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