254 lines
3.9 KiB
Plaintext
254 lines
3.9 KiB
Plaintext
Patient Summary Record Test Data – Set #5
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{| border="1" |
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!colspan="6"|Patient
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!scope="col"|Name
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!scope="col"|Date/Time of Birth
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!scope="col"|Gender
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!scope="col"|Identification Number
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!scope="col"|Identification Number Type
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!scope="col"|Address/Phone
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|----
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|Christine Taylor
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|09/22/1965 16:48:25
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|Female
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|9787478034
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|Medical Record Number
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|754 Angel Street Marshalltown Iowa 50158 641-544-9988
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|}
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“Source” for all data for this patient: Kathryn Thomson, MD
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{| border="1" |
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!colspan="5"|Problem List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Diagnosis
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|540.0
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|Acute Appendicitis
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|Resolved
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|01/09/2010
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|----
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|Diagnosis
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|434.91
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|Cerebrovascular Accident (Stroke)
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|Resolved
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|07/09/2009
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|----
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|Diagnosis
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|250.02
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|Diabetes Mellitus, Type 2
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|Active
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|03/30/2009
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|----
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|Symptom
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|401.9
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|Hypertension, Essential
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|Chronic
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|02/25/2008
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code*
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Disorder
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|74400008
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|Appendicitis
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|Resolved
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|01/09/2010
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|----
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|Disorder
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|230690007
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|Cerebrovascular Accident (Stroke)
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|Resolved
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|07/09/2009
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|----
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|Disorder
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|44054006
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|Diabetes Mellitus, Type 2
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|Active
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|03/30/2009
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|----
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|Disorder
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|59621000
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|Essential Hypertension
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|Chronic
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|02/25/2008
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|----
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|}
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{| border="1" |
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!colspan="10"|Medication List
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|----
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!scope="col"|RxNorm Code
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!scope="col"|Product
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!scope="col"|Generic Name
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!scope="col"|Brand Name
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!scope="col"|Strength
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!scope="col"|Dose
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!scope="col"|Route
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!scope="col"|Frequency
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!scope="col"|Date Started
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!scope="col"|Status
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|----
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|309362
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|Medication
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|clopidogrel
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|Plavix
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|75 mg
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|1 Tablet
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|PO
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|QD
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|07/15/2009
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|Active
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|----
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|205875
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|Medication
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|glyburide
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|Diabeta
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|2.5 mg
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|1 Tablet
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|PO
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|Q AM
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|03/30/2009
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|Active
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|----
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|209834
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|Medication
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|docusate
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|Colace
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|100 mg
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|1 Capsule
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|PO
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|BID
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|03/30/2009
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|Active
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|----
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|200801
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|Medication
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|furosemide
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|Lasix
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|20 mg
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|1 Tablet
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|PO
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|BID
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|02/25/2008
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|Active
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|----
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|628958
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|Medication
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|potassium chloride
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|Klor-Con
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|10 mEq
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|1 Tablet
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|PO
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|BID
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|02/25/2008
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|Active
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|----
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|884175
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|Medication
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|clonidine hydrochloride
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|Catapres
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|0.1 mg
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|1 Tablet
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|PO
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|BID
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|02/25/2008
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|Active
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|----
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|}
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{| border="1" |
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!colspan="5"|Medication Allergy List
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code
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!scope="col"|Medication/Agent
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!scope="col"|Reaction
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!scope="col"|Date Recorded
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|----
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|Drug Allergy
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|293620004
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|Indomethacin
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|Rash, dizziness, headache
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|06/05/2008
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|----
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|Drug Allergy
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|294506009
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|Ampicillin
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|Diarrhea, nausea, vomiting
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|05/25/1997
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|----
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|Drug Allergy
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|91939003
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|Sulfonamides
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|Hives, photosensitivity
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|08/25/1989
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|----
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|}
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{| border="1" |
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!colspan="5"|Diagnostic Test Results
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|----
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!scope="col"|Type
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!scope="col"|LOINC Code
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!scope="col"|Test (Normal Range)
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!scope="col"|Result
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!scope="col"|Date Performed
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|----
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|Chemistry
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|14771-0
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|Fasting Blood Glucose (70–100 mg/dl)
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|126 mg/dl
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|07/15/2010
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|----
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|Chemistry
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|2823-3
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|Potassium (3.5–5.3 mg/dl)
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|4.3 mg/dl
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|07/15/2010
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|----
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|Chemistry
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|14927-8
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|Triglycerides (<150 mg/dl)
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|178 mg/dl
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|07/15/2010
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|----
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|Imaging
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|42272-5
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|Chest X-ray, PA & Lateral
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|The heart outline is normal and the hilar and mediastinal vessels are of normal appearance
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|02/25/2008
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|----
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|}
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{| border="1" |
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!colspan="5"|Procedure List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
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!scope="col"|Procedure
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!scope="col"|Status
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!scope="col"|Date Performed
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|----
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|Surgical
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|47.09
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|Emergency Appendectomy
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|Completed
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|01/09/2010
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|----
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!scope="col"|Type
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!scope="col"|CPT Code*
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!scope="col"|Procedure
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!scope="col"|Status
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!scope="col"|Date Performed
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|----
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|Surgical
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|44950
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|Emergency Appendectomy
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|Completed
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|01/09/2010
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|----
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|} |