3.0 KiB
3.0 KiB
1 | Patient Summary Record Test Data – Set #2 |
---|---|
2 | Patient |
3 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
4 | Ruth Warholde|05/20/1954|Female|9836469798|Medical Record Number|225 Park Street |
5 | 23:59:45|Morton, |
6 | “Source” for all data for this patient: Jackson Shoals, MD |
7 | Problem List |
8 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
9 | Diagnosis|780.2|Syncope and collapse, vasovagal attack|Active|02/15/2010 |
10 | Diagnosis|434.91|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009 |
11 | Diagnosis|599.0|Urinary tract infection|Recurrent|09/22/2008 |
12 | Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|08/12/2007 |
13 | Symptom|401.9|Hypertension, essential|Chronic|05/16/2006 |
14 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
15 | Disorder|398665005|Vasovagal syncope|Active|02/15/2010 |
16 | Disorder|230690007|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009 |
17 | Disorder|197927001|Recurrent urinary tract infection|Recurrent|09/22/2008 |
18 | Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|08/12/2007 |
19 | Disorder|59621000|Essential Hypertension|Chronic|05/16/2006 |
20 | Medication List |
21 | RxNorm |
22 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
23 | Code |
24 | 209834|Medication|docusate|Colace|100 mg|1 Capsule|PO|BID|02/16/2010|Active |
25 | 205326|Medication|lisinopril|Zestril|30 mg|1 Tablet|PO|QD|07/15/2009|Active |
26 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/15/2009|Active |
27 | 197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/15/2009|Active |
28 | No Longer |
29 | 539712|Medication|nitrofurantoin|Macrobid|100 mg|1 Capsule|PO|QD|09/22/2008 |
30 | Active |
31 | ipratropium |
32 | Atrovent|18|By oral |
33 | 836370|Medication|bromide|2 puffs|QID|08/14/2007|Active |
34 | inhaler|mcg/puff|inhalation |
35 | monhydrate |
36 | clonidine |
37 | 884175|Medication|Catapres|0.1 mg|1 Tablet|PO|BID|05/16/2006|Active |
38 | hydrochloride |
39 | Medication Allergy List |
40 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
41 | Nausea, vomiting, rash, |
42 | Drug Allergy|293620004|Indomethacin|03/25/2003 |
43 | dizziness, headache |
44 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|07/26/1999 |
45 | Diagnostic Test Results |
46 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
47 | Small high right occipital lobe |
48 | contusion. No evidence of |
49 | Imaging|11539-4|CT, head|02/24/2010 |
50 | extra-axial blood. Significant |
51 | sinus disease. |
52 | Hematology|718-7|Hemoglobin (male: 14-18 g/dl|female: 12-16 g/dl)|13 g/dl|02/17/2010 |
53 | Hematology|4544-3|Hematocrit|(male: 40-54%|female: 36-48%)|38%|02/17/2010 |
54 | Chemistry|2951-2|Sodium (135–146 mg/dl)|136 mg/dl|02/17/2010 |
55 | Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|3.9 mg/dl|02/17/2010 |
56 | Imaging|34534-8|Electrocardiogram|Normal Sinus Rhythm|02/15/2010 |
57 | Urine culture, routine |
58 | Microbiology|630-4|Negative: No growth|10/02/2008 |
59 | (Negative: No growth|Positive: >10,000 CFU/ml) |
60 | Procedure List |
61 | Type|ICD-9 Code|Procedure|Status|Date Performed |
62 | Surgical|66.39|Bilateral tubal ligation|Completed|06/14/1990 |
63 | Type|CPT Code*|Procedure|Status|Date Performed |
64 | Surgical|58600|Bilateral tubal ligation| |