2.3 KiB
2.3 KiB
| 1 | Patient Summary Record Test Data – Set #3 |
|---|---|
| 2 | Patient |
| 3 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone |
| 4 | Lorraine|04/16/1957|Female|967385998|Medical Record Number|1020 Stuart Street |
| 5 | Blevins|20:15:35|Morton, |
| 6 | “Source” for all data for this patient: Louis Randolph, MD |
| 7 | Problem List |
| 8 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
| 9 | Diagnosis|715.35|Right hip osteoarthritis|Resolved|02/12/2010 |
| 10 | Finding|414.01|Coronary Artery Disease (CAD)|Chronic|05/05/2002 |
| 11 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
| 12 | Disorder|239872002|Right hip osteoarthritis|Resolved|02/12/2010 |
| 13 | Disorder|53741008|Coronary Arteriosclerosis|Chronic|05/05/2002 |
| 14 | Medication List |
| 15 | RxNorm |
| 16 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
| 17 | Code |
| 18 | 855320|Medication|warfarin|Coumadin|3 mg|1 Tablet|PO|QD|02/15/2010|Active |
| 19 | 209613|Medication|bisacodyl|Dulcolax|5 mg|1 Tablet|PO|QD|02/15/2010|Active |
| 20 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|05/15/2002|Active |
| 21 | 197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/15/2009|Active |
| 22 | Medication Allergy List |
| 23 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
| 24 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|06/06/1998 |
| 25 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|04/25/1994 |
| 26 | Diagnostic Test Results |
| 27 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
| 28 | Subchondral sclerosis, |
| 29 | 37721-8 |
| 30 | Imaging|X-ray, 2 views, Right Hip|increased density in|02/12/2010 |
| 31 | subchondral bone |
| 32 | No disease is seen in the lung |
| 33 | Imaging|24648-8|Chest X-ray, PA|06/05/2009 |
| 34 | fields or pleura |
| 35 | Hemoglobin (male: 14-18 g/dl |
| 36 | Hematology|718-7|11.2 g/dl|06/05/2009 |
| 37 | female: 12-16 g/dl) |
| 38 | Hematocrit (male: 40-54% |
| 39 | Hematology|4544-3|34%|06/05/2009 |
| 40 | female: 36-48%) |
| 41 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
| 42 | Prothrombin Time/ International Normalized Ratio (PT/INR) |
| 43 | Coagulation|34714-6|3.1|06/05/2009 |
| 44 | (2.5 – 3.5) |
| 45 | Procedure List |
| 46 | Type|ICD-9 Code|Procedure|Status|Date Performed |
| 47 | Surgical|81.51|Total Hip Replacement, Right|Completed|02/14/2010 |
| 48 | Cardiac|37.21|Cardiac catheterization|Completed|05/05/2002 |
| 49 | Type|CPT Code*|Procedure|Status|Date Performed |
| 50 | Surgical|27130|Total Hip Replacement, Right|Completed|02/14/2010 |
| 51 | Cardiac|93501|Cardiac catheterization|Completed|05/05/2002 |