632768297865636250EnglishV1.02006-03-01T16:09:46ZAA0001AA0002Primary Care ProviderAA0003AA0004AA0005Consulting Provider2006-03-23Request For ConsultAA0002BB0006AA0002BB0009BB0001Effective Date2005-07-01T04:00:00ZTermination Date2006-05-31T04:00:00ZPlan Code584AA0002Policy Number079087AA0002Group Number9023q4785AA0002Group NameDefaultAA0002Patient ID97865432567896543AA0002Primary Health InsuranceAA0002AA0006PayerAA0007BB0002Policy NumberN/AAA0002GuarantorAA0008AA0009BB0003Recorded Date2005-06-30T04:00:00ZCPR StatusCardioversion OnlyCommentFamily history of poor outcome after CPR. Prolonged sufferingCurrent and VerifiedAA0002BB0004Recorded Date2005-07-05T04:00:00ZAntibiotic StatusAntibiotics OnlyCurrent and VerifiedAA0010AA0011Durable Power of Attorney for HealthcareBB0005Onset32YearsMobilityLimitedChronicAA0002BB0006Onset1999-03-31T05:00:00ZDiagnosisCongestive Heart Failure428.0ICD9-CM2005ActiveAA0010BB0007Onset1984-02-29T05:00:00ZDiagnosisDiabetes Mellitus250.02ICD9-CM2005ActiveAA0010BB0008Onset1990-08-07T04:00:00ZDiagnosisHypertension403.10ICD9-CM2005ActiveAA0010BB0009Onset2003-01-24T05:00:00ZDiagnosisMyocardial Infarction410.80ICD9-CM2005ActiveAA0010BB0010Onset2005-09-23T04:00:00ZActiveAA0012AA0013Mother70YearsIllAA0012AA0002ProblemANEMIA UNSPECIFIED285.9ICD9-CM2005AA0012BB0011Marital StatusMarriedAA0002BB0012LanguageEnglishAA0002BB0013EthnicityOtherAA0002BB0014Religious PreferenceCatholicAA0002BB0015Pregnancies4AA0002BB0016Term Pregnancies3AA0002BB0017Pre-term Pregnancies1AA0002BB0018Birth HistoryNvdx3AA0002BB0019EmploymentFull-timeAA0002AA0014EmployerBB0020Date of Onset19YearsTobacco UseType: Cigarettes<br>Frequency: 1 pack / dayTypeCigarettesFrequency1 pack / dayCurrentAA0012BB0021Initial Occurrence1970-01-14T05:00:00ZAllergyPenicillins245FDB ALLERGY2005294513009SNOMED CT2005C0571425UMLS Concept2005CurrentAA0012BB0022PenicillinsAA0012PenicillinsRash/EruptionSevereBB0023Initial Occurrence2005-03-28T05:00:00ZAllergySulfa (Sulfonamides)305FDB ALLERGY2005CurrentAA0010BB0024Sulfa (Sulfonamides)AA0010Sulfa (Sulfonamides)FeverModerateBB0025Initial Occurrence2 years agoAllergyRagweed152E-MDS ALLERGY2005CurrentAA0012BB0026RagweedAA0012RagweedCongestionMildBB0027Prescription Date2005-03-28T05:00:00ZMedicationActiveAA0010metforminRX10006809RXNORM2005Glucophage XR00087606313NDC2005500mg 100tablet1 tablet PO bid1tabletPObidAA0002BB0007Hold dose if patient becomes markedly light headed.0BB0028Prescription Date2005-07-21T04:00:00ZMedicationActiveAA0010ezetimibe-simvastatinVytorin66582031231NDC200510mg20mg50tablet1 tablet PO bid1tabletPObidAA0002BB00060BB0029Prescription Date2005-10-28T04:00:00ZMedicationActiveAA0010insulin lisproRX10086009RXNORM2005Humalog00002751001NDC2005100units/mL100injection0 unit OR0unitAA0002BB00071ORSIG SpecifierFBS<801 unit ac OR1unitacAA0002BB00072ORSIG SpecifierFBS 80-1202 unit ac OR2unitacAA0002BB00073ORSIG SpecifierFBS 121-1603 unit ac OR3unitacAA0002BB00074ORSIG SpecifierFBS 161-2004 unit ac OR4unitacAA0002BB00075ORSIG SpecifierFBS 201-2505 unit ac OR5unitacAA0002BB00076ORSIG SpecifierFBS 251-3006 unit ac6unitacAA0002BB00070BB0030Prescription Date2005-10-28T04:00:00ZMedicationActiveAA0010predniSONERX10008640RXNORM2005PredniSONE00054474125NDC20051mg15tablet5 tablet PO qd 1 Days THEN5tabletPOqd1Days1THEN4 tablet PO qd 1 Days THEN4tabletPOqd1Days2THEN3 tablet PO qd 1 Days THEN3tabletPOqd1Days3THEN2 tablet PO qd 1 Days THEN2tabletPOqd1Days4THEN1 tablet PO qd 1 Days1tabletPOqd1Days0BB0031Prescription Date2005-10-28T04:00:00ZMedicationActiveAA0010nafcillinRX10007233RXNORM2005Nafcillin Sodium00338101741NDC20051g/50 mL1100 ml IVPB q4h100mlIVPBq4h0BB0032Prescription Date2005-10-28T04:00:00ZMedicationActiveAA0010influenza virus vaccine, live, trivalentFluMist66019010001NDC20051spray1 spray NAS1sprayNAS0BB0033Immunization Date2005-09-22T02:00:00ZImmunizationAA0012Influenza15HL7 CVX2.5C1548663UMLS Concept ID2005IDLeft armBB0034Assessment Time2005-09-24T02:00:00ZHeight & WeightAA0012BB0035ObservationHeight50373000SNOMED2005AA0002155cmBB0036ObservationWeight363808001SNOMED2005AA000255kgBB0037Assessment Time2005-09-24T02:00:00ZCardiac MonitoringAA0012BB0038ResultHeart Rate364075005SNOMED2005AA000273/minBB0039Assessment Time2005-09-24T02:00:00ZBlood PressureAA0012BB0040ResultSystolic271649006SNOMED2005AA0002130mm HgBB0041ResultDiastolic271650006SNOMED2005AA000290mm HgBB0042Assessment Time2005-09-24T02:00:00ZRespiratory RateAA0012BB0043ResultRespiratory Rate86290005SNOMED2005AA000223/minBB0044Ob/Gyn ObservationsAA0002BB0045ObservationPregnancy StateAA0002NoBB00462005-09-12ObservationLMPAA00029/12/2005BB0047Assessment Time2003-12-08T04:00:00ZComplete cbc w/auto diff wbcAA0007BB0048ResultSpun microhematocritAA000232.6L/LAbnormal LowBB0049Resultplasma hemoglobinAA00029.6G/LAbnormal LowBB0050ResultAutomated leukocyte countAA000218.510^3/uLAbnormal HighBB0051Assessment Time2005-10-29T02:00:00ZUrine culture/colony count87086CPT2005C0374001UMLS Concept2005AA0010BB0052ResultUrine culture/colony countAA0002<p><span id="_ctl0_OrderCompletionListControl1_DataListOrders__ctl1_DataListRequestOrders__ctl0_DataGridNondiscreteResultDetail__ctl2_LabelNondiscreteResultReport">FINAL REPORT *** </span></p>
<p><span>Culture Results Enterobacter aerogenes - GREATER THAN 100 X 10^6 COLONY FORMING UNITS (CFU)/L *** Sensitivity Results *** Organism :Entero aerogenes ANTIMICROBIAL THERAPEUTIC DOSE MIC BLOOD URINE ----------------------------------------------------------------------</span></p>
<p><span>AMPICILLIN NC >16 R R GENTAMICIN NC <=4 S S TOBRAMYCIN NC <=4 S S SEPTRA NC <=.5/9.5 S S NITROFURANTOIN NC <=32 S </span></p>NormalBB0053Assessment Time2005-10-29T02:00:00ZUrinalysis, nonauto w/scope81000CPT2005C0373517UMLS Concept2005AA0010BB0054ResultUrine BilirubinAA0002NegativeNormalBB0055ResultUrine EpithelialAA0002FewNormalBB0056ResultBone marrow biopsyAA0002NegativeNormalBB0057ResultUrine ProteinAA0002NegativeNormalBB0058ResultUrine appearanceAA0002ClearNormalBB0059ResultColorAA0002YellowNormalBB0060ResultSpecific GravityAA00021.005NormalBB0061ResultURINE PHAA00027.00NormalBB0062ResultUrine WBC'sAA0002FewNormalBB0063ResultUrine RBC'sAA0002FewNormalBB0064Procedure Date2005-09-23T04:00:00ZSurgicalCABG, arterial, two33534CPT2005C0371565UMLS Concept2005AA0010AA0002BB0006BB0065Procedure Date2006-03-01T05:00:00ZSurgeryTenotomy, adductor of hip, open27001CPT200576453002SNOMED CT2005C0186106UMLS Concept2005CompletedAA0002openright lateral decubitusleft hipBB0066Encounter Date2005-09-23T04:00:00ZEmergencyChest painAA0010Broward Medical CenterAA0015PractitionerAA0002BB0006BB0067Encounter Date2005-09-04T04:00:00ZOutpatientChest pain evaluationAA0010CCR Physician GroupAA0016PractitionerAA0002BB0006BB0068Treatment RecommendationDiabetic retinal evaluationIn ProcessAA0010BB0069Patients >10 years of age with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 3–5 years after the onset of diabetes. In general, screening for diabetic eye disease is not necessary before 10 years of age. AA0010BB0070OrderA1C MonitoringIn ProcessAA0010BB0071AA0010BB0072LabGlycated hemoglobin test83036CPT2005C0373638UMLS Concept2005AA00108Weeks52WeeksAA0002BB0007AA0017Consulting ProviderAA0016Consulting ProviderAA0010Primary Care ProviderAA0001JaneBHernandez1948-01-16T04:00:00ZFemaleSSN888-88-8888AA0002Home758 Las Olas Dr.Fort LauderdaleFL33011555-555-5555Home666-666-6666Alternate444-444-4444Mobile333-333-3333Pagernone@nowhere.comAA0002AA0002StevenWaldrenDr. Steven WaldrenFamily Practiceswaldren@aafp.orgAA0002AA0003Center for Health Information Technology - AAFPMain406 Copperline Dr.Chapel HillNC27516919-960-5290Main913-215-7968Mobiledkibbe@aafp.orgAA0002AA0004Solventus CCR ViewPortV1.0AA0002AA0005DavidChaseKibbeDr. David KibbeFamily PracticeHome406 Copperline Dr.Chapel HillNC27516919-960-5290Home913-215-7968Mobiledkibbe@aafp.orgAA0002AA0006Blue Cross Blue Shield of Florida BlueScriptAA0002AA0007StevenHernandez1968-08-20T04:00:00ZMaleSSN151436167AA0002AA0002AA0008JohnAdamSmithDr. John SmithHome94044 Link RoadSan FranciscoCA94304415-555-1212Homejsmith@ccrdemohealthclinic.comAA0002AA0009JohnRivera1965-01-03T04:00:00ZSiblingAA0002AA0010PeterPrimaryDr. Peter Primaryccrfp@hotmail.comAA0002AA0011RitaRiberaHome1822 McNab AveFort LauderdaleFL33072AA0002AA0012JohnGrayDr. John GrayHome800 E Las Olas BlvdFort LauderdaleFL33301954-555-1212Homeken.miller@solventus.comAA0002AA0013UnknownMotherAA0002AA0014Acme Corp.Main2000 N Flagler Dr.MiamiFL33044AA0002AA0015StephenGoldbergAA0002AA0016MyronMitralDr. Myron Mitralccrcardio@hotmail.comAA0002AA0017GaryGanglionDr. Gary Ganglionccrneuro@hotmail.comAA0002