Microsoft word - sample_cda.doc

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<FAM V="Levin"/>
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<caption>
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History of Present Illness
</caption>
<paragraph>
<content>
Henry Levin, the 7th is a 67 year old male referred for further
asthma management. Onset of asthma in his teens. He was
hospitalized twice last year, and already twice this year. He has
not been able to be weaned off steroids for the past several
months.
</content>
</paragraph>
</section>
<section>
<caption>Past Medical History</caption>
<list>
<item><content>Asthma</content></item>
<item><content>Hypertension</content></item>
<item><content>Osteoarthritis, right knee</content></item>
</list>
</section>
<section>
<caption>
<caption_cd V="10160-0" S="2.16.840.1.113883.6.1"/>Medications
</caption>
<list>
<item><content>Theodur 200mg BID</content></item>
<item><content>Proventil inhaler 2puffs QID PRN</content></item>
<item><content>Prednisone 20mg qd</content></item>
<item><content>HCTZ 25mg qd</content></item>
</list>
</section>
<section>
<caption>Allergies</caption>
<list>
<item><content>Penicillin - Hives</content></item>
<item><content>Aspirin - Wheezing</content></item>
</list>
</section>
<section>
<caption>Social History</caption>
<list>
<item>
<content>
Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.
</content>
</item>
<item><content>Alcohol :: rare</content></item>
</list>
</section>

<section>
<caption>
<caption_cd V="11384-5" S="2.16.840.1.113883.6.1"/>
Physical Examination
</caption>
<section>
<caption>
<caption_cd V="8716-3" S="2.16.840.1.113883.6.1"/>Vital Signs
</caption>
<list>
<item><content>BP 118/78</content></item>
<item><content>Resp 16 and unlabored</content></item>
<item><content>T 98.6F</content></item>
<item><content>HR 86 and regular</content></item>
</list>
</section>
<section>
<caption>
<caption_cd V="8709-8" S="2.16.840.1.113883.6.1"/>Skin
</caption>
<paragraph>
<content>Erythematous rash, palmar surface, left index finger.
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<REF V="rash.jpeg"/>
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</content>
</paragraph>
</section>
<section>
<caption>
<caption_cd V="11391-0" S="2.16.840.1.113883.6.1"/>Lungs
</caption>
<paragraph>
<content>Clear with no wheeze. Good air flow.</content>
</paragraph>
</section>
<section>
<caption>Cardiac</caption>
<paragraph>
<content>RRR with no murmur, no S3, no S4.</content>
</paragraph>
</section>
</section>

<section confidentiality="CONF2">
<caption>
<caption_cd V="11502-2" S="2.16.840.1.113883.6.1"/>Labs
</caption>
<list>
<item>
<content>
CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette,
clear lungs.
</content>
</item>
<item originator="DEV1"><content>Peak Flow
today: 260 l/m</content></item>
</list>
</section>
<section>
<caption>
<caption_cd V="11496-7" S="2.16.840.1.113883.6.1"/>Assessment
</caption>
<list>
<item>
<content>
<content ID="String001">Asthma</content>, with prior smoking
history. Difficulty weaning off steroids. Will try
gradual taper.
<coded_entry>
<coded_entry.value ORIGTXT="String001"
V="D2-51000" S="2.16.840.1.113883.6.5"/>
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</content>
</item>
<item><content>Hypertension, well-controlled.</content></item>
<item><content>Contact dermatitis on finger.</content></item>
</list>
</section>
<section>
<caption>
<caption_cd V="1234-X" S="2.16.840.1.113883.6.1"/>Plan
</caption>
<list>
<item><content>Complete PFTs with lung volumes.</content></item>
<item><content>Chem-7</content></item>
<item>
<content>
Provide educational material on inhaler usage and
peak flow self-monitoring.
</content>
</item>
<item>
<content>Decrease prednisone to 20qOD alternating
with 18qOD.</content>
</item>
<item><content>Hydrocortisone cream to finger BID.</content></item>
<item><content>RTC 1 week.</content></item>
</list>

</section>
</body>
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Source: http://www.engr.uconn.edu/~steve/Cse300/Sample_CDA.pdf

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Microsoft word - chapter 6.doc

CHAPTER 6 Chemotherapeutic Agents Questions DIRECTIONS (Questions 462 through 563): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered that is BEST in each case. 462. Which of the following beta-lactam antibiotics is most resistant to staphylococcal beta-lactamases? (A) amoxicillm (C) oxacillin (D)

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