| 1 | Patient Summary Record Test Data Set #2
|
|---|
| 2 |
|
|---|
| 3 | Patient
|
|---|
| 4 | Name Date/Time of Birth Gender Identification Number Identification Number Type Address/Phone
|
|---|
| 5 | Ruth Warholde 05/20/1954 Female 9836469798 Medical Record Number 225 Park Street
|
|---|
| 6 | 23:59:45 Morton,
|
|---|
| 7 |
|
|---|
| 8 | Source for all data for this patient: Jackson Shoals, MD
|
|---|
| 9 |
|
|---|
| 10 | Problem List
|
|---|
| 11 | Type ICD-9 Code Patient Problem Status Date Diagnosed
|
|---|
| 12 | Diagnosis 780.2 Syncope and collapse, vasovagal attack Active 02/15/2010
|
|---|
| 13 | Diagnosis 434.91 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
|
|---|
| 14 | Diagnosis 599.0 Urinary tract infection Recurrent 09/22/2008
|
|---|
| 15 | Diagnosis 496.0 Chronic Obstructive Pulmonary Disease Chronic 08/12/2007
|
|---|
| 16 | Symptom 401.9 Hypertension, essential Chronic 05/16/2006
|
|---|
| 17 |
|
|---|
| 18 | Type SNOMED Code* Patient Problem Status Date Diagnosed
|
|---|
| 19 | Disorder 398665005 Vasovagal syncope Active 02/15/2010
|
|---|
| 20 | Disorder 230690007 Cerebrovascular Accident (Stroke) Resolved 07/09/2009
|
|---|
| 21 | Disorder 197927001 Recurrent urinary tract infection Recurrent 09/22/2008
|
|---|
| 22 | Disorder 13645005 Chronic Obstructive Lung Disease Chronic 08/12/2007
|
|---|
| 23 | Disorder 59621000 Essential Hypertension Chronic 05/16/2006
|
|---|
| 24 |
|
|---|
| 25 | Medication List
|
|---|
| 26 | RxNorm
|
|---|
| 27 | Product Generic Name Brand Name Strength Dose Route Frequency Date Started Status
|
|---|
| 28 | Code
|
|---|
| 29 | 209834 Medication docusate Colace 100 mg 1 Capsule PO BID 02/16/2010 Active
|
|---|
| 30 | 205326 Medication lisinopril Zestril 30 mg 1 Tablet PO QD 07/15/2009 Active
|
|---|
| 31 | 309362 Medication clopidogrel Plavix 75 mg 1 Tablet PO QD 07/15/2009 Active
|
|---|
| 32 | 197361 Medication amlodipine Norvasc 5 mg 1 Tablet PO QD 07/15/2009 Active
|
|---|
| 33 | No Longer
|
|---|
| 34 | 539712 Medication nitrofurantoin Macrobid 100 mg 1 Capsule PO QD 09/22/2008
|
|---|
| 35 | Active
|
|---|
| 36 | ipratropium
|
|---|
| 37 | Atrovent 18 By oral
|
|---|
| 38 | 836370 Medication bromide 2 puffs QID 08/14/2007 Active
|
|---|
| 39 | inhaler mcg/puff inhalation
|
|---|
| 40 | monhydrate
|
|---|
| 41 | clonidine
|
|---|
| 42 | 884175 Medication Catapres 0.1 mg 1 Tablet PO BID 05/16/2006 Active
|
|---|
| 43 | hydrochloride
|
|---|
| 44 | Medication Allergy List
|
|---|
| 45 | Type SNOMED Code Medication/Agent Reaction Date Recorded
|
|---|
| 46 | Nausea, vomiting, rash,
|
|---|
| 47 | Drug Allergy 293620004 Indomethacin 03/25/2003
|
|---|
| 48 | dizziness, headache
|
|---|
| 49 | Drug Allergy 91939003 Sulfonamides Hives, photosensitivity 07/26/1999
|
|---|
| 50 |
|
|---|
| 51 | Diagnostic Test Results
|
|---|
| 52 | Type LOINC Code Test (Normal Range) Result Date Performed
|
|---|
| 53 | Small high right occipital lobe
|
|---|
| 54 | contusion. No evidence of
|
|---|
| 55 | Imaging 11539-4 CT, head 02/24/2010
|
|---|
| 56 | extra-axial blood. Significant
|
|---|
| 57 | sinus disease.
|
|---|
| 58 | Hematology 718-7 Hemoglobin (male: 14-18 g/dl female: 12-16 g/dl) 13 g/dl 02/17/2010
|
|---|
| 59 | Hematology 4544-3 Hematocrit (male: 40-54% female: 36-48%) 38% 02/17/2010
|
|---|
| 60 | Chemistry 2951-2 Sodium (135146 mg/dl) 136 mg/dl 02/17/2010
|
|---|
| 61 | Chemistry 2823-3 Potassium (3.55.3 mg/dl) 3.9 mg/dl 02/17/2010
|
|---|
| 62 | Imaging 34534-8 Electrocardiogram Normal Sinus Rhythm 02/15/2010
|
|---|
| 63 | Urine culture, routine
|
|---|
| 64 | Microbiology 630-4 Negative: No growth 10/02/2008
|
|---|
| 65 | (Negative: No growth Positive: >10,000 CFU/ml)
|
|---|
| 66 |
|
|---|
| 67 | Procedure List
|
|---|
| 68 | Type ICD-9 Code Procedure Status Date Performed
|
|---|
| 69 | Surgical 66.39 Bilateral tubal ligation Completed 06/14/1990
|
|---|
| 70 |
|
|---|
| 71 | Type CPT Code* Procedure Status Date Performed
|
|---|
| 72 | Surgical 58600 Bilateral tubal ligation
|
|---|
