2.5 KiB
2.5 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 | Christine Taylor|09/22/1965 16:48:25|Female|9787478034|Medical Record Number|754 Angel Street Marshalltown Iowa 50158 641-544-9988 |
| 5 | “Source” for all data for this patient: Kathryn Thomson, MD |
| 6 | Problem List |
| 7 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed |
| 8 | Diagnosis|540.0|Acute Appendicitis|Resolved|01/09/2010 |
| 9 | Diagnosis|434.91|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009 |
| 10 | Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|03/30/2009 |
| 11 | Symptom|401.9|Hypertension, Essential|Chronic|02/25/2008 |
| 12 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed |
| 13 | Disorder|74400008|Appendicitis|Resolved|01/09/2010 |
| 14 | Disorder|230690007|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009 |
| 15 | Disorder|44054006|Diabetes Mellitus, Type 2|Active|03/30/2009 |
| 16 | Disorder|59621000|Essential Hypertension|Chronic|02/25/2008 |
| 17 | Medication List |
| 18 | RxNorm Code|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status |
| 19 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/15/2009|Active |
| 20 | 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|03/30/2009|Active |
| 21 | 209834|Medication|docusate|Colace|100 mg|1 Capsule|PO|BID|03/30/2009|Active |
| 22 | 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|02/25/2008|Active |
| 23 | 628958|Medication|potassium chloride|Klor-Con|10 mEq|1 Tablet|PO|BID|02/25/2008|Active |
| 24 | 884175|Medication|clonidine hydrochloride|Catapres|0.1 mg|1 Tablet|PO|BID|02/25/2008|Active |
| 25 | Medication Allergy List |
| 26 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded |
| 27 | Drug Allergy|293620004|Indomethacin|Rash, dizziness, headache|06/05/2008 |
| 28 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|05/25/1997 |
| 29 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|08/25/1989 |
| 30 | Diagnostic Test Results |
| 31 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed |
| 32 | Chemistry|14771-0|Fasting Blood Glucose (70–100 mg/dl)|126 mg/dl|07/15/2010 |
| 33 | Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|4.3 mg/dl|07/15/2010 |
| 34 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|178 mg/dl|07/15/2010 |
| 35 | Imaging|42272-5|Chest X-ray, PA & Lateral|The heart outline is normal<br> and the hilar and mediastinal<br> vessels are of normal appearance|02/25/2008 |
| 36 | Procedure List |
| 37 | Type|ICD-9 Code|Procedure|Status|Date Performed |
| 38 | Surgical|47.09|Emergency Appendectomy|Completed|01/09/2010 |
| 39 | Type|CPT Code*|Procedure|Status|Date Performed |
| 40 | Surgical|44950|Emergency Appendectomy|Completed|01/09/2010 |