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| Condition | Onset Date / Period | Status |
|---|---|---|
| Chronic congestive heart failure | 28-Apr-2023 | active |
| Essential hypertension | 15-Feb-2012 | active |
| Recurrent urinary tract infection | 09-Aug-1996 | active |
| Viral sinusitis | 01-Feb-2021 - 22-Feb-2021 | inactive |
| Acute bronchitis | 06-Mar-2019 - 19-Mar-2019 | inactive |
| Medication | Since | Form | Dosage | Reason |
|---|---|---|---|---|
| Furosemide 40 mg oral tablet | 2025-04-30 | - | 1 tablet (40 mg) by mouth once daily | Chronic congestive heart failure (disorder) |
| Lisinopril 10 mg oral tablet | 2025-04-30 | - | 1 tablet (10 mg) by mouth once daily | Essential hypertension (disorder) |
| Vaccine | Date |
|---|---|
| Influenza virus antigen only vaccine product | 30-Apr-2025 |
| COVID-19 non-replicating viral vector vaccine | 21-Apr-2021 |
| Clostridium tetani toxoid antigen adsorbed only vaccine product | 15-Mar-2017 |
| Live attenuated Human alphaherpesvirus 3 only vaccine product | 15-Mar-2017 |
| Procedure | Date | Reason |
|---|---|---|
| Heart failure education | 14-Nov-2024 | Chronic congestive heart failure (disorder) |
| Oxygen administration by mask | 13-Nov-2024 | - |
| Placing subject in prone position | 13-Nov-2024 | - |
| Electrocardiographic procedure | 07-Nov-2024 | Chronic congestive heart failure (disorder) |
| Plain X-ray of chest | 07-Nov-2024 | - |
| Medication reconciliation | 07-Nov-2024 | - |
| No known allergies or intolerances |
| Active Planned Care / Goals | Start Date | Reason |
|---|---|---|
| Heart failure self management plan | 14-May-2023 | Chronic congestive heart failure (disorder) |
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| Lifestyle education regarding hypertension | 15-Feb-2012 | Essential hypertension (disorder) |
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| Vital Signs | 2025-04-30 | 2024-11-13 |
|---|---|---|
| Body Height | 164.5 cm | - |
| Pain severity - 0-10 verbal numeric rating [Score] - Reported | 3 {score} | - |
| Body Weight | 74.8 kg | 74.8 kg |
| Body mass index (BMI) [Ratio] | 27.6 kg/m2 | - |
| Heart rate | 92 /min | - |
| Respiratory rate | 15 /min | - |
| Blood pressure panel with all children optional | 72 mm[Hg] | - |
| Oxygen saturation in Arterial blood | - | 77 % |
| Recent Lab Observations | 13-MAY-2025 | Reference Range | Unit |
|---|---|---|---|
| Glucose [Mass/volume] in Blood | 69.0 L | 70 - 100 | mg/dL |
| Urea nitrogen [Mass/volume] in Blood | 8.6 | 7 - 20 | mg/dL |
| Creatinine [Mass/volume] in Blood | 0.7 | 0.5 - 1.1 | mg/dL |
| Calcium [Mass/volume] in Blood | 10.2 | 8.5 - 10.5 | mg/dL |
| Sodium [Moles/volume] in Blood | 136.5 | 135 - 145 | mmol/L |
| Potassium [Moles/volume] in Blood | 4.2 | 3.5 - 5.1 | mmol/L |
| Chloride [Moles/volume] in Blood | 110.4 H | 98 - 107 | mmol/L |
| Carbon dioxide, total [Moles/volume] in Blood | 20.0 L | 22 - 29 | mmol/L |
| No known devices |