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