[1030] | 1 | Patient Summary Record Test Data Set #4
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| 2 |
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| 3 | {| border="1"|
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| 4 | !colspan="6"|Patient
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| 5 | |----
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| 6 | !scope="col"|Name
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| 7 | !scope="col"|Date/Time of Birth
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| 8 | !scope="col"|Gender
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| 9 | !scope="col"|Identification Number
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| 10 | !scope="col"|Identification Number Type
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| 11 | !scope="col"|Address/Phone
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| 12 | |----
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| 13 | |Sally Eckerd
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| 14 | |08/08/1962 18:25:59
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| 15 | |Female
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| 16 | |998877799
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| 17 | |Medical Record Number
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| 18 | |754 Samuel Street,<br>Shawville,<br>Pennsylvania 16873<br>814-645-2981
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| 19 | |----
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| 20 | |}
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| 21 |
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| 22 | Source for all data for this patient: Mark Payne, MD
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| 23 |
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| 24 | {| border="1"|
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| 25 | !colspan="6"|Problem List
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| 26 | |----
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| 27 | !scope="col"|Type
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| 28 | !scope="col"|ICD-9 Code
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| 29 | !scope="col"|Patient Problem
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| 30 | !scope="col"|Status
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| 31 | !scope="col"|Date Diagnosed
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| 32 | |----
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| 33 | |Condition
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| 34 | |272.4
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| 35 | |Hyperlipidemia
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| 36 | |Active
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| 37 | |07/05/2006
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| 38 | |----
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| 39 | |Symptom
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| 40 | |401.9
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| 41 | |Hypertension, Essential
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| 42 | |Active
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| 43 | |07/05/2006
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| 44 | |----
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| 45 | |----
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| 46 | !scope="col"|Type
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| 47 | !scope="col"|SNOMED Code*
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| 48 | !scope="col"|Patient Problem
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| 49 | !scope="col"|Status
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| 50 | !scope="col"|Date Diagnosed
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| 51 | |----
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| 52 | |Disorder
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| 53 | |55822004
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| 54 | |Hyperlipidemia
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| 55 | |Active
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| 56 | |07/05/2006
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| 57 | |----
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| 58 | |Disorder
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| 59 | |59621000
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| 60 | |Essential Hypertension
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| 61 | |Active
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| 62 | |07/05/2006
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| 63 | |----
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| 64 | |}
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| 65 |
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| 66 | {| border="1"|
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| 67 | !colspan="10"|Medication List
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| 68 | |----
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| 69 | !scope="col"|RxNorm Code
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| 70 | !scope="col"|Product
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| 71 | !scope="col"|Generic Name
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| 72 | !scope="col"|Brand Name
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| 73 | !scope="col"|Strength
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| 74 | !scope="col"|Dose
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| 75 | !scope="col"|Route
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| 76 | !scope="col"|Frequency
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| 77 | !scope="col"|Date Started
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| 78 | !scope="col"|Status
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| 79 | |----
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| 80 | |617314
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| 81 | |Medication
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| 82 | |atorvastatin calcium
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| 83 | |Lipitor
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| 84 | |10 mg
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| 85 | |1 Tablet
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| 86 | |PO
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| 87 | |Q Day
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| 88 | |07/05/2006
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| 89 | |Active
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| 90 | |----
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| 91 | |200801
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| 92 | |Medication
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| 93 | |furosemide
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| 94 | |Lasix
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| 95 | |20 mg
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| 96 | |1 Tablet
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| 97 | |PO
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| 98 | |BID
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| 99 | |07/05/2006
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| 100 | |Active
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| 101 | |----
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| 102 | |628958
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| 103 | |Medication
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| 104 | |potassium chloride
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| 105 | |Klor-Con
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| 106 | |10 mEq
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| 107 | |1 Tablet
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| 108 | |PO
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| 109 | |BID
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| 110 | |07/05/2006
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| 111 | |Active
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| 112 | |----
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| 113 | |}
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| 114 |
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| 115 | {| border="1"|
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| 116 | !colspan="5"|Medication Allergy List
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| 117 | |----
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| 118 | !scope="col"|Type
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| 119 | !scope="col"|SNOMED Code
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| 120 | !scope="col"|Medication/Agent
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| 121 | !scope="col"|Reaction
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| 122 | !scope="col"|Date Recorded
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| 123 | |----
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| 124 | |Drug Allergy
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| 125 | |91936005
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| 126 | |Penicillin
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| 127 | |Rash and anaphylaxis
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| 128 | |05/22/1998
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| 129 | |----
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| 130 | |Drug Allergy
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| 131 | |293597001
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| 132 | |Codeine
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| 133 | |Hives
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| 134 | |02/17/1992
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| 135 | |----
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| 136 | |}
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| 137 |
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| 138 | {| border="1"|
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| 139 | !colspan="5"|Diagnostic Test Results
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| 140 | |----
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| 141 | !scope="col"|Type
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| 142 | !scope="col"|LOINC Code
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| 143 | !scope="col"|Test (Normal Range)
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| 144 | !scope="col"|Result
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| 145 | !scope="col"|Date Performed
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| 146 | |----
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| 147 | |Chemistry
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| 148 | |2823-3
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| 149 | |Potassium (3.55.3 mg/dl)
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| 150 | |4.5 mg/dl
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| 151 | |07/15/2009
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| 152 | |----
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| 153 | |Chemistry
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| 154 | |14647-2
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| 155 | |Total cholesterol (<200 mg/dl)
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| 156 | |180 mg/dl
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| 157 | |07/15/2009
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| 158 | |----
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| 159 | |Chemistry
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| 160 | |14646-4
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| 161 | |HDL cholesterol (?40 mg/dl)
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| 162 | |38 mg/dl
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| 163 | |07/15/2009
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| 164 | |----
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| 165 | |Chemistry
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| 166 | |2089-1
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| 167 | |LDL cholesterol (<100 mg/dl)
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| 168 | |120 mg/dl
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| 169 | |07/15/2009
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| 170 | |----
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| 171 | |Chemistry
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| 172 | |14927-8
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| 173 | |Triglycerides (<150 mg/dl)
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| 174 | |187 mg/dl
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| 175 | |07/15/2009
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| 176 | |----
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| 177 | |Imaging
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| 178 | |42272-5
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| 179 | |Chest X-ray, PA & Lateral
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| 180 | |The heart outline is normal<br>and the hilar and<br>mediastinal vessels are of<br>normal appearance
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| 181 | |07/15/2009
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| 182 | |----
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| 183 | |}
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| 184 |
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| 185 |
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