1 | Patient Summary Record Test Data Set #3
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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 | |Lorraine Blevins
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14 | |04/16/1957<br>20:15:35
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15 | |Female
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16 | |967385998
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17 | |Medical Record Number
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18 | |1020 Stuart Street<br>Morton, <br>Illinois 61550<br> 309-374-8938
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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: Louis Randolph, 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 | |Diagnosis
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34 | |715.35
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35 | |Right hip osteoarthritis
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36 | |Resolved
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37 | |02/12/2010
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38 | |----
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39 | |Finding
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40 | |414.01
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41 | |Coronary Artery Disease (CAD)
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42 | |Chronic
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43 | |05/05/2002
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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 | |239872002
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54 | |Right hip osteoarthritis
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55 | |Resolved
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56 | |02/12/2010
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57 | |----
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58 | |Disorder
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59 | |53741008
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60 | |Coronary Arteriosclerosis
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61 | |Chronic
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62 | |05/05/2002
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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 | |855320
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81 | |Medication
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82 | |warfarin
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83 | |Coumadin
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84 | |3 mg
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85 | |1 Tablet
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86 | |PO
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87 | |QD
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88 | |02/15/2010
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89 | |Active
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90 | |----
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91 | |209613
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92 | |Medication
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93 | |bisacodyl
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94 | |Dulcolax
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95 | |5 mg
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96 | |1 Tablet
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97 | |PO
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98 | |QD
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99 | |02/15/2010
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100 | |Active
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101 | |----
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102 | |309362
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103 | |Medication
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104 | |clopidogrel
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105 | |Plavix
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106 | |75 mg
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107 | |1 Tablet
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108 | |PO
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109 | |QD
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110 | |05/15/2002
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111 | |Active
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112 | |----
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113 | |197361
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114 | |Medication
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115 | |amlodipine
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116 | |Norvasc
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117 | |5 mg
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118 | |1 Tablet
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119 | |PO
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120 | |QD
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121 | |07/15/2009
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122 | |Active
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123 | |----
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124 | |}
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125 |
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126 | {| border="1"|
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127 | !colspan="5"|Medication Allergy List
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128 | |----
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129 | !scope="col"|Type
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130 | !scope="col"|SNOMED Code
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131 | !scope="col"|Medication/Agent
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132 | !scope="col"|Reaction
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133 | !scope="col"|Date Recorded
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134 | |----
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135 | |Drug Allergy
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136 | |91939003
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137 | |Sulfonamides
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138 | |Hives, photosensitivity
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139 | |06/06/1998
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140 | |----
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141 | |Drug Allergy
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142 | |294506009
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143 | |Ampicillin
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144 | |Diarrhea, nausea, vomiting
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145 | |04/25/1994
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146 | |----
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147 | |}
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148 |
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149 | {| border="1"|
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150 | !colspan="5"|Diagnostic Test Results
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151 | |----
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152 | !scope="col"|Type
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153 | !scope="col"|LOINC Code
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154 | !scope="col"|Test (Normal Range)
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155 | !scope="col"|Result
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156 | !scope="col"|Date Performed
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157 | |----
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158 | |Imaging
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159 | |37721-8
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160 | |X-ray, 2 views, Right Hip
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161 | |Subchondral sclerosis,<br> increased density in<br>subchondral bone
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162 | |02/12/2010
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163 | |----
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164 | |Imaging
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165 | |24648-8
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166 | |Chest X-ray, PA
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167 | |No disease is seen in<br> the lung fields or pleura
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168 | |06/05/2009
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169 | |----
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170 | |Hematology
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171 | |718-7
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172 | |Hemoglobin (male: 14-18 g/dl<br>female: 12-16 g/dl)
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173 | |11.2 g/dl
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174 | |06/05/2009
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175 | |----
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176 | |Hematology
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177 | |4544-3
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178 | |Hematocrit (male: 40-54% <br>female: 36-48%)
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179 | |34%
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180 | |06/05/2009
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181 | |----
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182 | |Coagulation
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183 | |34714-6
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184 | |Prothrombin Time/ International Normalized Ratio (PT/INR)<br>(2.5 3.5)
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185 | |3.1
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186 | |06/05/2009
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187 | |----
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188 | |}
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189 |
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190 | {| border="1"|
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191 | !colspan="5"|Procedure List
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192 | |----
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193 | !scope="col"|Type
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194 | !scope="col"|ICD-9 Code
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195 | !scope="col"|Procedure
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196 | !scope="col"|Status
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197 | !scope="col"|Date Performed
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198 | |----
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199 | |Surgical
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200 | |81.51
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201 | |Total Hip Replacement, Right
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202 | |Completed
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203 | |02/14/2010
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204 | |----
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205 | |Cardiac
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206 | |37.21
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207 | |Cardiac catheterization
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208 | |Completed
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209 | |05/05/2002
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210 | |----
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211 | |----
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212 | !scope="col"|Type
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213 | !scope="col"|CPT Code*
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214 | !scope="col"|Procedure
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215 | !scope="col"|Status
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216 | !scope="col"|Date Performed
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217 | |----
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218 | |Surgical
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219 | |27130
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220 | |Total Hip Replacement, Right
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221 | |Completed
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222 | |02/14/2010
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223 | |----
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224 | |Cardiac
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225 | |93501
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226 | |Cardiac catheterization
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227 | |Completed
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228 | |05/05/2002
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229 | |----
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