| Substance | Reaction | Severity | Status |
|---|---|---|---|
| Penicillin | Hives, Anaphylaxis | Severe | Active |
| Sulfa drugs | Rash | Moderate | Active |
| Medication | Dose | Route | Frequency | Status |
|---|---|---|---|---|
| Metformin 500 mg tablet | 500 mg | Oral | Twice daily | Active |
| Lisinopril 10 mg tablet | 10 mg | Oral | Once daily | Active |
| Condition | ICD-10 | Onset | Status |
|---|---|---|---|
| Type 2 Diabetes Mellitus | E11.9 | 2021-03-15 | Active |
| Essential Hypertension | I10 | 2019-07-01 | Active |
| Date | Observation | Value | Unit |
|---|---|---|---|
| 2025-06-01 | Blood Pressure (Systolic) | 128 | mmHg |
| 2025-06-01 | Blood Pressure (Diastolic) | 82 | mmHg |
| 2025-06-01 | Heart Rate | 72 | /min |
| 2025-06-01 | Body Temperature | 98.6 | °F |
| 2025-06-01 | Body Weight | 68 | kg |
| 2025-06-01 | Body Height | 165 | cm |
| 2025-06-01 | BMI | 24.98 | kg/m2 |
| 2025-06-01 | Oxygen Saturation | 98 | % |
| Test | Result | Unit | Reference Range | Date |
|---|---|---|---|---|
| HbA1c | 6.8 | % | 4.0–5.6 | 2025-05-15 |
| Fasting Glucose | 118 | mg/dL | 70–99 | 2025-05-15 |
| Serum Creatinine | 0.9 | mg/dL | 0.6–1.2 | 2025-05-15 |
| eGFR | 88 | mL/min/1.73m2 | >60 | 2025-05-15 |
| LDL Cholesterol | 102 | mg/dL | <100 | 2025-05-15 |
| Vaccine | Date | Status |
|---|---|---|
| Influenza (seasonal), injectable, preservative free | 2024-10-01 | Completed |
| COVID-19 mRNA (Moderna) | 2024-09-15 | Completed |
| Procedure | CPT | Date | Status |
|---|---|---|---|
| Hemoglobin A1c measurement | 83036 | 2025-05-15 | Completed |
| Office visit, established patient, moderate complexity | 99214 | 2025-06-01 | Completed |
| Category | Value | Date |
|---|---|---|
| Smoking status | Never smoker | 2025-06-01 |
| Alcohol use | Occasional (social) | 2025-06-01 |
| Employment | Employed full-time | 2025-06-01 |