| Status | Name | Category | Onset | Abatement |
|---|---|---|---|---|
| active | Pneumonia | Encounter Diagnosis | 2024-07-01 | 2024-07-17 |
| active |
Essential hypertension
|
Comorbidities | N/A | N/A |
| active |
Type 2 diabetes mellitus
|
Comorbidities | N/A | N/A |
| Parameter | Value | Unit |
|---|---|---|
| Respiratory Rate | 16 | /bpm |
| Oxygen Saturation | 94 | % |
| Heart Rate | 60 | /bpm |
| Systolic Blood Pressure | 80 | mmHg |
| Diastolic Blood Pressure | 60 | mmHg |
| Temperature |
31
|
'C |
| Pain Score | 8 |
| Parameter | Value | Unit |
|---|---|---|
| Height | 168 | cm |
| Weight | 55 | kg |
| BMI | 19.5 |
kg/m2
|
| Waist Circumference | 28 | cm |
| Smoking Status | true |
| Lifetime smoking use | 15 years |
| Date quit smoking | 19/7/2024 |
| Smoking device | Cigarette |
| Smoking history | Patient has been smoking for the past 15 years, have plan to quit now |
Authored Date: 19-Jul-2024
Author: SAIFULDAULAH BIN MOHD HAFIZ NGOO
Please select your gender: male
How often do you have a drink containing alcohol?: Monthly or less
How many standard drinks containing alcohol do you have on a typical day when drinking?: 3 or 4
How often do you have six or more drinks on one occasion?: Less than monthly
During the past year, how often have you found that you were not able to stop drinking once you had started?: Less than monthly
During the past year, how often have you failed to do what was normally expected of you because of drinking?: Weekly
During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?: Weekly
During the past year, how often have you had a feeling of guilt or remorse after drinking?: Monthly
During the past year, how often have you been unable to remember what happened the night before because you had been drinking?: Monthly
Have you or someone else been injured as a result of your drinking?: Yes, during the past year
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?: Yes, but not in the past year
Total score [AUDIT]: 20
Outcome Summary [AUDIT]: Likelihood of alcohol dependence (moderate-severe alcohol use disorder)
| Performed | Test | Conclusion |
|---|---|---|
|
2024-07-01T12:25:35+08:00
|
Hemoglobin A1c/Hemoglobin.total (HbA1c)
|
7.2% |
Performed Date: 01-Jul-2024 08:00
Performer: Saifuldaulah Bin Mohd Hafiz Ngoo
Weight: 55kg
Authored Date: 19-Jul-2024
Performer: Saifuldaulah Bin Mhd Hafiz Ngoo
Please select your gender: male
How often do you have a drink containing alcohol?: Monthly or less
How many standard drinks containing alcohol do you have on a typical day when drinking?: 3 or 4
How often do you have six or more drinks on one occasion?: Less than monthly
During the past year, how often have you found that you were not able to stop drinking once you had started?: Less than monthly
During the past year, how often have you failed to do what was normally expected of you because of drinking?: Weekly
During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?: Weekly
During the past year, how often have you had a feeling of guilt or remorse after drinking?: Monthly
During the past year, how often have you been unable to remember what happened the night before because you had been drinking?: Monthly
Have you or someone else been injured as a result of your drinking?: Yes, during the past year
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?: Yes, but not in the past year
Total score [AUDIT]: 20
Outcome Summary [AUDIT]: Likelihood of alcohol dependence (moderate-severe alcohol use disorder)