Berta Miramontes
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Race: White
Ethnicity: Hispanic
Gender: F
Age: 56
Birth Date: 1966-07-01
Marital Status: S
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ALLERGIES:
No Known Allergies
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MEDICATIONS:
2021-02-13[STOPPED] : Acetaminophen 325 MG Oral Tablet
2006-01-08[CURRENT] : Naproxen sodium 220 MG Oral Tablet for Osteoarthritis of knee
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CONDITIONS:
2022-10-20 - : Polyp of colon
2022-08-05 - : Part-time employment (finding)
2021-07-30 - 2022-08-05 : Stress (finding)
2021-07-30 - 2022-08-05 : Part-time employment (finding)
2021-02-13 - 2021-03-14 : Sprain of ankle
2020-07-24 - : Refugee (person)
2020-07-24 - 2021-07-30 : Not in labor force (finding)
2019-07-19 - : Social isolation (finding)
2018-07-13 - : Limited social contact (finding)
2018-07-13 - 2019-07-19 : Part-time employment (finding)
2016-07-01 - 2017-10-20 : Polyp of colon
2015-06-26 - : Miscarriage in first trimester
2014-07-25 - 2017-07-07 : Social isolation (finding)
2014-01-10 - : Has a criminal record (finding)
2014-01-10 - : Anemia (disorder)
2014-01-03 - : Chronic sinusitis (disorder)
2012-07-20 - : Prediabetes
2008-07-11 - 2014-01-10 : Social isolation (finding)
2006-01-08 - : Osteoarthritis of knee
2000-09-15 - 2006-07-07 : Limited social contact (finding)
1994-09-09 - 1997-09-12 : Limited social contact (finding)
1988-09-02 - : Body mass index 40+ - severely obese (finding)
1985-08-30 - 1991-09-06 : Limited social contact (finding)
1985-08-30 - 1988-09-02 : Part-time employment (finding)
1984-08-24 - : Received higher education (finding)
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CARE PLANS:
2021-02-13[STOPPED] : Physiotherapy care plan (record artifact)
Reason: Sprain of ankle
Activity: Rest, ice, compression and elevation treatment programme
Activity: Stretching exercises
2012-07-20[CURRENT] : Diabetes self management plan
Reason: Prediabetes
Activity: Diabetic diet
Activity: Exercise therapy
2006-01-08[CURRENT] : Musculoskeletal care
Reason: Osteoarthritis of knee
Activity: Joint mobility exercises
Activity: Heat therapy
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REPORTS:
2022-08-05 : Alcohol Use Disorder Identification Test - Consumption [AUDIT-C]
- Total score [AUDIT-C] 2.0 {score}
2022-08-05 : Patient Health Questionnaire 2 item (PHQ-2) [Reported]
- Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 1.0 {score}
2022-08-05 : Humiliation, Afraid, Rape, and Kick questionnaire [HARK]
- Total score [HARK] 0.0 {score}
2022-08-05 : Lipid Panel
- Total Cholesterol 165.3 mg/dL
- Triglycerides 108.5 mg/dL
- Low Density Lipoprotein Cholesterol 89.8 mg/dL
- High Density Lipoprotein Cholesterol 53.8 mg/dL
2022-08-05 : Basic Metabolic Panel
- Glucose 99.3 mg/dL
- Urea Nitrogen 10.9 mg/dL
- Creatinine 1.2 mg/dL
- Calcium 8.7 mg/dL
- Sodium 142.2 mmol/L
- Potassium 4.6 mmol/L
- Chloride 103.7 mmol/L
- Carbon Dioxide 24.2 mmol/L
2021-07-30 : Patient Health Questionnaire 2 item (PHQ-2) [Reported]
- Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 0.0 {score}
2021-07-30 : Humiliation, Afraid, Rape, and Kick questionnaire [HARK]
- Total score [HARK] 0.0 {score}
2021-07-30 : Basic Metabolic Panel
- Glucose 98.1 mg/dL
- Urea Nitrogen 11.4 mg/dL
- Creatinine 1.4 mg/dL
- Calcium 9.0 mg/dL
- Sodium 143.0 mmol/L
- Potassium 4.7 mmol/L
- Chloride 109.4 mmol/L
- Carbon Dioxide 20.1 mmol/L
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OBSERVATIONS:
2022-10-20 : Hemoglobin.gastrointestinal [Presence] in Stool by Immunologic method 5.5 ng/mL
2022-10-20 : Polyp size greatest dimension by CAP cancer protocols 2.5 mm
2022-08-05 : Total score [AUDIT-C] 2.0 {score}
2022-08-05 : Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 1.0 {score}
2022-08-05 : Total score [HARK] 0.0 {score}
2022-08-05 : Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]
- In the past year, have you been afraid of your partner or ex-partner? No
- Do you feel physically and emotionally safe where you currently live? Yes
- Are you a refugee? Yes
- In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility? Yes
- Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you? Not at all
- How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)? Less than once a week
- Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? No
- In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? Phone
- During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any benefits. 43474 /a
- What is your main insurance? None/uninsured
- What is your current work situation? Part-time or temporary work
- What is the highest level of school that you have finished? More than high school
- What address do you live at? 872 White Row Suite 87
- Are you worried about losing your housing? No
- What is your housing situation today? I have housing
- How many family members, including yourself, do you currently live with? 4.0 {#}
- What language are you most comfortable speaking? Language other than English
- Have you been discharged from the armed forces of the United States? No
- At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income? No
- Which race(s) are you? White
- Are you Hispanic or Latino? No
2022-08-05 : Hemoglobin A1c/Hemoglobin.total in Blood 6.2 %
2022-08-05 : Tobacco smoking status Never smoked tobacco (finding)
2022-08-05 : High Density Lipoprotein Cholesterol 53.8 mg/dL
2022-08-05 : Low Density Lipoprotein Cholesterol 89.8 mg/dL
2022-08-05 : Triglycerides 108.5 mg/dL
2022-08-05 : Total Cholesterol 165.3 mg/dL
2022-08-05 : Carbon Dioxide 24.2 mmol/L
2022-08-05 : Chloride 103.7 mmol/L
2022-08-05 : Potassium 4.6 mmol/L
2022-08-05 : Sodium 142.2 mmol/L
2022-08-05 : Calcium 8.7 mg/dL
2022-08-05 : Creatinine 1.2 mg/dL
2022-08-05 : Urea Nitrogen 10.9 mg/dL
2022-08-05 : Glucose 99.3 mg/dL
2022-08-05 : Respiratory rate 16.0 /min
2022-08-05 : Heart rate 82.0 /min
2022-08-05 : Blood Pressure
- Diastolic Blood Pressure 78.0 mm[Hg]
- Systolic Blood Pressure 129.0 mm[Hg]
2022-08-05 : Body Mass Index 43.8 kg/m2
2022-08-05 : Body Weight 120.7 kg
2022-08-05 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 4.0 {score}
2022-08-05 : Body Height 166.0 cm
2021-07-30 : Patient Health Questionnaire 2 item (PHQ-2) total score [Reported] 0.0 {score}
2021-07-30 : Total score [HARK] 0.0 {score}
2021-07-30 : Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences [PRAPARE]
- In the past year, have you been afraid of your partner or ex-partner? No
- Do you feel physically and emotionally safe where you currently live? Yes
- Are you a refugee? Yes
- In the past year, have you spent more than 2 nights in a row in a jail, prison, detention center, or juvenile correctional facility? Yes
- Stress is when someone feels tense, nervous, anxious or can't sleep at night because their mind is troubled. How stressed are you? Somewhat
- How often do you see or talk to people that you care about and feel close to (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)? Less than once a week
- Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? No
- In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? Medicine or Any Health Care
- During the past year, what was the total combined income for you and the family members you live with? This information will help us determine if you are eligible for any benefits. 43474 /a
- What is your main insurance? None/uninsured
- What is your current work situation? Part-time or temporary work
- What is the highest level of school that you have finished? More than high school
- What address do you live at? 872 White Row Suite 87
- Are you worried about losing your housing? No
- What is your housing situation today? I have housing
- How many family members, including yourself, do you currently live with? 4.0 {#}
- What language are you most comfortable speaking? Language other than English
- Have you been discharged from the armed forces of the United States? No
- At any point in the past 2 years, has season or migrant farm work been your or your family's main source of income? No
- Which race(s) are you? White
- Are you Hispanic or Latino? No
2021-07-30 : Hemoglobin A1c/Hemoglobin.total in Blood 5.9 %
2021-07-30 : Tobacco smoking status Never smoked tobacco (finding)
2021-07-30 : Carbon Dioxide 20.1 mmol/L
2021-07-30 : Chloride 109.4 mmol/L
2021-07-30 : Potassium 4.7 mmol/L
2021-07-30 : Sodium 143.0 mmol/L
2021-07-30 : Calcium 9.0 mg/dL
2021-07-30 : Creatinine 1.4 mg/dL
2021-07-30 : Urea Nitrogen 11.4 mg/dL
2021-07-30 : Glucose 98.1 mg/dL
2021-07-30 : Respiratory rate 15.0 /min
2021-07-30 : Heart rate 69.0 /min
2021-07-30 : Blood Pressure
- Diastolic Blood Pressure 84.0 mm[Hg]
- Systolic Blood Pressure 144.0 mm[Hg]
2021-07-30 : Body Mass Index 43.8 kg/m2
2021-07-30 : Body Weight 120.7 kg
2021-07-30 : Pain severity - 0-10 verbal numeric rating [Score] - Reported 1.0 {score}
2021-07-30 : Body Height 166.0 cm
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PROCEDURES:
2022-10-20 : Rectal polypectomy for Polyp of colon
2022-10-20 : Screening for occult blood in feces (procedure) for Polyp of colon
2022-10-20 : Colonoscopy
2022-08-05 : Assessment using Alcohol Use Disorders Identification Test - Consumption (procedure)
2022-08-05 : Assessment of substance use (procedure)
2022-08-05 : Depression screening using Patient Health Questionnaire Two-Item score (procedure)
2022-08-05 : Depression screening (procedure)
2022-08-05 : Screening for domestic abuse (procedure)
2022-08-05 : Assessment of health and social care needs (procedure)
2021-07-30 : Depression screening using Patient Health Questionnaire Two-Item score (procedure)
2021-07-30 : Depression screening (procedure)
2021-07-30 : Screening for domestic abuse (procedure)
2021-07-30 : Medication Reconciliation (procedure)
2021-07-30 : Assessment of health and social care needs (procedure)
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IMMUNIZATIONS:
2022-08-05 : Influenza, seasonal, injectable, preservative free
2021-07-30 : Influenza, seasonal, injectable, preservative free
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ENCOUNTERS:
2022-10-20 (Dr. Ronald Emard) : Encounter at UMASS MEMORIAL HEALTHALLIANCE CLINTON HOSPITAL INC
2022-08-05 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
2021-07-30 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
2021-02-13 (Dr. Darrick Hoppe) : Encounter at HIGHLANDS, THE
2020-07-24 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
2019-07-19 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
2018-07-13 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
2016-07-01 (Dr. Ronald Emard) : Encounter at UMASS MEMORIAL HEALTHALLIANCE CLINTON HOSPITAL INC
2015-06-26 (Dr. Ronald Emard) : Encounter at UMASS MEMORIAL HEALTHALLIANCE CLINTON HOSPITAL INC : Encounter for Normal pregnancy
2014-07-25 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
2014-01-10 (Dr. Ronald Emard) : Encounter at UMASS MEMORIAL HEALTHALLIANCE CLINTON HOSPITAL INC : Encounter for Anemia (disorder)
2014-01-10 (Dr. Ronald Emard) : Encounter at UMASS MEMORIAL HEALTHALLIANCE CLINTON HOSPITAL INC : Encounter for Sinusitis (disorder)
2014-01-03 (Dr. Ronald Emard) : Encounter at UMASS MEMORIAL HEALTHALLIANCE CLINTON HOSPITAL INC : Encounter for Sinusitis (disorder)
2012-07-20 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
2008-07-11 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
2006-01-08 (Dr. Ronald Emard) : Encounter at UMASS MEMORIAL HEALTHALLIANCE CLINTON HOSPITAL INC : Encounter for Osteoarthritis of knee
2000-09-15 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
1994-09-09 (Dr. Darrick Hoppe) : Encounter at HIGHLANDS, THE : Encounter for Normal pregnancy
1988-09-02 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
1985-08-30 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
1984-08-24 (Dr. Olinda Paucek) : Encounter at COMMUNITY HEALTH CONNECTIONS
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IMAGING STUDIES:
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