1.3.6.1.4.1.22812.1.999.1021362EnglishV1.0CCR Creation DateTime2006-04-25T17:20:47ZPatient.39Person.20ProviderSiteOrganizationTouchWorksInformationSystemPatient.39PatientFor the patientPayerPrimary Health InsuranceMedicareTouchWorksPR.10005400051000540005TouchWorksDiagnosisStable ANGINA PECTORIS (413.9) SeverityStable413.9ICD9-CMActiveTouchWorksPR.10005700011000570001TouchWorksDiagnosisATYPICAL DEPRESSIVE DISORDER (296.82) 296.82ICD9-CMActiveTouchWorksPR.10005400171000540017TouchWorksDiagnosisCHRONIC OBSTRUCTIVE PULMONARY DISEASE (496) 496ICD9-CMActiveTouchWorksPR.10005400131000540013TouchWorksDiagnosisCONGESTIVE HEART FAILURE Improving (428.0) 428.0ICD9-CMActiveTouchWorksPR.10005400091000540009TouchWorksDiagnosisCORONARY ARTERY DISEASE (414.00) 414.00ICD9-CMActiveTouchWorksPR.10005400011000540001TouchWorksDiagnosisDIABETES MELLITUS TYPE II (250.00) 250.00ICD9-CMActiveTouchWorksPR.10005400211000540021TouchWorksDiagnosisHYPOTHYROIDISM (244.9) 244.9ICD9-CMActiveTouchWorksPR.10005500011000550001TouchWorksDiagnosisMaternal history of BREAST NEOPLASM MALIGNANT CARCINOMA (V16.3) V16.3ICD9-CMActiveTouchWorksDiagnosisMaternal history of BREAST NEOPLASM MALIGNANT CARCINOMA (V16.3) V16.3ICD9-CMTouchWorksPR.10005400371000540037TouchWorksDiagnosisMaternal history of DIABETES MELLITUS TYPE II (250.00) 250.00ICD9-CMActiveTouchWorksDiagnosisMaternal history of DIABETES MELLITUS TYPE II (250.00) 250.00ICD9-CMTouchWorksPR.10005500051000550005TouchWorksDiagnosisPaternal history of LARGE INTESTINE MALIGNANT CARCINOMA PSEUDOSARCOMATOUS (153.9) 153.9ICD9-CMActiveTouchWorksDiagnosisPaternal history of LARGE INTESTINE MALIGNANT CARCINOMA PSEUDOSARCOMATOUS (153.9) 153.9ICD9-CMTouchWorksPR.10005500131000550013TouchWorksDiagnosissmoking cigarettes (V15.82) V15.82ICD9-CMActiveTouchWorksAL.10005900191000590019TouchWorksAllergyCapoten TABSActiveTouchWorksPR.1000590019.1MedicationCapoten TABS54868141501NDCTouchWorksCapoten TABSCoughME.100058000129 May 2002 - (Last: 11 May 2004)1000580001TouchWorksMedicationAlbuterol 90 MCG/ACT Aerosol Soln; INHALE 2 PUFFS EVERY 4-6 HOURS, SPACED 60 SECONDS APART. ; RxActiveTouchWorksAlbuterol 90 MCG/ACT Aerosol Soln66267099517NDCINHALE 2 PUFFS EVERY 4-6 HOURS, SPACED 60 SECONDS APART.ME.100055002502 Nov 2001 - 1000550025TouchWorksMedicationBaby Aspirin 81 MG Chew Tab; CHEW AND SWALLOW 1 TABLET DAILY. ; RxActiveTouchWorksBaby Aspirin 81 MG Chew Tab54868453000NDCCHEW AND SWALLOW 1 TABLET DAILY.ME.100057000516 Apr 2002 - (Last: 27 Feb 2004)1000570005TouchWorksMedicationFluoxetine HCl 20 MG Cap; TAKE 1 CAPSULE DAILY. ; RxActiveTouchWorksFluoxetine HCl 20 MG Cap66267048830NDCProzac 20 MG CapTAKE 1 CAPSULE DAILY.ME.1019090001118 Nov 2005 - 10190900011TouchWorksMedicationFurosemide 40 MG Tab; TAKE 1 TABLET DAILY AS DIRECTED. ; RxActiveTouchWorksFurosemide 40 MG Tab68115015030NDCLasix 40 MG TabTAKE 1 TABLET DAILY AS DIRECTED.ME.1019110001118 Nov 2005 - 10191100011TouchWorksMedicationFurosemide 40 MG Tab; TAKE 1 TABLET DAILY AS DIRECTED. ; RxActiveTouchWorksFurosemide 40 MG Tab68115015030NDCLasix 40 MG TabTAKE 1 TABLET DAILY AS DIRECTED.ME.100055003302 Nov 2001 - (Last: 29 Jan 2004)1000550033TouchWorksMedicationHydrochlorothiazide 50 MG Tab; TAKE 1 TABLET EVERY MORNING. ; RxActiveTouchWorksHydrochlorothiazide 50 MG Tab66267010790NDCTAKE 1 TABLET EVERY MORNING.ME.100055003702 Nov 2001 - (Last: 29 Jan 2004)1000550037TouchWorksMedicationLevothyroxine Sodium 100 MCG Tab; TAKE 1 TABLET DAILY. ; RxActiveTouchWorksLevothyroxine Sodium 100 MCG Tab58016093150NDCSynthroid 100 MCG TabTAKE 1 TABLET DAILY.ME.100055002102 Nov 2001 - (Last: 29 Jan 2004)1000550021TouchWorksMedicationMetformin HCl 500 MG Tab; TAKE 1 TABLET EVERY 12 HOURS WITH FOOD. ; RxActiveTouchWorksMetformin HCl 500 MG Tab66116069560NDCTAKE 1 TABLET EVERY 12 HOURS WITH FOOD.ME.100055002902 Nov 2001 - (Last: 25 Aug 2003)1000550029TouchWorksMedicationNitroglycerin 0.4 MG SL Tab; TAKE AS DIRECTED. ; RxActiveTouchWorksNitroglycerin 0.4 MG SL Tab62515071870NDCTAKE AS DIRECTED.ME.100056000116 Nov 2001 - (Last: 29 Jan 2004)1000560001TouchWorksMedicationPotassium Chloride 10 MEQ Cap CR; TAKE 1 CAPSULE TWICE DAILY. ; RxActiveTouchWorksPotassium Chloride 10 MEQ Cap CR55045169500NDCTAKE 1 CAPSULE TWICE DAILY.IM.100206000112 Apr 19951002060001TouchWorksImmunizationDTActiveTouchWorksDTIM.100055001702 Nov 20011000550017TouchWorksImmunizationPneumo (Pneumovax); #1ActiveTouchWorksPneumo (Pneumovax)1IM.100055001902 Nov 20011000550019TouchWorksImmunizationInfluenza (Split); #1ActiveTouchWorksInfluenza (Split)1IM.101133000101 Nov 20041011330001TouchWorksImmunizationInfluenza (Split); #2ActiveTouchWorksInfluenza (Split)2VI.120 Dec 2004 12:16 PMVitalSignsRecorded by: jmedici on 20 Dec 2004 12:16 PMTouchWorksVI.10113400091011340009TouchWorksObservationBP SYSActiveTouchWorks138VI.10113400131011340013TouchWorksObservationBP DIASActiveTouchWorks72VI.10113400211011340021TouchWorksObservationPUL RATEActiveTouchWorks74b/minVI.10113400291011340029TouchWorksObservationRESPActiveTouchWorks20r/minVI.10113400171011340017TouchWorksObservationTEMPActiveTouchWorks98.6FVI.10113400251011340025TouchWorksObservationWGTActiveTouchWorks142lbVI.10113400331011340033TouchWorksObservationO2ActiveTouchWorks96(%SpO2)RS.120 Dec 2004 12:34 PMResultl Microalbumin, Random UrineTouchWorksRS.10113402031011340203TouchWorksResultUrine Alb/Creat RatioTouchWorks24.0RS.220 Dec 2004 12:32 PMResultl Lipid ProfileTouchWorksRS.10113401791011340179TouchWorksResultT CholTouchWorks189.0mg/dlRS.10113401831011340183TouchWorksResultTrigTouchWorks220.0mg/dlRS.10113401871011340187TouchWorksResultLDLTouchWorks125.0mg/dlRS.10113401911011340191TouchWorksResultHDLTouchWorks36.0mg/dlRS.10113401951011340195TouchWorksResultLDL/HDLTouchWorks3.4000001RS.320 Dec 2004 12:30 PMResultl Hemoglobin A1CTouchWorksRS.10113401711011340171TouchWorksResultHgb A1CTouchWorks7.0999999%RS.420 Dec 2004 12:23 PMResultl Comp Metabolic ProfileTouchWorksRS.10113401111011340111TouchWorksResultAlbuminTouchWorks3.8g/dlRS.10113401151011340115TouchWorksResultAlkaline PhosTouchWorks80.0iu/lRS.10113401191011340119TouchWorksResultALTTouchWorks35.0iu/lRS.10113401231011340123TouchWorksResultASTTouchWorks33.0iu/lRS.10113401271011340127TouchWorksResultBilirubin TotalTouchWorks1.0mg/dlRS.10113401311011340131TouchWorksResultGlucoseTouchWorks128.0mg/dlRS.10113401351011340135TouchWorksResultBUNTouchWorks28.0mg/dlRS.10113401391011340139TouchWorksResultCreatinineTouchWorks1.1mg/dlRS.10113401431011340143TouchWorksResultCalciumTouchWorks10.0mg/dlRS.10113401471011340147TouchWorksResultSodiumTouchWorks140.0mEq/lRS.10113401511011340151TouchWorksResultPotassiumTouchWorks3.5999999mEq/lRS.10113401551011340155TouchWorksResultChlorideTouchWorks101.0mEq/lRS.10113401591011340159TouchWorksResultTotal Co2TouchWorks24.0mEq/lRS.10113401631011340163TouchWorksResultTotal ProteinTouchWorks6.0999999g/dlPatient.39StellaPatersonStella Paterson1924-02-27FemalePatient ID031230084615500TouchWorksEHRSSN349-12-3159TouchWorksEHRMail487 Pine StreetBurlingtonVT05403(802)658-9321HomeTouchWorksPerson.20JamesMediciDr.Unknown20TouchWorksInternal MedicineMailjmedici@nwh.comTouchWorksSiteSite: 3MailTouchWorksTouchWorksTouchWorks by Allscripts Healthcare SolutionsEHR10.2.1.22180TouchWorksPayorMedicareTouchWorks