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