[1024] | 1 | Patient Summary Record Test Data Set #5
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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 | |Christine Taylor
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| 14 | |09/22/1965 16:48:25
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| 15 | |Female
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| 16 | |9787478034
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| 17 | |Medical Record Number
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| 18 | |754 Angel Street Marshalltown Iowa 50158 641-544-9988
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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: Kathryn Thomson, 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 | |540.0
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| 35 | |Acute Appendicitis
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| 36 | |Resolved
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| 37 | |01/09/2010
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| 38 | |----
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| 39 | |Diagnosis
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| 40 | |434.91
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| 41 | |Cerebrovascular Accident (Stroke)
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| 42 | |Resolved
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| 43 | |07/09/2009
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| 44 | |----
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| 45 | |Diagnosis
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| 46 | |250.02
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| 47 | |Diabetes Mellitus, Type 2
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| 48 | |Active
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| 49 | |03/30/2009
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| 50 | |----
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| 51 | |Symptom
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| 52 | |401.9
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| 53 | |Hypertension, Essential
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| 54 | |Chronic
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| 55 | |02/25/2008
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| 56 | |----
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| 57 | |----
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| 58 | !scope="col"|Type
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| 59 | !scope="col"|SNOMED Code*
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| 60 | !scope="col"|Patient Problem
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| 61 | !scope="col"|Status
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| 62 | !scope="col"|Date Diagnosed
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| 63 | |----
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| 64 | |Disorder
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| 65 | |74400008
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| 66 | |Appendicitis
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| 67 | |Resolved
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| 68 | |01/09/2010
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| 69 | |----
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| 70 | |Disorder
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| 71 | |230690007
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| 72 | |Cerebrovascular Accident (Stroke)
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| 73 | |Resolved
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| 74 | |07/09/2009
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| 75 | |----
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| 76 | |Disorder
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| 77 | |44054006
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| 78 | |Diabetes Mellitus, Type 2
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| 79 | |Active
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| 80 | |03/30/2009
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| 81 | |----
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| 82 | |Disorder
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| 83 | |59621000
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| 84 | |Essential Hypertension
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| 85 | |Chronic
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| 86 | |02/25/2008
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| 87 | |----
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| 88 | |}
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| 89 |
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| 90 | {| border="1"|
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| 91 | !colspan="10"|Medication List
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| 92 | |----
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| 93 | !scope="col"|RxNorm Code
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| 94 | !scope="col"|Product
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| 95 | !scope="col"|Generic Name
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| 96 | !scope="col"|Brand Name
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| 97 | !scope="col"|Strength
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| 98 | !scope="col"|Dose
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| 99 | !scope="col"|Route
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| 100 | !scope="col"|Frequency
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| 101 | !scope="col"|Date Started
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| 102 | !scope="col"|Status
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| 103 | |----
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| 104 | |309362
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| 105 | |Medication
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| 106 | |clopidogrel
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| 107 | |Plavix
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| 108 | |75 mg
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| 109 | |1 Tablet
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| 110 | |PO
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| 111 | |QD
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| 112 | |07/15/2009
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| 113 | |Active
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| 114 | |----
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| 115 | |205875
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| 116 | |Medication
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| 117 | |glyburide
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| 118 | |Diabeta
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| 119 | |2.5 mg
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| 120 | |1 Tablet
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| 121 | |PO
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| 122 | |Q AM
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| 123 | |03/30/2009
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| 124 | |Active
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| 125 | |----
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| 126 | |209834
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| 127 | |Medication
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| 128 | |docusate
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| 129 | |Colace
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| 130 | |100 mg
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| 131 | |1 Capsule
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| 132 | |PO
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| 133 | |BID
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| 134 | |03/30/2009
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| 135 | |Active
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| 136 | |----
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| 137 | |200801
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| 138 | |Medication
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| 139 | |furosemide
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| 140 | |Lasix
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| 141 | |20 mg
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| 142 | |1 Tablet
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| 143 | |PO
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| 144 | |BID
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| 145 | |02/25/2008
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| 146 | |Active
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| 147 | |----
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| 148 | |628958
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| 149 | |Medication
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| 150 | |potassium chloride
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| 151 | |Klor-Con
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| 152 | |10 mEq
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| 153 | |1 Tablet
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| 154 | |PO
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| 155 | |BID
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| 156 | |02/25/2008
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| 157 | |Active
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| 158 | |----
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| 159 | |884175
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| 160 | |Medication
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| 161 | |clonidine hydrochloride
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| 162 | |Catapres
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| 163 | |0.1 mg
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| 164 | |1 Tablet
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| 165 | |PO
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| 166 | |BID
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| 167 | |02/25/2008
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| 168 | |Active
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| 169 | |----
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| 170 | |}
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| 171 |
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| 172 | {| border="1"|
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| 173 | !colspan="5"|Medication Allergy List
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| 174 | |----
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| 175 | !scope="col"|Type
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| 176 | !scope="col"|SNOMED Code
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| 177 | !scope="col"|Medication/Agent
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| 178 | !scope="col"|Reaction
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| 179 | !scope="col"|Date Recorded
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| 180 | |----
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| 181 | |Drug Allergy
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| 182 | |293620004
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| 183 | |Indomethacin
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| 184 | |Rash, dizziness, headache
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| 185 | |06/05/2008
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| 186 | |----
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| 187 | |Drug Allergy
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| 188 | |294506009
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| 189 | |Ampicillin
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| 190 | |Diarrhea, nausea, vomiting
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| 191 | |05/25/1997
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| 192 | |----
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| 193 | |Drug Allergy
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| 194 | |91939003
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| 195 | |Sulfonamides
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| 196 | |Hives, photosensitivity
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| 197 | |08/25/1989
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| 198 | |----
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| 199 | |}
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| 200 |
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| 201 | {| border="1"|
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| 202 | !colspan="5"|Diagnostic Test Results
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| 203 | |----
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| 204 | !scope="col"|Type
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| 205 | !scope="col"|LOINC Code
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| 206 | !scope="col"|Test (Normal Range)
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| 207 | !scope="col"|Result
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| 208 | !scope="col"|Date Performed
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| 209 | |----
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| 210 | |Chemistry
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| 211 | |14771-0
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| 212 | |Fasting Blood Glucose (70100 mg/dl)
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| 213 | |126 mg/dl
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| 214 | |07/15/2010
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| 215 | |----
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| 216 | |Chemistry
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| 217 | |2823-3
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| 218 | |Potassium (3.55.3 mg/dl)
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| 219 | |4.3 mg/dl
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| 220 | |07/15/2010
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| 221 | |----
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| 222 | |Chemistry
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| 223 | |14927-8
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| 224 | |Triglycerides (<150 mg/dl)
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| 225 | |178 mg/dl
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| 226 | |07/15/2010
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| 227 | |----
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| 228 | |Imaging
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| 229 | |42272-5
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| 230 | |Chest X-ray, PA & Lateral
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| 231 | |The heart outline is normal<br> and the hilar and mediastinal<br> vessels are of normal appearance
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| 232 | |02/25/2008
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| 233 | |----
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| 234 | |}
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| 235 |
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| 236 | {| border="1"|
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| 237 | !colspan="5"|Procedure List
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| 238 | |----
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| 239 | !scope="col"|Type
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| 240 | !scope="col"|ICD-9 Code
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| 241 | !scope="col"|Procedure
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| 242 | !scope="col"|Status
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| 243 | !scope="col"|Date Performed
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| 244 | |----
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| 245 | |Surgical
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| 246 | |47.09
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| 247 | |Emergency Appendectomy
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| 248 | |Completed
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| 249 | |01/09/2010
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| 250 | |----
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| 251 | |----
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| 252 | !scope="col"|Type
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| 253 | !scope="col"|CPT Code*
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| 254 | !scope="col"|Procedure
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| 255 | !scope="col"|Status
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| 256 | !scope="col"|Date Performed
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| 257 | |----
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| 258 | |Surgical
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| 259 | |44950
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| 260 | |Emergency Appendectomy
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| 261 | |Completed
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| 262 | |01/09/2010
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| 263 | |----
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| 264 | |}
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| 265 |
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| 266 |
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