72 lines
7.8 KiB
Plaintext
72 lines
7.8 KiB
Plaintext
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Patient Summary Record Test Data <20> Set #2
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Patient
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Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
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Ruth Warholde 05/20/1954 Female 9836469798 Medical Record Number 225 Park Street
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23:59:45 Morton,
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<EFBFBD>Source<EFBFBD> for all data for this patient: Jackson Shoals, MD
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Problem List
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Type ICD-9 Code Patient Problem Status Date Diagnosed
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Diagnosis 780.2 Syncope and collapse, vasovagal attack Active 02/15/2010
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Diagnosis 434.91 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
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Diagnosis 599.0 Urinary tract infection Recurrent 09/22/2008
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Diagnosis 496.0 Chronic Obstructive Pulmonary Disease Chronic 08/12/2007
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Symptom 401.9 Hypertension, essential Chronic 05/16/2006
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Type SNOMED Code* Patient Problem Status Date Diagnosed
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Disorder 398665005 Vasovagal syncope Active 02/15/2010
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Disorder 230690007 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
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Disorder 197927001 Recurrent urinary tract infection Recurrent 09/22/2008
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Disorder 13645005 Chronic Obstructive Lung Disease Chronic 08/12/2007
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Disorder 59621000 Essential Hypertension Chronic 05/16/2006
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Medication List
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RxNorm
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Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
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Code
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209834 Medication docusate Colace 100 mg 1 Capsule PO BID 02/16/2010 Active
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205326 Medication lisinopril Zestril 30 mg 1 Tablet PO QD 07/15/2009 Active
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309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 07/15/2009 Active
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197361 Medication amlodipine Norvasc 5 mg 1 Tablet PO QD 07/15/2009 Active
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No Longer
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539712 Medication nitrofurantoin Macrobid 100 mg 1 Capsule PO QD 09/22/2008
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Active
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ipratropium
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Atrovent 18 By oral
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836370 Medication bromide 2 puffs QID 08/14/2007 Active
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inhaler mcg/puff inhalation
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monhydrate
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clonidine
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884175 Medication Catapres 0.1 mg 1 Tablet PO BID 05/16/2006 Active
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hydrochloride
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Medication Allergy List
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Type SNOMED Code Medication/Agent Reaction Date Recorded
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Nausea, vomiting, rash,
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Drug Allergy 293620004 Indomethacin 03/25/2003
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dizziness, headache
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Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 07/26/1999
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Diagnostic Test Results
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Type LOINC Code Test (Normal Range) Result Date Performed
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Small high right occipital lobe
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contusion. No evidence of
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Imaging 11539-4 CT, head 02/24/2010
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extra-axial blood. Significant
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sinus disease.
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Hematology 718-7 Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl) 13 g/dl 02/17/2010
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Hematology 4544-3 Hematocrit (male: 40-54% female: 36-48%) 38% 02/17/2010
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Chemistry 2951-2 Sodium (135<33>146 mg/dl) 136 mg/dl 02/17/2010
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Chemistry 2823-3 Potassium (3.5<EFBFBD>5.3 mg/dl) 3.9 mg/dl 02/17/2010
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Imaging 34534-8 Electrocardiogram Normal Sinus Rhythm 02/15/2010
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Urine culture, routine
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Microbiology 630-4 Negative: No growth 10/02/2008
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(Negative: No growth Positive: >10,000 CFU/ml)
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Procedure List
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Type ICD-9 Code Procedure Status Date Performed
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Surgical 66.39 Bilateral tubal ligation Completed 06/14/1990
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Type CPT Code* Procedure Status Date Performed
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Surgical 58600 Bilateral tubal ligation
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