+// Skin Exam
+// Erythematous rash, palmar surface, left index finger.
+//
+
+ assertEquals("Skin Exam", fp.evaluateToString(e, "component.structuredBody.component.section.component.section.where(code.code='8709-8' and code.codeSystem='2.16.840.1.113883.6.1').title.dataString"));
+ } catch (Exception e) {
+ System.out.println(e.getMessage());
+ e.printStackTrace();
+ throw e;
+ }
}
- @Test
+ @Ignore
public void testDCI() throws FHIRFormatError, DefinitionException, FileNotFoundException, IOException, FHIRException {
try {
- Element e = Manager.parse(context, new FileInputStream("C:\\work\\org.hl7.fhir.us\\ccda-to-fhir-maps\\cda\\IAT2-Discharge_Summary-DCI.xml"), FhirFormat.XML);
- Manager.compose(context, e, new FileOutputStream("C:\\temp\\ccda.xml"), FhirFormat.XML, OutputStyle.PRETTY, null);
+ Element e = Manager.parse(context,
+ new FileInputStream("C:\\work\\org.hl7.fhir.us\\ccda-to-fhir-maps\\cda\\IAT2-Discharge_Summary-DCI.xml"),
+ FhirFormat.XML);
+
+ Manager.compose(context, e, new FileOutputStream("C:\\temp\\ccda.xml"), FhirFormat.XML, OutputStyle.PRETTY, null);
// Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge_Summary-DCI.out.json"), FhirFormat.JSON, OutputStyle.PRETTY, null);
// Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge_Summary-DCI.out.ttl"), FhirFormat.TURTLE, OutputStyle.PRETTY, null);
} catch (Exception e) {
@@ -44,20 +134,44 @@ public class CDARoundTripTests {
}
}
- @Test
- public void testEpic() throws FHIRFormatError, DefinitionException, FileNotFoundException, IOException, FHIRException {
- Element e = Manager.parse(context, new FileInputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.xml"), FhirFormat.XML);
- Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.xml"), FhirFormat.XML, OutputStyle.PRETTY, null);
- Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.json"), FhirFormat.JSON, OutputStyle.PRETTY, null);
- Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.ttl"), FhirFormat.TURTLE, OutputStyle.PRETTY, null);
+ @Ignore
+ public void testEpic()
+ throws FHIRFormatError, DefinitionException, FileNotFoundException, IOException, FHIRException {
+ Element e = Manager.parse(context,
+ new FileInputStream(
+ "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.xml"),
+ FhirFormat.XML);
+ Manager.compose(context, e,
+ new FileOutputStream(
+ "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.xml"),
+ FhirFormat.XML, OutputStyle.PRETTY, null);
+ Manager.compose(context, e,
+ new FileOutputStream(
+ "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.json"),
+ FhirFormat.JSON, OutputStyle.PRETTY, null);
+ Manager.compose(context, e,
+ new FileOutputStream(
+ "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-Discharge-Homework-Epic.out.ttl"),
+ FhirFormat.TURTLE, OutputStyle.PRETTY, null);
}
- @Test
- public void testDHIT() throws FHIRFormatError, DefinitionException, FileNotFoundException, IOException, FHIRException {
- Element e = Manager.parse(context, new FileInputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.xml"), FhirFormat.XML);
- Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.xml"), FhirFormat.XML, OutputStyle.PRETTY, null);
- Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.json"), FhirFormat.JSON, OutputStyle.PRETTY, null);
- Manager.compose(context, e, new FileOutputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.ttl"), FhirFormat.TURTLE, OutputStyle.PRETTY, null);
+ @Ignore
+ public void testDHIT()
+ throws FHIRFormatError, DefinitionException, FileNotFoundException, IOException, FHIRException {
+ Element e = Manager.parse(context,
+ new FileInputStream("C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.xml"),
+ FhirFormat.XML);
+ Manager.compose(context, e,
+ new FileOutputStream(
+ "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.xml"),
+ FhirFormat.XML, OutputStyle.PRETTY, null);
+ Manager.compose(context, e,
+ new FileOutputStream(
+ "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.json"),
+ FhirFormat.JSON, OutputStyle.PRETTY, null);
+ Manager.compose(context, e,
+ new FileOutputStream(
+ "C:\\work\\org.hl7.fhir.test\\ccda-to-fhir-maps\\testdocuments\\IAT2-DS-Homework-DHIT.out.ttl"),
+ FhirFormat.TURTLE, OutputStyle.PRETTY, null);
}
-
-}
+}
\ No newline at end of file
diff --git a/org.hl7.fhir.r5/src/test/resources/cda/cda-original.xml b/org.hl7.fhir.r5/src/test/resources/cda/cda-original.xml
new file mode 100644
index 000000000..ba6497772
--- /dev/null
+++ b/org.hl7.fhir.r5/src/test/resources/cda/cda-original.xml
@@ -0,0 +1,1098 @@
+
+
+
+
+
+ Good Health Clinic Consultation Note
+
+
+
+
+ Levin
+ Henry
+ the 7th
+
+
+
+
+
+
+
+
+
+
+ Dolin
+ Robert
+ MD
+
+
+
+
+
+
+
+
+
+ Good Health Clinic
+
+
+
+
+
+
+
+ Dolin
+ Robert
+ MD
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Dolin
+ Robert
+ MD
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ History of Present Illness
+
+ Henry Levin, the 7th
+ is a 67 year old male referred for further asthma management. Onset of asthma in his twenties
+ teens . He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months.
+
+
+
+
+
+
+ Past Medical History
+
+
+ -
+
Asthma
+
+ -
+
Hypertension (see HTN.cda for details)
+
+ -
+
Osteoarthritis,
+ right knee
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Medications
+
+
+ - Theodur 200mg BID
+ - Proventil inhaler 2puffs QID PRN
+ - Prednisone 20mg qd
+ - HCTZ 25mg qd
+
+
+
+
+ Theodur 200mg BID
+
+
+
+
+
+
+
+
+
+
+
+
+ Proventil inhaler 2puffs QID PRN
+
+
+
+
+
+
+
+
+
+
+
+
+ Prednisone 20mg qd
+
+
+
+
+
+
+
+
+
+
+
+
+ HCTZ 25mg qd
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Allergies and Adverse Reactions
+
+
+ - Penicillin - Hives
+ - Aspirin - Wheezing
+ - Codeine - Itching and nausea
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Family history
+
+
+ - Father had fatal MI in his early 50's.
+ - No cancer or diabetes.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Social History
+
+
+ - Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.
+ - Alcohol :: rare
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Physical Examination
+
+
+
+ Vital Signs
+
+
+
+
+ Date / Time
+ April 7, 2000 14:30
+ April 7, 2000 15:30
+
+
+ Height
+ 177 cm (69.7 in)
+
+
+ Weight
+ 194.0 lbs (88.0 kg)
+
+
+ BMI
+ 28.1 kg/m2
+
+
+ BSA
+ 2.05 m2
+
+
+ Temperature
+ 36.9 C (98.5 F)
+ 36.9 C (98.5 F)
+
+
+ Pulse
+ 86 / minute
+ 84 / minute
+
+
+ Rhythm
+ Regular
+ Regular
+
+
+ Respirations
+ 16 / minute, unlabored
+ 14 / minute
+
+
+ Systolic
+ 132 mmHg
+ 135 mmHg
+
+
+ Diastolic
+ 86 mmHg
+ 88 mmHg
+
+
+ Position / Cuff
+ Left Arm
+ Left Arm
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Skin Exam
+ Erythematous rash, palmar surface, left index finger.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Lungs
+ Clear with no wheeze. Good air flow.
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Cardiac
+ RRR with no murmur, no S3, no S4.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Labs
+
+
+ - CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs.
+ - Peak Flow today: 260 l/m
+
+
+
+
+
+
+
+
+
+
+
+ normal cardiac silhouette
+
+
+
+
+
+
+ radiopacities
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ In-office Procedures
+
+
+ - Suture removal, left forearm.
+
+
+
+
+
+
+
+
+
+
+
+ Assessment
+
+
+ - Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper.
+ - Hypertension, well-controlled.
+ - Contact dermatitis on finger.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Plan
+
+
+ - Complete PFTs with lung volumes.
+ - Chem-7 tomorrow.
+ - Teach peak flow rate measurement.
+ - Decrease prednisone to 20qOD alternating with 18qOD.
+ - Hydrocortisone cream to finger BID.
+ - RTC 1 week.
+
+
+
+
+ Complete PFTs with lung volumes.
+
+
+
+
+
+
+
+
+
+ Chem-7
+
+ Chem-7 tomorrow
+
+
+
+
+
+
+
+
+
+
+
+
+ prednisone 20qOD alternating with 18qOD.
+
+
+
+
+
+
+
+
+
+
+ Hydrocortisone cream to finger BID.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
diff --git a/org.hl7.fhir.r5/src/test/resources/cda/cda-roundtrip.json b/org.hl7.fhir.r5/src/test/resources/cda/cda-roundtrip.json
new file mode 100644
index 000000000..5c0e75a74
--- /dev/null
+++ b/org.hl7.fhir.r5/src/test/resources/cda/cda-roundtrip.json
@@ -0,0 +1,2360 @@
+{
+ "resourceType": "ClinicalDocument",
+ "id": {
+ "extension": "c266",
+ "root": "2.16.840.1.113883.19.4"
+ },
+ "code": {
+ "code": "11488-4",
+ "codeSystem": "2.16.840.1.113883.6.1",
+ "codeSystemName": "LOINC",
+ "displayName": "Consultation note"
+ },
+ "title": {
+ "dataString": "Good Health Clinic Consultation Note"
+ },
+ "effectiveTime": {
+ "value": "2000-04-07"
+ },
+ "confidentialityCode": {
+ "code": "N",
+ "codeSystem": "2.16.840.1.113883.5.25"
+ },
+ "languageCode": {
+ "code": "en-US"
+ },
+ "setId": {
+ "extension": "BB35",
+ "root": "2.16.840.1.113883.19.7"
+ },
+ "versionNumber": {
+ "value": 2
+ },
+ "recordTarget": [
+ {
+ "patientRole": {
+ "id": [
+ {
+ "extension": "12345",
+ "root": "2.16.840.1.113883.19.5"
+ }
+ ],
+ "patient": {
+ "name": [
+ {
+ "family": [
+ {
+ "dataString": "Levin"
+ }
+ ],
+ "given": [
+ {
+ "dataString": "Henry"
+ }
+ ],
+ "suffix": [
+ {
+ "dataString": "the 7th"
+ }
+ ]
+ }
+ ],
+ "administrativeGenderCode": {
+ "code": "M",
+ "codeSystem": "2.16.840.1.113883.5.1"
+ },
+ "birthTime": {
+ "value": "1932-09-24"
+ }
+ },
+ "providerOrganization": {
+ "id": [
+ {
+ "root": "2.16.840.1.113883.19.5"
+ }
+ ]
+ }
+ }
+ }
+ ],
+ "author": [
+ {
+ "time": {
+ "value": "2000-04-07T14:00:00"
+ },
+ "assignedAuthor": {
+ "id": [
+ {
+ "extension": "KP00017",
+ "root": "2.16.840.1.113883.19.5"
+ }
+ ],
+ "assignedPerson": {
+ "name": [
+ {
+ "family": [
+ {
+ "dataString": "Dolin"
+ }
+ ],
+ "given": [
+ {
+ "dataString": "Robert"
+ }
+ ],
+ "suffix": [
+ {
+ "dataString": "MD"
+ }
+ ]
+ }
+ ]
+ },
+ "representedOrganization": {
+ "id": [
+ {
+ "root": "2.16.840.1.113883.19.5"
+ }
+ ]
+ }
+ }
+ }
+ ],
+ "custodian": {
+ "assignedCustodian": {
+ "representedCustodianOrganization": {
+ "id": [
+ {
+ "root": "2.16.840.1.113883.19.5"
+ }
+ ],
+ "name": {
+ "dataString": "Good Health Clinic"
+ }
+ }
+ }
+ },
+ "legalAuthenticator": {
+ "time": {
+ "value": "2000-04-08"
+ },
+ "signatureCode": {
+ "code": "S"
+ },
+ "assignedEntity": {
+ "id": [
+ {
+ "extension": "KP00017",
+ "root": "2.16.840.1.113883.19.5"
+ }
+ ],
+ "assignedPerson": {
+ "name": [
+ {
+ "family": [
+ {
+ "dataString": "Dolin"
+ }
+ ],
+ "given": [
+ {
+ "dataString": "Robert"
+ }
+ ],
+ "suffix": [
+ {
+ "dataString": "MD"
+ }
+ ]
+ }
+ ]
+ },
+ "representedOrganization": {
+ "id": [
+ {
+ "root": "2.16.840.1.113883.19.5"
+ }
+ ]
+ }
+ }
+ },
+ "relatedDocument": [
+ {
+ "typeCode": "RPLC",
+ "parentDocument": {
+ "id": [
+ {
+ "extension": "a123",
+ "root": "2.16.840.1.113883.19.4"
+ }
+ ],
+ "setId": {
+ "extension": "BB35",
+ "root": "2.16.840.1.113883.19.7"
+ },
+ "versionNumber": {
+ "value": 1
+ }
+ }
+ }
+ ],
+ "componentOf": {
+ "encompassingEncounter": {
+ "id": [
+ {
+ "extension": "KPENC1332",
+ "root": "2.16.840.1.113883.19.6"
+ }
+ ],
+ "effectiveTime": {
+ "value": "2000-04-07"
+ },
+ "encounterParticipant": [
+ {
+ "typeCode": "CON",
+ "time": {
+ "value": "2000-04-07"
+ },
+ "assignedEntity": {
+ "id": [
+ {
+ "extension": "KP00017",
+ "root": "2.16.840.1.113883.19.5"
+ }
+ ],
+ "assignedPerson": {
+ "name": [
+ {
+ "family": [
+ {
+ "dataString": "Dolin"
+ }
+ ],
+ "given": [
+ {
+ "dataString": "Robert"
+ }
+ ],
+ "suffix": [
+ {
+ "dataString": "MD"
+ }
+ ]
+ }
+ ]
+ },
+ "representedOrganization": {
+ "id": [
+ {
+ "root": "2.16.840.1.113883.19.5"
+ }
+ ]
+ }
+ }
+ }
+ ],
+ "location": {
+ "healthCareFacility": {
+ "classCode": "DSDLOC",
+ "code": {
+ "code": "GIM",
+ "codeSystem": "2.16.840.1.113883.5.10588",
+ "displayName": "General internal medicine clinic"
+ }
+ }
+ }
+ }
+ },
+ "component": {
+ "structuredBody": {
+ "component": [
+ {
+ "section": {
+ "code": {
+ "code": "10164-2",
+ "codeSystem": "2.16.840.1.113883.6.1",
+ "codeSystemName": "LOINC"
+ },
+ "title": {
+ "dataString": "History of Present Illness"
+ },
+ "text": "Henry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his twenties teens . He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months. \n\t\t\t\t\t\t
"
+ }
+ },
+ {
+ "section": {
+ "code": {
+ "code": "10153-2",
+ "codeSystem": "2.16.840.1.113883.6.1",
+ "codeSystemName": "LOINC"
+ },
+ "title": {
+ "dataString": "Past Medical History"
+ },
+ "text": "Asthma Hypertension (see HTN.cda for details) Osteoarthritis, \n\t\t\t\t\t\t\t\t\tright knee Theodur 200mg BID Proventil inhaler 2puffs QID PRN Prednisone 20mg qd HCTZ 25mg qd Penicillin - Hives Aspirin - Wheezing Codeine - Itching and nausea Father had fatal MI in his early 50's. No cancer or diabetes. Smoking :: 1 PPD between the ages of 20 and 55, and then he quit. Alcohol :: rare Date / Time April 7, 2000 14:30 April 7, 2000 15:30 Height 177 cm (69.7 in) Weight 194.0 lbs (88.0 kg) BMI 28.1 kg/m2 BSA 2.05 m2 Temperature 36.9 C (98.5 F) 36.9 C (98.5 F) Pulse 86 / minute 84 / minute Rhythm Regular Regular Respirations 16 / minute, unlabored 14 / minute Systolic 132 mmHg 135 mmHg Diastolic 86 mmHg 88 mmHg Position / Cuff Left Arm Left Arm
Erythematous rash, palmar surface, left index finger.\n\t\t\t\t\t\t\t\t
Clear with no wheeze. Good air flow.
",
+ "entry": [
+ {
+ "observation": {
+ "classCode": "OBS",
+ "moodCode": "EVN",
+ "code": {
+ "code": "48348007",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "Chest clear"
+ },
+ "statusCode": {
+ "code": "completed"
+ },
+ "methodCode": [
+ {
+ "code": "37931006",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "Auscultation"
+ }
+ ]
+ }
+ },
+ {
+ "observation": {
+ "classCode": "OBS",
+ "moodCode": "EVN",
+ "negationInd": true,
+ "code": {
+ "code": "56018004",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "Wheezing"
+ },
+ "statusCode": {
+ "code": "completed"
+ },
+ "methodCode": [
+ {
+ "code": "37931006",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "Auscultation"
+ }
+ ]
+ }
+ }
+ ]
+ }
+ },
+ {
+ "section": {
+ "code": {
+ "code": "10223-2",
+ "codeSystem": "2.16.840.1.113883.6.1",
+ "codeSystemName": "LOINC"
+ },
+ "title": {
+ "dataString": "Cardiac"
+ },
+ "text": "RRR with no murmur, no S3, no S4.
",
+ "entry": [
+ {
+ "observation": {
+ "classCode": "OBS",
+ "moodCode": "EVN",
+ "code": {
+ "code": "76863003",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "Normal heart rate"
+ },
+ "statusCode": {
+ "code": "completed"
+ },
+ "methodCode": [
+ {
+ "code": "37931006",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "Auscultation"
+ }
+ ]
+ }
+ },
+ {
+ "observation": {
+ "classCode": "OBS",
+ "moodCode": "EVN",
+ "negationInd": true,
+ "code": {
+ "code": "88610006",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "heart murmur"
+ },
+ "statusCode": {
+ "code": "completed"
+ },
+ "methodCode": [
+ {
+ "code": "37931006",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "Auscultation"
+ }
+ ]
+ }
+ },
+ {
+ "observation": {
+ "classCode": "OBS",
+ "moodCode": "EVN",
+ "negationInd": true,
+ "code": {
+ "code": "277455002",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "Third heart sound"
+ },
+ "statusCode": {
+ "code": "completed"
+ },
+ "methodCode": [
+ {
+ "code": "37931006",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "Auscultation"
+ }
+ ]
+ }
+ },
+ {
+ "observation": {
+ "classCode": "OBS",
+ "moodCode": "EVN",
+ "code": {
+ "code": "60721002",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "Fourth heart sound inaudible"
+ },
+ "statusCode": {
+ "code": "completed"
+ },
+ "methodCode": [
+ {
+ "code": "37931006",
+ "codeSystem": "2.16.840.1.113883.6.96",
+ "codeSystemName": "SNOMED CT",
+ "displayName": "Auscultation"
+ }
+ ]
+ }
+ }
+ ]
+ }
+ }
+ ]
+ }
+ },
+ {
+ "section": {
+ "code": {
+ "code": "11502-2",
+ "codeSystem": "2.16.840.1.113883.6.1",
+ "codeSystemName": "LOINC"
+ },
+ "title": {
+ "dataString": "Labs"
+ },
+ "text": "CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs. Peak Flow today: 260 l/m Suture removal, left forearm. Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper. Hypertension, well-controlled. Contact dermatitis on finger. Complete PFTs with lung volumes. Chem-7 tomorrow. Teach peak flow rate measurement. Decrease prednisone to 20qOD alternating with 18qOD. Hydrocortisone cream to finger BID. RTC 1 week.
+ Good Health Clinic Consultation Note
+
+
+
+
+ Levin
+ Henry
+ the 7th
+
+
+
+
+
+
+
+
+
+
+ Dolin
+ Robert
+ MD
+
+
+
+
+
+
+
+
+
+ Good Health Clinic
+
+
+
+
+
+
+
+ Dolin
+ Robert
+ MD
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Dolin
+ Robert
+ MD
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ History of Present Illness
+
+ Henry Levin, the 7
+ th
+ is a 67 year old male referred for further asthma management. Onset of asthma in his
+ twenties
+ teens . He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months.
+
+
+
+
+
+
+
+ Past Medical History
+
+
+ -
+
Asthma
+
+ -
+
Hypertension (see HTN.cda for details)
+
+ -
+
Osteoarthritis,
+
+ right knee
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Medications
+
+
+ - Theodur 200mg BID
+ - Proventil inhaler 2puffs QID PRN
+ - Prednisone 20mg qd
+ - HCTZ 25mg qd
+
+
+
+
+ Theodur 200mg BID
+
+
+
+
+
+
+
+
+
+
+
+
+ Proventil inhaler 2puffs QID PRN
+
+
+
+
+
+
+
+
+
+
+
+
+ Prednisone 20mg qd
+
+
+
+
+
+
+
+
+
+
+
+
+ HCTZ 25mg qd
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Allergies and Adverse Reactions
+
+
+ - Penicillin - Hives
+ - Aspirin - Wheezing
+ - Codeine - Itching and nausea
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Family history
+
+
+ - Father had fatal MI in his early 50's.
+ - No cancer or diabetes.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Social History
+
+
+ - Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.
+ - Alcohol :: rare
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Physical Examination
+
+
+
+ Vital Signs
+
+
+
+
+ Date / Time
+ April 7, 2000 14:30
+ April 7, 2000 15:30
+
+
+ Height
+ 177 cm (69.7 in)
+
+
+ Weight
+ 194.0 lbs (88.0 kg)
+
+
+ BMI
+ 28.1 kg/m2
+
+
+ BSA
+ 2.05 m2
+
+
+ Temperature
+ 36.9 C (98.5 F)
+ 36.9 C (98.5 F)
+
+
+ Pulse
+ 86 / minute
+ 84 / minute
+
+
+ Rhythm
+ Regular
+ Regular
+
+
+ Respirations
+ 16 / minute, unlabored
+ 14 / minute
+
+
+ Systolic
+ 132 mmHg
+ 135 mmHg
+
+
+ Diastolic
+ 86 mmHg
+ 88 mmHg
+
+
+ Position / Cuff
+ Left Arm
+ Left Arm
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Skin Exam
+ Erythematous rash, palmar surface, left index finger.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Lungs
+ Clear with no wheeze. Good air flow.
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Cardiac
+ RRR with no murmur, no S3, no S4.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Labs
+
+
+ - CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs.
+ - Peak Flow today: 260 l/m
+
+
+
+
+
+
+
+
+
+
+
+ normal cardiac silhouette
+
+
+
+
+
+
+ radiopacities
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ In-office Procedures
+
+
+ - Suture removal, left forearm.
+
+
+
+
+
+
+
+
+
+
+
+ Assessment
+
+
+ - Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper.
+ - Hypertension, well-controlled.
+ - Contact dermatitis on finger.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ Plan
+
+
+ - Complete PFTs with lung volumes.
+ - Chem-7 tomorrow.
+ - Teach peak flow rate measurement.
+ - Decrease prednisone to 20qOD alternating with 18qOD.
+ - Hydrocortisone cream to finger BID.
+ - RTC 1 week.
+
+
+
+
+ Complete PFTs with lung volumes.
+
+
+
+
+
+
+
+
+
+ Chem-7
+
+ Chem-7 tomorrow
+
+
+
+
+
+
+
+
+
+
+
+
+ prednisone 20qOD alternating with 18qOD.
+
+
+
+
+
+
+
+
+
+
+ Hydrocortisone cream to finger BID.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
\ No newline at end of file