| [1020] | 1 | Patient Summary Record Test Data Set #5
|
|---|
| 2 |
|
|---|
| 3 | Patient
|
|---|
| 4 | Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone
|
|---|
| 5 | Christine Taylor|09/22/1965|Female|9787478034|Medical Record Number|754 Angel Street
|
|---|
| 6 | 16:48:25|Marshalltown
|
|---|
| 7 | Iowa|50158
|
|---|
| 8 | 641-544-9988
|
|---|
| 9 |
|
|---|
| 10 | Source for all data for this patient: Kathryn Thomson, MD
|
|---|
| 11 |
|
|---|
| 12 | Problem List
|
|---|
| 13 | Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed
|
|---|
| 14 | Diagnosis|540.0|Acute Appendicitis|Resolved|01/09/2010
|
|---|
| 15 | Diagnosis|434.91|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
|
|---|
| 16 | Diagnosis|250.02|Diabetes Mellitus, Type 2|Active|03/30/2009
|
|---|
| 17 | Symptom|401.9|Hypertension, Essential|Chronic|02/25/2008
|
|---|
| 18 |
|
|---|
| 19 | Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed
|
|---|
| 20 | Disorder|74400008|Appendicitis|Resolved|01/09/2010
|
|---|
| 21 | Disorder|230690007|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009
|
|---|
| 22 | Disorder|44054006|Diabetes Mellitus, Type 2|Active|03/30/2009
|
|---|
| 23 | Disorder|59621000|Essential Hypertension|Chronic|02/25/2008
|
|---|
| 24 |
|
|---|
| 25 | Medication List
|
|---|
| 26 | RxNorm
|
|---|
| 27 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
|---|
| 28 | Code
|
|---|
| 29 | 309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/15/2009|Active
|
|---|
| 30 | 205875|Medication|glyburide|Diabeta|2.5 mg|1 Tablet|PO|Q AM|03/30/2009|Active
|
|---|
| 31 | 209834|Medication|docusate|Colace|100 mg|1 Capsule|PO|BID|03/30/2009|Active
|
|---|
| 32 | 200801|Medication|furosemide|Lasix|20 mg|1 Tablet|PO|BID|02/25/2008|Active
|
|---|
| 33 | potassium
|
|---|
| 34 | 628958|Medication|Klor-Con|10 mEq|1 Tablet|PO|BID|02/25/2008|Active
|
|---|
| 35 | chloride
|
|---|
| 36 | RxNorm
|
|---|
| 37 | |Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status
|
|---|
| 38 | Code
|
|---|
| 39 | clonidine
|
|---|
| 40 | 884175|Medication|Catapres|0.1 mg|1 Tablet|PO|BID|02/25/2008|Active
|
|---|
| 41 | hydrochloride
|
|---|
| 42 |
|
|---|
| 43 | Medication Allergy List
|
|---|
| 44 | Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded
|
|---|
| 45 | Drug Allergy|293620004|Indomethacin|Rash, dizziness, headache|06/05/2008
|
|---|
| 46 | Drug Allergy|294506009|Ampicillin|Diarrhea, nausea, vomiting|05/25/1997
|
|---|
| 47 | Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|08/25/1989
|
|---|
| 48 |
|
|---|
| 49 | Diagnostic Test Results
|
|---|
| 50 | Type|LOINC Code|Test (Normal Range)|Result|Date Performed
|
|---|
| 51 | Chemistry|14771-0|Fasting Blood Glucose (70100 mg/dl)|126 mg/dl|07/15/2010
|
|---|
| 52 |
|
|---|
| 53 | Chemistry|2823-3|Potassium (3.55.3 mg/dl)|4.3 mg/dl|07/15/2010
|
|---|
| 54 | Chemistry|14927-8|Triglycerides (<150 mg/dl)|178 mg/dl|07/15/2010
|
|---|
| 55 |
|
|---|
| 56 | The heart outline is normal
|
|---|
| 57 | 42272-5|and the hilar and
|
|---|
| 58 | Imaging|Chest X-ray, PA & Lateral|mediastinal vessels are of|02/25/2008
|
|---|
| 59 |
|
|---|
| 60 | normal appearance
|
|---|
| 61 |
|
|---|
| 62 | Procedure List
|
|---|
| 63 | Type|ICD-9 Code|Procedure|Status|Date Performed
|
|---|
| 64 | Surgical|47.09|Emergency Appendectomy|Completed|01/09/2010
|
|---|
| 65 |
|
|---|
| 66 | Type|CPT Code*|Procedure|Status|Date Performed
|
|---|
| 67 | Surgical|44950|Emergency Appendectomy|Completed|01/09/2010
|
|---|
| 68 |
|
|---|
| 69 |
|
|---|
