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