1 | Patient Summary Record Test Data Set #4
|
---|
2 |
|
---|
3 | Patient
|
---|
4 | Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
|
---|
5 | Sally Eckerd 08/08/1962 Female 998877799 Medical Record Number 754 Samuel Street,
|
---|
6 | Shawville,
|
---|
7 | 18:25:59
|
---|
8 | Source for all data for this patient: Mark Payne, MD
|
---|
9 |
|
---|
10 | Problem List
|
---|
11 | Type ICD-9 Code Patient Problem Status Date Diagnosed
|
---|
12 | Condition 272.4 Hyperlipidemia Active 07/05/2006
|
---|
13 | Symptom 401.9 Hypertension, Essential Active 07/05/2006
|
---|
14 |
|
---|
15 | Type SNOMED Code* Patient Problem Status Date Diagnosed
|
---|
16 | Disorder 55822004 Hyperlipidemia Active 07/05/2006
|
---|
17 | Disorder 59621000 Essential Hypertension Active 07/05/2006
|
---|
18 |
|
---|
19 | Medication List
|
---|
20 | RxNorm
|
---|
21 | Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
---|
22 | Code
|
---|
23 | atorvastatin
|
---|
24 | 617314 Medication Lipitor 10 mg 1 Tablet PO Q Day 07/05/2006 Active
|
---|
25 | calcium
|
---|
26 | 200801 Medication furosemide Lasix 20 mg 1 Tablet PO BID 07/05/2006 Active
|
---|
27 | (potassium
|
---|
28 | 628958 Medication Klor-Con 10 mEq 1 Tablet PO BID 07/05/2006 Active
|
---|
29 | chloride
|
---|
30 |
|
---|
31 | Medication Allergy List
|
---|
32 | Type SNOMED Code Medication/Agent Reaction Date Recorded
|
---|
33 | Drug Allergy 91936005 Penicillin Rash and anaphylaxis 05/22/1998
|
---|
34 | Drug Allergy 293597001 Codeine Hives 02/17/1992
|
---|
35 |
|
---|
36 | Diagnostic Test Results
|
---|
37 | Type LOINC Code Test (Normal Range) Result Date Performed
|
---|
38 | Chemistry 2823-3 Potassium (3.55.3 mg/dl) 4.5 mg/dl 07/15/2009
|
---|
39 |
|
---|
40 | Chemistry 14647-2 Total cholesterol (<200 mg/dl) 180 mg/dl 07/15/2009
|
---|
41 |
|
---|
42 | Chemistry 14646-4 HDL cholesterol (?40 mg/dl) 38 mg/dl 07/15/2009
|
---|
43 |
|
---|
44 | Chemistry 2089-1 LDL cholesterol (<100 mg/dl) 120 mg/dl 07/15/2009
|
---|
45 |
|
---|
46 | Chemistry 14927-8 Triglycerides (<150 mg/dl) 187 mg/dl 07/15/2009
|
---|
47 |
|
---|
48 | Type LOINC Code Test (Normal Range) Result Date Performed
|
---|
49 | Imaging 42272-5 The heart outline is normal 07/15/2009
|
---|
50 | Chest X-ray, PA & Lateral and the hilar and
|
---|
51 |
|
---|
52 |
|
---|