Chart · view recorded under the Health care operations purpose
✦ AI Ask about this patient
✦ AI Start ambient note
✦ AI Draft instructions
Drafts awaiting signature
0
AI summary
drafted by claude-sonnet-5 from this record · verify against the chart
Francisco Tallchief is a 20-year-old male with a history of gastroesophageal reflux disease diagnosed in 2024, currently managed with daily omeprazole. He has had periodic follow-up visits, including a recent routine health maintenance telehealth visit. No abnormal lab results are on record at this time.
Drives care
- Gastroesophageal reflux disease
- Ongoing omeprazole therapy for symptom control
Watch
- No recent labs on file to assess reflux control or medication effects
- Confirm symptom status at next visit given chronic PPI use
- Verify continuity of care given reliance on telehealth encounters
Active problems
| Condition | Status | Onset |
|---|---|---|
| Gastroesophageal reflux disease (disorder) | active | Apr 6, 2024 |
Active medications
| Medication | Dosage | Since |
|---|---|---|
| Omeprazole 20 MG Oral Capsule | 20 mg daily | Sep 5, 2023 |
Allergies
| Substance | Reaction | Verification |
|---|---|---|
| No known allergies recorded. | ||
Recent results
| Test | Value | When |
|---|---|---|
| Heart rate | 70.1 /min | Dec 19, 2026 |
| Glucose | 147.9 mg/dL | Dec 3, 2026 |
| TSH | 1.7 mIU/L | Dec 8, 2023 |
| Oxygen saturation | 96.3 % | Nov 4, 2023 |
| Systolic blood pressure | 119.4 mmHg | Aug 19, 2023 |
| Systolic blood pressure | 156.5 mmHg | Jun 6, 2023 |
| Total cholesterol | 150.9 mg/dL | Apr 24, 2023 |
| Total cholesterol | 175.9 mg/dL | Jan 3, 2023 |
Notes & documents
| Document | Author | Date | |
|---|---|---|---|
| No unrestricted documents. | |||