61 lines
2.3 KiB
Plaintext
61 lines
2.3 KiB
Plaintext
|
Patient Summary Record Test Data <20> Set #3
|
|||
|
|
|
|||
|
|
Patient
|
|||
|
|
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
|||
|
|
Lorraine|04/16/1957|Female|967385998|Medical Record Number|1020 Stuart Street
|
|||
|
|
Blevins|20:15:35|Morton,
|
|||
|
|
|
|||
|
|
<EFBFBD>Source<EFBFBD> for all data for this patient: Louis Randolph, MD
|
|||
|
|
|
|||
|
|
Problem List
|
|||
|
|
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
|||
|
|
Diagnosis|715.35|Right hip osteoarthritis|Resolved|02/12/2010
|
|||
|
|
Finding|414.01|Coronary Artery Disease (CAD)|Chronic|05/05/2002
|
|||
|
|
|
|||
|
|
Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
|||
|
|
Disorder|239872002|Right hip osteoarthritis|Resolved|02/12/2010
|
|||
|
|
Disorder|53741008|Coronary Arteriosclerosis|Chronic|05/05/2002
|
|||
|
|
|
|||
|
|
Medication List
|
|||
|
|
RxNorm
|
|||
|
|
|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
|||
|
|
Code
|
|||
|
|
855320|Medication|warfarin|Coumadin|3 mg|1 Tablet|PO|QD|02/15/2010|Active
|
|||
|
|
209613|Medication|bisacodyl|Dulcolax|5 mg|1 Tablet|PO|QD|02/15/2010|Active
|
|||
|
|
309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|05/15/2002|Active
|
|||
|
|
197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/15/2009|Active
|
|||
|
|
|
|||
|
|
Medication Allergy List
|
|||
|
|
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
|||
|
|
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|06/06/1998
|
|||
|
|
Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|04/25/1994
|
|||
|
|
|
|||
|
|
Diagnostic Test Results
|
|||
|
|
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
|||
|
|
Subchondral sclerosis,
|
|||
|
|
37721-8
|
|||
|
|
Imaging|X-ray, 2 views, Right Hip|increased density in|02/12/2010
|
|||
|
|
subchondral bone
|
|||
|
|
No disease is seen in the lung
|
|||
|
|
Imaging|24648-8|Chest X-ray, PA|06/05/2009
|
|||
|
|
fields or pleura
|
|||
|
|
Hemoglobin (male: 14-18 g/dl
|
|||
|
|
Hematology|718-7|11.2 g/dl|06/05/2009
|
|||
|
|
female: 12-16 g/dl)
|
|||
|
|
Hematocrit (male: 40-54%
|
|||
|
|
Hematology|4544-3|34%|06/05/2009
|
|||
|
|
female: 36-48%)
|
|||
|
|
Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
|||
|
|
Prothrombin Time/ International Normalized Ratio (PT/INR)
|
|||
|
|
Coagulation|34714-6|3.1|06/05/2009
|
|||
|
|
(2.5 <20> 3.5)
|
|||
|
|
|
|||
|
|
Procedure List
|
|||
|
|
Type|ICD-9 Code|Procedure|Status|Date Performed
|
|||
|
|
Surgical|81.51|Total Hip Replacement, Right|Completed|02/14/2010
|
|||
|
|
Cardiac|37.21|Cardiac catheterization|Completed|05/05/2002
|
|||
|
|
|
|||
|
|
Type|CPT Code*|Procedure|Status|Date Performed
|
|||
|
|
Surgical|27130|Total Hip Replacement, Right|Completed|02/14/2010
|
|||
|
|
Cardiac|93501|Cardiac catheterization|Completed|05/05/2002
|