<effectiveTime value="20040809142222"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <!-- ******************************************************** Information Recipient ******************************************************** --> <informationRecipient typeCode="PRCP"> <intendedRecipient classCode="ASSIGNED"> <id extension="ppump" root="DCCD2C68-389B-44c4-AD99-B8FB2DAD1493"/> <addr> <streetAddressLine>4444 Healthcare Drive</streetAddressLine> <city>Ann Arbor</city> <state>BC</state> <postalCode>A1B 2C3</postalCode> <country>CA</country> </addr> <telecom value="tel:1-555-555-1009" use="WP"/> <telecom value="fax:1(555)5551199" use="WP"/> <informationRecipient> <name> <prefix>Dr.</prefix> <given>Patrick</given> <given>P.</given> <family>Pump</family> <suffix>Sr.</suffix> </name> </informationRecipient> <receivedOrganization> <name>Level 7 Healthcare, Inc</name> </receivedOrganization> </intendedRecipient> </informationRecipient> <!-- ******************************************************** Author ******************************************************** --> <author> <time value="20040812120000"/> <assignedAuthor> <id extension="hhippocrates" root="DCCD2C68-389B-44c4-AD99-B8FB2DAD1493"/> <addr> <streetAddressLine>4444 Healthcare Drive</streetAddressLine> <city>Ann Arbor</city> <state>BC</state> <postalCode>A1B 2C3</postalCode> <country>CA</country> </addr> <telecom value="tel:(555)555-1003" use="WP"/> <telecom value="fax:(555)555-1133" use="WP"/> <assignedPerson> <name> <prefix>Dr.</prefix> <given>Harold</given> <given>H.</given> <family>Hippocrates</family> <suffix>the 1st</suffix> </name> </assignedPerson> </assignedAuthor> </author> <author> <time value="20040812120000"/> <assignedAuthor> <id extension="hhippocrates" root="DCCD2C68-389B-44c4-AD99-B8FB2DAD1493"/> <assignedAuthoringDevice> <softwareName>e-MS Web</softwareName> </assignedAuthoringDevice> </assignedAuthor> </author> <!-- ******************************************************** Custodian ******************************************************** --> <custodian typeCode="CST"> <assignedCustodian> <representedCustodianOrganization> <id extension="123" root="7EEF0BCC-F03E-4742-A736-8BAC57180C5F"/> <name>Level 7 Healthcare, Inc</name> </representedCustodianOrganization> </assignedCustodian> </custodian> <!-- ******************************************************** Record Target ******************************************************** --> <recordTarget typeCode="RCT" contextControlCode="OP"> <patient classCode="PAT"> <id extension="9999999999" root="2BFBA1E9-79C2-4bbb-B589-41B949BD6A3B" assigningAuthorityName="BC-PHN"/> <id extension="99999-9" assigningAuthorityName="WCB"/> <addr> <streetAddressLine>2222 Home Street</streetAddressLine> <city>Ann Arbor</city> <state>BC</state> <postalCode>A1B 2C3</postalCode> <country>CA</country> </addr> <telecom value="ph:555555-2003" use="HP"/> <telecom value="email:Eve.Everywoman@eg.net" use="HP"/> <patientPatient> <name> <prefix>Mrs.</prefix> <given>Eve</given> <given>E.</given> <family>Everywoman</family> <suffix>Jr.</suffix> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1" codeSystemName="HL7 - Administrative Gender" displayName="Female"/> <birthTime value="19650516"/> <languageCommunication> <languageCode code="EN"/> </languageCommunication> </patientPatient> </patient> </recordTarget> <!-- ******************************************************** Participant - Contact ******************************************************** --> <participant typeCode="NOT"> <participatingEntity classCode="CON"> <code code="HUSB" codeSystem="F05716F7-BA77-4641-A8D8-6E3948CCD321" codeSystemName="HL7: PersonalRelationshipRoleType" displayName="Husband"/> <addr> <streetAddressLine>2222 Home Street</streetAddressLine> <city>Ann Arbor</city> <state>BC</state> <postalCode>A1B 2C3</postalCode> <country>CA</country> </addr> <telecom value="tel:(555)555-5001" use="H"/> <telecom value="mailto:Neville.Nuclear@eg.net" use="H"/> <associatedPerson> <name> <prefix>Mr.</prefix> <given>Neville</given> <given>N.</given> <family>Nuclear</family> <suffix>III</suffix> </name> </associatedPerson> </participatingEntity> </participant> <participant typeCode="NOT"> <participatingEntity classCode="CON"> <code code="NCHLD" codeSystem="F05716F7-BA77-4641-A8D8-6E3948CCD321" codeSystemName="HL7: PersonalRelationshipRoleType" displayName="Natural Child"/> <addr> <streetAddressLine>6666 Home Street</streetAddressLine> <city>Ann Arbor</city> <state>BC</state> <postalCode>A1B 2C3</postalCode> <country>CA</country> </addr> <telecom value="tel:(555)555-5001" use="H"/> <telecom value="mailto:Nancy.Nuclear@eg.net" use="H"/> <associatedPerson> <name> <prefix>Ms.</prefix> <given>Nancy</given> <given>N.</given> <family>Nuclear</family> <suffix>Sr.</suffix> </name> </associatedPerson> </participatingEntity> </participant> <!-- ******************************************************** Related Document ******************************************************** --> <relatedDocument typeCode="APND"> <parentDocument> <id extension="C7F36C19-64F0-4a8d-859B-2404F07A2434" root="2.16.840.1.113883.3.933"/> <code code="34140-4" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Referral"/> <text>A previous referral is related to this document</text> </parentDocument> </relatedDocument> <!-- ******************************************************** e-MS CDA Structured Body ******************************************************** --> <component> <structuredBody> <!-- ******************************************************** Purpose ******************************************************** --> <component> <section> <code code="001" codeSystem="7BA9BFFD-D25F-44e8-A7B0-0DF214D6845B" codeSystemName="e-MS Document Section Codes" displayName="Purpose"/> <title>Referral Purpose Please see this patient regarding occasional occurrences of arrhythmia at rest accompanied with mild shortness of breath. Mild exercise leads to faintness and mild chest pain. Urgency: expedite
Other Provider Reason
Dr. Vera V. Valve at Level 7 Healthcare, Inc High blood pressure in the past
Dr. Sara S. Specialize at Good Health Hospital 24 Hour ECG recording
Comments: The patient expressed that this problem has gradually been getting worse over the course of the past year and a half. Please see this patient regarding occasional occurrences of arrhythmia at rest accompanied with mild shortness of breath. Mild exercise leads to faintness and mild chest pain. The patient expressed that this problem has gradually been getting worse over the course of the past year and a half. Dr. Vera V. Valve at Level 7 Healthcare High blood pressure in the past Dr. Sara S. Specialize at Good Health Hospital 24 Hour ECG recording
Alerts
Alert Comments Date
History of violence Mostly towards family members 1999
History of mental illness Mild anxiety disorder August 2000
History of violence Mostly towards family members History of mental illness Mild anxiety disorder
Social History/Risks
Social History/Risk Comments Date
Smoking 2 packs of cigarettes per day in her early teens 1979-1982
Alcohol consumption 3 glasses of wine per day January 2000
Smoking 2 packs of cigarettes per day starting in her early teens. Alcohol consumption 3 glasses of wine per day.
Examination Measurements
Height Weight Blood Pressure Pulse
January 13, 2000 172 cm 65 Kg 130/80 80 BPM
March 18, 2001 172 cm 70 Kg 145/95 90 BPM
September 22, 2003 172 cm 78 Kg 160/110 92 BPM
August 9, 2004 172 cm 80 Kg 160/130 94 BPM
Active Problem List
Active Problem Description Date
Hypertension Continuing to increase in severity. December 2002
This is continuing to increase in severity.
Current Medications
Medication Name DIN DIN Name Dose Admin Route Frequency Repeats Effective Date
Accupril 5 mg 01947664 Quinapril 10 mg Orally 2 per day 2 Jan 15, 2003
Accupril 5 mg.
Medical History
Problem Comments Date
Meningitis No permanent effects. 1975
Closed fractured rib Patient is unsure of which rib it was. 1994
No permanent effects. Patient is unsure of which rib it was.
Surgical History
Description Date
Appendectomy June 1970
Cholelithotomy January 17, 2004
Appendectomy Cholelithotomy
Medical Imaging History
Procedure Results Date
Chest x-ray Nothing unusual could be observed. X-ray image is attached. July 14, 2004
Chest x-ray Nothing unusual could be observed. X-ray image is attached.
Other Treatments
Other Treatment Outcome Date
Herbal remedy The patient did not experience any improvement in her condition November 2003-February 2004
Herbal remedy The patient did not experience any improvement in her condition.
Allergies
Allergy Type Severity Comments Date
Penicillin Mild Penicillin. Resulting in hives. Patient hasn’t been tested recently to see if this is still an active allergy 1965
Dairy products Moderate Dairy. Resulting in puffy eyes 1970-1985
Penicillin. Resulting in hives. Patient hasn’t been tested recently to see if this is still an active allergy Dairy. Resulting in puffy eyes
Immunization
Immunization Date
Hepatitis A September 24, 2000
Hepatitis A January 27, 2002
Inactivated Polio Vaccine (study) March 13, 1985
Measles Mumps Rubella April 30, 1995
Labs
Type Collection Date Result/Unit Normal Result Range Abnormal?
troponin I (TnI) February 26, 2004 0.5 ng/mL less than 0.5 ng/mL No
creatine phosphokinase (CPK) February 26, 2004 180 u/L 5-200 u/L No
lactate dehydrogenase (LDH) February 26, 2004 400 u/L 200-650 u/L No
Past Referrals and Hospitalizations
Location/Person Type Reason Date
Good Health Hospital Specialist Pneumonia 1996
Pneumonia.
Family History The patient’s father died of a myocardial infarction at the age of 65.