1.8 KiB
1.8 KiB
1 | Patient Summary Record Test Data – Set #4 |
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2 | Patient |
3 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
4 | Sally Eckerd|08/08/1962 18:25:59|Female|998877799|Medical Record Number|754 Samuel Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-2981 |
5 | “Source” for all data for this patient: Mark Payne, MD |
6 | Problem List |
7 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
8 | Condition|272.4|Hyperlipidemia|Active|07/05/2006 |
9 | Symptom|401.9|Hypertension, Essential|Active|07/05/2006 |
10 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
11 | Disorder|55822004|Hyperlipidemia|Active|07/05/2006 |
12 | Disorder|59621000|Essential Hypertension|Active|07/05/2006 |
13 | Medication List |
14 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
15 | 617314|Medication|atorvastatin calcium|Lipitor|10 mg|1 Tablet|PO|Q Day|07/05/2006|Active |
16 | 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|07/05/2006|Active |
17 | 628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|07/05/2006|Active |
18 | Medication Allergy List |
19 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
20 | Drug Allergy|91936005|Penicillin|Rash and anaphylaxis|05/22/1998 |
21 | Drug Allergy|293597001|Codeine|Hives|02/17/1992 |
22 | Diagnostic Test Results |
23 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
24 | Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.5 mg/dl|07/15/2009 |
25 | Chemistry|14647-2|Total cholesterol (<200 mg/dl)|180 mg/dl|07/15/2009 |
26 | Chemistry|14646-4|HDL cholesterol (?40 mg/dl)|38 mg/dl|07/15/2009 |
27 | Chemistry|2089-1|LDL cholesterol (<100 mg/dl)|120 mg/dl|07/15/2009 |
28 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|187 mg/dl|07/15/2009 |
29 | Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is normal<br>and the hilar and<br>mediastinal vessels are of<br>normal appearance|07/15/2009 |