ID ActualReleaseDate NameOfYouth RaceEthnicity MediCalID ResidentialAddress Telephone MediCalHealthPlan HealthScreenings HealthAssessments ChronicConditions PrescribedMedications Notes CarePlanNotes
1 2023-10-26 Marcus Johnson African American MC987654321 123 Oak Street, Oakland, CA 94601 (510) 555-0101 Anthem Blue Cross Completed: BMI, Blood Pressure, TB, Hepatitis C. All within normal range except elevated BP. Moderate risk for cardiovascular disease. Good physical health overall. Mild anxiety noted. Hypertension (Stage 1), Generalized Anxiety Disorder Lisinopril 10mg daily, Hydrochlorothiazide 12.5mg daily Client is motivated to manage his health. Has family support in the area. Patient presents with new diagnosis of Hypertension. Education provided on low-sodium diet, importance of regular exercise, and medication adherence. Plan for bi-weekly BP checks for first month. Will refer to primary care for ongoing management. Anxiety is well-managed with current coping strategies; will monitor.
2 2023-11-15 Jessica Martinez Hispanic/Latina MC123456789 456 Maple Ave, Los Angeles, CA 90001 (213) 555-0155 Health Net Completed: BMI, Blood Pressure, TB, HIV. Hep C positive. Dental screening shows urgent need for care. High risk due to chronic Hepatitis C infection. Nutritional assessment indicates poor diet. Hepatitis C (genotype 1a), Dental Caries Multivitamin daily, Ibuprofen 400mg as needed for pain Hep C treatment has been initiated. Patient has stable housing. Primary focus is linkage to Hepatology for HCV treatment with Mavyret. Patient has started 8-week regimen and is tolerating well. Coordinated care with dentist for multiple extractions and eventual dentures. Emphasized importance of abstaining from alcohol. Patient engaged and optimistic about treatment.
3 2023-09-01 David Chen Asian MC246801357 789 Pine Road, San Francisco, CA 94102 (415) 555-0199 Kaiser Permanente Completed: All screenings. BMI indicates obesity. Blood glucose elevated. High risk for Type 2 Diabetes. Sleep assessment reveals probable sleep apnea. Obesity (BMI 33), Pre-Diabetes, Obstructive Sleep Apnea Metformin 500mg twice daily Patient has CPAP machine but does not use it consistently. Seeking employment. Goals are weight loss and glycemic control. Discussed diabetes prevention program referral. Nutritionist consultation scheduled. Reinforced critical importance of CPAP compliance for cardiovascular health and energy levels. Patient set a goal to walk 30 minutes daily. Follow-up in 2 weeks to check progress.
4 2023-12-10 Amanda Williams Caucasian MC135792468 101 Elm Blvd, Sacramento, CA 95814 (916) 555-0123 Molina Healthcare Completed: BMI, BP, TB. BP mildly elevated. Depression screening (PHQ-9) score: 15 (moderate severity). Mental health is primary concern. Physically healthy. Major Depressive Disorder, Recurrent Sertraline 100mg daily History of trauma. Has outpatient therapist appointment set up. Patient is transitioning back to existing mental health care team. PHQ-9 indicates need for continued medication and therapy. Safety plan reviewed. Patient agrees to schedule with therapist within one week. Will monitor for side effects from Sertraline (started 2 weeks ago). Strong support system noted.
5 2024-01-05 Tyrese Jackson African American MC864209753 222 Cedar Ln, Compton, CA 90220 (310) 555-0167 Blue Shield of CA Completed: All screenings unremarkable. Excellent physical health. Low risk. No chronic conditions. High resilience noted. None None Client is athletic and focused on finding work. No health concerns. Patient is in excellent health with no ongoing medical needs. Provided education on maintaining healthy habits and accessing preventive care (e.g., annual physicals). Encouraged to connect with a PCP for establish care. No further follow-up needed from re-entry program.
6 2023-08-20 Maria Garcia Hispanic/Latina MC555444333 333 Vine Street, San Diego, CA 92101 (619) 555-0177 Community Health Group Completed: BMI, BP. Diagnosed with Asthma. Dental screening showed gingivitis. Well-controlled asthma. Requires dental cleaning. Asthma Albuterol inhaler, use as needed Uses inhaler rarely, mostly during allergy season. Good medication adherence. Asthma action plan reviewed. Patient demonstrates proper inhaler technique. Refill provided. Encouraged to keep inhaler accessible. Referral to low-cost dental clinic for cleaning. Patient is health-literate and manages her condition well.
7 2024-02-14 James Wilson Caucasian MC777888999 444 Redwood Dr, Riverside, CA 92501 (951) 555-0188 Inland Empire Health Plan Completed: BMI, BP, TB. All normal. Patient reports chronic knee pain. Assessment confirms likely osteoarthritis from old injury. No signs of acute issue. Osteoarthritis (right knee) Acetaminophen 1000mg as needed, Naproxen 220mg as needed Former construction worker. Pain interferes with job seeking. Conservative pain management plan initiated. Educated on weight-bearing exercise, use of heat/ice, and OTC medication regimen. Referred to vocational rehab for job training that accommodates knee limitations. Discussed potential for physical therapy evaluation if no improvement in 4 weeks.
8 2023-07-30 Sophia Kim Asian MC222333444 555 Birch Cir, San Jose, CA 95110 (408) 555-0190 Santa Clara Family Health Plan Completed: Vision screening failed. BMI, BP normal. Reports headaches. Vision assessment confirms myopia. Headaches are likely tension-related and exacerbated by eye strain. Myopia, Tension Headaches Ibuprofen 400mg as needed for headache Has not had an eye exam in over 5 years. Needs glasses. Priority is linkage to optometrist. Provided referral for low-cost eye exam and glasses. Patient advised to limit screen time and take visual breaks. Headaches should be re-evaluated after corrective lenses are obtained. Patient appreciative of the resource.
9 2024-03-22 Michael Davis African American MC999000111 666 Spruce Ave, Fresno, CA 93701 (559) 555-0111 CalViva Health Completed: BMI indicates overweight. BP normal. HbA1c: 6.8% (Diabetes). Newly diagnosed Type 2 Diabetes. Patient is unaware of disease management. Type 2 Diabetes Metformin 1000mg daily Patient expressed shock at diagnosis. Willing to learn. Significant education provided on diabetes: diet, exercise, monitoring, and medication. Referred to diabetes education class and nutritionist. Glucometer training provided. Goal is to achieve HbA1c under 7%. Emphasized that this is a manageable condition. Follow-up scheduled in 1 month to check glucose logs and adjust Metformin as needed.
10 2023-11-01 Bryan Miller Caucasian MC888777666 777 Magnolia St, Long Beach, CA 90802 (562) 555-0124 L.A. Care Health Plan Completed: BMI, BP normal. TB test positive (latent). STI screening negative. Diagnosed with Latent TB Infection (LTBI). Requires treatment. Otherwise healthy. Latent Tuberculosis Infection Isoniazid 300mg daily, Pyridoxine 50mg daily (for 9 months) Patient is anxious about taking medication for so long. Needs education on importance. Initiated treatment for LTBI. Extensive education provided on the importance of completion to prevent active TB disease. Discussed side effects to watch for (e.g., liver toxicity). Monthly follow-up scheduled for medication refills and monitoring. Patient verbalized understanding and agreed to treatment plan.
11 2023-12-01 Elena Rodriguez Hispanic/Latina MC112233445 890 Sunset Blvd, San Francisco, CA 94110 (415) 555-0200 Anthem Blue Cross Completed: BMI, BP, Vision. BP slightly elevated. Vision screening suggests presbyopia. Low risk for chronic disease. Needs reading glasses. Mild stress related to re-entry. None None Client is a non-smoker. Eager to reconnect with family. Patient is in good overall health. Discussed lifestyle strategies to manage borderline BP, including stress reduction techniques. Provided a referral for a vision exam. Encouraged to establish care with a PCP for annual wellness checks.
12 2024-04-10 Devin Brown African American MC556677889 123 Jaguar Rd, Oakland, CA 94605 (510) 555-0201 Kaiser Permanente Completed: BMI, BP, TB, Hep C. All normal. Dental screening reveals two cavities. Good physical health. Requires dental work. None None Client is an avid runner. Has a job interview next week. No acute medical issues. Healthy, active patient. Referred to a dental clinic for restorative work. Reinforced importance of preventive dental care. No further medical follow-up needed.
13 2023-10-10 Kevin Zhang Asian MC998877665 456 Tech Way, San Jose, CA 95123 (408) 555-0202 Santa Clara Family Health Plan Completed: BMI, BP. Reports persistent heartburn and acid reflux. Assessment suggests Gastroesophageal Reflux Disease (GERD). GERD Omeprazole 20mg daily Symptoms worsen with coffee and spicy food. Avoids medication. Educated patient on dietary modifications for GERD (avoiding triggers, smaller meals). Encouraged consistent use of Omeprazole for 4 weeks to heal esophageal inflammation. Plan to reassess symptoms after trial period.
14 2024-01-25 Brianna Thompson Caucasian MC443322116 789 Galaxy Lane, Los Angeles, CA 90015 (213) 555-0203 Health Net Completed: BMI, BP, Depression (PHQ-9). PHQ-9 score: 18 (moderately severe). Mental health is a significant concern. Patient reports low energy and anhedonia. Major Depressive Disorder Escitalopram 10mg daily History of PTSD. Has a supportive partner. Initiated medication for depression. Discussed potential side effects and delayed onset of action (2-4 weeks). Safety plan reviewed. Coordinated with existing therapist to ensure continuity of care. Scheduled close follow-up in 2 weeks to monitor medication response.
15 2023-11-30 Carlos Mendez Hispanic/Latino MC777665544 321 Mission St, Salinas, CA 93901 (831) 555-0204 Central California Alliance for Health Completed: BMI, BP, TB. BP highly elevated. Random glucose: 220 mg/dL. High risk. Hypertensive urgency and suspected untreated diabetes. Hypertension (Stage 2), Type 2 Diabetes Lisinopril 20mg daily, Metformin 1000mg twice daily Patient was unaware of these conditions. Frightened but engaged. Urgent need for BP and glucose control. Initiated dual medication therapy. Provided extensive education on both conditions, including home monitoring. Arranged same-week appointment with a primary care provider for ongoing management. Emphasized critical importance of adherence.
16 2024-02-28 Tiffany Brooks African American MC123987456 654 Artist Ave, Berkeley, CA 94704 (510) 555-0205 Blue Shield of CA Completed: BMI, BP normal. Asthma screening positive. Uses inhaler frequently. Poorly controlled persistent asthma. Asthma Albuterol inhaler, Fluticasone/Salmeterol 100/50mcg twice daily Triggers include smoke and pollen. Wakes up at night coughing. Switched patient to a combination inhaler for better long-term control. Reviewed proper inhaler technique and created a detailed asthma action plan. Goal is to reduce rescue inhaler use to less than twice a week. Follow-up in 1 month to assess control.
17 2023-09-15 Victor Petrov Caucasian MC555111222 987 fir Ct, Sacramento, CA 95816 (916) 555-0206 Molina Healthcare Completed: BMI, BP, TB. Old shoulder injury causes pain and limited range of motion. Assessment confirms adhesive capsulitis (frozen shoulder). Frozen Shoulder (left) Naproxen 500mg twice daily as needed for pain Injury occurred 6 months ago. Pain limits daily activities. Referred to physical therapy to restore range of motion and reduce pain. Educated on home exercises and use of NSAIDs for pain and inflammation. Discussed expected slow recovery (6 months to 2 years). Patient motivated to engage in PT.
18 2024-03-05 Leilani Kealoha Native Hawaiian/Pacific Islander MC864213579 555 Aloha Way, Honolulu, HI 96815 (808) 555-0207 AlohaCare Completed: BMI indicates obesity. BP normal. High risk for diabetes per screening. High risk for metabolic disease. Strong family history of diabetes. Obesity (BMI 36), Pre-Diabetes None Client expresses desire to lose weight for her children. Culturally prefers group activities. Focused on diabetes prevention. Referred to a culturally appropriate lifestyle change program. Discussed dietary changes and incorporating traditional activities like hula for exercise. Will follow up on progress in 1 month. Goal is 5% weight loss.
19 2023-08-05 Darnell Smith African American MC159487263 741 Liberty St, Philadelphia, PA 19106 (215) 555-0208 Keystone First Completed: BMI, BP, TB, Hep C. Hep C Ab positive. BP elevated. Chronic Hepatitis C infection. Hypertension. Hepatitis C, Hypertension Lisinopril 10mg daily Patient has been unaware of Hep C status. Anxious but ready to address it. Linked patient to hepatology for HCV RNA confirmation and treatment evaluation. Excellent cure rates expected with new medications. Initiated Lisinopril for BP control. Addressed patient anxiety with clear information and a definitive treatment plan.
21 2024-01-15 Ramon Silva Hispanic/Latino MC286429753 369 Grove St, Stockton, CA 95202 (209) 555-0210 Health Net Completed: BMI, BP. Poor dentition, multiple missing teeth. Reports difficulty eating. Primary issue is dental health, impacting nutritional status. Otherwise healthy. None None Patient is embarrassed by smile and avoids certain foods. Motivated for dental work. Primary goal is restorative dental care. Provided referral to a dental school clinic for extensive work, including possible partial dentures. Discussed soft food diet options in the interim. Patient is a high priority for dental intervention to improve quality of life and nutrition.
22 2023-12-20 Tasha Wilkins African American MC975318642 159 MLK Blvd, Richmond, CA 94804 (510) 555-0211 Anthem Blue Cross Completed: BMI, BP, Depression (PHQ-9). PHQ-9 score: 10 (mild). Anxiety (GAD-7) score: 14 (moderate). Mental health assessment indicates mixed anxiety and depressive disorder. Generalized Anxiety Disorder, Mild Depressive Disorder Sertraline 50mg daily (to target both anxiety and depression) History of panic attacks. Uses meditation to cope. Starting new job soon. Initiated low dose SSRI. Discussed delayed onset of action and potential initial side effects (nausea, jitteriness). Reinforced use of meditation and mindfulness techniques. Scheduled follow-up in 2 weeks to assess medication tolerance and efficacy. Encouraged to avoid caffeine.
23 2024-04-05 Kenji Tanaka Asian MC642975318 753 Sakura Lane, San Francisco, CA 94122 (415) 555-0212 Kaiser Permanente Completed: BMI, BP normal. Skin screening reveals suspicious mole on back. Referred for dermatology evaluation. No other concerns. None None Patient has a family history of melanoma. Very concerned about the mole. Urgent referral to dermatology for biopsy of atypical mole. Patient educated on ABCDEs of melanoma. Plan is to monitor closely and proceed with excision if necessary. reassured patient that early detection is key. High priority due to family history.
24 2023-11-05 Angelica Cruz Hispanic/Latina MC123456000 852 Mission St, Daly City, CA 94014 (650) 555-0213 San Francisco Health Plan Completed: BMI indicates underweight. BP normal. Anemia screening positive (low Hgb). Nutritional assessment suggests iron deficiency anemia. Poor dietary intake. Iron Deficiency Anemia Ferrous Sulfate 325mg daily, Vitamin C 500mg daily (to aid absorption) Patient is a picky eater and avoids red meat. Reports fatigue and dizziness. Initiated iron supplementation. Educated on iron-rich foods (leafy greens, beans, fortified cereals) and importance of Vitamin C for absorption. Discussed managing side effects like constipation. Referred to a nutritionist. Goal is to normalize Hgb levels and resolve fatigue. Follow-up in 1 month for repeat lab work.
25 2024-02-10 Leroy Jones African American MC000789456 456 Hardwood St, Compton, CA 90221 (310) 555-0214 L.A. Care Health Plan Completed: BMI, BP, TB. Old gunshot wound to leg with chronic nerve pain. Assessment confirms chronic neuropathic pain syndrome. Peripheral Neuropathy Gabapentin 300mg three times daily Pain interferes with sleep and standing for long periods. Previous medications ineffective. Initiated Gabapentin for neuropathic pain. Titrating dose slowly to minimize dizziness and drowsiness. Set realistic expectations for pain management (goal is 50% reduction, not elimination). Referred to pain clinic for comprehensive management. Discussed non-pharmacological strategies like gentle stretching.
26 2023-10-01 Mei Lin Asian MC789123456 987 Summit Ave, Oakland, CA 94610 (510) 555-0215 Blue Shield of CA Completed: BMI, BP normal. Hearing screening shows significant loss in right ear. Audiology assessment confirms unilateral sensorineural hearing loss. Unilateral Hearing Loss (right side) None Injury-related from years ago. Has adapted but struggles in noisy environments. Referred to ENT for further evaluation and to discuss options such as a hearing aid for the right ear. Educated on strategies for communication, like positioning on the left side. No medical treatment available for the loss itself, focus is on auditory rehabilitation.
27 2024-03-15 Brandon White Caucasian MC456123789 654 River Rd, San Diego, CA 92108 (619) 555-0216 Community Health Group Completed: BMI, BP normal. STI screening positive for Chlamydia. Treated on site. No chronic conditions. Treated for acute STI. None Azithromycin 1g single dose, Doxycycline 100mg twice daily for 7 days Patient was asymptomatic. Agreed to notify partners. Treated for uncomplicated chlamydial infection. Provided extensive education on STI prevention, including consistent condom use. Emphasized the importance of partner notification and treatment to prevent reinfection. Advised to return for a test-of-cure in 3 months. Reiterated the importance of regular STI screening.
28 2023-09-20 Derek Johnson African American MC321654987 123 Plains St, Bakersfield, CA 93301 (661) 555-0217 Kern Family Health Care Completed: BMI indicates obesity. BP elevated. HbA1c: 5.9% (normal). Metabolic syndrome. High risk for diabetes and cardiovascular disease. Obesity (BMI 31), Hypertension (Stage 1) Lisinopril 5mg daily Patient drinks 2-3 sugary sodas daily. Sedentary lifestyle. Focus on aggressive lifestyle modification. Initiated low-dose ACE inhibitor for BP. Discussed cutting out sugary drinks as a primary goal. Referred to nutrition counseling and a free community exercise program. Goal is weight loss and preventing progression to diabetes. Follow-up in 1 month to check BP and discuss progress.
29 2024-04-18 Isabella Rossi Caucasian MC159753468 357 Vineyard Way, Napa, CA 94558 (707) 555-0218 Partnership HealthPlan of CA Completed: BMI, BP normal. Allergy screening positive for environmental allergens. Assessment confirms seasonal allergic rhinitis. Allergic Rhinitis Fluticasone nasal spray daily, Cetirizine 10mg daily as needed Symptoms include sneezing, itchy eyes, and runny nose, worse in spring. Educated on allergen avoidance strategies. Initiated first-line treatment with nasal corticosteroid spray for better control than oral antihistamines alone. Advised to start medication at first sign of symptoms. Plan is for seasonal management. Patient understands treatment regimen.
30 2023-08-28 Mateo Garcia Hispanic/Latino MC852963741 741 Construction Ave, Fresno, CA 93721 (559) 555-0219 CalViva Health Completed: BMI, BP normal. Musculoskeletal exam reveals chronic lower back pain. Assessment suggests mechanical low back pain, likely from heavy lifting. Chronic Low Back Pain Ibuprofen 600mg as needed for pain, Cyclobenzaprine 10mg at night as needed for muscle spasms Pain is a barrier to returning to previous construction work. Developed a plan for conservative management: physical therapy referral for core strengthening, education on proper lifting techniques, and a short course of muscle relaxants for acute flares. Discussed alternative career paths that are less physically demanding. Focus on functional improvement.
31 2024-05-15 Shawn Johnson African American MC741852963 963 East Ave, Modesto, CA 95350 (209) 555-0220 Health Net Completed: BMI, BP normal. Dental screening shows severe gingivitis and plaque buildup. Primary concern is periodontal disease. Otherwise healthy. Periodontal Disease Chlorhexidine mouthwash twice daily Patient reports gums bleed when brushing. Has not seen a dentist in over 10 years. Referred urgently to a dentist for deep cleaning and evaluation. Educated on proper oral hygiene technique. Goal is to prevent tooth loss and manage active infection. Patient committed to improving dental health.
32 2023-07-14 Olivia Parker Caucasian MC963852741 258 West St, Santa Cruz, CA 95060 (831) 555-0221 Central California Alliance for Health Completed: BMI, BP. Depression (PHQ-9) score: 20 (severe). Suicidal ideation denied. Severe major depressive episode. High risk for self-harm. Major Depressive Disorder, Severe Fluoxetine 20mg daily History of self-harm in adolescence. Isolates self in room. Initiated SSRI and scheduled daily wellness checks with community health worker. Created detailed safety plan with emergency contacts. expedited appointment with psychiatrist and therapist. High-priority case for close mental health monitoring.
33 2024-06-01 Darius King African American MC159357486 357 Jazz Blvd, New Orleans, LA 70116 (504) 555-0222 Louisiana Healthcare Connections Completed: BMI, BP, HbA1c. HbA1c: 10.5% (poorly controlled diabetes). Diabetes is uncontrolled. High risk for complications. Type 2 Diabetes, Uncontrolled Metformin 1000mg twice daily, Glipizide 5mg daily Patient admits to poor diet and not checking blood sugar. Overwhelmed. Critical need for diabetes education and management. Referred to endocrinologist. Provided glucometer and trained on use. Set strict goals for blood glucose monitoring before meals. Emphasized risk of complications. Family involved in care plan.
34 2023-08-10 Ethan Moore Caucasian MC486275139 654 Lakeview Dr, Lake Tahoe, CA 96150 (530) 555-0223 Anthem Blue Cross Completed: BMI, BP normal. Sports physical reveals old ACL tear with instability. Orthopedic assessment confirms ACL deficiency in right knee. ACL Tear (old, unrepaired) Ibuprofen 600mg as needed for pain Patient wants to return to skiing and hiking. Knee gives way during activity. Referred to orthopedic surgery for consultation. Discussed potential for reconstructive surgery vs. physical therapy. advised to avoid high-impact activities until evaluated. Provided knee stabilizer for daily use.
35 2024-02-05 Nina Patel Asian MC753159486 852 Curry Lane, Artesia, CA 90701 (562) 555-0224 L.A. Care Health Plan Completed: BMI, BP normal. Vision screening shows severe myopia. High myopia. Requires corrective lenses urgently. Severe Myopia None Patient cannot see clearly beyond a few inches. Unable to read or recognize faces. Urgent referral to optometrist for prescription glasses. Patient is functionally blind without correction. High priority for vision care to enable safe navigation and job seeking.
36 2023-12-12 Juan Martinez Hispanic/Latino MC357486912 147 South St, San Antonio, TX 78205 (210) 555-0225 Blue Cross Blue Shield of Texas Completed: BMI, BP elevated. Cholesterol panel shows high LDL. High risk for cardiovascular disease. Metabolic syndrome. Hyperlipidemia, Hypertension (Stage 1) Atorvastatin 20mg daily, Lisinopril 10mg daily Family history of heart disease. Eats a lot of fried foods. Initiated statin and ACE inhibitor. Strong emphasis on therapeutic lifestyle changes: low-fat diet, exercise. Referred to nutritionist. Goal is to reduce LDL by 50% and normalize BP. Follow-up labs in 3 months.
37 2024-01-31 Aaliyah Brown African American MC912486735 963 Soul Food Ave, Memphis, TN 38116 (901) 555-0226 UnitedHealthcare Completed: BMI indicates obesity. BP normal. Sleep study confirms sleep apnea. Severe obstructive sleep apnea. High risk for cardiovascular events. Obesity (BMI 38), Severe Obstructive Sleep Apnea None yet Patient reports extreme daytime sleepiness and loud snoring. Referred to sleep medicine for CPAP titration and setup. Emphasized that treatment is critical for heart health and reducing daytime fatigue. Discussed weight loss as a long-term goal to improve condition.
39 2024-03-30 Luis Hernandez Hispanic/Latino MC287469135 123 Taco Blvd, Phoenix, AZ 85012 (602) 555-0228 Arizona Complete Health Completed: BMI, BP normal. Foot exam reveals loss of sensation (neuropathy). Diabetic peripheral neuropathy. Previously undiagnosed diabetes suspected. Peripheral Neuropathy, Rule Out Diabetes None yet Patient reports tingling and numbness in feet for several months. Urgent orders for HbA1c and metabolic panel. Referred to podiatry and neurology. Education on foot care to prevent ulcers. Diagnosis of diabetes is likely; plan will be finalized after lab results.
40 2023-10-05 Zoe Mitchell Caucasian MC135792468 456 Artisan St, Portland, OR 97205 (503) 555-0229 CareOregon Completed: BMI, BP normal. Complexion pale. Reports heavy menstrual bleeding. Assessment suggests anemia secondary to menorrhagia. Menorrhagia, Iron Deficiency Anemia Ferrous Sulfate 325mg daily, Tranexamic acid during menses Patient has history of fibroids. Anemia causing significant fatigue. Initiated iron therapy. Referred to gynecology for evaluation of fibroids and management of heavy bleeding. Treatment plan aims to address both the cause and symptom of anemia.
41 2024-04-22 Malik Williams African American MC864209751 753 Basketball Ct, Chicago, IL 60612 (773) 555-0230 Blue Cross Blue Shield of Illinois Completed: BMI, BP normal. Asthma screening positive. Uses rescue inhaler daily. Poorly controlled persistent asthma. Frequent exacerbations. Persistent Asthma Albuterol inhaler, started on Budesonide/Formoterol 160/4.5mcg twice daily Triggers include cold air and exercise. Limits his ability to play sports. Switched to combination inhaler for maintenance and control. provided detailed asthma action plan. Educated on importance of daily controller medication. Goal is to reduce rescue inhaler use to less than once a week.
42 2023-09-05 Chloe Davis Caucasian MC123450987 159 Bookworm Ln, Seattle, WA 98104 (206) 555-0231 Molina Healthcare Completed: BMI, BP normal. Diagnosed with migraines. Assessment confirms migraine without aura. Migraine Disorder Sumatriptan 50mg as needed for migraine, Topiramate 25mg daily for prevention Migraines occur 2-3 times a month, are debilitating. Initiated preventive therapy with Topiramate. provided abortive medication for acute attacks. Educated on trigger tracking (stress, lack of sleep, certain foods). Follow-up in 1 month to assess prevention efficacy.
43 2024-05-05 José Lopez Hispanic/Latino MC987654321 321 Family Rd, Miami, FL 33135 (305) 555-0232 Sunshine Health Completed: BMI, BP, Glucose. Random glucose: 300 mg/dL. Diabetes is uncontrolled and likely new onset. Type 2 Diabetes, New Onset Metformin 500mg twice daily, Glipizide 5mg daily Patient reports excessive thirst and urination. Family history of diabetes. Urgent diabetes education initiated. Started on dual medication therapy. Provided glucometer and training. Referred to endocrinology. Emphasized critical need for dietary changes and medication adherence.
44 2023-07-30 Caleb Smith Caucasian MC456789123 654 Lumberjack Ave, Spokane, WA 99201 (509) 555-0233 Community Health Plan of Washington Completed: BMI, BP normal. Hearing test shows significant loss in both ears. Bilateral sensorineural hearing loss. Requires hearing aids. Bilateral Sensorineural Hearing Loss None Worked in construction without ear protection for 20 years. Difficulty communicating. Referred to ENT and audiology for hearing aid evaluation and fitting. discussed communication strategies. Explored vocational rehab for potential job retraining.
45 2024-01-10 Bianca Jones African American MC789456123 987 Fashion St, Atlanta, GA 30318 (404) 555-0234 Peach State Health Plan Completed: BMI, BP normal. Skin exam reveals extensive psoriasis plaques. Moderate to severe psoriasis affecting quality of life. Psoriasis Topical Clobetasol cream, referred for phototherapy Condition is itchy and embarrassing for patient. Avoids short sleeves. Initiated high-potency topical steroid. Referred to dermatology for advanced treatment options like phototherapy or biologics. Focus on improving skin clearance and quality of life.
46 2023-11-01 Noah Wilson Caucasian MC321654987 159 Engineer Dr, Raleigh, NC 27601 (919) 555-0235 UnitedHealthcare Completed: BMI, BP normal. Diagnosed with ADHD as a child. Assessment confirms ongoing symptoms of adult ADHD impacting job performance. Adult ADHD Started on Extended-Release Methylphenidate 18mg daily Reports inability to focus, disorganization, and impulsivity. Initiated trial of stimulant medication. Referred for ADHD coaching and cognitive behavioral therapy. Goal is to improve executive functioning skills for successful employment.
47 2024-04-01 Sofia Ramirez Hispanic/Latina MC654987321 753 Salsa St, El Paso, TX 79901 (915) 555-0236 Blue Cross Blue Shield of Texas Completed: BMI, BP normal. Prenatal labs show iron deficiency. Otherwise healthy pregnancy with common secondary anemia. Pregnancy, Iron Deficiency Anemia Prenatal Vitamin, additional Ferrous Sulfate 325mg daily 18 weeks pregnant. Fatigue is increasing. Increased iron supplementation to treat anemia. Reassured that this is common in pregnancy. Emphasized importance of nutrition and prenatal care attendance. Follow-up CBC in 4 weeks.
48 2023-08-15 Gabriel Lewis African American MC987321654 456 Bass Pl, Detroit, MI 48201 (313) 555-0237 Meridian Health Plan Completed: BMI, BP elevated. Urinalysis shows proteinuria (+2). Concern for underlying kidney disease. Hypertension likely contributor. Hypertension (Stage 2), Proteinuria Lisinopril 20mg daily (for BP and kidney protection) Family history of kidney failure. Very concerned about results. Initiated ACE inhibitor for dual benefit. Referred to nephrology for further workup. Orders for 24-hour urine collection and metabolic panel. Education on low-sodium diet.
49 2024-02-20 Maya Chen Asian MC147258369 789 Scholar Way, Cambridge, MA 02138 (617) 555-0238 MassHealth Completed: BMI, BP normal. High anxiety regarding transition to community. Primary issue is adjustment disorder with anxiety. No physical health problems. Adjustment Disorder with Anxiety Referred to therapy, no medications initiated Graduate student. Feels overwhelmed by re-entry process. Focus on mental health support and resource connection. Referred to university counseling services and a support group for formerly incarcerated individuals. Encouraged to use academic resources. Stress management techniques taught.
50 2023-12-25 David Jones Caucasian MC369258147 252 Christmas Ave, Denver, CO 80202 (303) 555-0239 Colorado Medicaid Completed: BMI, BP normal. Frostbite injury to toes from past homelessness. Old frostbite injury with residual neuropathy and cold sensitivity. Frostbite Sequelae Gabapentin 100mg three times daily for neuropathic pain Toes are numb but painfully sensitive to cold. Initiated Gabapentin for neuropathic pain. Educated on importance of protecting feet from cold. Referred to podiatry for ongoing care. Provided resources for warm clothing and stable housing support.
51 2024-03-10 Jasmine Allen African American MC582416739 123 Harmony Ln, Nashville, TN 37201 (615) 555-0240 UnitedHealthcare Completed: BMI, BP normal. Vocal hoarseness persistent for 3 months. Referred to ENT for evaluation of chronic laryngitis. Chronic Laryngitis None Singer in a local band. Very concerned about voice. Referred to ENT for laryngoscopy to rule out nodules or polyps. Advised vocal rest and hydration. Stress management recommended.
52 2023-10-18 Brian Taylor Caucasian MC739184625 456 Data Dr, Austin, TX 78701 (512) 555-0241 Blue Cross Blue Shield of Texas Completed: BMI, BP normal. Diagnosed with GERD. Symptoms well-controlled with medication. GERD well-managed. No other issues. GERD Omeprazole 20mg daily Works in tech. Symptoms controlled if medication taken regularly. Patient is stable on current regimen. Encouraged to continue medication and avoid trigger foods. Annual follow-up sufficient.
53 2024-05-28 Maria Gonzalez Hispanic/Latina MC625937481 789 Sunshine Blvd, Tucson, AZ 85701 (520) 555-0242 Arizona Complete Health Completed: BMI, BP normal. Skin cancer screening reveals multiple actinic keratoses. Sun damage noted. Requires dermatology treatment. Actinic Keratosis Fluorouracil cream prescribed Lived in desert entire life. Fair skin. History of sunburns. Referred to dermatology for cryotherapy of larger lesions. Prescribed topical chemotherapy cream for field treatment. Sun protection education emphasized.
54 2023-09-12 Kevin Brown African American MC481629573 321 Trailway St, Boulder, CO 80302 (303) 555-0243 Colorado Medicaid Completed: BMI, BP normal. Concussion 3 weeks ago with persistent headaches. Post-concussion syndrome. Cognitive assessment normal. Post-Concussion Syndrome Acetaminophen as needed for headache Injury from fall. Difficulty with screens and bright lights. Recommend cognitive rest: limit screens, reading. Gradual return to activities. Follow-up in 4 weeks if symptoms persist. Neurologist referral if not improving.
55 2024-04-15 Lisa Wang Asian MC573486192 654 Dragon St, Chinatown, NY 10013 (212) 555-0244 EmblemHealth Completed: BMI, BP normal. Osteoporosis screening shows low bone density for age. Osteopenia diagnosed. Increased fracture risk. Osteopenia Calcium 1200mg daily, Vitamin D 1000IU daily Family history of osteoporosis. Small frame. Initiated calcium and vitamin D supplementation. Weight-bearing exercise recommended. DEXA scan follow-up in 2 years. Fall prevention strategies discussed.
56 2023-11-30 Anthony Russo Caucasian MC192837465 987 Pizza Way, Brooklyn, NY 11201 (347) 555-0245 Healthfirst Completed: BMI indicates obesity. BP elevated. Sleep apnea symptoms reported. High probability of obstructive sleep apnea. Obesity (BMI 34), Suspected Sleep Apnea None yet Loud snoring, daytime sleepiness. Works night shifts. Referred for sleep study. Recommended weight loss and positional therapy. Discussed potential CPAP treatment.
57 2024-01-22 Danielle Green African American MC465728391 147 Soul St, Philadelphia, PA 19103 (215) 555-0246 Keystone First Completed: BMI, BP normal. PCOS diagnosed by history and symptoms. PCOS with irregular periods and hirsutism. Polycystic Ovary Syndrome (PCOS) Metformin 500mg daily, Spironolactone 50mg daily Weight gain around middle. Irregular periods. Initiated Metformin for insulin resistance and Spironolactone for hirsutism. Weight loss and exercise goals set. Gynecologist follow-up scheduled.
58 2024-06-05 Carlos Mendez Hispanic/Latino MC391846275 258 Salsa Ave, San Antonio, TX 78207 (210) 555-0247 Blue Cross Blue Shield of Texas Completed: BMI, BP normal. Tennis elbow diagnosed clinically. Lateral epicondylitis confirmed. Lateral Epicondylitis (Tennis Elbow) Naproxen 500mg twice daily, elbow brace Construction worker. Pain when gripping tools. Initiated NSAID and provided tennis elbow brace. Referred to physical therapy. Modified duty recommended temporarily.
59 2023-08-05 Amanda White Caucasian MC275639184 369 Snow Dr, Minneapolis, MN 55401 (612) 555-0248 UCare Completed: BMI, BP normal. Seasonal Affective Disorder history. Well in summer months. No current depression. Seasonal Affective Disorder (in remission) None Moves to warmer climate every winter. Plans same this year. No treatment needed currently. Discussed light therapy options for winter. Follow-up scheduled for October.
60 2024-02-14 Tyrone Johnson African American MC184527393 741 Blues Ave, St. Louis, MO 63101 (314) 555-0249 Home State Health Completed: BMI, BP normal. Ganglion cyst on wrist. Benign ganglion cyst. No treatment needed unless painful. Ganglion Cyst None Cyst fluctuates in size. Not currently painful. Education provided on benign nature of cyst. Recommend return if becomes painful or limits mobility. Surgical options discussed if future symptoms.
61 2023-12-08 Emily Chang Asian MC393716482 852 Lantern Ln, Seattle, WA 98101 (206) 555-0250 Molina Healthcare Completed: BMI, BP normal. IBS with constipation diagnosed. Irritable bowel syndrome predominately constipation. Irritable Bowel Syndrome with Constipation Polyethylene glycol daily, Hyoscyamine as needed for cramping Stress exacerbates symptoms. Dietary fiber helps. Initiated daily osmotic laxative and antispasmodic. Dietary modification recommended. Stress management techniques taught.
62 2024-03-25 Miguel Rodriguez Hispanic/Latino MC482593717 963 Fútbol Ct, Los Angeles, CA 90026 (213) 555-0251 L.A. Care Health Plan Completed: BMI, BP normal. Hamstring strain from soccer. Acute hamstring strain grade I. Hamstring Strain Ibuprofen 600mg three times daily, RICE protocol Soccer player. Injury occurred during game. Recommended rest, ice, compression, elevation. Physical therapy referral for rehabilitation. Return to play gradually in 3-4 weeks.
63 2023-10-10 Sarah Wilson Caucasian MC717284536 159 Book St, Portland, OR 97201 (503) 555-0252 CareOregon Completed: BMI, BP normal. Rosacea diagnosed. Mild rosacea with facial redness and flushing. Rosacea Metronidazole gel 0.75% daily, Sunscreen Symptoms worsen with sun, heat, and alcohol. Initiated topical antibiotic. Trigger avoidance education. Dermatology follow-up if not improved in 8 weeks.
64 2024-05-01 Jamal Harris African American MC536491827 357 Jazz Pl, New Orleans, LA 70113 (504) 555-0253 Louisiana Healthcare Connections Completed: BMI, BP normal. Gout attack in great toe. Acute gouty arthritis. Gout Indomethacin 50mg three times daily, Colchicine 0.6mg twice daily Previous gout attack 2 years ago. Dietary indiscretion. Initiated NSAID and colchicine for acute attack. Allopurinol considered for prophylaxis after attack resolves. Dietary education provided.
65 2023-09-28 Jennifer Lopez Hispanic/Latina MC827364915 654 Mariachi Sq, San Diego, CA 92113 (619) 555-0254 Community Health Group Completed: BMI, BP normal. Carpal tunnel syndrome symptoms. Clinical diagnosis of carpal tunnel syndrome. Carpal Tunnel Syndrome Wrist splint at night, Ibuprofen as needed Tingling in hands at night. Works as a cashier. Initiated conservative treatment with night splinting. Ergonomic evaluation recommended. Surgery discussed if symptoms persist.
66 2024-04-08 Robert Smith Caucasian MC915243876 987 Rock St, Cleveland, OH 44101 (216) 555-0255 Buckeye Health Plan Completed: BMI, BP normal. Plantar fasciitis diagnosis. Plantar fasciitis with heel pain. Plantar Fasciitis Stretching exercises, heel cups, NSAIDs as needed Pain worse in morning. Stands all day at work. Recommended calf stretches, supportive shoes, and heel cups. Physical therapy referral. Night splint discussed if not improved.
67 2023-11-15 Priya Patel Asian MC876129345 123 Spice Rd, Edison, NJ 08817 (732) 555-0256 Horizon NJ Health Completed: BMI, BP normal. Vitamin B12 deficiency per labs. Vitamin B12 deficiency, likely dietary. Vitamin B12 Deficiency Vitamin B12 1000mcg daily Lifelong vegetarian. Reports fatigue and tingling. Initiated B12 supplementation. Education on B12-fortified foods. Follow-up labs in 3 months to check levels.
68 2024-02-29 James Brown African American MC345298761 456 Funk Ave, Augusta, GA 30901 (706) 555-0257 Peach State Health Plan Completed: BMI, BP normal. Benign prostatic hyperplasia symptoms. BPH with urinary frequency and urgency. Benign Prostatic Hyperplasia Tamsulosin 0.4mg daily Wakes up 3-4 times nightly to urinate. Initiated alpha-blocker medication. Follow-up in 4 weeks to assess symptom improvement. Urology referral if no improvement.
69 2023-10-22 Michelle Kim Asian MC761982453 789 K-Pop Blvd, Los Angeles, CA 90020 (213) 555-0258 Kaiser Permanente Completed: BMI, BP normal. Contact dermatitis from cosmetics. Allergic contact dermatitis. Contact Dermatitis Hydrocortisone cream 2.5% twice daily, Avoidance of allergen Rash on face and neck. Started new skincare products. Recommended discontinuation of new products. Initiated topical steroid. Patch testing discussed if condition persists.
70 2024-05-20 Thomas Davis Caucasian MC453627189 147 Classic Rd, Memphis, TN 38103 (901) 555-0259 UnitedHealthcare Completed: BMI, BP normal. Tinnitus persistent for 6 months. Subjective tinnitus, likely noise-induced. Tinnitus Sound therapy recommended, White noise machine Worked in loud factory for 15 years. No hearing protection. Referred to audiology. Counseling on sound therapy and tinnitus retraining therapy. Hearing protection education provided.
71 2024-03-15 Brandon Cruz Hispanic/Latino MC228833774 123 Palm St, Miami, FL 33125 (305) 555-0260 Sunshine Health BMI, BP normal. Dental caries noted. Good overall health. Requires dental fillings. None None Enjoys swimming and outdoor activities. Referred to dentist for restoration. No other health concerns. Encouraged to maintain healthy habits.
72 2023-08-28 Tiffany Johnson African American MC337744115 456 Oak Lane, Chicago, IL 60609 (773) 555-0261 Blue Cross Blue Shield of IL BMI indicates overweight. BP slightly elevated. Risk for metabolic syndrome. Encouraged lifestyle changes. None None Family history of diabetes. Motivated to improve diet. Focus on weight management through nutrition and exercise. Provided resources for healthy cooking classes. Follow-up in 2 months.
73 2024-06-12 Daniel Kim Asian MC446655226 789 Pine Ave, Seattle, WA 98133 (206) 555-0262 Molina Healthcare BMI, BP normal. Vision screening shows astigmatism. Requires corrective lenses. Otherwise healthy. Astigmatism None Struggles with night driving and reading. Referred to optometrist for prescription glasses. Education on eye strain prevention. No other interventions needed.
74 2023-11-05 Maria Rodriguez Hispanic/Latina MC555566337 321 Cedar Rd, Houston, TX 77003 (713) 555-0263 Blue Cross Blue Shield of TX BMI, BP normal. Depression screening: mild symptoms. Adjustment disorder with depressed mood. Mild Depression Referred to therapy Recently separated from family. Feeling isolated. Connected with community support groups. Therapy referral provided. Follow-up in 4 weeks to assess mood.
75 2024-04-18 Christopher Lee Asian MC664477448 654 Elm St, San Francisco, CA 94110 (415) 555-0264 Anthem Blue Cross BMI, BP normal. Allergies: pollen and dust mites. Seasonal allergic rhinitis. Allergic Rhinitis Cetirizine 10mg daily as needed Symptoms worse in spring and fall. Allergy management education provided. Recommended OTC antihistamines during allergy season.
76 2023-09-30 Amanda Garcia Hispanic/Latina MC773388559 987 Birch Blvd, Phoenix, AZ 85016 (602) 555-0265 Arizona Complete Health BMI, BP normal. Mild anemia detected. Iron deficiency anemia. Iron Deficiency Anemia Ferrous Sulfate 325mg daily Vegetarian diet. Reports fatigue. Iron supplementation initiated. Nutrition counseling for iron-rich plant foods. Follow-up blood work in 6 weeks.
77 2024-01-25 Marcus Williams African American MC882299660 147 Walnut St, Atlanta, GA 30310 (404) 555-0266 Peach State Health Plan BMI, BP normal. Old ankle injury with occasional pain. Previous fracture healed well. Mild arthritis possible. None Ibuprofen 400mg as needed Basketball player. Avoids hard cuts due to pain. Physical therapy referral for strengthening. Activity modification advice. Orthopedic follow-up if pain persists.
78 2023-12-12 Jessica Brown Caucasian MC991100771 258 Maple Dr, Denver, CO 80205 (303) 555-0267 Colorado Medicaid BMI, BP normal. Migraine diagnosis confirmed. Migraine without aura. Migraine Disorder Sumatriptan 50mg as needed Stress and lack of sleep are triggers. Migraine management education. Stress reduction techniques taught. Neurology referral if frequency increases.
79 2024-05-05 David Martinez Hispanic/Latino MC110011882 369 Spruce Ave, San Antonio, TX 78212 (210) 555-0268 Blue Cross Blue Shield of TX BMI indicates obesity. BP elevated. Metabolic syndrome. High diabetes risk. Obesity, Hypertension Lisinopril 10mg daily Family history of heart disease. Weight management program referral. Nutrition and exercise planning. BP medication initiated. Close monitoring needed.
80 2023-10-20 Sarah Wilson Caucasian MC229922993 741 Willow Ln, Philadelphia, PA 19102 (215) 555-0269 Keystone First BMI, BP normal. GERD symptoms reported. Gastroesophageal reflux disease. GERD Omeprazole 20mg daily Symptoms worse after spicy foods. Dietary modification advice. Medication initiated. Follow-up in 4 weeks to assess symptom control.
81 2024-02-15 Michael Taylor African American MC338833004 852 Magnolia St, Detroit, MI 48204 (313) 555-0270 Meridian Health Plan BMI, BP normal. Sports physical clearance. Excellent physical health. None None College basketball recruit. No health concerns. Cleared for all sports activities. Encouraged to maintain current health practices. Annual physical recommended.
82 2023-11-30 Emily Chen Asian MC447744115 963 Redwood Rd, Boston, MA 02108 (617) 555-0271 MassHealth BMI, BP normal. Vitamin D deficiency. Low vitamin D levels. Vitamin D Deficiency Vitamin D 2000IU daily Limited sun exposure. Vitamin D supplementation initiated. Sun exposure advice. Follow-up levels in 3 months.
83 2024-06-25 James Johnson Caucasian MC556655226 159 Sequoia Ct, Portland, OR 97209 (503) 555-0272 CareOregon BMI, BP normal. Anxiety symptoms noted. Generalized anxiety disorder. Anxiety Disorder Referred to therapy Performance anxiety at work. Therapy referral provided. Relaxation techniques taught. Follow-up in 1 month. Medication not indicated at this time.
84 2023-09-15 Olivia Davis African American MC665566337 357 Aspen Way, Baltimore, MD 21201 (410) 555-0273 Maryland Medicaid BMI, BP normal. Psoriasis flare-up. Moderate psoriasis. Psoriasis Topical steroid cream Stress-related flare. Dermatology referral. Stress management counseling. Topical treatment initiated.
85 2024-03-08 Ethan Anderson Caucasian MC774477448 468 Juniper Blvd, Nashville, TN 37203 (615) 555-0274 UnitedHealthcare BMI, BP normal. ADHD diagnosis confirmed. Attention deficit hyperactivity disorder. ADHD Referred to psychiatry Difficulty with focus and organization. Psychiatry referral for medication evaluation. Behavioral strategies discussed. Academic accommodations recommended.
86 2023-12-28 Sophia Thomas African American MC883388559 579 Sycamore St, Cleveland, OH 44105 (216) 555-0275 Buckeye Health Plan BMI, BP normal. Seasonal allergies. Allergic rhinitis. Allergic Rhinitis Fluticasone nasal spray Symptoms worse in spring. Allergy management education. Nasal spray technique demonstrated. Follow-up as needed.
87 2024-04-12 Alexander White Caucasian MC992299660 684 Poplar Ave, Indianapolis, IN 46202 (317) 555-0276 Indiana Medicaid BMI, BP normal. Mild eczema. Atopic dermatitis. Eczema Hydrocortisone cream 1% Dry skin patches on arms. Moisturizer recommendation. Mild steroid cream for flare-ups. Dermatology referral if not controlled.
88 2023-10-05 Isabella Martinez Hispanic/Latina MC101110771 795 Cedar Lane, Kansas City, MO 64101 (816) 555-0277 Missouri Medicaid BMI, BP normal. IBS symptoms. Irritable bowel syndrome. IBS Fiber supplements Stress-related symptoms. Dietary modification advice. Stress management techniques. Fiber supplementation recommended.
89 2024-01-18 William Thompson Caucasian MC202220882 906 Oak Boulevard, Las Vegas, NV 89101 (702) 555-0278 Nevada Medicaid BMI, BP normal. Sleep difficulties. Insomnia. Insomnia Sleep hygiene education Difficulty falling asleep. Sleep hygiene education. Relaxation techniques. Follow-up in 2 weeks. Medication not indicated initially.
90 2023-11-12 Mia Robinson African American MC303330993 117 Pine Street, Milwaukee, WI 53202 (414) 555-0279 Wisconsin Medicaid BMI, BP normal. Annual wellness exam. Excellent health. No concerns. None None Active in sports. No complaints. Preventive health education. Encouraged to maintain healthy lifestyle. Annual follow-up recommended.
91 2024-05-30 Noah Harris Caucasian MC404440004 228 Maple Avenue, New Orleans, LA 70112 (504) 555-0280 Louisiana Healthcare Connections BMI, BP normal. Anxiety about future. Adjustment disorder with anxiety. Adjustment Disorder Counseling referral Worried about job prospects. Counseling services arranged. Career guidance provided. Support group recommendation.
92 2023-08-22 Ava Clark Caucasian MC505550115 339 Elm Street, Oklahoma City, OK 73102 (405) 555-0281 Oklahoma Medicaid BMI, BP normal. Mild acne. Acne vulgaris. Acne Topical benzoyl peroxide Self-conscious about skin. Dermatology referral. Topical treatment initiated. Skincare education provided.
93 2024-02-08 Liam Lewis African American MC606660226 441 Birch Lane, Memphis, TN 38103 (901) 555-0282 UnitedHealthcare BMI, BP normal. Sports physical. Healthy athlete. None None Football player. No concerns. Cleared for sports participation. Injury prevention education. Annual follow-up recommended.
94 2023-12-03 Charlotte Walker Caucasian MC707770337 552 Walnut Drive, Louisville, KY 40202 (502) 555-0283 Kentucky Medicaid BMI, BP normal. Seasonal depression. Seasonal affective disorder. SAD Light therapy recommendation Symptoms in winter months. Light therapy discussed. Counseling referral. Follow-up before winter season.
95 2024-04-28 Benjamin Young Asian MC808880448 663 Spruce Court, Salt Lake City, UT 84101 (801) 555-0284 Utah Medicaid BMI, BP normal. Asthma well-controlled. Stable asthma. Asthma Albuterol inhaler as needed Uses inhaler rarely. Asthma action plan reviewed. Refill provided. Continue current management.
96 2023-09-08 Harper King Caucasian MC909990559 774 Fir Avenue, Albuquerque, NM 87102 (505) 555-0285 New Mexico Medicaid BMI, BP normal. Dry eyes. Dry eye syndrome. Dry Eye Syndrome Artificial tears Computer use exacerbates. Artificial tear recommendation. Computer breaks advised. Ophthalmology referral if persists.
97 2024-03-22 Lucas Green African American MC010100660 885 Redwood Road, Tucson, AZ 85701 (520) 555-0286 Arizona Complete Health BMI, BP normal. Healthy exam. No health issues. None None Active lifestyle. Good diet. Preventive health education. Continue current healthy practices. Annual follow-up.
98 2023-10-15 Evelyn Scott Caucasian MC121210771 996 Sequoia Lane, Fresno, CA 93701 (559) 555-0287 CalViva Health BMI, BP normal. Mild anxiety. Adjustment anxiety. Anxiety Counseling referral Nervous about new job. Counseling services arranged. Relaxation techniques taught. Follow-up in 1 month.
99 2024-01-08 Henry Adams Caucasian MC232320882 107 Aspen Drive, Bakersfield, CA 93301 (661) 555-0288 Kern Family Health Care BMI, BP normal. Back strain. Musculoskeletal strain. None Ibuprofen as needed Lifting injury at work. Physical therapy referral. Proper lifting education. Follow-up if not improved.
100 2023-11-28 Amelia Nelson Caucasian MC343430993 218 Juniper Street, Stockton, CA 95202 (209) 555-0289 Health Net BMI, BP normal. Wellness exam. Excellent health. None None No complaints. Active lifestyle. Preventive health education. Encourage regular check-ups. No follow-up needed.
