171 lines
2.8 KiB
Plaintext
171 lines
2.8 KiB
Plaintext
Patient Summary Record Test Data – Set #3
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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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|Jane Andrews
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|05/12/1955 09:30:15
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|Female
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|9639275266
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|Medical Record Number
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|355 1st Street<br>Fargo,<br>North Dakota 54102<br>701-366-8364
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|----
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|}
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“Source” for all data for this patient: Robert James, 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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|486
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|Pneumonia
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|Resolved
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|01/22/2010
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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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|10/10/1999
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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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|233604007
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|Pneumonia
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|Resolved
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|01/22/2010
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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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|10/10/1999
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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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!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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|308460
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|Medication
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|azithromycin
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|Azithromycin
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|250 mg
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|1 Tablet
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|PO
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|QD
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|01/22/2010
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|No Longer Active
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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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|Inhaled
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|QID
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|10/10/1999
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|Active
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|630208
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|Medication
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|albuterol sulfate
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|Albuterol Inhaler
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|2.5 mg/3ml
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|2 Puffs
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|Inhaled
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|Q 4 PRN
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|10/10/1999
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|Active
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|----
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{| border="1"|
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!colspan="5"|Medication Allergy List
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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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|91936005
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|Penicillin
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|Rash and anaphylaxis
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|06/10/2009
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|----
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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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|04/25/1988
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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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|42272-5
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|Imaging
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|Chest X-ray, PA & Lateral
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|Hyperinflated lungs with<br>flattened diaphragm and<br>central pulmonary artery<br>enlargement
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|02/15/2010
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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<br>female: 12-16 g/dl)
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|16 g/dl
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|12/22/2009
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|----
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|Hematology
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|4544-3
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|Hematocrit (male: 40-54%<br>female: 36-48%)
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| 45%
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|12/22/2009
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|----
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|Cardiology
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|34534-8
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|Electrocardiogram
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|Normal Sinus Rhythm
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|12/22/2009
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|----
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