69 lines
6.3 KiB
Plaintext
69 lines
6.3 KiB
Plaintext
|
Patient Summary Record Test Data <20> Set #5
|
|||
|
|
|
|||
|
|
Patient
|
|||
|
|
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
|
|||
|
|
Christine Taylor 09/22/1965 Female 9787478034 Medical Record Number 754 Angel Street
|
|||
|
|
16:48:25 Marshalltown
|
|||
|
|
Iowa 50158
|
|||
|
|
641-544-9988
|
|||
|
|
|
|||
|
|
<EFBFBD>Source<EFBFBD> for all data for this patient: Kathryn Thomson, MD
|
|||
|
|
|
|||
|
|
Problem List
|
|||
|
|
Type ICD-9 Code Patient Problem Status Date Diagnosed
|
|||
|
|
Diagnosis 540.0 Acute Appendicitis Resolved 01/09/2010
|
|||
|
|
Diagnosis 434.91 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
|
|||
|
|
Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 03/30/2009
|
|||
|
|
Symptom 401.9 Hypertension, Essential Chronic 02/25/2008
|
|||
|
|
|
|||
|
|
Type SNOMED Code* Patient Problem Status Date Diagnosed
|
|||
|
|
Disorder 74400008 Appendicitis Resolved 01/09/2010
|
|||
|
|
Disorder 230690007 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
|
|||
|
|
Disorder 44054006 Diabetes Mellitus, Type 2 Active 03/30/2009
|
|||
|
|
Disorder 59621000 Essential Hypertension Chronic 02/25/2008
|
|||
|
|
|
|||
|
|
Medication List
|
|||
|
|
RxNorm
|
|||
|
|
Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
|||
|
|
Code
|
|||
|
|
309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 07/15/2009 Active
|
|||
|
|
205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 03/30/2009 Active
|
|||
|
|
209834 Medication docusate Colace 100 mg 1 Capsule PO BID 03/30/2009 Active
|
|||
|
|
200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 02/25/2008 Active
|
|||
|
|
potassium
|
|||
|
|
628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 02/25/2008 Active
|
|||
|
|
chloride
|
|||
|
|
RxNorm
|
|||
|
|
Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
|||
|
|
Code
|
|||
|
|
clonidine
|
|||
|
|
884175 Medication Catapres 0.1 mg 1 Tablet PO BID 02/25/2008 Active
|
|||
|
|
hydrochloride
|
|||
|
|
|
|||
|
|
Medication Allergy List
|
|||
|
|
Type SNOMED Code Medication/Agent Reaction Date Recorded
|
|||
|
|
Drug Allergy 293620004 Indomethacin Rash, dizziness, headache 06/05/2008
|
|||
|
|
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 05/25/1997
|
|||
|
|
Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 08/25/1989
|
|||
|
|
|
|||
|
|
Diagnostic Test Results
|
|||
|
|
Type LOINC Code Test (Normal Range) Result Date Performed
|
|||
|
|
Chemistry 14771-0 Fasting Blood Glucose (70<37>100 mg/dl) 126 mg/dl 07/15/2010
|
|||
|
|
|
|||
|
|
Chemistry 2823-3 Potassium (3.5<EFBFBD>5.3 mg/dl) 4.3 mg/dl 07/15/2010
|
|||
|
|
Chemistry 14927-8 Triglycerides (<150 mg/dl) 178 mg/dl 07/15/2010
|
|||
|
|
|
|||
|
|
The heart outline is normal
|
|||
|
|
42272-5 and the hilar and
|
|||
|
|
Imaging Chest X-ray, PA & Lateral mediastinal vessels are of 02/25/2008
|
|||
|
|
|
|||
|
|
normal appearance
|
|||
|
|
|
|||
|
|
Procedure List
|
|||
|
|
Type ICD-9 Code Procedure Status Date Performed
|
|||
|
|
Surgical 47.09 Emergency Appendectomy Completed 01/09/2010
|
|||
|
|
|
|||
|
|
Type CPT Code* Procedure Status Date Performed
|
|||
|
|
Surgical 44950 Emergency Appendectomy Completed 01/09/2010
|
|||
|
|
|
|||
|
|
|