Directive | Description | Verification | Supporting Document(s) |
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Resuscitation status |
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Dr. Robert Dolin, Feb 13, 2011 |
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Substance | Overall Severity | Reaction | Reaction Severity | Status |
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ALLERGENIC EXTRACT, PENICILLIN |
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Inactive |
Codeine |
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Active |
Aspirin |
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Active |
Encounter | Performer | Location | Date |
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Performer Name | Community Urgent Care Center | 20090227130000+0500 |
Checkup Examination
Diagnosis | Age At Onset |
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Myocardial Infarction (cause of death) | 57 |
Diabetes | 40 |
Functional or Cognitive Finding | Observation | Observation Date | Condition Status |
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Independently able | March 11, 2009 | Active | |
Dyspnea | February 2007 | Active | |
Cognitive Function Finding | April 2007 | Active | |
Aggressive behavior | March 11, 2009 | Active |
Vaccine | Date | Status |
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Nov 1999 | Completed |
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Dec 1998 | Completed |
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Dec 1998 | Completed |
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1997 | Refused |
Supply/Device | Date Supplied |
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Automatic implantable cardioverter/defibrillator | Nov 1999 |
Total hip replacement prosthesis | 1998 |
Wheelchair | 1999 |
Medication | Directions | Start Date | Status | Indications | Fill Instructions |
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0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN wheezing | 20070103 | Active | Pneumonia (233604007 SNOMED CT) | Generic Substitition Allowed |
Payer name | Policy type / Coverage type | Policy ID | Covered party ID | Policy Holder |
---|---|---|---|---|
Good Health Insurance | Extended healthcare / Family | Contract Number | 1138345 | Patient's Mother |
Planned Activity | Planned Date |
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Colonoscopy | 20120512 |
Procedure | Date |
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1998 |
LABORATORY INFORMATION | |
Chemistries and drug levels | |
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13.2 |
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6.7 |
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123 (L) |
Liver Functions and Other Laboratory Values | |
ALT (SGPT) | 31.0 |
AST (SGOT) | 18.0 |
GGT | 28.0 Alk |
Phos | 86.0 |
Total Bili | 0.1 |
Albumin | 3.2 |
Blood Count | |
White Count | 7.7 |
Platelets | 187.0 |
Hematocrit | 23.7 |
Hemoglobin | 8.1 |
ELECTROCARDIOGRAM (EKG) INFORMATION | |
EKG | Sinus rhythm without acute changes |
Social History Element | Description | Effective Dates |
---|---|---|
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1 pack per day | 20050501 to 20090227130000+0500 |
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None | 20090227130000+0500 - today |
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None | 20050501 - |
Date / Time: | Nov 14, 1999 | April 7, 2000 |
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Height |
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Weight |
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Blood Pressure |
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