 0.5 mL
-
-
- diphth,pertus(acell),tetanus (BOOSTRIX) 2.5-8-5 Lf-mcg-Lf/0.5mL
- vaccine 0.5 mL
-
-
- tranexamic acid (CYKLOKAPRON) 1,000 mg/100 mL (10 mg/mL) 1,000
- mg (premix) in NS 100 mL
-
-
- methylergonovine (METHERGINE) injection 200 mcg
-
-
- carboprost (HEMABATE) injection 250 mcg
-
-
- oxytocin (PITOCIN) injection 10 Units
-
-
- oxytocin (PITOCIN) 30 unit/500 mL (0.06 units/mL) in NS infusion
-
-
- miSOPROStol (CYTOTEC) rectal tablet 800 mcg
-
-
- Post-Partum Hemorrhage Kit
-
-
- promethazine (PHENERGAN) tablet 25 mg
-
-
- promethazine (PHENERGAN) injection 6.25 mg
-
-
-
-
-
-
- diphenhydrAMINE (BENADRYL ALLERGY) tablet 25 mg
-
-
- benzocaine-menthoL (DERMOPLAST) 20-0.5 % topical spray
-
-
- Prenatal multivitamin tablet 1 tablet
-
-
- lidocaine PF (XYLOCAINE) 10 mg/mL (1 %) injection 2 mg
-
-
- simethicone (MYLICON) chewable tablet 160 mg
-
-
- magnesium hydroxide (milk of magnesia) 400 mg(166 mg elemental
- magnesium)/5 mL oral suspension 30 mL
-
-
- HYDROcodone-acetaminophen (NORCO) 5-325 mg per tablet 1 tablet
-
-
- acetaminophen (TYLENOL) tablet 650 mg
-
-
- NIFEdipine (PROCARDIA) capsule 10 mg
-
-
-
-
-
-
- Certified Nurse Midwife
-
-
-
-
-
-
- Certified Registered Nurse Anesthetist
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Resident
-
-
-
-
-
-
- OBSTETRICS & GYNECOLOGY
-
-
-
-
-
-
-
-
-
-
- Resident
-
-
-
-
-
-
-
-
-
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 08/08/2024 9:00 AM CDT | -Clinical Support | -
- |
- - | - |
| 08/08/2024 9:30 AM CDT | -Routine Prenatal | -
- |
-
- |
- - |
| 08/08/2024 10:00 AM CDT | -Office Visit | -
- |
-
- |
- - |
| 08/15/2024 9:00 AM CDT | -Clinical Support | -
- |
- - | - |
| Name | -Type | -Priority | -Associated Diagnoses | -Date/Time | -
|---|---|---|---|---|
|
- |
- Lab | -STAT | -- | 07/26/2024 2:18 PM CDT | -
|
- |
- Lab | -Routine | -- | 07/26/2024 1:43 PM CDT | -
|
- |
- Lab | -STAT | -- | 07/28/2024 3:41 PM CDT | -
| Name | -Type | -Priority | -Associated Diagnoses | -Order Schedule | -
|---|---|---|---|---|
|
- |
- Lab | -STAT | -- | Once for 1 Occurrences starting 7/26/24 until 7/26/24 | -
|
- |
- Lab | -Routine | -- | Once for 1 Occurrences starting 7/26/24 until 7/26/24 | -
|
- |
- Lab | -STAT | -- | STAT for 1 Occurrences starting 7/28/24 until 7/28/24 | -
-
-
-
-
-
-
-
-
-
-
-
-
- Certified Nurse Midwife
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Obstetrics and Gynecology
-
-
-
-
-
-
- Women's Health Nurse Practitioner
-
-
- Obstetrics and Gynecology
-
-
-
-
-
-
- Obstetrics and Gynecology
-
-
-
-
-
-
- Obstetrics and Gynecology
-
- | Active Problems | -Noted Date | -Diagnosed Date | -
|---|---|---|
| Postpartum state | -07/28/2024 | -- |
|
- 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. - |
- ||
| Encounter for induction of labor | -07/26/2024 | -- |
|
- 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 - |
- ||
| Nicotine use | -07/26/2024 | -- |
|
- 6 cigarettes day Nicotine - patch ordered - |
- ||
| Custody issue | -07/26/2024 | -- |
|
- 1st child in foster care Social - work PP - |
- ||
| Septic pulmonary embolism | -07/26/2024 | -- |
|
- Hx of septic PE in 2017 - and 2020 - - Echocardiogram ordered PCN - to be admin within 1 hr of delivery See MFM note - |
- ||
| Encounter for triage in pregnant patient | -07/24/2024 | -- |
|
- - NST appropriate for GA - - Discharged to home with strict return precautions - Discharged to home - with scheduled IOL tomorrow 7/25 @ 2200 - |
- ||
| Positive GBS test | -07/22/2024 | -- |
|
- PCN for GBS prophylaxis - |
- ||
| Fetal growth restriction antepartum | -07/18/2024 | -- |
|
- Dx at 36 weeks TWT. - Repeat growth at 38 weeks. - |
- ||
| Pregnancy | -03/22/2024 | -- |
|
- EDD 8/15/24 by LMP NIPT - low risk female - - Precautions reviewed Discussed - IOL at 39-40wks, will continue to discuss Start weekly visits next week GBS - next visit - |
- ||
| Polysubstance use disorder | -03/22/2024 | -- |
|
- 7/25 Presumptive + MDMA Utox - collected on admission - |
- ||
| Chronic hypertension affecting pregnancy | -03/22/2024 | -- |
|
- Multiple mild range BPs - in outside records - - Normotensive Denies - S&S of pre-e HELLP labs collected - |
- ||
| Short interval between pregnancies affecting pregnancy, - antepartum | -03/22/2024 | -- |
| Syphilis | -03/19/2024 | -- |
|
- Reports treatment in 2022 - - Retreated in June 2024 Titers - ordered - |
- ||
| Chronic hepatitis C virus infection | -03/19/2024 | -- |
|
- AST/ALT mildly elevated - on NOB labs - - Viral load and HIV - collected - |
- ||
| Rh negative state in antepartum period | -03/19/2024 | -- |
| Pregnant | -Comments | -
|---|---|
| Yes | -- |
-
-
-
-
-
-
- OBSTETRICS & GYNECOLOGY
-
-
-
-
-
-
-
-
-
-
-
-
- Women's Health Nurse Practitioner
-
-
-
-
-
-
- Certified Nurse Midwife
-
-
-
-
-
-
-
-
-
-
-
- | Reason | -Comments | -
|---|---|
| Scheduled Induction | -- |
| Specialty | -Diagnoses / Procedures | -Referred By Contact | -Referred To Contact | -
|---|---|---|---|
| - |
- - |
-
- |
-
- |
-
| Referral ID | -Status | -Reason | -Start Date | -Expiration Date | -Visits Requested | -Visits Authorized | -
|---|---|---|---|---|---|---|
| 19268797 | -- | - | - | - | 1 | -1 | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - eGFRcr | -
- |
- >=60 mL/min/1.73 m2 | -- | - | VUMC CERNER LAB | -- |
|
- - GFR - Categories in Chronic Kidney Disease (CKD) GFR GFR - (mL/min/1.73 Category: square meters) Interpretation: G1 90 or - greater Normal or high* G2 60-89 Mild decrease* G3a - 45-59 Mild to moderate decrease G3b 30-44 Moderate to severe - decrease G4 15-29 Severe decrease G5 14 or less Kidney - failure *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) This test was performed at: Vanderbilt Hospital - Laboratory,CLIA #44D0659066,Adam Seegmiller MD, PhD,1301 Medical Center - Drive, 4605 TVC,Nashville,TN,37232, |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | - | 07/27/2024 12:21 PM CDT | -07/27/2024 1:12 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Linda L Johnson CNM | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| White - Blood Cells | -
- |
- 3.9 - 10.7 x10(3)/mcL | -- | - | VUMC CERNER LAB | -- |
| Red - Blood Cells | -4.09 | -4.00 - 5.50 x10(6)/mcL | -- | - | VUMC CERNER LAB | -- |
| - Hemoglobin | -11.8 | -11.8 - 16.0 gm/dL | -- | - | VUMC CERNER LAB | -- |
| - Hematocrit | -
- |
- 36 - 43 % | -- | - | VUMC CERNER LAB | -- |
| Mean - Cell Volume | -86 | -81 - 98 fL | -- | - | VUMC CERNER LAB | -- |
| Mean - Cell Hemoglobin | -28.9 | -27.0 - 32.0 pg | -- | - | VUMC CERNER LAB | -- |
| Mean - Cell Hemoglobin Concentration | -33.6 | -31.0 - 35.0 gm/dL | -- | - | VUMC CERNER LAB | -- |
| RDW - SD | -40.7 | -37.4 - 52.4 fL | -- | - | VUMC CERNER LAB | -- |
| RDW - CV | -13.2 | -11.1 - 14.3 % | -- | - | VUMC CERNER LAB | -- |
| - Platelet | -344 | -135 - 371 x10(3)/mcL | -- | - | VUMC CERNER LAB | -- |
| Mean - Platelet Volume | -9.7 | -9.3 - 12.8 fL | -- | - | VUMC CERNER LAB | -- |
| Nucleated - RBC | -0 | -0 - 0 /100 WBC | -- | - | VUMC CERNER LAB | -- |
| Nucleated - RBC Abs | -
- |
- 0.00 - 0.00 x10(3)/mcL | -- | - | VUMC CERNER LAB | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | - | 07/27/2024 12:21 PM CDT | -07/27/2024 1:12 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Linda L Johnson CNM | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Sodium - Level | -
- |
- 136 - 145 mmol/L | -- | - | VUMC CERNER LAB | -- |
| Potassium - Level | -
- |
- 3.3 - 4.8 mmol/L | -- | - | VUMC CERNER LAB | -- |
|
- |
- ||||||
| Chloride - Level | -105 | -98 - 107 mmol/L | -- | - | VUMC CERNER LAB | -- |
| Carbon - Dioxide | -
- |
- 22 - 29 mmol/L | -- | - | VUMC CERNER LAB | -- |
| Anion - Gap | -9 | -mmol/L | -- | - | VUMC CERNER LAB | -- |
| Glucose - Level | -84 | -70 - 99 mg/dL | -- | - | VUMC CERNER LAB | -- |
| Blood - Urea Nitrogen | -9 | -7 - 21 mg/dL | -- | - | VUMC CERNER LAB | -- |
| Creatinine - Level | -0.58 | -0.57 - 1.11 mg/dL | -- | - | VUMC CERNER LAB | -- |
| Calcium - Level Total | -
- |
- 8.4 - 10.5 mg/dL | -- | - | VUMC CERNER LAB | -- |
| Bilirubin - Total | -
- |
- 0.2 - 1.2 mg/dL | -- | - | VUMC CERNER LAB | -- |
|
- |
- ||||||
| Albumin - Level | -
- |
- 3.5 - 5.2 gm/dL | -- | - | VUMC CERNER LAB | -- |
| Protein - Total | -
- |
- 6.0 - 8.3 gm/dL | -- | - | VUMC CERNER LAB | -- |
|
- |
- ||||||
| Alkaline - Phosphatase | -91 | -40 - 150 unit/L | -- | - | VUMC CERNER LAB | -- |
| Aspartate - Aminotransferase | -
- |
- 5 - 40 unit/L | -- | - | VUMC CERNER LAB | -- |
| Alanine - Aminotransferase | -
- |
- 0 - 55 unit/L | -- | - | VUMC CERNER LAB | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | - | 07/27/2024 12:21 PM CDT | -07/27/2024 1:12 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Linda L Johnson CNM | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| RA - Volume Single Plane | -34 | -milliliter | -- | - | VUMC SECTRA | -- |
| Right - Atrial Volume 2D | -33.29 | -milliliter | -- | - | VUMC SECTRA | -- |
| Right - Atrial Area 2D | -14.22 | -cm2 | -- | - | VUMC SECTRA | -- |
| LA - Length 2D A2C | -14.01 | -cm2 | -- | - | VUMC SECTRA | -- |
| LA - Length 2D A2C | -14.01 | -cm2 | -- | - | VUMC SECTRA | -- |
| LA - Volume Area Length | -49.02 | -milliliter | -- | - | VUMC SECTRA | -- |
| LA - Volume Area Length Index BSA | -22.80 | -milliliter per square meter | -- | - | VUMC SECTRA | -- |
| Left - Atrium Volume 2D | -45 | -milliliter | -- | - | VUMC SECTRA | -- |
| Left - Atrium Volume 2D | -21 | -milliliter per square meter | -- | - | VUMC SECTRA | -- |
| LA - Max Volume 2D A2C | -37 | -milliliter | -- | - | VUMC SECTRA | -- |
| LA - Max Volume 2D A4C | -46.52 | -milliliter | -- | - | VUMC SECTRA | -- |
| LA - Length 2D A4C | -17.56 | -cm2 | -- | - | VUMC SECTRA | -- |
| LA - Length 2D A4C | -17.56 | -cm2 | -- | - | VUMC SECTRA | -- |
| Left - Atrium A-P Diameter | -3.3 | -cm | -- | - | VUMC SECTRA | -- |
| RV - Free wall pk S' | -0.2 | -meter per second | -- | - | VUMC SECTRA | -- |
| - TAPSE | -1.84 | -cm | -- | - | VUMC SECTRA | -- |
| Right - Ventricle Internal Diameter Diastole Plax | -3.05 | -cm | -- | - | VUMC SECTRA | -- |
| PV - Antegrade Peak Velocity | -0.76 | -meter per second | -- | - | VUMC SECTRA | -- |
| LVOT - mn grad | -0.9 | -millimeters Of Mercury | -- | - | VUMC SECTRA | -- |
| LV - Relative Wall Thickness | -40.22 | -percent | -- | - | VUMC SECTRA | -- |
| Mitral - Valve E' Lateral Velocity | -0.14 | -meter per second | -- | - | VUMC SECTRA | -- |
| LV - E/e' Ratio Mean | -4.63 | -- | - | - | VUMC SECTRA | -- |
| LV - End Diastolic Volume BiPlane | -100.46 | -milliliter | -- | - | VUMC SECTRA | -- |
| LV - End Diastolic Volume BiPlane Index BSA | -46.73 | -milliliter per square meter | -- | - | VUMC SECTRA | -- |
| LV - End Diastolic Volume 2C | -86.51 | -milliliter | -- | - | VUMC SECTRA | -- |
| LV - End Diastolic Volume 4C | -115.93 | -milliliter | -- | - | VUMC SECTRA | -- |
| LV - Ejection Fraction 2D BI | -57 | -percent | -- | - | VUMC SECTRA | -- |
| LV - Ejection Fraction 2D Teich | -67.24 | -percent | -- | - | VUMC SECTRA | -- |
| LV - End Systolic Volume BiPlane | -42.83 | -milliliter | -- | - | VUMC SECTRA | -- |
| LV - End Systolic Volume BiPlane Index BSA | -19.92 | -milliliter per square meter | -- | - | VUMC SECTRA | -- |
| LV - End Systolic Volume 2C | -35.94 | -milliliter | -- | - | VUMC SECTRA | -- |
| LV - End Systolic Volume 4C | -47.06 | -milliliter | -- | - | VUMC SECTRA | -- |
| LV - Posterior Thickness Diastole | -0.88 | -0.6 - 1.1 cm | -- | - | VUMC SECTRA | -- |
| LV - Septal Thickness Diastole | -0.85 | -0.6 - 1.1 cm | -- | - | VUMC SECTRA | -- |
| LV - Internal Diameter Diastole | -4.40 | -5.92 - 8.22 cm | -- | - | VUMC SECTRA | -- |
| LV - Internal Diameter Systole | -2.77 | -3.46 - 5.23 cm | -- | - | VUMC SECTRA | -- |
| LVOT - peak vel | -0.69 | -meter per second | -- | - | VUMC SECTRA | -- |
| AV - LVOT peak gradient | -1.90 | -millimeters Of Mercury | -- | - | VUMC SECTRA | -- |
| LVOT - peak VTI | -12.81 | -cm | -- | - | VUMC SECTRA | -- |
| Doppler - LVOT Stroke Volume Index | -21.9 | -milliliter per square meter | -- | - | VUMC SECTRA | -- |
| Doppler - LVOT Stroke Volume | -47.15 | -milliliter | -- | - | VUMC SECTRA | -- |
| LVOT - diameter | -2.17 | -cm | -- | - | VUMC SECTRA | -- |
| TV - Regurgitation Peak Velocity | -2.05 | -meter per second | -- | - | VUMC SECTRA | -- |
| TV - Regurgitation Peak Gradient | -16.82 | -millimeters Of Mercury | -- | - | VUMC SECTRA | -- |
| PV - Acceleration Time | -0.15 | -s | -- | - | VUMC SECTRA | -- |
| PV - Antegrade Peak Gradient | -3.55 | -millimeters Of Mercury | -- | - | VUMC SECTRA | -- |
| Mitral - Valve A Wave Peak Velocity | -0.52 | -meter per second | -- | - | VUMC SECTRA | -- |
| Mitral - Valve E Wave Peak Velocity | -0.65 | -meter per second | -- | - | VUMC SECTRA | -- |
| Mitral - Valve E/A | -1.26 | -- | - | - | VUMC SECTRA | -- |
| MV - Antegrade PHT | -0.05 | -s | -- | - | VUMC SECTRA | -- |
| Mitral - Valve E Wave Deceleration Time | -0.18 | -s | -- | - | VUMC SECTRA | -- |
| MV - Area PHT | -4.27 | -cm2 | -- | - | VUMC SECTRA | -- |
| Ao - peak vel | -1.22 | -meter per second | -- | - | VUMC SECTRA | -- |
| AV - peak gradient | -5.93 | -millimeters Of Mercury | -- | - | VUMC SECTRA | -- |
| AV - mean gradient | -3.50 | -millimeters Of Mercury | -- | - | VUMC SECTRA | -- |
| Ao - VTI | -19.72 | -cm | -- | - | VUMC SECTRA | -- |
| AV - area peak vel | -2.09 | -cm2 | -- | - | VUMC SECTRA | -- |
| AV - Area Index - BSA Peak Velocity | -0.97 | -square centimeter per square meter | -- | - | VUMC SECTRA | -- |
| AV - area by cont VTI | -2.39 | -cm2 | -- | - | VUMC SECTRA | -- |
| AV - Area Index - BSA VTI | -1.11 | -square centimeter per square meter | -- | - | VUMC SECTRA | -- |
| Aorta - Ascending diameter 2D | -2.73 | -cm | -- | - | VUMC SECTRA | -- |
| Aortic - root | -2.94 | -cm | -- | - | VUMC SECTRA | -- |
| IVC - Max | -1.29 | -cm | -- | - | VUMC SECTRA | -- |
| AV - Velocity Ratio | -0.65 | -- | - | - | VUMC SECTRA | -- |
| - ZLVIDS | --3.39 | -- | - | - | VUMC SECTRA | -- |
| - ZLVIDD | --4.61 | -- | - | - | VUMC SECTRA | -- |
| Right - Atrial Pressure | -3 | -mmHg | -- | - | VUMC SECTRA | -- |
| Anatomical Region | -Laterality | -Modality | -
|---|---|---|
| - | - | Ultrasound | -
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | - | - |
| Narrative | -
|---|
|
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Elite Paul CNM | -CV ECHO PROCEDURES | -
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Urine - Protein Level | -
- |
- <=15 mg/dL | -- | - | VUMC CERNER LAB | -- |
| Urine - Creatinine | -132 | -40 - 200 mg/dL | -- | - | VUMC CERNER LAB | -- |
| Urine - Protein/Creatinine Ratio | -
- |
- <=0.20 mg/mg | -- | - | VUMC CERNER LAB | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Urine | -- | - | 07/26/2024 3:23 PM CDT | -07/26/2024 4:38 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Elite Paul CNM | -LAB URINE ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Amphetamines - Urine Screen | -
- |
- Cutoff 300 ng/mL | -- | - | VUMC CERNER LAB | -- |
|
- - Presumptive Negative by immunoassay. Testing by - mass spectrometry is available on request. |
- ||||||
| Barbiturates - Urine Screen | -
- |
- Cutoff 200 ng/mL | -- | - | VUMC CERNER LAB | -- |
|
- - Presumptive Negative by immunoassay. Testing by - mass spectrometry is available on request. |
- ||||||
| Benzodiazepines - Urine Screen | -
- |
- Cutoff 200 ng/mL | -- | - | VUMC CERNER LAB | -- |
|
- - Presumptive Negative by immunoassay. Testing by - mass spectrometry is available on request. |
- ||||||
| THC - Urine Screen | -
- |
- Cutoff 50 ng/mL | -- | - | VUMC CERNER LAB | -- |
|
- - Presumptive Negative by immunoassay. Testing by - mass spectrometry is available on request. |
- ||||||
| Cocaine - Urine Screen | -
- |
- Cutoff 150 ng/mL | -- | - | VUMC CERNER LAB | -- |
|
- - Presumptive Negative by immunoassay. Testing by - mass spectrometry is available on request. |
- ||||||
| Methadone - Urine Screen | -
- |
- Cutoff 150 ng/mL | -- | - | VUMC CERNER LAB | -- |
|
- - Presumptive Negative by immunoassay. Testing by - mass spectrometry is available on request. |
- ||||||
| Opiates - Urine Screen | -
- |
- Cutoff 300 ng/mL | -- | - | VUMC CERNER LAB | -- |
|
- - Presumptive Negative by immunoassay. Testing by - mass spectrometry is available on request. |
- ||||||
| Phencyclidine - Urine Screen | -
- |
- Cutoff 25 ng/mL | -- | - | VUMC CERNER LAB | -- |
|
- - Presumptive Negative by immunoassay. Testing by - mass spectrometry is available on request. |
- ||||||
| Propoxyphene - Urine Screen | -
- |
- Cutoff 300 ng/mL | -- | - | VUMC CERNER LAB | -- |
|
- - Presumptive Negative by immunoassay. Testing by - mass spectrometry is available on request. |
- ||||||
| Creatinine, - Urine | -127.4 | -20.0 - 400.0 mg/dL | -- | - | VUMC CERNER LAB | -- |
| CDASU - 9 Comments | -
- |
- - | - | - | VUMC CERNER LAB | -- |
|
- - The absence of expected drug(s) and/or drug - metabolite(s) may indicate non-compliance, inappropriate timing of - specimen collection relative to drug administration, poor drug - absorption, diluted/adulterated urine, or limitations of testing. - The concentration at which the screening test can detect a drug or metabolite - varies within a drug class. Specimens for which drugs or drug - classes are detected by the screen are reflexed to a second, more - specific technology (GC/MS and/or LC-MS/MS). The concentration - value must be greater than or equal to the cutoff to be reported - as positive. Interpretive questions should be directed to the - laboratory. Oxycodone results are reported with the opiates - results. MDMA results are reported with the amphetamines results. - The following opioids are not detected in this test: fentanyl, - buprenorphine, meperidine, tramadol, and tapentadol. A - comprehensive panel that includes these opioids is available or - individual opioid testing can be ordered. Refer to aruplab.com for - test information. For medical purposes only; not valid for - forensic use. Performed By: ARUP Laboratories 500 Chipeta Way Salt - Lake City, UT 84108 Laboratory Director: Jonathan R. Genzen, MD, - PhD CLIA Number: 46D0523979 |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Urine | -- | - | 07/26/2024 3:23 PM CDT | -07/26/2024 7:50 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Elite Paul CNM | -LAB URINE ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| HIV - P24 Antigen + 1/2 Ab | -
- |
- Negative | -- | - | VUMC CERNER LAB | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | - | 07/26/2024 2:18 PM CDT | -07/26/2024 5:13 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Elite Paul CNM | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Hepatitis - C Antibody | -
- |
- Negative | -- | - | VUMC CERNER LAB | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | - | 07/26/2024 2:18 PM CDT | -07/26/2024 5:13 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Elite Paul CNM | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Antibody - ID | -POS, Anti-D Probably due to RhIg | -- | - | - | VUMC BLOOD BANK | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 07/26/2024 1:43 PM CDT | -07/26/2024 2:10 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Samantha Selhorst MD, MS | -LAB BLOOD BANK TEST ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Treponemal - Antibody IgG | -
- |
- Negative | -- | - | VUMC CERNER LAB | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | - | 07/26/2024 1:43 PM CDT | -07/26/2024 3:31 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Melissa Ann Stec CNM | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| ABO - Type | -B | -- | - | - | VUMC BLOOD BANK | -- |
| Rh - Type Auto | -NEG | -- | - | - | VUMC BLOOD BANK | -- |
| Ab - Screen | -POS | -- | - | - | VUMC BLOOD BANK | -- |
| Specimen - Expiration | -07/29/2024 23:59 | -- | - | - | VUMC BLOOD BANK | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | - | 07/26/2024 1:43 PM CDT | -07/26/2024 2:10 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Melissa Ann Stec CNM | -LAB BLOOD BANK TEST ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
- Transthoracic echo (TTE) complete with or without contrast per
- protocol
-
-
-
-
-
-
- Cardiovascular Disease
-
-
- Certified Nurse Midwife
-
-
- RA Volume Single Plane
-
-
- Right Atrial Volume 2D
-
-
- Right Atrial Area 2D
-
-
- LA Length 2D A2C
-
-
- LA Length 2D A2C
-
-
- LA Volume Area Length
-
-
- LA Volume Area Length Index BSA
-
-
- Left Atrium Volume 2D
-
-
- Left Atrium Volume 2D
-
-
- LA Max Volume 2D A2C
-
-
- LA Max Volume 2D A4C
-
-
- LA Length 2D A4C
-
-
- LA Length 2D A4C
-
-
- Left Atrium A-P Diameter
-
-
- RV Free wall pk S'
-
-
- TAPSE
-
-
- Right Ventricle Internal Diameter Diastole Plax
-
-
- PV Antegrade Peak Velocity
-
-
- LVOT mn grad
-
-
- LV Relative Wall Thickness
-
-
- Mitral Valve E' Lateral Velocity
-
-
- LV E/e' Ratio Mean
-
-
- LV End Diastolic Volume BiPlane
-
-
- LV End Diastolic Volume BiPlane Index BSA
-
-
- LV End Diastolic Volume 2C
-
-
- LV End Diastolic Volume 4C
-
-
- LV Ejection Fraction 2D BI
-
-
- LV Ejection Fraction 2D Teich
-
-
- LV End Systolic Volume BiPlane
-
-
- LV End Systolic Volume BiPlane Index BSA
-
-
- LV End Systolic Volume 2C
-
-
- LV End Systolic Volume 4C
-
-
- LV Posterior Thickness Diastole
-
-
- LV Septal Thickness Diastole
-
-
- LV Internal Diameter Diastole
-
-
- LV Internal Diameter Systole
-
-
- LVOT peak vel
-
-
- AV LVOT peak gradient
-
-
- LVOT peak VTI
-
-
- Doppler LVOT Stroke Volume Index
-
-
- Doppler LVOT Stroke Volume
-
-
- LVOT diameter
-
-
- TV Regurgitation Peak Velocity
-
-
- TV Regurgitation Peak Gradient
-
-
- PV Acceleration Time
-
-
- PV Antegrade Peak Gradient
-
-
- Mitral Valve A Wave Peak Velocity
-
-
- Mitral Valve E Wave Peak Velocity
-
-
- Mitral Valve E/A
-
-
- MV Antegrade PHT
-
-
- Mitral Valve E Wave Deceleration Time
-
-
- MV Area PHT
-
-
- Ao peak vel
-
-
- AV peak gradient
-
-
- AV mean gradient
-
-
- Ao VTI
-
-
- AV area peak vel
-
-
- AV Area Index - BSA Peak Velocity
-
-
- AV area by cont VTI
-
-
- AV Area Index - BSA VTI
-
-
- Aorta Ascending diameter 2D
-
-
- Aortic root
-
-
- IVC Max
-
-
- AV Velocity Ratio
-
-
- ZLVIDS
-
-
- ZLVIDD
-
-
- Right Atrial Pressure
-
-
- Radiology Study observation (narrative)
-
-
-
-
- Narrative
-
-
- Type/Scrn (ABO/Rh/Ab Scrn)
-
-
- Certified Nurse Midwife
-
-
- Blood
-
-
- ABO Type
-
-
- Rh Type Auto
-
-
- Ab Screen
-
-
- Specimen Expiration
-
-
- Treponemal IgG
-
-
- Certified Nurse Midwife
-
-
-
-
- Treponemal Antibody IgG
-
-
- Lab Interpretation
-
-
- Antibody ID
-
-
- Resident
-
-
- Antibody ID
-
-
- Hepatitis C IgG w/Rfx PCR
-
-
- Certified Nurse Midwife
-
-
-
-
- Hepatitis C Antibody
-
-
- Lab Interpretation
-
-
- HIV P24 Ag and HIV 1/2 Ab
-
-
- Certified Nurse Midwife
-
-
-
-
- HIV P24 Antigen + 1/2 Ab
-
-
- UR Drug Scrn 9 Pnl w/Rfx Conf-ARUP
-
-
- Certified Nurse Midwife
-
-
-
-
- Amphetamines Urine Screen
-
-
- Barbiturates Urine Screen
-
-
- Benzodiazepines Urine Screen
-
-
- THC Urine Screen
-
-
- Cocaine Urine Screen
-
-
- Methadone Urine Screen
-
-
- Opiates Urine Screen
-
-
- Phencyclidine Urine Screen
-
-
- Propoxyphene Urine Screen
-
-
- Creatinine, Urine
-
-
- CDASU 9 Comments
-
-
- UR Protein/Creatinine Ratio
-
-
- Certified Nurse Midwife
-
-
-
-
- Urine Protein Level
-
-
- Urine Creatinine
-
-
- Urine Protein/Creatinine Ratio
-
-
- Lab Interpretation
-
-
- CMP
-
-
- Certified Nurse Midwife
-
-
-
-
- Sodium Level
-
-
- Potassium Level
-
-
- Chloride Level
-
-
- Carbon Dioxide
-
-
- Anion Gap
-
-
- Glucose Level
-
-
- Blood Urea Nitrogen
-
-
- Creatinine Level
-
-
- Calcium Level Total
-
-
- Bilirubin Total
-
-
- Albumin Level
-
-
- Protein Total
-
-
- Alkaline Phosphatase
-
-
- Aspartate Aminotransferase
-
-
- Alanine Aminotransferase
-
-
- Lab Interpretation
-
-
- CBC
-
-
- Certified Nurse Midwife
-
-
-
-
- White Blood Cells
-
-
- Red Blood Cells
-
-
- Hemoglobin
-
-
- Hematocrit
-
-
- Mean Cell Volume
-
-
- Mean Cell Hemoglobin
-
-
- Mean Cell Hemoglobin Concentration
-
-
- RDW SD
-
-
- RDW CV
-
-
- Platelet
-
-
- Mean Platelet Volume
-
-
- Nucleated RBC
-
-
- Nucleated RBC Abs
-
-
- Lab Interpretation
-
-
- eGFRcr
-
-
- Certified Nurse Midwife
-
-
-
-
- eGFRcr
-
- | Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Every Day | -Cigarettes | -0.5 | -6.1 | -Started: 01/01/2018; Last attempted to quit: 02/24/2024 | -
| Smokeless Tobacco: Never | -- | - | - | - |
| Alcohol Use | -Standard Drinks/Week | -Comments | -
|---|---|---|
| Not Currently | -0 (1 standard drink = 0.6 oz pure alcohol) | -- |
| PHQ-2 | -Answer | -Date Recorded | -
|---|---|---|
| PHQ-9 Score | -0 | -03/18/2024 | -
| Pregnant | -Comments | -
|---|---|
| Yes | -- |
| Sex and Gender Information | -Value | -Date Recorded | -
|---|---|---|
| Sex Assigned at Birth | -Not on file | -- |
| Gender Identity | -Female | -02/12/2024 10:53 AM CST | -
| Sexual Orientation | -Not on file | -- |
| COVID-19 Exposure | -Response | -Date Recorded | -
|---|---|---|
| In the last 10 days, have you been in contact with someone who was confirmed - or suspected to have Coronavirus/COVID-19? | -No / Unsure | -7/26/2024 2:10 PM CDT | -
-
-
-
-
-
-
- Patient History
-
-
- Smoking Tobacco Use
-
-
- Smokeless Tobacco Use
-
-
- Passive Exposure
-
-
- PHQ-2
-
-
-
-
-
-
-
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 07/26/2024 12:59 PM CDT - Present | -Hospital Encounter | -
- |
-
- - - |
- - |
-
-
-
-
- Certified Nurse Midwife
-
-
- Certified Nurse Midwife
-
-
- Certified Nurse Midwife
-
-
- Postpartum
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Office Visit Family Medicine Family Medicine CDC COVID-19 webpage Additional information might be required for reporting, that can be found here. If you have additional questions or need a consultation, TDH can be reached 615-741-7247 or (800) 404-3006. Link to CDC page with treatment guidelines If you have additional questions regarding disease reporting, the Tennessee Department of Health can be reached 615-741-7247 or (800) 404-3006. Spouse Office Visit Family Medicine Family Medicine | Name | -Administration Dates | -Next Due | -
|---|---|---|
| Anthrax | -- | |
| FLU VACCINE (IIV4) EQUAL TO 6MONTHS-35MONTHS OLD WITH PRESERVATIVE (VFC) | -- | |
| Flu vaccine (IIV4) 6months and older, preservative free | -- | |
| Flu vaccine, quadrivalent, intranasal 2years-49 years (VFC) | -
- |
- - |
| Hep A / Hep B | -- | |
| Hep A, Adult | -
- |
- - |
| IPV | -- | |
| Influenza, Split (incl. purified surface antigen) | -- | |
| Influenza, Unspecified | -
- |
- - |
| Influenza, injectable, MDCK, quadrivalent | -
- |
- - |
| Influenza, live, intranasal | -- | |
| Influenza, seasonal, injectable, preservative free | -- | |
| MMR | -- | |
| Meningococcal MPSV4 | -
- |
- - |
| Novel influenza-H1N1-09 | -
- |
- - |
| OPV | -
- |
- - |
| PPD Test | -
- |
- - |
| Pneumococcal Polysaccharide PPV23 | -
- |
- - |
| TD (adult), 2 Lf tetanus toxoid, preservative free, adsorbed | -- | |
| Tdap | -- | |
| Tetanus toxoid, adsorbed | -
- |
- - |
| Typhoid, ViCPs | -- | |
| Yellow Fever | -
- |
- - |
- Family Medicine
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- Family Medicine Family Medicine
- | Problem | -Noted Date | -Diagnosed Date | -
|---|---|---|
| BMI 29.0-29.9,adult | -11/03/2023 | -- |
| Type 2 diabetes mellitus with hyperosmolarity without coma, without long-term current use of insulin | -06/23/2023 | -- |
| Hyperlipidemia | -06/23/2023 | -- |
| Hypertension | -06/23/2023 | -- |
|
- stable - |
- ||
| Viral infection, unspecified | -06/23/2023 | -- |
| Edema | -06/08/2023 | -- |
| COVID-19 | -01/21/2022 | -- |
| Plantar fasciitis | -06/22/2019 | -- |
|
- Uses inserts--podiatry referral - |
- ||
| Baker's cyst of knee, right | -06/05/2019 | -- |
| Carpal tunnel syndrome | -06/22/2018 | -- |
| Cubital tunnel syndrome of both upper extremities | -06/22/2018 | -- |
| Type 2 diabetes mellitus | -06/01/2017 | -- |
| Fusion of spine, cervical region | -06/01/2016 | -- |
| Arthritis | -06/01/2015 | -- |
| Diverticulitis | -02/01/2009 | -- |
Family Medicine | Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| POCT Covid Rapid Test - PCR | -
- |
- - | - | - | ABBOTT | -- |
|
- - M839591 |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| - | - | - | 07/29/2024 3:29 PM CDT | -- |
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Allison Leigh Rasnic NP | -LAB POINT OF CARE TEST DOCKED DEVICE ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
- - | - |
- |
-
POCT Rapid Test Covid 19 Family Medicine POCT Covid Rapid Test - PCR Lab Interpretation | Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Every Day | -Cigarettes | -0.5 | -15 | -- |
| Smokeless Tobacco: Never | -- | - | - | - |
| Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Every Day | -Cigarettes | -0.5 | -15 | -- |
| Smokeless Tobacco: Never | -- | - | - | - |
| Alcohol Use | -Standard Drinks/Week | -Comments | -
|---|---|---|
| Yes | -2 (1 standard drink = 0.6 oz pure alcohol) | -OCCASIONAL | -
| Humiliation, Afraid, Rape, and Kick questionnaire | -Answer | -Date Recorded | -
|---|---|---|
| Within the last year, have you been afraid of your partner or ex-partner? | -No | -06/22/2023 | -
| Within the last year, have you been humiliated or emotionally abused in other ways by your partner or ex-partner? | -Patient declined | -06/22/2023 | -
| Within the last year, have you been kicked, hit, slapped, or otherwise physically hurt by your partner or ex-partner? | -No | -06/22/2023 | -
| Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner? | -No | -06/22/2023 | -
| Social Connection and Isolation Panel [NHANES] | -Answer | -Date Recorded | -
|---|---|---|
| In a typical week, how many times do you talk on the phone with family, friends, or neighbors? | -More than three times a week | -06/22/2023 | -
| How often do you get together with friends or relatives? | -Three times a week | -06/22/2023 | -
| How often do you attend church or religious services? | -1 to 4 times per year | -06/22/2023 | -
| Do you belong to any clubs or organizations such as church groups, unions, fraternal or athletic groups, or school groups? | -Yes | -06/22/2023 | -
| How often do you attend meetings of the clubs or organizations you belong to? | -1 to 4 times per year | -06/22/2023 | -
| Are you married, widowed, divorced, separated, never married, or living with a partner? | -Married | -06/22/2023 | -
| AUDIT-C | -Answer | -Date Recorded | -
|---|---|---|
| Q1: How often do you have a drink containing alcohol? | -2-4 times a month | -06/22/2023 | -
| Q2: How many drinks containing alcohol do you have on a typical day when you are drinking? | -1 or 2 | -06/22/2023 | -
| Q3: How often do you have six or more drinks on one occasion? | -Never | -06/22/2023 | -
| Overall Financial Resource Strain (CARDIA) | -Answer | -Date Recorded | -
|---|---|---|
| How hard is it for you to pay for the very basics like food, housing, medical care, and heating? | -Not hard at all | -06/22/2023 | -
| PHQ-2 | -Answer | -Date Recorded | -
|---|---|---|
| Patient Health Questionnaire-2 Score | -4 | -04/25/2024 | -
| Finnish Institute of Occupational Health - Occupational Stress Questionnaire | -Answer | -Date 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 much | -06/22/2023 | -
| Exercise Vital Sign | -Answer | -Date Recorded | -
|---|---|---|
| On average, how many days per week do you engage in moderate to strenuous exercise (like a brisk walk)? | -2 days | -06/22/2023 | -
| On average, how many minutes do you engage in exercise at this level? | -30 min | -06/22/2023 | -
| Hunger Vital Sign | -Answer | -Date Recorded | -
|---|---|---|
| Within the past 12 months, you worried that your food would run out before you got the money to buy more. | -Never true | -06/22/2023 | -
| Within the past 12 months, the food you bought just didn't last and you didn't have money to get more. | -Never true | -06/22/2023 | -
| PRAPARE - Transportation | -Answer | -Date Recorded | -
|---|---|---|
| In the past 12 months, has lack of transportation kept you from medical appointments or from getting medications? | -No | -06/22/2023 | -
| In the past 12 months, has lack of transportation kept you from meetings, work, or from getting things needed for daily living? | -No | -06/22/2023 | -
| Housing Stability | -Answer | -Date Recorded | -
|---|---|---|
| In the last 12 months, was there a time when you were not able to pay the mortgage or rent on time? | -No | -06/22/2023 | -
| In the last 12 months, how many places have you lived? | -3 | -06/22/2023 | -
| 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)? | -No | -06/22/2023 | -
| Health Literacy | -Answer | -Date Recorded | -
|---|---|---|
| Do you ever need help reading medical materials? | -2 | -06/22/2023 | -
| Child Care | -Answer | -Date Recorded | -
|---|---|---|
| Child Care: Difficult to Study or Work | -Not on file | -07/08/2024 | -
| Sex and Gender Information | -Value | -Date Recorded | -
|---|---|---|
| Sex Assigned at Birth | -Male | -06/22/2023 12:50 PM CDT | -
| Gender Identity | -Male | -06/22/2023 12:50 PM CDT | -
| Sexual Orientation | -Straight | -06/22/2023 12:50 PM CDT | -
| Job Start Date | -Occupation | -Industry | -
|---|---|---|
| Not on file | -Not on file | -Not on file | -
Neurology Family Medicine Humiliation, Afraid, Rape, and Kick questionnaire
-
-
-
- Social Connection and Isolation Panel [NHANES]
-
-
-
-
-
- AUDIT-C
-
-
- Patient History Smoking Tobacco Use Smokeless Tobacco Use Passive Exposure Overall Financial Resource Strain (CARDIA)
- PHQ-2
- Finnish Institute of Occupational Health - Occupational Stress Questionnaire
- Exercise Vital Sign
-
- Hunger Vital Sign
-
- PRAPARE - Transportation
-
- Housing Stability
-
-
- Health Literacy
- Child Care
- | Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 07/29/2024 12:30 PM CDT | -Office Visit | -
- |
-
- |
-
- |
-
- Family Medicine Family Medicine
- Hospital Encounter
-
-
- Pediatrics
-
-
- Pediatrics
-
-
- Obstetrics
-
-
-
-
- Additional information for required disease reporting
- must be submitted to the Tennessee Department of Health within 1
- week. This additional information can be found here.
-
-
-
- CDC website with STD treatment guidelines.
-
-
- If you have additional questions regarding disease
- reporting, the Tennessee Department of Health can be reached
- 615-741-7247.
-
-
- Mother
-
-
- Hospital Encounter
-
-
- Pediatrics
-
-
- Pediatrics
-
-
- Obstetrics
-
- | Name | -Administration Dates | -Next Due | -
|---|---|---|
| Hepatitis B Pediatric/Adolescent | -
- |
- - |
-
-
-
-
- Registered Nurse
-
-
- Registered Nurse
-
- | Medication Order | -MAR Action | -Action Date | -Dose | -Rate | -Site | -
|---|---|---|---|---|---|
|
- |
- Given | -07/25/2024 8:09 PM CDT | -1 Application | -- | - |
| - | - | ||||
|
- |
- Given | -07/25/2024 8:09 PM CDT | -1 mg | -- | Left Anterior Thigh | -
| - | - | ||||
-
-
-
-
- Registered Nurse
-
-
- Pediatrics
-
-
-
-
-
-
- Registered Nurse
-
- | Problem | -Noted Date | -Diagnosed Date | -
|---|---|---|
| Term newborn delivered vaginally, current hospitalization | -07/26/2024 | -- |
| Term birth of newborn female | -07/25/2024 | -- |
-
-
-
- | Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Newborn - TN Screen | -
- |
- - | - | 07/28/2024 11:01 AM CDT | -NONINTERFACED REFERENCE LAB | -- |
|
- |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | Capillary / Unknown | -07/26/2024 8:56 PM CDT | -07/27/2024 4:41 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Georgette Rochelle Sevier MD | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
- - | - |
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Bedside - Glucose | -59 | -45 - 110 mg/dL | -- | 07/26/2024 2:01 PM CDT | -BAPTIST MEMORIAL HOSPITAL-WOMENS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -BLOOD SPECIMEN / Unknown | -- | 07/26/2024 1:44 PM CDT | -07/26/2024 2:01 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Georgette Rochelle Sevier MD | -POINT OF CARE TEST ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| RPR | -
- |
- Non Reactive | -- | 07/29/2024 3:28 PM CDT | -AEL | -- |
|
- - American - Esoteric Laboratories 1701 Century Center Cove Memphis, TN 38134 Laboratory Director: - Holly H. Pierce, M.D. CLIA# 44D0889744 |
- ||||||
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | Venipuncture / Unknown | -07/26/2024 8:00 AM CDT | -07/26/2024 8:21 AM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Georgette Rochelle Sevier MD | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| - Hematocrit | -55.2 | -45.0 - <65.0 % | -- | 07/26/2024 8:32 AM CDT | -BAPTIST MEMORIAL HOSPITAL-WOMENS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -- | Venipuncture / Unknown | -07/26/2024 8:00 AM CDT | -07/26/2024 8:21 AM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Georgette Rochelle Sevier MD | -LAB BLOOD ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Bedside - Glucose | -67 | -45 - 110 mg/dL | -- | 07/26/2024 8:31 AM CDT | -BAPTIST MEMORIAL HOSPITAL-WOMENS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -BLOOD SPECIMEN / Unknown | -- | 07/26/2024 7:34 AM CDT | -07/26/2024 8:31 AM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Georgette Rochelle Sevier MD | -POINT OF CARE TEST ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Bedside - Glucose | -58 | -45 - 110 mg/dL | -- | 07/26/2024 7:48 PM CDT | -BAPTIST MEMORIAL HOSPITAL-WOMENS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -BLOOD SPECIMEN / Unknown | -- | 07/26/2024 4:45 AM CDT | -07/26/2024 7:48 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Georgette Rochelle Sevier MD | -POINT OF CARE TEST ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Bedside - Glucose | -63 | -45 - 110 mg/dL | -- | 07/26/2024 1:52 AM CDT | -BAPTIST MEMORIAL HOSPITAL-WOMENS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -BLOOD SPECIMEN / Unknown | -- | 07/26/2024 1:42 AM CDT | -07/26/2024 1:52 AM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Georgette Rochelle Sevier MD | -POINT OF CARE TEST ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Bedside - Glucose | -73 | -45 - 110 mg/dL | -- | 07/26/2024 10:13 AM CDT | -BAPTIST MEMORIAL HOSPITAL-WOMENS | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -BLOOD SPECIMEN / Unknown | -- | 07/25/2024 9:51 PM CDT | -07/26/2024 10:13 AM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Georgette Rochelle Sevier MD | -POINT OF CARE TEST ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| DAT - direct IgG | -Negative | -- | - | 07/25/2024 9:32 PM CDT | -BMH - WOMENS BLOOD BANK LABORATORY | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -CORD BLOOD SPECIMEN / Unknown | -Collection / Unknown | -07/25/2024 8:09 PM CDT | -07/25/2024 8:23 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Georgette Rochelle Sevier MD | -BLOOD BANK TEST ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| ABO - Cord Blood | -A | -- | - | 07/25/2024 9:32 PM CDT | -BMH - WOMENS BLOOD BANK LABORATORY | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -CORD BLOOD SPECIMEN / Unknown | -Collection / Unknown | -07/25/2024 8:09 PM CDT | -07/25/2024 8:23 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Georgette Rochelle Sevier MD | -BLOOD BANK TEST ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
| Component | -Value | -Ref Range | -Test Method | -Analysis Time | -Performed At | -Pathologist Signature | -
|---|---|---|---|---|---|---|
| Maternal - Data | -See mother's chart for maternal Type and Screen results. | -- | - | 07/25/2024 9:32 PM CDT | -BMH - WOMENS BLOOD BANK LABORATORY | -- |
| Specimen (Source) | -Anatomical Location / Laterality | -Collection Method / Volume | -Collection Time | -Received Time | -
|---|---|---|---|---|
| Blood | -CORD BLOOD SPECIMEN / Unknown | -Collection / Unknown | -07/25/2024 8:09 PM CDT | -07/25/2024 8:23 PM CDT | -
| Narrative | -
|---|
|
- |
-
| Authorizing Provider | -Result Type | -
|---|---|
| Georgette Rochelle Sevier MD | -BLOOD BANK TEST ORDERABLES | -
| Performing Organization | -Address | -City/State/ZIP Code | -Phone Number | -
|---|---|---|---|
|
- |
-
- |
-
- |
-
- |
-
- Cord blood workup
-
-
- Pediatrics
-
-
- Blood
-
-
- Maternal Data
-
-
- Collection
-
-
- ABO Group Cord Blood
-
-
- Pediatrics
-
-
- Blood
-
-
- ABO Cord Blood
-
-
- Collection
-
-
- Coombs Test, Direct, IgG
-
-
- Pediatrics
-
-
- Blood
-
-
- DAT direct IgG
-
-
- Collection
-
-
- Glucose bedside
-
-
- Pediatrics
-
-
- Blood
-
-
- Bedside Glucose
-
-
- Lab Interpretation
-
-
- Glucose bedside
-
-
- Pediatrics
-
-
- Blood
-
-
- Bedside Glucose
-
-
- Lab Interpretation
-
-
- Glucose bedside
-
-
- Pediatrics
-
-
- Blood
-
-
- Bedside Glucose
-
-
- Lab Interpretation
-
-
- Glucose bedside
-
-
- Pediatrics
-
-
- Blood
-
-
- Bedside Glucose
-
-
- Lab Interpretation
-
-
- Hematocrit
-
-
- Pediatrics
-
-
- Blood
-
-
- Hematocrit
-
-
- Lab Interpretation
-
-
- Venipuncture
-
-
- RPR quantitative
-
-
- Pediatrics
-
-
- Blood
-
-
- RPR
-
-
- Venipuncture
-
-
- Glucose bedside
-
-
- Pediatrics
-
-
- Blood
-
-
- Bedside Glucose
-
-
- Lab Interpretation
-
-
- Newborn screen TN panel
-
-
- Pediatrics
-
-
- Blood
-
-
- Newborn TN Screen
-
-
- Capillary
-
- | Tobacco Use | -Types | -Packs/Day | -Years Used | -Date | -
|---|---|---|---|---|
| Smoking Tobacco: Never Assessed | -- | - | - | - |
| Sex and Gender Information | -Value | -Date Recorded | -
|---|---|---|
| Sex Assigned at Birth | -Not on file | -- |
| Gender Identity | -Not on file | -- |
| Sexual Orientation | -Not on file | -- |
| Date | -Type | -Department | -Care Team (Latest Contact Info) | -Description | -
|---|---|---|---|---|
| 07/25/2024 8:08 PM CDT - 07/27/2024 3:52 PM CDT | -Hospital Encounter | -
- |
-
- |
- Discharge Disposition: Home | -
-
-
-
-
- Pediatrics
-
-
- Obstetrics
-
-
-
-
-
-