SSN # 112193857477

ID :112193857477

Print Date :09/22/2018, 19:54:31

Patient Name: Gordillo, Yamid DoB:10/01/1996 Sex: Male

Age 21y 11m 21d

Ethnicity: White Marital Status : Single Occupation : Administrator

Evaluation date: 09/22/2018, 20:01:28 Information Source: Self / Reliability : Seems reliable

Chief Complaint
Gastriti Crónica

History of Present Illness

Paciente que presenta ardor en la boca del estomago.

Medication History

Medicament Indication Start End Active

Personal History
Automated report about patient important conditions Annotations about the patient conditions & history

Diseases
Disease Severity Status Active Infectious Diagnosed Remarks

Surgeries
Immunizations

Vaccine Dose Date Next Dose Observations

Family History and Genetic Information

Family Information

Patient Genetic Abnormalities / “Disease Genes”

Socioeconomics

Socioeconomic Status :
Housing conditions :
Educational Level : Secondary School

Lifestyle

Sexuality : . .

Physical Examination
Vital Signs
Temperature Systolic
Blood Pressure
Diastolic
Heart rate Respiratory Rate Oxygen
Saturation

Anthropometry
Height Waist BMI
Weight Hip WHR

Level of Conciousness / Glasgow Scale

Eyes 4/4 Verbal 5/5 Motor 6/6 Total 15 / 15

Glasgow

Signs and Symptoms

Type Clinical finding Comments

Diagnostics Section
Other Hypotheses / DDx

Information about the Diagnosis

Care Plan