Delbert Collins =============== Race: White Ethnicity: Non-Hispanic Gender: M Age: 56 Birth Date: 1965-12-23 Marital Status: M -------------------------------------------------------------------------------- ALLERGIES: No Known Allergies -------------------------------------------------------------------------------- MEDICATIONS: 2022-10-12[CURRENT] : sacubitril 97 MG / valsartan 103 MG Oral Tablet for Chronic congestive heart failure (disorder) 2022-10-12[CURRENT] : carvedilol 25 MG Oral Tablet for Chronic congestive heart failure (disorder) 2022-10-12[CURRENT] : Furosemide 40 MG Oral Tablet for Chronic congestive heart failure (disorder) 2015-12-31[CURRENT] : Nitroglycerin 0.4 MG/ACTUAT Mucosal Spray 2015-12-31[CURRENT] : 24 HR metoprolol succinate 100 MG Extended Release Oral Tablet 2015-12-31[CURRENT] : Simvastatin 20 MG Oral Tablet 2015-12-31[CURRENT] : Clopidogrel 75 MG Oral Tablet -------------------------------------------------------------------------------- CONDITIONS: 2022-09-23 - : Chronic congestive heart failure (disorder) 2021-03-08 - 2021-04-01 : COVID-19 2021-03-08 - 2021-03-08 : Suspected COVID-19 2021-03-08 - 2021-04-01 : Loss of taste (finding) 2021-03-08 - 2021-04-01 : Fever (finding) 2021-03-08 - 2021-04-01 : Wheezing (finding) 2021-03-08 - 2021-04-01 : Dyspnea (finding) 2021-03-08 - 2021-04-01 : Fatigue (finding) 2021-03-08 - 2021-04-01 : Cough (finding) 2016-01-04 - : Abnormal findings diagnostic imaging heart+coronary circulat (finding) 2015-12-24 - : Reports of violence in the environment (finding) 2015-12-24 - : Part-time employment (finding) 2015-12-24 - : Ischemic heart disease (disorder) 2014-01-16 - : Victim of intimate partner abuse (finding) 2010-01-07 - : Stress (finding) 2006-06-08 - 2008-01-03 : Stress (finding) 2006-06-08 - 2008-01-03 : Part-time employment (finding) 2005-12-29 - 2006-06-08 : Part-time employment (finding) 2000-03-09 - 2005-12-29 : Stress (finding) 1991-02-28 - : Anemia (disorder) 1991-02-28 - : Prediabetes 1988-02-25 - 1994-03-03 : Stress (finding) 1988-02-25 - : Limited social contact (finding) 1988-02-25 - : Body mass index 30+ - obesity (finding) 1984-02-16 - 1985-02-21 : Limited social contact (finding) 1984-02-16 - : Received higher education (finding) -------------------------------------------------------------------------------- CARE PLANS: 2022-10-12[CURRENT] : Heart failure self management plan Reason: Chronic congestive heart failure (disorder) Activity: low salt diet education Activity: physical exercise 2021-03-08[STOPPED] : Infectious disease care plan (record artifact) Activity: Airborne precautions (procedure) Activity: Isolation of infected patient (procedure) 2021-03-08[STOPPED] : Infectious disease care plan (record artifact) Activity: Airborne precautions (procedure) Activity: Personal protective equipment (physical object) 1991-02-28[CURRENT] : Diabetes self management plan Reason: Prediabetes Activity: Diabetic diet Activity: Exercise therapy -------------------------------------------------------------------------------- REPORTS: 2022-10-12 : Basic Metabolic Panel - Glucose 65.0 mg/dL - Urea Nitrogen 13.9 mg/dL - Creatinine 1.0 mg/dL - Calcium 9.3 mg/dL - Sodium 142.9 mmol/L - Potassium 3.7 mmol/L - Chloride 101.2 mmol/L - Carbon Dioxide 28.2 mmol/L 2022-10-12 : Heartfailure Tracking Panel - Left ventricular Ejection fraction 27.4 % 2022-09-23 : New York Heart Association Functional Classification panel - Functional capacity NYHA Class II - Objective assessment of cardiovascular disease NYHA Objective evidence of severe cardiovascular disease 2022-09-23 : Iron and Iron binding capacity panel - Serum or Plasma - Iron [Mass/volume] in Serum or Plasma 93.1 ug/dL - Iron binding capacity [Mass/volume] in Serum or Plasma 400.9 ug/dL - Iron saturation [Mass Fraction] in Serum or Plasma 19.9 % 2022-09-23 : Iron panel - Serum or Plasma - Ferritin [Mass/volume] in Serum or Plasma 68.4 ug/L 2022-09-23 : Troponin I.cardiac panel - Serum or Plasma by High sensitivity method - Troponin I.cardiac [Mass/volume] in Serum or Plasma by High sensitivity method 0.0 pg/mL 2022-09-23 : Lipid Panel - Total Cholesterol 157.7 mg/dL - Triglycerides 114.3 mg/dL - Low Density Lipoprotein Cholesterol 80.9 mg/dL - High Density Lipoprotein Cholesterol 53.9 mg/dL 2022-09-23 : Comprehensive metabolic 2000 panel - Serum or Plasma - Glucose [Mass/volume] in Serum or Plasma 90.1 mg/dL - Urea nitrogen [Mass/volume] in Serum or Plasma 11.9 mg/dL - Creatinine [Mass/volume] in Serum or Plasma 1.0 mg/dL - Calcium [Mass/volume] in Serum or Plasma 9.7 mg/dL - Sodium [Moles/volume] in Serum or Plasma 138.2 mmol/L - Potassium [Moles/volume] in Serum or Plasma 4.1 mmol/L - Chloride [Moles/volume] in Serum or Plasma 106.1 mmol/L - Carbon dioxide, total [Moles/volume] in Serum or Plasma 24.9 mmol/L - Glomerular filtration rate/1.73 sq M.predicted 102.6 mL/min - Protein [Mass/volume] in Serum or Plasma 6.3 g/dL - Albumin [Mass/volume] in Serum or Plasma 4.3 g/dL - Bilirubin.total [Mass/volume] in Serum or Plasma 1.1 mg/dL - Alkaline phosphatase [Enzymatic activity/volume] in Serum or Plasma 39.8 U/L - Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma 25.0 U/L - Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma 29.2 U/L 2022-09-23 : Complete blood count (hemogram) panel - Blood by Automated count - Leukocytes [#/volume] in Blood by Automated count 6.4 10*3/uL - Erythrocytes [#/volume] in Blood by Automated count 5.5 10*6/uL - Hemoglobin [Mass/volume] in Blood 15.2 g/dL - Hematocrit [Volume Fraction] of Blood by Automated count 40.0 % - MCV [Entitic volume] by Automated count 87.9 fL - MCH [Entitic mass] by Automated count 31.2 pg - MCHC [Mass/volume] by Automated count 32.3 g/dL - Erythrocyte distribution width [Ratio] by Automated count 13.1 % - Platelets [#/volume] in Blood by Automated count 393.6 10*3/uL 2021-03-08 : SARS-CoV-2 RNA Pnl Resp NAA+probe - SARS-CoV-2 RNA Pnl Resp NAA+probe Detected (qualifier value) 2021-03-08 : Influenza virus A and B Ag panel - Nasopharynx by Rapid immunoassay - Influenza virus A Ag [Presence] in Nasopharynx by Rapid immunoassay Not detected (qualifier value) - Influenza virus B Ag [Presence] in Nasopharynx by Rapid immunoassay Not detected (qualifier value) -------------------------------------------------------------------------------- OBSERVATIONS: 2022-10-12 : Carbon Dioxide 28.2 mmol/L 2022-10-12 : Chloride 101.2 mmol/L 2022-10-12 : Potassium 3.7 mmol/L 2022-10-12 : Sodium 142.9 mmol/L 2022-10-12 : Calcium 9.3 mg/dL 2022-10-12 : Creatinine 1.0 mg/dL 2022-10-12 : Urea Nitrogen 13.9 mg/dL 2022-10-12 : Glucose 65.0 mg/dL 2022-10-12 : Left ventricular Ejection fraction 27.4 % 2022-09-23 : Objective assessment of cardiovascular disease NYHA Objective evidence of severe cardiovascular disease 2022-09-23 : Functional capacity NYHA Class II 2022-09-23 : Iron saturation [Mass Fraction] in Serum or Plasma 19.9 % 2022-09-23 : Iron binding capacity [Mass/volume] in Serum or Plasma 400.9 ug/dL 2022-09-23 : Iron [Mass/volume] in Serum or Plasma 93.1 ug/dL 2022-09-23 : Ferritin [Mass/volume] in Serum or Plasma 68.4 ug/L 2022-09-23 : Troponin I.cardiac [Mass/volume] in Serum or Plasma by High sensitivity method 0.0 pg/mL 2022-09-23 : Hemoglobin A1c/Hemoglobin.total in Blood 6.0 % 2022-09-23 : High Density Lipoprotein Cholesterol 53.9 mg/dL 2022-09-23 : Low Density Lipoprotein Cholesterol 80.9 mg/dL 2022-09-23 : Triglycerides 114.3 mg/dL 2022-09-23 : Total Cholesterol 157.7 mg/dL 2022-09-23 : Magnesium [Mass/volume] in Serum or Plasma 2.0 mg/dL 2022-09-23 : Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma 29.2 U/L 2022-09-23 : Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma 25.0 U/L 2022-09-23 : Alkaline phosphatase [Enzymatic activity/volume] in Serum or Plasma 39.8 U/L 2022-09-23 : Bilirubin.total [Mass/volume] in Serum or Plasma 1.1 mg/dL 2022-09-23 : Albumin [Mass/volume] in Serum or Plasma 4.3 g/dL 2022-09-23 : Protein [Mass/volume] in Serum or Plasma 6.3 g/dL 2022-09-23 : Glomerular filtration rate/1.73 sq M.predicted 102.6 mL/min 2022-09-23 : Carbon dioxide, total [Moles/volume] in Serum or Plasma 24.9 mmol/L 2022-09-23 : Chloride [Moles/volume] in Serum or Plasma 106.1 mmol/L 2022-09-23 : Potassium [Moles/volume] in Serum or Plasma 4.1 mmol/L 2022-09-23 : Sodium [Moles/volume] in Serum or Plasma 138.2 mmol/L 2022-09-23 : Calcium [Mass/volume] in Serum or Plasma 9.7 mg/dL 2022-09-23 : Creatinine [Mass/volume] in Serum or Plasma 1.0 mg/dL 2022-09-23 : Urea nitrogen [Mass/volume] in Serum or Plasma 11.9 mg/dL 2022-09-23 : Glucose [Mass/volume] in Serum or Plasma 90.1 mg/dL 2022-09-23 : Platelets [#/volume] in Blood by Automated count 393.6 10*3/uL 2022-09-23 : Erythrocyte distribution width [Ratio] by Automated count 13.1 % 2022-09-23 : MCHC [Mass/volume] by Automated count 32.3 g/dL 2022-09-23 : MCH [Entitic mass] by Automated count 31.2 pg 2022-09-23 : MCV [Entitic volume] by Automated count 87.9 fL 2022-09-23 : Hematocrit [Volume Fraction] of Blood by Automated count 40.0 % 2022-09-23 : Hemoglobin [Mass/volume] in Blood 15.2 g/dL 2022-09-23 : Erythrocytes [#/volume] in Blood by Automated count 5.5 10*6/uL 2022-09-23 : Leukocytes [#/volume] in Blood by Automated count 6.4 10*3/uL 2022-09-23 : NT-proBNP 1984.0 pg/mL 2022-09-23 : Body Weight 83.6 kg 2022-09-23 : Symptom Rales (finding) 2022-09-23 : Symptom Edema (finding) 2022-09-23 : Symptom Orthopnea (finding) 2022-09-23 : Symptom Paroxysmal dyspnea (finding) 2022-09-23 : Symptom Dyspnea (finding) 2022-09-23 : Symptom Dyspnea on exertion (finding) 2021-03-08 : SARS-CoV-2 RNA Pnl Resp NAA+probe Detected (qualifier value) 2021-03-08 : Influenza virus B Ag [Presence] in Nasopharynx by Rapid immunoassay Not detected (qualifier value) 2021-03-08 : Influenza virus A Ag [Presence] in Nasopharynx by Rapid immunoassay Not detected (qualifier value) 2021-03-08 : Body Weight 91.0 kg 2021-03-08 : Blood Pressure - Diastolic Blood Pressure 75.0 mm[Hg] - Systolic Blood Pressure 76.0 mm[Hg] 2021-03-08 : Oxygen saturation in Arterial blood 86.4 % 2021-03-08 : Heart rate 160.2 /min 2021-03-08 : Respiratory rate 21.0 /min 2021-03-08 : Body temperature 40.5 Cel -------------------------------------------------------------------------------- PROCEDURES: 2022-10-12 : Medication Reconciliation (procedure) 2022-10-12 : Echocardiography (procedure) 2022-09-23 : Assessment using New York Heart Association Classification (procedure) for Chronic congestive heart failure (disorder) 2022-09-23 : Plain chest X-ray (procedure) 2022-09-23 : Electrocardiographic procedure for Chronic congestive heart failure (disorder) 2021-03-08 : Face mask (physical object) for Suspected COVID-19 2020-12-23 : Colonoscopy -------------------------------------------------------------------------------- IMMUNIZATIONS: 2021-04-29 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 100 mcg/0.5mL dose 2021-04-01 : SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 100 mcg/0.5mL dose -------------------------------------------------------------------------------- ENCOUNTERS: 2022-10-12 (Dr. Gabriel Reilly) : Encounter at Fitchburg Outpatient Clinic : Encounter for Chronic congestive heart failure (disorder) 2022-09-23 (Dr. Gabriel Reilly) : Encounter at Fitchburg Outpatient Clinic : Encounter for Chronic congestive heart failure (disorder) 2021-04-29 (Dr. Rocio Montaño) : Encounter at CAMBRIDGE PUBLIC HEALTH COMMISSION 2021-04-01 (Dr. Rocio Montaño) : Encounter at CAMBRIDGE PUBLIC HEALTH COMMISSION 2021-03-08 (Dr. Rocio Montaño) : Encounter at CAMBRIDGE PUBLIC HEALTH COMMISSION 2020-12-23 (Dr. Rocio Montaño) : Encounter at CAMBRIDGE PUBLIC HEALTH COMMISSION 2016-01-04 (Dr. Gabriel Reilly) : Encounter at Fitchburg Outpatient Clinic : Encounter for Ischemic heart disease (disorder) 2015-12-26 (Dr. Rocio Montaño) : Encounter at CAMBRIDGE PUBLIC HEALTH COMMISSION : Encounter for Viral sinusitis (disorder) 2015-12-24 (Dr. Rocio Montaño) : Encounter at CAMBRIDGE PUBLIC HEALTH COMMISSION 2014-01-16 (Dr. Enriqueta Barton) : Encounter at DAVIS SQUARE FAMILY PRACTICE 2010-01-07 (Dr. Enriqueta Barton) : Encounter at DAVIS SQUARE FAMILY PRACTICE 2006-06-08 (Dr. Rocio Montaño) : Encounter at CAMBRIDGE PUBLIC HEALTH COMMISSION 2005-12-29 (Dr. Enriqueta Barton) : Encounter at DAVIS SQUARE FAMILY PRACTICE 2000-03-09 (Dr. Enriqueta Barton) : Encounter at DAVIS SQUARE FAMILY PRACTICE 1991-02-28 (Dr. Enriqueta Barton) : Encounter at DAVIS SQUARE FAMILY PRACTICE 1988-02-25 (Dr. Enriqueta Barton) : Encounter at DAVIS SQUARE FAMILY PRACTICE 1984-02-16 (Dr. Enriqueta Barton) : Encounter at DAVIS SQUARE FAMILY PRACTICE -------------------------------------------------------------------------------- IMAGING STUDIES: 2022-10-12 : Ultrasound, Heart structure (body structure) 2022-09-23 : Computed Radiography, Thoracic structure (body structure) --------------------------------------------------------------------------------