34 lines
1.8 KiB
Plaintext
34 lines
1.8 KiB
Plaintext
|
Patient Summary Record Test Data <20> Set #3
|
|||
|
|
|
|||
|
|
Patient
|
|||
|
|
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
|||
|
|
Jane Andrews|05/12/1955 09:30:15|Female|9639275266|Medical Record Number|355 1st Street<br>Fargo,<br>North Dakota 54102<br>701-366-8364
|
|||
|
|
|
|||
|
|
<EFBFBD>Source<EFBFBD> for all data for this patient: Robert James, MD
|
|||
|
|
|
|||
|
|
Problem List
|
|||
|
|
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
|||
|
|
Diagnosis|486|Pneumonia|Resolved|01/22/2010
|
|||
|
|
Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|10/10/1999
|
|||
|
|
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
|||
|
|
Disorder|233604007|Pneumonia|Resolved|01/22/2010
|
|||
|
|
Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|10/10/1999
|
|||
|
|
|
|||
|
|
Medication List
|
|||
|
|
RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
|||
|
|
308460|Medication|azithromycin|Azithromycin|250 mg|1 Tablet|PO|QD|01/22/2010|No Longer Active
|
|||
|
|
836370|Medication|ipratropium bromide monhydrate|Atrovent Inhaler|18 mcg/puff|2 Puffs|Inhaled|QID|10/10/1999|Active
|
|||
|
|
630208|Medication|albuterol sulfate|Albuterol Inhaler|2.5 mg/3ml|2 Puffs|Inhaled|Q 4 PRN|10/10/1999|Active
|
|||
|
|
|
|||
|
|
Medication Allergy List
|
|||
|
|
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
|||
|
|
Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|06/10/2009
|
|||
|
|
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1988
|
|||
|
|
|
|||
|
|
Diagnostic Test Results
|
|||
|
|
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
|||
|
|
42272-5|Imaging|Chest X-ray, PA & Lateral|Hyperinflated lungs with<br>flattened diaphragm and<br>central pulmonary artery<br>enlargement|02/15/2010
|
|||
|
|
Hematology|718-7|Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)|16 g/dl|12/22/2009
|
|||
|
|
Hematology|4544-3|Hematocrit (male: 40-54%<br>female: 36-48%)| 45%|12/22/2009
|
|||
|
|
Cardiology|34534-8|Electrocardiogram|Normal Sinus Rhythm|12/22/2009
|