46 lines
4.1 KiB
Plaintext
46 lines
4.1 KiB
Plaintext
|
Patient Summary Record Test Data <20> Set #5
|
|||
|
|
|
|||
|
|
Patient
|
|||
|
|
Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
|
|||
|
|
Matthew Brown 09/22/1965 Male 988730987 Medical Record Number 754 Sharp Street
|
|||
|
|
16:48:25 Aurora,
|
|||
|
|
Colorado 80011
|
|||
|
|
303-544-9988
|
|||
|
|
|
|||
|
|
<EFBFBD>Source<EFBFBD> for all data for this patient: Pamela Jones, MD
|
|||
|
|
|
|||
|
|
Problem List
|
|||
|
|
Type ICD-9 Code Patient Problem Status Date Diagnosed
|
|||
|
|
Diagnosis 250.02 Diabetes Mellitus, Type 2 Active 07/17/2009
|
|||
|
|
Symptom 401.9 Hypertension, Essential Active 06/05/2008
|
|||
|
|
|
|||
|
|
Type SNOMED Code* Patient Problem Status Date Diagnosed
|
|||
|
|
Disorder 44054006 Diabetes Mellitus, Type 2 Active 07/17/2009
|
|||
|
|
Disorder 59621000 Essential Hypertension Active 06/05/2008
|
|||
|
|
|
|||
|
|
Medication List
|
|||
|
|
RxNorm
|
|||
|
|
Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
|||
|
|
Code
|
|||
|
|
205875 Medication glyburide Diabeta 2.5 mg 1 Tablet PO Q AM 07/17/2009 Active
|
|||
|
|
200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 06/05/2008 Active
|
|||
|
|
potassium
|
|||
|
|
628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 06/05/2008 Active
|
|||
|
|
chloride
|
|||
|
|
Medication Allergy List
|
|||
|
|
Type SNOMED Code Medication/Agent Reaction Date Recorded
|
|||
|
|
Drug Allergy 294506009 Ampicillin Diarrhea, nausea, vomiting 03/25/1997
|
|||
|
|
Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 04/25/1989
|
|||
|
|
|
|||
|
|
Diagnostic Test Results
|
|||
|
|
Type LOINC Code Test (Normal Range) Result Date Performed
|
|||
|
|
Chemistry 14771-0 Fasting Blood Glucose (70<37>100 mg/dl) 145 mg/dl 07/17/2009
|
|||
|
|
|
|||
|
|
Hemistry 2823-3 Potassium (3.5<EFBFBD>5.3 mg/dl) 4.5 mg/dl 07/17/2009
|
|||
|
|
Chemistry 14927-8 Triglycerides (<150 mg/dl) 187 mg/dl 07/17/2009
|
|||
|
|
|
|||
|
|
The heart outline is normal
|
|||
|
|
42272-5 and the hilar and
|
|||
|
|
Imaging Chest X-ray, PA & Lateral mediastinal vessels are of 07/17/2009
|
|||
|
|
|
|||
|
|
normal appearance
|