1.7 KiB
1.7 KiB
1 | Patient Summary Record Test Data – Set #5 |
---|---|
2 | Patient |
3 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
4 | Matthew Brown|09/22/1965|Male|988730987|Medical Record Number|754 Sharp Street |
5 | 16:48:25|Aurora, |
6 | Colorado|80011 |
7 | 303-544-9988 |
8 | “Source” for all data for this patient: Pamela Jones, MD |
9 | Problem List |
10 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
11 | Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|07/17/2009 |
12 | Symptom|401.9|Hypertension, Essential|Active|06/05/2008 |
13 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
14 | Disorder|44054006|Diabetes Mellitus, Type 2|Active|07/17/2009 |
15 | Disorder|59621000|Essential Hypertension|Active|06/05/2008 |
16 | Medication List |
17 | RxNorm |
18 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
19 | Code |
20 | 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|07/17/2009|Active |
21 | 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|06/05/2008|Active |
22 | potassium |
23 | 628958|Medication|Klor-Con|10 mEq|1 Tablet|PO|BID|06/05/2008|Active |
24 | chloride |
25 | Medication Allergy List |
26 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
27 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|03/25/1997 |
28 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|04/25/1989 |
29 | Diagnostic Test Results |
30 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
31 | Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|145 mg/dl|07/17/2009 |
32 | Hemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.5 mg/dl|07/17/2009 |
33 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|187 mg/dl|07/17/2009 |
34 | The heart outline is normal |
35 | 42272-5|and the hilar and |
36 | Imaging|Chest X-ray, PA & Lateral|mediastinal vessels are of|07/17/2009 |
37 | normal appearance |