Patient Summary Record Test Data – Set #2 

Patient 
Name|Date/Time of Birth|Gender|Identification Number|Identification Number Type|Address/Phone 
Ruth Warholde|05/20/1954|Female|9836469798|Medical Record Number|225 Park Street 
23:59:45|Morton, 

“Source” for all data for this patient: Jackson Shoals, MD 

Problem List 
Type|ICD-9 Code|Patient Problem|Status|Date Diagnosed 
Diagnosis|780.2|Syncope and collapse, vasovagal attack|Active|02/15/2010 
Diagnosis|434.91|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009 
Diagnosis|599.0|Urinary tract infection|Recurrent|09/22/2008 
Diagnosis|496.0|Chronic Obstructive Pulmonary Disease|Chronic|08/12/2007 
Symptom|401.9|Hypertension, essential|Chronic|05/16/2006 

Type|SNOMED Code*|Patient Problem|Status|Date Diagnosed 
Disorder|398665005|Vasovagal syncope|Active|02/15/2010 
Disorder|230690007|Cerebrovascular Accident (Stroke)|Resolved|07/09/2009 
Disorder|197927001|Recurrent urinary tract infection|Recurrent|09/22/2008 
Disorder|13645005|Chronic Obstructive Lung Disease|Chronic|08/12/2007 
Disorder|59621000|Essential Hypertension|Chronic|05/16/2006 

Medication List 
RxNorm 
|Product|Generic Name|Brand Name|Strength|Dose|Route|Frequency|Date Started|Status 
Code 
209834|Medication|docusate|Colace|100 mg|1 Capsule|PO|BID|02/16/2010|Active 
205326|Medication|lisinopril|Zestril|30 mg|1 Tablet|PO|QD|07/15/2009|Active 
309362|Medication|clopidogrel|Plavix|75 mg|1 Tablet|PO|QD|07/15/2009|Active 
197361|Medication|amlodipine|Norvasc|5 mg|1 Tablet|PO|QD|07/15/2009|Active 
No Longer 
539712|Medication|nitrofurantoin|Macrobid|100 mg|1 Capsule|PO|QD|09/22/2008 
Active 
ipratropium 
Atrovent|18|By oral 
836370|Medication|bromide|2 puffs|QID|08/14/2007|Active 
inhaler|mcg/puff|inhalation 
monhydrate 
clonidine 
884175|Medication|Catapres|0.1 mg|1 Tablet|PO|BID|05/16/2006|Active 
hydrochloride 
Medication Allergy List 
Type|SNOMED Code|Medication/Agent|Reaction|Date Recorded 
Nausea, vomiting, rash, 
Drug Allergy|293620004|Indomethacin|03/25/2003 
dizziness, headache 
Drug Allergy|91939003|Sulfonamides|Hives, photosensitivity|07/26/1999 

Diagnostic Test Results 
Type|LOINC Code|Test (Normal Range)|Result|Date Performed 
Small high right occipital lobe 
contusion. No evidence of 
Imaging|11539-4|CT, head|02/24/2010 
extra-axial blood. Significant 
sinus disease. 
Hematology|718-7|Hemoglobin (male: 14-18 g/dl|female: 12-16 g/dl)|13 g/dl|02/17/2010 
Hematology|4544-3|Hematocrit|(male: 40-54%|female: 36-48%)|38%|02/17/2010 
Chemistry|2951-2|Sodium (135–146 mg/dl)|136 mg/dl|02/17/2010 
Chemistry|2823-3|Potassium (3.5–5.3 mg/dl)|3.9 mg/dl|02/17/2010 
Imaging|34534-8|Electrocardiogram|Normal Sinus Rhythm|02/15/2010 
Urine culture, routine 
Microbiology|630-4|Negative: No growth|10/02/2008 
(Negative: No growth|Positive: >10,000 CFU/ml) 

Procedure List 
Type|ICD-9 Code|Procedure|Status|Date Performed 
Surgical|66.39|Bilateral tubal ligation|Completed|06/14/1990 

Type|CPT Code*|Procedure|Status|Date Performed 
Surgical|58600|Bilateral tubal ligation|