298 lines
4.5 KiB
Plaintext
298 lines
4.5 KiB
Plaintext
Patient Summary Record Test Data – Set #2
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{| border="1"|
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!colspan="6"|Patient
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|----
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!scope="col"|Name
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!scope="col"|Date/Time of Birth
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!scope="col"|Gender
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!scope="col"|Identification Number
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!scope="col"|Identification Number Type
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!scope="col"|Address/Phone
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|----
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|Ruth Warholde
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|05/20/1954<br>23:59:45
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|Female
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|9836469798
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|Medical Record Number
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|225 Park Street <br>Morton, <br>Illinois 61550<br>309-354-9385
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|----
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|----
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“Source” for all data for this patient: Jackson Shoals, MD
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{| border="1"|
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!colspan="6"|Problem List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Diagnosis
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|780.2
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|Syncope and collapse, vasovagal attack
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|Active
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|02/15/2010
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|----
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|Diagnosis
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|434.91
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|Cerebrovascular Accident (Stroke)
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|Resolved
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|07/09/2009
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|----
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|Diagnosis
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|599.0
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|Urinary tract infection
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|Recurrent
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|09/22/2008
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|----
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|Diagnosis
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|496.0
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|Chronic Obstructive Pulmonary Disease
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|Chronic
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|08/12/2007
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|----
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|Symptom
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|401.9
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|Hypertension, essential
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|Chronic
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|05/16/2006
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code*
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!scope="col"|Patient Problem
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!scope="col"|Status
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!scope="col"|Date Diagnosed
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|----
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|Disorder
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|398665005
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|Vasovagal syncope
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|Active
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|02/15/2010
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|----
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|Disorder
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|230690007
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|Cerebrovascular Accident (Stroke)
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|Resolved
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|07/09/2009
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|----
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|Disorder
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|197927001
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|Recurrent urinary tract infection
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|Recurrent
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|09/22/2008
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|----
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|Disorder
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|13645005
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|Chronic Obstructive Lung Disease
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|Chronic
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|08/12/2007
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|----
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|Disorder
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|59621000
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|Essential Hypertension
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|Chronic
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|05/16/2006
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|----
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|}
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{| border="1"|
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!colspan="10"|Medication List
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|----
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!scope="col"|RxNorm Code
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!scope="col"|Product
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!scope="col"|Generic Name
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!scope="col"|Brand Name
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!scope="col"|Strength
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!scope="col"|Dose
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!scope="col"|Route
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!scope="col"|Frequency
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!scope="col"|Date Started
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!scope="col"|Status
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|----
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|209834
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|Medication
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|docusate
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|Colace
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|100 mg
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|1 Capsule
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|PO
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|BID
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|02/16/2010
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|Active
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|----
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|205326
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|Medication
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|lisinopril
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|Zestril
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|30 mg
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|1 Tablet
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|PO
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|QD
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|07/15/2009
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|Active
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|----
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|309362
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|Medication
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|clopidogrel
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|Plavix
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|75 mg
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|1 Tablet
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|PO
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|QD
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|07/15/2009
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|Active
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|----
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|197361
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|Medication
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|amlodipine
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|Norvasc
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|5 mg
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|1 Tablet
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|PO
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|QD
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|07/15/2009
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|Active
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|----
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|539712
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|Medication
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|nitrofurantoin
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|Macrobid
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|100 mg
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|1 Capsule
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|PO
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|QD
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|09/22/2008
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|No Longer Active
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|----
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|836370
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|Medication
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|ipratropium bromide monhydrate
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|Atrovent inhaler
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|18 mcg/puff
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|2 puffs
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|By oral inhalation
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|QID
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|08/14/2007
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|Active
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|----
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|884175
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|Medication
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|clonidine hydrochloride
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|Catapres
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|0.1 mg
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|1 Tablet
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|PO
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|BID
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|05/16/2006
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|Active
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|----
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|}
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{| border="1"|
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!colspan="5"|Medication Allergy List
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|----
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!scope="col"|Type
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!scope="col"|SNOMED Code
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!scope="col"|Medication/Agent
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!scope="col"|Reaction
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!scope="col"|Date Recorded
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|----
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|Drug Allergy
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|293620004
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|Indomethacin
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|Nausea, vomiting, rash, dizziness, headache
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|03/25/2003
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|Drug Allergy
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|91939003
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|Sulfonamides
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|Hives, photosensitivity
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|07/26/1999
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|----
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|}
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{| border="1"|
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!colspan="5"|Diagnostic Test Results
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|----
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!scope="col"|Type
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!scope="col"|LOINC Code
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!scope="col"|Test (Normal Range)
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!scope="col"|Result
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!scope="col"|Date Performed
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|----
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|Imaging
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|11539-4
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|CT, head
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|Small high right occipital lobe <br>contusion. No evidence of <br>extra-axial blood. Significant <br>sinus disease.
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|02/24/2010
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|----
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|Hematology
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|718-7
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|Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl)
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|13 g/dl
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|02/17/2010
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|----
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|Hematology
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|4544-3
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|Hematocrit (male: 40-54% female: 36-48%)
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|38%
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|02/17/2010
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|----
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|Chemistry
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|2951-2
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|Sodium (135–146 mg/dl)
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|136 mg/dl
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|02/17/2010
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|----
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|Chemistry
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|2823-3
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|Potassium (3.5–5.3 mg/dl)
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|3.9 mg/dl
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|02/17/2010
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|----
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|Imaging
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|34534-8
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|Electrocardiogram
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|Normal Sinus Rhythm
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|02/15/2010
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|----
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|Microbiology
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|630-4
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|Urine culture, routine <br>(Negative: No growth Positive: >10,000 CFU/ml)
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|Negative: No growth
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|10/02/2008
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|----
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|}
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{| border="1"|
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!colspan="5"|Procedure List
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|----
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!scope="col"|Type
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!scope="col"|ICD-9 Code
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!scope="col"|Procedure
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!scope="col"|Status
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!scope="col"|Date Performed
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|----
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|Surgical
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|66.39
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|Bilateral tubal ligation
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|Completed
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|06/14/1990
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|----
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||
|----
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!scope="col"|Type
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!scope="col"|CPT Code*
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!scope="col"|Procedure
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!scope="col"|Status
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!scope="col"|Date Performed
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|----
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|Surgical
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|58600
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|Bilateral tubal ligation
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|----
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