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9/16/2020 Patient chart - Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 1/6
PATIENT YAHINMA JIMENEZ DOB 10/04/1979 AGE 40 yrs SEX Female PRN JY850918
FACILITY Bene�ca Medical Center T (305) 559-3167 F (786) 482-5707 10511 North Kendall Drive Suite C201 Miami, FL 33176
Patient identifying details and demographics
FIRST NAME YAHINMA MIDDLE NAME - LAST NAME JIMENEZ SSN -
SEX Female DATE OF BIRTH 10/04/1979 DATE OF DEATH - PRN JY850918
RACE - ETHNICITY - PREF. LANGUAGE - STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 10260 SW 96 Terrace
ADDRESS LINE 2 - CITY Miami STATE FL ZIP CODE 33176
CONTACT BY - EMAIL - HOME PHONE - MOBILE PHONE (786) 452-5420 OFFICE PHONE - OFFICE EXTENSION -
FAMILY INFORMATION
NEXT OF KIN - RELATION TO PATIENT - PHONE - ADDRESS -
PATIENT'S MOTHER'S MAIDEN NAME
-
Vitals �owsheet - YAHINMA JIMENEZ
05/22/20 9:01 AM
Vitals
Weight 270 lb
BMI 45.63
BP 132/81 mmHg
Temperature 98.2 °F
Pulse 78 bpm
Respiratory rate 18 bpm
O2 Saturation 98 %
Pain 3
Height 64.5 in
9/16/2020 Patient chart - Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 2/6
Diagnoses
Current ACUITY START STOP
(R73.03) Prediabetes Chronic 06/09/2020
Comment: As noted in lab results. 06/02/2020. by Mario Gonzalez-Leyva on 06/09/20
(E78.1) Pure hyperglyceridemia Chronic 06/09/2020
Comment: As noted in lab results. 06/02/2020. by Mario Gonzalez-Leyva on 06/09/20
(E66.01) Morbid (severe) obesity due to excess calories Chronic 05/22/2020
(B36.9) Super�cial mycosis, unspeci�ed Chronic 05/22/2020
(E55.9) Vitamin D de�ciency, unspeci�ed Chronic 05/22/2020
Comment: As noted in lab results. 06/02/2020. by Mario Gonzalez-Leyva on 06/09/20
Medication Ergocalciferol
(L83) Acanthosis nigricans Chronic 05/22/2020
(M54.2) Cervicalgia Chronic 05/22/2020
(Z00.01) Encounter for general adult medical examination with abnormal �ndings
05/22/2020
(Z71.3) Dietary counseling and surveillance 05/22/2020
(Z68.42) Body mass index (BMI) 45.0-49.9, adult 05/22/2020
Historical ACUITY START STOP
No historical diagnoses
Drug Allergies
Active SEVERITY/REACTIONS ONSET
Patient has no known drug allergies
Food Allergies
Active SEVERITY/REACTIONS ONSET
No food allergies recorded
Environmental Allergies
Active SEVERITY/REACTIONS ONSET
No environmental allergies recorded
9/16/2020 Patient chart - Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 3/6
Medications
Active SIG START/STOP ASSOCIATED DX
Clotrimazole w/ Betamethasone (Clotrimazole-Betamethasone) 1-0.05 % External Cream
1 application topically to a�ected area 2 times per day
- -
EScript (veri�ed): 05/22/20 Prescriber: Mario Gonzalez-Leyva SIG: 1 application topically to a�ected area 2 times per day Re�lls: 1 Quantity: 45
Diclofenac Sodium (Topical) (Diclofenac Sodium) 1 % Transdermal Gel
2 grams topically to a�ected area 4 times per day
- -
EScript (veri�ed): 07/21/20 Prescriber: Mario Gonzalez-Leyva SIG: 2 grams topically to a�ected area 4 times per day Re�lls: 2 Quantity: 1
EScript (veri�ed): 06/30/20 Prescriber: Mario Gonzalez-Leyva SIG: 2 grams topically to a�ected area 4 times per day Re�lls: 3 Quantity: 1
EScript (veri�ed): 05/22/20 Prescriber: Mario Gonzalez-Leyva SIG: 2 grams topically to a�ected area 4 times per day Re�lls: 2 Quantity: 1
Ergocalciferol 1.25 MG (50000 UT) Oral Capsule
Take 1 capsule (50,000 units) by mouth weekly
- Vitamin D de�ciency
EScript (veri�ed): 06/09/20 Prescriber: Mario Gonzalez-Leyva SIG: Take 1 capsule (50,000 units) by mouth weekly Re�lls: 5 Quantity: 4
Ibuprofen 600 MG Oral Tablet Take 1 tablet (600 mg) by mouth 3 times per day with food or milk as needed
- -
EScript (veri�ed): 06/28/20 Prescriber: Mario Gonzalez-Leyva SIG: TOME UNA TABLETA POR VIA ORAL TRES VECES AL DIA WITH FOOD OR MILK AS NEEDED Re�lls: 1 Quantity: 60
EScript (veri�ed): 05/22/20 Prescriber: Mario Gonzalez-Leyva SIG: Take 1 tablet (600 mg) by mouth 3 times per day with food or milk as needed Re�lls: 1 Quantity: 60
O�oxacin (Otic) (O�oxacin) 0.3 % Otic Solution
10 drops into the a�ected ear 3 times per day for 7 days
- -
EScript (veri�ed): 08/25/20 Prescriber: Mario Gonzalez-Leyva SIG: 10 drops into the a�ected ear 3 times per day for 7 days Re�lls: 0 Quantity: 1
Historical SIG START/STOP ASSOCIATED DX
No historical medications recorded
Immunizations
DATE VACCINE SOURCE LOT NUMBER
EXPIRES COMMENT
No immunizations recorded for this patient.
9/16/2020 Patient chart - Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 4/6
Social history
TOBACCO USE RECORDED
Current tobacco use Non-smoker 05/22/2020
ALCOHOL USE RECORDED
No alcohol use history available for this patient
SOCIAL HISTORY (FREE-TEXT)
Alcohol, social drinker. Co�ee( less than one cup per day), no drugs.
FINANCIAL RESOURCES RECORDED
No �nancial resources recorded for this patient
EDUCATION RECORDED
No education recorded for this patient
PHYSICAL ACTIVITY RECORDED
No physical activity available for this patient
NUTRITION HISTORY RECORDED
No nutrition history available for this patient
STRESS RECORDED
No stress available for this patient
SOCIAL ISOLATION AND CONNECTION RECORDED
No social isolation and connection available for this patient
EXPOSURE TO VIOLENCE RECORDED
No exposure to violence history available for this patient
GENDER IDENTITY
Female
SEXUAL ORIENTATION
Straight or heterosexual
9/16/2020 Patient chart - Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 5/6
Past medical history
MAJOR EVENTS
-Cholecystectomy(19 years old) -Left breast reduction(20 years old) -Left ectopic pregnancy(2005) -Uterine �broids(2016) -Abdominoplasty, Breast implant(2016) Obstetric history: P6D1A4Ectopic pregnancy1
ONGOING MEDICAL PROBLEMS
Morbid obesity
PREVENTIVE CARE
Preventive care -Mammogram: Pap smear; negative. Performed 06/03/2020. Genital culture; Negative. 06/03/2020. -EKG: Normal sinus rhythm. Performed 05/22/2020. -Chest X rays: -HbA1C: Elevated for PreDiabetes. 5.9%. 06/02/2020. -Tumor markers: Within normal limits. 06/02/2020. -AAA screening: -DEXA SCAN: -FOBT: -FIT-DNA: -Spirometry: -EGD: -Colonoscopy: -Eye exam: -Dental exam: 05/22/2020 -Flu Vaccine: -Pneumonia Vaccine: -Shingles Vaccine:
SOCIAL HISTORY
Alcohol, social drinker. Co�ee( less than one cup per day), no drugs.
Family health history
DIAGNOSIS ONSET DATE
No Family health history recorded
FAMILY HEALTH HISTORY (FREE TEXT)
Father: deceased. heart Attack Mother: Alive. HTN, Gout Brother: Alive. Allergies. Renal failure Daughter: Alive. healthy
Active health concerns
DESCRIPTION EFFECTIVE DATE
No active health concerns recorded
Inactive health concerns
9/16/2020 Patient chart - Patient: YAHINMA JIMENEZ DOB: 10/04/1979 PRN: JY850918
https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/af3a8cfe-7a60-4f71-9603-59949cac09a2/summary 6/6
OBESITY DIET EDUCATION (PROCEDURE)
Start date: 05/22/2020
Status: Performed
WEIGHT CONTROL EDUCATION (PROCEDURE)
Start date: 05/22/2020
Status: Performed
DESCRIPTION EFFECTIVE DATE
No inactive health concerns recorded
Active Goals
DESCRIPTION EFFECTIVE DATE
No active goals recorded
Inactive Goals
DESCRIPTION EFFECTIVE DATE
No inactive goals recorded
Screenings/ Interventions/ Assessments
