1.7 KiB
1.7 KiB
1 | Patient Summary Record Test Data – Set #5 |
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2 | Patient |
3 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
4 | Matthew Brown|09/22/1965 16:48:25|Male|988730987|Medical Record Number|754 Sharp Street<br>Aurora,<br>Colorado 80011<br>303-544-9988 |
5 | “Source” for all data for this patient: Pamela Jones, MD |
6 | Problem List |
7 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
8 | Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|07/17/2009 |
9 | Symptom|401.9|Hypertension, Essential|Active|06/05/2008 |
10 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
11 | Disorder|44054006|Diabetes Mellitus, Type 2|Active|07/17/2009 |
12 | Disorder|59621000|Essential Hypertension|Active|06/05/2008 |
13 | Medication List |
14 | RxNorm Code |
15 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
16 | 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|07/17/2009|Active |
17 | 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|06/05/2008|Active |
18 | 628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|06/05/2008|Active |
19 | Medication Allergy List |
20 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
21 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/25/1997 |
22 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1989 |
23 | Diagnostic Test Results |
24 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
25 | Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|145 mg/dl|07/17/2009 |
26 | Hemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.5 mg/dl|07/17/2009 |
27 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|187 mg/dl|07/17/2009 |
28 | 42272-5|Imaging|Chest X-ray, PA & Lateral|The heart outline is normal<br>and the hilar and<br>mediastinal vessels are of<br>normal appearance|07/17/2009 |