3.0 KiB
3.0 KiB
1 | Patient Summary Record Test Data – Set #2 |
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2 | Patient |
3 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
4 | Ruth Warholde|05/20/1954<br>23:59:45|Female|9836469798|Medical Record Number|225 Park Street <br>Morton, <br>Illinois 61550<br>309-354-9385 |
5 | | |
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 Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
22 | 209834|Medication|docusate|Colace|100 mg|1 Capsule|PO|BID|02/16/2010|Active |
23 | 205326|Medication|lisinopril|Zestril|30 mg|1 Tablet|PO|QD|07/15/2009|Active |
24 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/15/2009|Active |
25 | 197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/15/2009|Active |
26 | 539712|Medication|nitrofurantoin|Macrobid|100 mg|1 Capsule|PO|QD|09/22/2008|No Longer Active |
27 | 836370|Medication|ipratropium bromide monhydrate|Atrovent inhaler|18 mcg/puff|2 puffs|By oral inhalation|QID|08/14/2007|Active |
28 | 884175|Medication|clonidine hydrochloride|Catapres|0.1 mg|1 Tablet|PO|BID|05/16/2006|Active |
29 | Medication Allergy List |
30 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
31 | Drug Allergy|293620004|Indomethacin|Nausea, vomiting, rash, dizziness, headache|03/25/2003 |
32 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|07/26/1999 |
33 | Diagnostic Test Results |
34 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
35 | Imaging|11539-4|CT, head|Small high right occipital lobe <br>contusion. No evidence of <br>extra-axial blood. Significant <br>sinus disease. |02/24/2010 |
36 | Hematology|718-7|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)|13 g/dl|02/17/2010 |
37 | Hematology|4544-3|Hematocrit (male: 40-54% female: 36-48%)|38%|02/17/2010 |
38 | Chemistry|2951-2|Sodium (135–146 mg/dl)|136 mg/dl|02/17/2010 |
39 | Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|3.9 mg/dl|02/17/2010 |
40 | Imaging|34534-8|Electrocardiogram|Normal Sinus Rhythm|02/15/2010 |
41 | Microbiology|630-4|Urine culture, routine <br>(Negative: No growth Positive: >10,000 CFU/ml)|Negative: No growth|10/02/2008 |
42 | Procedure List |
43 | Type|ICD-9 Code|Procedure|Status|Date Performed |
44 | Surgical|66.39|Bilateral tubal ligation|Completed|06/14/1990 |
45 | Type|CPT Code*|Procedure|Status|Date Performed |
46 | Surgical|58600|Bilateral tubal ligation| |