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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